1. Management of severe falciparum malaria Dr SK Mishra,MD Ispat General Hospit al, Rourkela 769005 India

2. Falciparum malaria is a potentially fatal disease Successful treatment completely cures without disability Early diagnosis and prompt treatment prevents fatal complications 2

3. Severe malaria 1. Cerebral malaria 2. Acute renal failure 3. ARDS 4. Severe anaemia (Hb 3 mg%)

4. Diagnosis of malaria 1. History and clinical features * locality, travel history * fever * spleno-hepatomegaly * presence of complications 2. Laboratory diagnosis3

5. * Drug history * Anti malarials * Blood transfusion History of - haemoglobinopathy - diabetes - alcoholism/ jaundice 4

6. Specifically ask / look for - fever with duration - headache - vomiting, diarrhoea - urine output and colour - cough / dyspnoea/ bleeding - altered sensorium / seizures - pregnancy 5

7. Clinical examination Pallor, icterus bleeding signs early signs of pulm oedema consolidation arrhythmia hepatosplenomegaly uterus6

8. CNS Examination Sensorium /coma score - Glasgow coma score - Blantyre coma score - decerebration Pupils, Fundus examination Neck stiffness Plantar reflex 7

9. Laboratory diagnosis w Microscopy w Immunological tests w Antigen capture tests w Antibody detection tests w QBC test w DNA probe w PCR8

10. Microscopy gold standard for diagnosis thick smear: rapid diagnosis thin : species identification other advantage - platelets, anaemia, toxic picture I f negative : repeat blood test 6 hourly for 6 times 9

11. Why parasites are not detected at times in peripheral smear ? a. sequestration in deep vascular bed b. partially treated patients c. prophylactic antimalarial treatment d. inexperienced microscopist e. poor quality staining 10

12. Antigen capture tests * Pf-ICT test * Parasight-F test/ Malacheck etc Principle: dipstick antigen capture assay employs a monoclonal antibody detecting the Pf.HRP-2 antigen in the blood Rapid, simple, sensitive test Species specificity 11

13. Antibody detection test - RIA - ELISA antibody persists for a long time so not helpful in acute infection 12

14. QBC test Spinning blood in a specialised capillary tubes in which parasite DNA is stained with acridine orange. Detected by ultraviolet microscope Sensitive and specific (?) in Experienced hands 13

15. PCR test Sensitive Can identify different species Takes 48- 72 hours Expensive Available in selected places only DNA Probes 14

16. Cerebral malaria Coma scoring Exclude other causes of coma 1. ABC of coma care 2. Prompt institution of antimalarials 3. Treatment of hyperpyrexia 4. Management of other complications 5. Treatment of associated infections17

17. Antimalarial therapy Parenteral therapy is a must as rapid parasitecidal action is warranted Mainstay of therapy is Quinine - Loading dose or not ? - IV is the route of choice - Donot reduce the dose in first 48 hours of quinine therapy - 20% renal and 80% hepatic clearance 18

18. Quinine therapy 10 mg/ kg body weight over 4 hours every 8 hourly in DNS or dextrose. If therapy has to continue beyond 48 hours reduce dose to 2/3rd. T 1/2 healthy subjects - 11 hours uncomplicated patients 16 hours cerebral malaria - 18 hours 19

19. Side effects: Minor: cinchonism, tinnitus deafness, vertigo, vomiting does not require stoppage of quinine treatment. Severe: hypoglycemia, DIC, haemolysis, arrhythmia, thrombocytopenia etc. These complications are rare. 20

20. Artemisinine compounds Rapid schizonticidal drug Arteether (E-mal) inj 150 mg deep im od x 3 days Artemether (Larither) Inj 80 mg im bid x 3 days or Inj. 80 mg bid first day then od x 4 days Artesunate (falcigo) Unstable, to be prepared before administration 2.4 mg/kg first dosem then 1.2 mg 12 hr then daily for 3-4 days 21

21. COMMON ERRORS IN MANAGEMENT OF SEVERE MALARIA 1.Failure to diagnose associated complications such as bacterial infections, eclampsia, Gram negative septicemia etc. 2. Missed hypoglycaemia 3. Misjudgement of severity 22

22. 4.Errors of fluid and electrolytic replacement 5.Errors in anti-malarial chemotherapy 6. Delay in starting treatment Unjustified withholding of antimalarial drug for the fear of toxicity e.g. Quinine in pregnant women, in hypoglycaemia -Inadequate dosage administration -Failure to control the rate of IV infusion23

23. 7. Delay in considering obstetrics intervention pregnant women suffering from malaria 8.Missed / late diagnosis of ARDS, acute pulmonary oedema 9 Use of inappropriate ancillary therapies e.g. steroids,. 10. Delay in starting dialysis 24

24. This lecture is prepared exclusively for Supercourse