Malaria

Malaria

MALARIA CEREBRAL IN CHILDREN

Pembimbing: Dr. HERI, SpA

Disusun oleh:Dr. WULAN ERVINNA

Tanggal 21 Januari 2013

IDENTITAS PASIEN • Nama : An. Rivaldi• Umur : 13 tahun • Jenis Kelamin : Laki-laki

IDENTITAS

IBU• Nama : Ny. Jamalia• Umur : 55 tahun• Pekerjaan : IRT• Pendidikan : SD

AYAH • Nama : Tn. Barsani• Umur : 60 tahun • Pekerjaan : petani• Pendidikan : SD

IDENTITAS ORANG TUA PASIEN

• Persalinan : tidak diketahui• Bayi lahir cukup bulan • BBL : tidak diketahui• PB : tidak diketahui• Kelainan kongenital : -

Riw. Imunisasi : tidak diketahui

RIWAYAT KELAHIRAN

• Penyakit yang pernah diderita : Disangkal • Riwayat dirawat : Disangkal

• Psikologi / Perkembangan Mental : Normal

TUMBUH KEMBANG

Ikhtisar KasusSeorang anak laki-laki, usia 13 tahun, BB = 65 kg, dibawa orangtuanya pada hari Senin, 21

Januari 2013 pukul 21.50 ke UGD RS AM Parikesit dengan:

Keluhan Utama: pasien tidak sadarkan diriKeluhan Tambahan:demam menggigil, muntah, mimisan, seperti orang kejang, gelisah, meracau

Ikhtisar Kasus

Riwayat perjalanan penyakit:4 hari SMRS, pasien mengeluh demam

disertai menggigil dan keringat dingin,

dirasakan di seluruh tubuh, serta sakit

kepala. Oleh ibunya pasien dibawa berobat ke

mantri dan diberi obat 4 macam tetapi ibu

pasien tidak tahu nama obatnya, dikatakan

pasien terkena demam tifoid. Setelah minum obat demam pasien turun sebentar, lalu

kemudian naik kembali. Mimisan (+), gusi berdarah(-), mual

muntah (+) setiap kali makan.

3 hari SMRS demam tidak turun juga, pasien

mengeluh sakit kepalanya semakin berat. Nafsu makan

dan aktivitasnya mulai menurun, muntah semakin sering, tidak mau makan,

pasien seperti orang kebingungan, meracau dan

gelisah. 1 hari SMRS kaki dan tangan pasien semakin

dingin. Pasien tampak seperti orang kejang 1x,

mata mendelik ke atas,tangan kelojotan dan setelah itu semakin lemas, tidak bisa dibangunkan. 1 bulan sebelumnya pasien

bekerja ke hutan dan baru 1 minggu kembali dr hutan.Karena keluhan-keluhan

tersebut, orangtua pasien segera membawa pasien ke

UGD RS AM Parikesit.

Riwayat Perjalanan Penyakit

21 Januari 2013Pemeriksaan Fisik

Keadaan Umum:Tampak Sakit SedangKesadaran : E3M4V3FrekNadi : 72 x/menit (Reg, kuat angkat, isi cukup)Frek Nafas : 22 x/menit (Reg, adekuat)T D : 100/40 mmHgSuhu : 38.50 C (axilla)K/L : CA -/-, SI -/-Thoraks : Ins: Pergerakan dinding dada simetris

Pal: Vocal fremitus kanan = kiri Per: Sonor kanan = kiri Aus: BND Bronkhial, Rh -/-, Wh -/- BJ I & II Normal

Abdomen : Ins: Perut tampak datar Pal: Nyeri tekan (+), hati teraba 1 jari

bac, limpa tdk teraba besar

Per: Tympani Aus: Bising Usus (+) 4x/menit

Ekstremitas: Akral dingin, Capillary refill < 2 detikKulit : Turgor cukup,

Hasil Laboratorium 21 Januari 2013 pkl 21.50•Hematologi•Hb : 14,4•Leukosit : 14.100•Trombosit : 71.000•Ht : 47•Hitung Jenis•Basofil : >53•Eosinofil : •Batang : •Segmen:•Limfosit : 28,8•Monosit : 16,9

•Malaria : Fr +•Widal : TO -, AO -, TH 1/80, AH 1/80•GDS : 110•Ur 40, Cr 1,0•Na 140, Ka 5.0, Cl 112

Dengan keadaan tersebut di atas, pasien mendapatkan penanganan di UGD sebagai berikut:

- O2 2 -3 lpm- IVFD: D5% 650 cc+ 1300 mg CAP (162 cc/jam IP) selama 4 jam selanjutnya D51/2NS 143 cc/jam selama 4 jam- IVFD: D5% 325 cc+ 650 mg CAP (162 cc/jam IP) selama 2 jam selanjutnya D51/2NS 143 cc/jam selama 6 jam- IVFD: D5% 325 cc+ 650 mg CAP (162 cc/jam IP) selama 2 jam selanjutnya D51/2NS 143 cc/jam selama 6 jam- Inj Ceftriaxone 2x 1 gr IV- PCT 3x500 mg

Pada pukul 03.15 dari Pemeriksaan Fisik didapatkan:KU: lemahFP: 46 kali/menitFN: 160 kali/menitTD: 120/70 mmHg

Dokter menjelaskan kepada orangtua pasien bahwa keadaan anak kritis dan dianjurkan untuk segera dirawat di ICU

Pada pukul 06.30 dari Pemeriksaan Fisik didapatkan:KU: lemahFP: 46kali/menitFN: 227kali/menitTD: 90/80 mmHg

Instruksi dokter saat itu: - CIV: Widahes 325cc/jam, Asering 325 cc/jam - Obs KU, TTV, tanda perdarahan, GDS

Penatalaksanaan

Pukul 15..00.Hasil H2TL ulangHb/Ht/Leukosit/Trombosit: 13,0/38/9200/55.000

Instruksi dokter: - CIV: Widahes325cc/jam, Asering 325 cc/jam - Obs KU, TTV, tanda perdarahan, GDS, H2TL

Penatalaksanaan

Pasien dipindahkan ke ICU,terpasang selang NGT berisi cairan warna hitam kental, urin pada DC kuning pekat.

HepatomegalySplenomegaly

(malaria)Cairan bebas

abdomen

Hasil Foto USG 22 Januari 2013

S: gelisah +O: KU/Kesadaran : Tampak Sakit Berat Apatis

FN : 128x/mnt, RR 40x/mnt, TD 100/50 mmHg, Suhu 38,9 CK/L : anemis -/-, ikterik -/-Thoraks : vesikuler, rhonki -/-, wheezing -/-, BJ normal, gallop -, murmur -Abdomen : BU +, supel, NT +, hati teraba 2 jari bac

A: Malaria CerebralP: - CIV: Asering 162 cc/jam dan D51/2NS 162cc/jam+CAP 2,6 cc

habiskan dalam 3 jam - O2 2-3 lpm

- MM/ Ceftriaxone 2x1 gr ivParacetamol inj 3x500 mg dripVit K 1mg dlm 500cc Asering per hari

- Puasa NGT : 100 cc cairan hitam kentalUrine : 500 cc pekat kehitaman

Follow Up 22 Januari 2013 Pukul 14.00 Visit dr. Heri• Instruksi:

• Periksa DL, elektrolit, GDS jam 21.00

• Cek GDS tiap 3 jam• Terapi lain lanjut

21. 30 Advice dr. Hery• Infus pump

81 cc/jam• Cek ulang DL

jam 03.00

Pemeriksaan H2TL ulang pkl 21.00Hb/Ht/Leukosit/Trombosit: 11,2/33/8.270/71.000

S: gelisah -, tampang bingung, nyeri perutO: KU/Kesadaran : Tampak Sakit Berat Apatis

FN : 94x/mnt, RR 28x/mnt, TD 90/60 mmHg, Suhu 37 CK/L : anemis -/-, ikterik -/-Thoraks : vesikuler, rhonki -/-, wheezing -/-, BJ normal, gallop -, murmur -Abdomen : BU +, supel, NT +, hati teraba 2 jari bac

A: Malaria CerebralP: - CIV: Asering 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam)

habiskan dalam 3 jam tiap 8 jam - O2 2-3 lpm

- MM/ Ceftriaxone 2x1 gr ivTamolif 3x500 mg dripVit K 1mg dlm 500cc Asering per hariRanitidin 2x1 ampul

- Puasa NGT : 100 cc cairan hitam kental, urin 50cc kuning pekat

Follow Up 23 Januari 2013 Pukul 08.00 Visit dr. Heri• Instruksi:

• Periksa DL, elektrolit, GDS tiap 6 jam

• Terapi lain lanjut

05. 30 Advice dr. Hery• Transfusi PRC

1 kolf

Pemeriksaan H2TL ulang pkl 03.00Hb/Ht/Leukosit/Trombosit: 10,8/33/7.700/90.000

S: gelisah -, tampang bingung, nyeri perutO: KU/Kesadaran : Tampak Sakit Berat Apatis

FN : 89x/mnt, RR 28x/mnt, TD 130/80 mmHg, Suhu 37 CK/L : anemis -/-, ikterik -/-Thoraks : vesikuler, rhonki -/-, wheezing -/-, BJ normal, gallop -, murmur -Abdomen : BU +, supel, NT +, hati teraba 2 jari bac

A: Malaria CerebralP: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc

(81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm

- MM/Ceftriaxone 2x1 gr ivTamolif 3x500 mg dripVit K 1mg dlm 500cc dlm D5% per hariRanitidin 2x1 ampul

- Puasa NGT : 100 cc cairan hitam kental, urin 50cc kuning pekat

Follow Up 24 Januari 2013Pukul 08.00 Visit dr. Heri• Instruksi:

• Periksa DL, tiap 12, GDS tiap 6 jam• Terapi lain lanjut

Pemeriksaan H2TL ulang Hb/Ht/Leukosit/Trombosit: 12/34/7.200/110.000

25 Januari 2013 26 Januari 2013 27 Januari 2013

S: demam -, nyeri perutO: KU/Kesadaran: Tampak Sakit Berat ApatisFN : 89x/mnt, RR 28x/mnt, TD 130/80 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bacA: Malaria CerebralP: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/Ceftriaxone 2x1 gr ivTamolif 3x500 mg dripVit K 1mg dlm 500cc dlm D5% per hariRanitidin 2x1 ampulNGT : 20 cc cairan coklat hitam kental, urin 100cc kuning jernihDiet sonde 8x30cc

Lab: Hb 10,7, Ht 33%, Leukosit 7100, Trombosit 172.000

S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat ApatisFN : 80x/mnt, RR 24x/mnt, TD 110/56 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bacA: Malaria CerebralP: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/Ceftriaxone 2x1 gr ivRanitidin 2x1 ampulPCT 500mg k/pDiet sonde 12x50cc

Lab: Hb 11,3, Ht 33%, Leukosit 7400, Trombosit 237.000Cek DL per hari dan DDR

S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat ApatisFN : 80x/mnt, RR 24x/mnt, TD 131/72 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bacA: Malaria CerebralP: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/Ceftriaxone 2x1 gr ivRanitidin 2x1 ampulPCT 500mg k/pDiet : susu 12x80cc dan bubur saring 3x1/2 porsi

Lab: Hb 11,, Ht 26%, Leukosit 8200, Trombosit 301.000Cek DL per hari dan DDR

28Januari 2013 29 Januari 2013

S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat Apatis TD 109/769 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bacA: Malaria CerebralP: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/Ceftriaxone 2x1 gr ivRanitidin 2x1 ampul stopPCT 500mg k/pElkana 1x1 cthDiet : susu 12x100cc dan bubur saring 3x1 porsi

S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat Apatis TD 109/769 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bacA: Malaria CerebralP: - CIV: D51/2NS 81cc/jam dan D5% 14 tpm - O2 2-3 lpm - MM/Ceftriaxone 2x1 gr ivRanitidin 2x1 ampul stopPCT 500mg k/pElkana 1x1 cthDiet : susu 12x120cc dan bubur saring 3x1 porsi

Lab: Hb 11,, Ht 26%, Leukosit 8200, Trombosit 301.000Cek DL per hari dan DDR

Introduction• Malaria is a tropic life threatening disease.• A disease caused by members of the protozoan

genus Plasmodium, a widespread group of sporozoans that pasitize the human liver and red blood cells.

• There are 4 species:– plasmodium falciparum– plasmodium vivax– plasmodium ovale– plasmodium malariae

Problem statement (world)

• 109 countries are endemic for malaria• 3.3 billion people were at risk of malaria in

2006• 1.2 billion at higher risk(WHO African and

SE Asia)• Childhood death occurs mainly due to

cerebral malaria and anemia

- Haya -

(2-6)Classical features include cyclic

symptoms

- Haya -

• chills and shakingCold

stage: • fever, headache,

vomiting, seizures in children .

Hot stage:

• weaknessSweating stage:

- Haya -

- Haya -

mild jaundice, pallor and bilateral conjunctival haemorrhages associated with P. falciparum infection.

(5-6)

- Haya -

Tropical splenomegaly in a patient with evidence of hypersplenism living in a P. falciparum endemic area.

(6-6)

uncomplicated malaria

in special groups (young children, pregnant women, HIV /AIDS)

in travellers (from non-malaria endemic regions)in epidemics and complex emergency situations

4 | Guidelines for the Treatment of Malaria

severe malaria

Clinical features and classification of malaria

UNCOMPLICATED MALARIA (all species)

– Uncomplicated malaria definition:

Fever and any of the following: • Headache,• Body and joint pains• Feeling cold and sometimes shivering• Loss of appetite and sometimes abdominal pains• Diarrhoea, nausea and vomiting.• Hepatospleenomegaly

Table 1: WHO case definition of Severe Falciparum MalariaCerebral malaria Unrousable coma (GCS < 11/15), with peripheral P.

falciparum parasitaemia after exclusion of other causes of encephalopathy

Severe anaemia Normocytic anaemia with haemoglobin <5 g dl−1 (haematocrit<15%) in presence of parasitaemia >10 000 ml−1

Respiratory distress Pulmonary oedema or acute respiratory distress syndrome (ARDS) Would now also include rapid laboured ‘acidotic’ breathing sometimes abnormal in rhythm

Renal failure Urine output of less than 400 ml in 24 h (or <12 ml kg−1 in children) and a serum creatinine >265 mmol l−1 (>3.0 mg dl−1)

Hypoglycaemia Whole blood glucose <2.2 mmol l−1 (40 mg dl−1)

Circulatory collapse (shock) Systolic blood pressure <70 mmHg or core-skin temperature difference >10°C

Coagulation failure Spontaneous bleeding and/or laboratory evidence of disseminated intravascular coagulation

Complicated malaria:

Impaired consciousness of any degree, Prostration, Jaundice, Intractable vomiting, Parasitaemia ≥2% in non-immune individuals (no previous malaria)

Such patients with complicated malaria should be managed as severe malaria, i.e. with parenteral antimalarials even though they do not necessarily meet the criteria of severe disease.

***Levels of parasitaemia should be interpreted in the light of immunity Online ISSN 1471-8391 - Print ISSN 0007-1420Copyright © 2012 Oxford University Press

http://www.oxfordjournals.org/our_journals/terms.html

Diagnosis - RDT

Parasitological confirmation is done by thin-thick blood smear microscopy examination or by dipstick (Rapid Diagnostic Test [RDT]).

Differential diagnosis for severe malaria

• 1. Meningoencefalitis • 2. Stroke• 3. Tifoid ensefalopati • 4. Hepatitis• 5. Leptospirosis berat • 6. Glomerulonefritis akut atau kronik • 7. Sepsis• 8. DHF atau DSS

THE PHARMACOLOGY OF ANTIMALARIALS

Class Definition Examples

Class Definition Examples Class Definition Examples

Blood schizonticidal drugs

Act on (erythrocytic) stage of the parasite thereby terminating clinical illness

Quinine, artemisinins, amodiaquine, chloroquine, lumefantrine, tetracyclinea , atovaquone, sulphadoxine, clindamycina , proguanila

Tissue schizonticidal drugs

Act on primary tissue forms of plasmodia which initiate the erythrocytic stage. They block furtherdevelopment of theinfection

Primaquine, pyrimethamine,proguanil, tetracycline

Gametocytocidal drugs

Destroy sexual forms of theparasite thereby preventing transmission of infection tomosquitoes

Primaquine, artemisinins,quinineb

a Slow acting, cannot be used alone to avert clinical symptomsb Weakly gametocytocidal

THE PHARMACOLOGY OF ANTIMALARIALS (cont.)

Class Definition Examples

Class Definition Examples Class Definition Examples

Hypnozoitocidal drugs These act on persistentliver stages of P.ovaleand P.vivax which causerecurrent illness

Primaquine, tafenoquine

Sporozontocidal drugs These act by affectingfurther development ofgametocytes into oocyteswithin the mosquito thusabating transmission

Primaquine, proguanil,chlorguanil

1. Treatment of severe falciparum malaria

Preferred regime Alternative regime

IV Artesunate (60mg): 2.4mg/kg on admission, followed by 2.4mg/kg at 12h & 24h, then once daily for 7 days.

Once the patient can tolerate oral therapy, treatment should be switched to a complete dosage of Riamet (artemether/lumefantrine) for 3 day.

IV Quinine loading 7mg salt /kg over 1hr followed by infusion quinine 10mg salt/kg over 4 hrs, then 10mg salt/kg Q8H or IV Quinine 20mg/kg over 4 hrs, then 10mg/kg Q8H.PlusAdult & child >8yrs old: Doxycycline (3.5mg/kg once daily)or Pregnant women & child < 8yrs old: Clindamycin (10mg/kg twice daily). Both drug can be given for 7 days.

Reconstitute with 5% Sodium Bicarbonate & shake 2-3min until clear solution obtained. Then add 5ml of D5% or 0.9%NaCl to create total volume of 6ml.Slow IV injection with rate of 3-4ml/min or IM injection to the anterior thigh.The solution should be prepared freshly for each administration & should not be stored.

Dilute injection quinine in 250ml od D5% and infused over 4hrs.

Infusion rate should not exceed 5 mg salt/kg per hour.

2. Treatment of uncomplicated p.falciparum


Artemether plus lumefantrine(Riamet)(1 tab: 20mg artemether/120mg lumefantrine)

Quinine sulphate (300mg/tab)

Weight Group

Day 1 Day 2 Day3 Day 1-7: Quinine 10mg salt/kg PO Q8H

Plus*Doxycycline (3.5mg/kg once a day) OR

*Clindamycin (10mg/kg twice a day)

*Any of these combinations should be given for 7 days.Doxycycline: Children>8yrClindamycin: Children<8yr

5-14kg 1 tab stat then 8hr later

1 tab Q12H 1 tab Q12H





>34kg 4 tab stat then 8hr later


Take immediately after a meal or drink containing at least 1.2g fat to enhance lumefantrine absorption.Add primaquine 0.75mg base salt/kg single dose if gametocyte is present at any time during treatment.

Dosage and administration Plasmodium falciparum for young infant

Age Group Weight group Artesunate or *Quinine

0 - 4 months <5 kg

** IM first dose Artesunate 1.2 mg/kg or IM Arthemeter 1.6 mg/kg)

***Oral Artesunate 2mg/kg/day day 2 to day 7

Oral Quinine 10 mg/kgTDS for 4 days then 15-20 mg/kg TDS for 4 days

Source: Malaria in Children, Department of tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University.

** Preferably Artesunate/Artemether IM on day 1 if available *** When Artesunate/Artemether IM is unavailable, give oral Artesunate from day 1 to day 7* Treat the young infant with Quinine when oral Artesunate is not available

Children under 5 kg or below 4 months should not be given Riamet instead treat with the following regimen (see table).

3. Treatment of malaria caused by p.knowlesi & mixed infection (p. falciparum + p. vivax)

• Treat as p. falciparum

Important notesRiamet tablets should be taken with or after food. Patient with acute malaria re frequently averse to food, the dose may be taken with fluid and encourage patient to resume normal eating as soon as food can be tolerated.Watch all patients swallowing the first dose of Riamet® and observe for 1 hour after the intake. In the event of vomiting within one hour of administration, a repeat dose should be taken.For small children Riamet® can be crushed, diluted in water and then put either directly into the mouth using a syringe or given with a spoon.Riamet may cause fatigue and dizziness. Warn patient not to drive or use machines.Instruct patient to report signs/symptoms of QT interval prolongation.

Treatment in specific population & situations

Specific populations


Pregnancy Quinine plus clindamycin to be given for 7 day

Artesunate plus Clindamycin for 7 days is indicated if first line treatment fails

Lactating women

Should receive standard antimalarial treatment (including ACTs) except for dapsone, primaquine and tetracyclines, which should be withheld during lactation

Hepatic impairment

Chloroquine: 30-50% is modified by liver, appropriate dosage adjustment is needed, monitor closely.Quinine : Mild to moderate hepatic impairment-no dosage adjustment, monitor closely. Artemisinins : No dosage adjustment

Renal Impairment

Chloroquine : ClCr<10ml/min-50% of normal dose.Hemodialysis, peritoneal dialysis: 50% of normal dose.Continuous Renal Replacement Therapy(CRRT) :100% of normal dose.Quinine : .ClCr 10-50ml/min : Administer Q8-12H, CLCr<10ml/min : administer Q24H,Severe chronic renal failure not on dialysis : initial dose: 600mg followed by 300mg Q12H, Hemo- or peritoneal dialysis: administer Q24H ,Continuous arteriovenous or hemodialysis: Administer Q8-12H.Artemisinin : no dosage adjustment.

Treatment of complications of malaria

• Severe & complicated falciparum or knowlesi malaria is a medical emergency that requires intervention and intensive care as rapidly as possible.

• Fluid, electolyte glucose & acid-base balance must be monitored.Intake & output should be carefully recorded.

Immediate clinical management of severe manifestations and complications of P. falciparum

malariaDefinitive clinical features Immediate management/treatment

Come (Cerebral malaria) Monitor & record level of consciousness using Glaslow coma scale, temperature, respiratory, and depth, BP and vital signs.

Hyperpyrexia (rectal body temperature >40°C)

Treated by sponging, fanning &with an antipyretic drug.Rectal paracetamol is preferred over more nephrotoxic drugs (e.g. NSAIDs)

Convulsions A slow IV injection of diazepam(0.15mg/kg, maximum 20mg for adults).

Hypoglycaemia (glucose conc. <2.8mmol/L)

Correct with 50% dextrose (as infusion fluids). Check blood glucose Q4-6H in the first 48hrs.

Severe anaemia (hb < 7g/dl)

Transfuse with packed cells. Monitor carefully to avoid fluid overload. Give small IV dose of frusemide, 20mg, as necessary during blood transfusion to avoid circulatory overload.

Acute pulmonary oedema Prop patient upright (45°), give oxygen, give IV diuretic (but most patient response poorly to diuretics), stop intravenous fluids. Early mechanical ventilation should be considered.

Immediate clinical management of severe manifestations and complications of P. falciparum

malaria (cont.)

Definitive clinical features Immediate management/treatment

Acute renal failure (urine output <400ml in 24hrs in adults or 0.5ml/kg/hr, failing to improve after rehydration & a serum creatinine of >265μmol/L)

Exclude pre-renal causes by assessing hydration status. Rule out urinary tract obstruction by abdominal examination or ultrasound.Give intravenous normal salineIf in established renal failure add haemofiltration or haemodialysis, or if unavailable, peritoneal dialysis.

Disseminated intravascularCoagulopathy (DIVC)

Transfuse with packed cell, clotting factors or platelet.Usual regime: Cryoprecipitate 10units,platelets 4-8units, fresh frozen plasma(10-15ml/kg).For prolonged PT, give vitamin K, 10mg by slow IV injection.

metabolic acidosis Infuse sodium bicarbonate 8.4% 1mg/kg over 30min and repeat if needed.if severe, add haemodialysis.

Shock (hypotension with systolic blood pressure <70mmHg)

Suspect septicaemia, take blood for cultures; give parenteral broad-spectrum antimicrobials, correct haemodynamic disturbances.

Monitoring & follow-up• Blood smear should be repeated daily

(twice daily in severe infection). Within 48-72 hr after start of treatment, patients usually become afebrile and improve clinically except in complicated cases.

• All patients should be investigated with repeated blood film of malarial parasite one month upon recovery of malarial infection, to ensure no recrudescence.

Prevention

•Avoid mosquito bites:Wearing long sleeves, trousers.Insecticide Treated BednetsRepellent creams or sprays.

Malaria vaccine• Vaccination against malaria is a burning issue today• Several vaccine candidates are now being tested in

africa, asia and US• A vaccine developed in columbia (SPF 66) advanced

to phase 3 trials in africa but failed to show efficacy in chiildren under 1

• Another vaccine (RTS, S/AS02) with the potential to prevent infection and ameliorate disease is being tested by GlaxoSmithKline and the MVI at PATH in Phase I trial in Gambia

• In phase II in 2002 trials of the vaccine are being conducted among the children in Mozambique, which suffers from year-round malaria transmission offering a better opportunity to evaluate vaccine performance

• This vaccine has been safely tested in adult volunteeers in Belgium, Gambia, kenya and US

• only potential malarial vaccine

References

• WHO Guidelines for the treatment of malaria -- 2nd edition.(2010)• Management of severe malaria : a practical handbook. – 2nd ed.(2000)• MICROMEDEX 2.0• NATIONAL GUIDELINES FOR THE DIAGNOSIS, TREATMENT AND

PREVENTION OF MALARIA IN KENYA.THIRD EDITION 2010.• http://www.akademisains.gov.my/download/tropical/Lokman.pdf• http://www.who.int/malaria/publications/country-profiles/profile_mys_e

n.pdf

http://www.akademisains.gov.my/download/tropical/Lokman.pdf

http://www.who.int/malaria/publications/country-profiles/profile_mys_en.pdf

http://www.who.int/malaria/publications/country-profiles/profile_mys_en.pdf

Malaria vaccine• Vaccination against malaria is a burning issue today• Several vaccine candidates are now being tested in

africa, asia and US• A vaccine developed in columbia (SPF 66) advanced

to phase 3 trials in africa but failed to show efficacy in chiildren under 1

• Another vaccine (RTS, S/AS02) with the potential to prevent infection and ameliorate disease is being tested by GlaxoSmithKline and the MVI at PATH in Phase I trial in Gambia

• In phase II in 2002 trials of the vaccine are being conducted among the children in Mozambique, which suffers from year-round malaria transmission offering a better opportunity to evaluate vaccine performance

• This vaccine has been safely tested in adult volunteeers in Belgium, Gambia, kenya and US

• only potential malarial vaccine

Thank you…

Malaria

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