N234 Malaria Swati Y Bhave Imm Past President
N=234 Malaria Swati Y Bhave Imm Past President IAP
N=234 Indian Scenario Malaria cases in millions 7 6 5 4 3 1954 Malaria eradication programme initiated 2 1 0 1961 -70 1971 -80 1981 -90 1991 -2000
N=234 Indian Scenario Delhi, Bombay, Madras, Calcutta, Ahmedabad, Bhopal, Baroda, Hyderabad, Jaipur, Lucknow, & Bangalore 80% of malaria cases in the country (11 major cities) New Delhi Hyderabad
N=234 MATERIAL & METHODS • Between 1994 - 1998 hospitalized 234 cases of malaria in Bombay Hospital & MRC • Divided in the age group of < 1 yr, 1 -5 yrs, 612 yrs and 13 -17 yrs. • Complete clinical examination & Laboratory parameters • Analysis of drug resistance Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 AGE & SEX SMEAR POSITIVITY DISTRIBUTION 32. 05 Smear -ve 8. 11 Mixed Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC 26. 49 Vivax 41. 45 Falciparum
N=234 Clinical signs & symptoms of Malaria Classical: Fever with chills, Anemia, Hepatospleenomegaly, Multisystem involvement Varied manifestations Hematological, GI, Renal, Resp, CNS General symptoms: Malaise, headache, bodyache, anorexia, failure to thrive, weight loss
N=234 Presenting Symptoms • GI: abd pain, vomiting, diarrhea • Icterus: hepatitis • Resp: Cough URI, Pnem, ARDS • CNS : alter sensorium, neur deficits • Renal, electrolyte, metabolic Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 Diagnosis of malaria Peripheral smear : diagnostic Correct technique, expertise, Repeated smears; at least 6 Malaria antigens Malaria antibodies Bone marrow
N=234 Malarial fever in children Any type of fever can occur in malaria Type of fever depends upon/: Age, immune status, first attack, species Can mimic TB , typhoid Rule out malaria in all cases of fever specially PUO NO FEVER: neonates, chronic
PERCENTAGE N=234 Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 Hepato-spleenomegaly Depends upon age, duration, type, pre-existing pathology: iron def anemia, only spleen more common than only liver No organomegaly
PERCENTAGE N=234 Percentage Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 Hepatic dysfunction Mimic hepatitis DD: typhoid Viral ( higher range of enzymes) Hepatic dysfunction & fever : malaria needs to be ruled out
N=234 Hepatic dysfunction SGPT SGOT BILI Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 Other lab tests • • Renal profile done in all cases Serum electrolytes - normal in 99% Only one case of acute renal failure Routine urine done in all, abnormal in 37 (15. 81%) Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 False Positive Widal in malaria Many reports of widal positive in malaria Sometimes malaria is seen in typhoid patients on treatment hence dual infection can exist But more often this is false positive widal proved by negative blood culture, non changing titre most cases lower than diagnostic titre & Fever responding to antimalarials
WIDAL TEST N=234 • • Widal test done in 57 (24. 35%) & was +ve in 17. 54%, none with significant titres. Blood culture done in 78 (33. 33%) cases with fever > 7 days and hepatospleenomegaly, showed no growth. Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 Anemia in malaria Depends upon Age Duration severity of attack, Degree of hemolysis : Falciparum Pre-existing state of anemia
N=234 Hemoglobin in malaria
N=234 WBC count in Malaria Any type of count can occur Leucopenia, leucocytosis, leukemoid reaction, Respiratory symptoms leucopenia viral leucocytois esp neutrophilia : bacterial Monocytosis ? Indirect evidence
WBC count PERCENTAGE N=234 Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
PERCENTAGE N=234 Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 Platelet count • THROMBOCYTOPENIA • VERY GOOD EVIDENCE OF MALARIA • BLEEDING RARE • CROWDING OF BONE MARROW BY PARASITE • QYICKLY RETURNS TO NORMAL ON TREATEMENT Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
PERCENTAGE N=234 Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 • What to do in Smear -ve cases? • Indirect evidence of malaria raised LDH, raised retic count, mild hepatic dysfunction, monocytosis & thrombocytopenia. LDH RETIC PLATELET MONOCYTES Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 Drug resistance Falciparum resistance to Chloroquine increasing reports all over the country also reports of resistance to second line drugs S/P & mefloquine Timely use of quinine & artemsinine derivatives reduce mortality of cerebral malaria some reports of vivax resistance to chloroquine & second line drugs
N=234 PERCENTAGE CHLOROQUINE RESISTANCE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
Analysis of Chloroquine resistance WHO gradation DRUG RESISTANCE TO FALCIPARUM PERCENTAGE N=234 Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 PATTERN OF DRUG RESISTANCE 120 RESISTANT SENSITIVE NOT USED 100 80 60 40 20 0 F V S CHLORO QUINE S/P F V S MEFLO QUINE QUININE F V S ART. DERI. Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234 CONCLUSION ¬ In our series ¬ Falciparum cases had more GI symptoms, whereas ¬ Vivax had more Resp symptoms ¬ The age group of 6 -12 had maximal symptoms and good chloroquine sensitivity Malaria can be missed unless high index of suspicion.
N=234 CONCLUSION (contd. . ) ¬ Leucocytosis, Neutrophilia with respiratory symptoms can be misdiagnosed as bacterial infection. ¬ Leucopenia with respiratory symptoms can be misdiagnosed as viral infection. ¬ Gastroenteritis with persistent fever needs malaria smear examinations. ¬ Hepatitis dysfunction : Generally mild unlike viral hepatitis
N=234 Cerebral Malaria • Unaurousable coma • Exclusion of other encphalopathies • Confirmation of P. falciparam (undiagnosed coma with neurological manifestations of any degree are treated as cerebral malaria)
N=234 Pathophysiology • Capillary Blockade * Agglutination * RBC Heavy – Parasite load * Trophozoites & Gametocytes * Capillary endothelium too sticky • Rupture of RBC- Schizont Merozoites, Hemozoin pigments, RBC proteins, Malaria Toxins (Pyrogenic, Hemolytic, Endotheliotoxic, Histo-toxic)
N=234 Modes of Presentation • • Recurrent Seizures, Hyperthermia, Hypoglycaemia Renal Failure / Renal Dysfunction Hepatic Dysfunction & Icterus Fluid, Electrolyte & Acid Base Disturbance • • Pulmonary Odema, Circulatory Collapse Black Water Fever , (Intravascular Haemolysis) DIC & Bleeding Diathesis, Migraine, Sciatica Cough, Aphonia, Anorexia, Abdominal Pain • Psychiatric Disorder, Excessive Crying. .
N=234 Complications & sequele • Complications • Hypoglycemia, Severe Anemia, Metabolic Acidosis, Bacteria Infections ( Gm -ve ) Acute Pulmonary Odema, Acute Renal Failure • Sequele • Hemiplegia, Cortical Blindness, Ataxia • Behavioral Disturbances, Tremors • Polyneuropathy, GB syndrome •
N=234 934 Source NC Mathur Hyderabad N: 534 Cerebral Manifestations Ceb. Encph. 98% Asymptomatic 20% Psychiatry 2% Cerebellar 5% Peripheral Spinal Neurit disorders 5% 5% Hemiplegia 4% Extra Pyramidal 5% Pyramidal 10% Cr. Nr. 6%
N=234 Mortality in cerebral malaria N= 534 • Majority do well • Overall mortality 14. 36% (81) • 0 -1 : 41. 6% (19) • 1 -5 : 23. 5% (28) 0 -1 yr 1 -5 yrs 6 -12 yrs • 6 -12 Source NC Mathur Hyderabad : 8. 5% (34)
NC mathur N=234 n=534 Poor Prognosis Mortality higher in • Comatose Children who present < 72 hrs : 21. 1% > 72 hrs : 47. 6% • with Seizures : 32. 4% • with Decerebrate Rigidity : 57. 2% Source NC Mathur Hyderabad contd…
N=234 Mortality higher in contd…. • Travellers : 20. 6% • Hyperparasitemia (> 5% or > 25000/microlit) • PCV < 20% • Hb% < 7 gm% • Hypoglycemia : < 60 mg/dl • Malnutrition • Fever > 3 days at admission
N=234 Nc mathur n= 534 MRI & MRS Lactic acid peak N-acetyl acetate peak subdude Thalamic infarcts Source NC Mathur Hyderabad
N=234 N=534 nc mathur Source Dr NC Mathur Hyderabad MRI (Magnetic Resonance Imaging) Thalamic infarcts 28 Aug 29 Sep
N=234 Conclusions • Malaria is increasing global problem and high index of suspicion is required for diagnosis • in cerebral malaria, complications are less and Survival is good if diagnosed early and treatment initiated • Physician should be well versed with multisystem, varied and rare manifestations • and be aware of the available drugs and pattern of drug resistance in the area
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