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Malaria Swati Y Bhave Imm Past President IAP

Malaria Swati Y Bhave Imm Past President IAP. Indian Scenario. 7. 6. 5. 4. 1954 Malaria eradication programme initiated. Malaria cases in millions. 3. 2. 1. 0. 1961-70. 1971-80. 1981-90. 1991-2000. Hyderabad. Indian Scenario.

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Malaria Swati Y Bhave Imm Past President IAP

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  1. Malaria Swati Y Bhave Imm Past President IAP

  2. Indian Scenario 7 6 5 4 1954 Malaria eradication programme initiated Malaria cases in millions 3 2 1 0 1961-70 1971-80 1981-90 1991-2000

  3. Hyderabad Indian Scenario Delhi, Bombay, Madras, Calcutta, Ahmedabad, Bhopal, Baroda, Hyderabad, Jaipur, Lucknow, & Bangalore New Delhi 80% of malaria cases in the country (11 major cities)

  4. 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, 6-12 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

  5. 26.49 Vivax 32.05 Smear -ve 41.45 Falciparum 8.11 Mixed AGE & SEX DISTRIBUTION SMEAR POSITIVITY Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  6. 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

  7. 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

  8. Diagnosis of malaria Peripheral smear : diagnostic Correct technique, expertise, Repeated smears; at least 6 Malaria antigens Malaria antibodies Bone marrow

  9. 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

  10. PERCENTAGE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  11. Hepato-spleenomegaly Depends upon age, duration, type, pre-existing pathology: iron def anemia, only spleen more common than only liver No organomegaly

  12. PERCENTAGE P e r c e n t a g e Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  13. Hepatic dysfunction Mimic hepatitis DD: typhoid Viral ( higher range of enzymes) Hepatic dysfunction & fever : malaria needs to be ruled out

  14. Hepatic dysfunction BILI SGPT SGOT Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  15. 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

  16. 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

  17. WIDAL TEST • 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 hepato-spleenomegaly, showed no growth. Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  18. Anemia in malaria Depends upon Age Duration severity of attack, Degree of hemolysis : Falciparum Pre-existing state of anemia

  19. Hemoglobin in malaria

  20. 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

  21. WBC count PERCENTAGE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  22. PERCENTAGE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  23. THROMBOCYTOPENIA VERY GOOD EVIDENCE OF MALARIA BLEEDING RARE CROWDING OF BONE MARROW BY PARASITE QYICKLY RETURNS TO NORMAL ON TREATEMENT Platelet count Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  24. PERCENTAGE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  25. LDH RETIC PLATELET MONOCYTES • What to do in Smear -ve cases? • Indirect evidence of malaria raised LDH, raised retic count, mild hepatic dysfunction, monocytosis & thrombocytopenia. Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  26. 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

  27. CHLOROQUINE RESISTANCE PERCENTAGE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  28. Analysis of Chloroquine resistance WHO gradation DRUG RESISTANCE TO FALCIPARUM PERCENTAGE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  29. 120 100 80 60 40 20 0 F V F V F V S F V F V S S S S S/P CHLORO QUINE MEFLO QUINE QUININE ART. DERI. RESISTANT NOT USED SENSITIVE PATTERN OF DRUG RESISTANCE Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC

  30. 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.

  31. 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

  32. 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)

  33. 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)

  34. 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 ..

  35. Complications & sequele • Complications • Hypoglycemia,Severe Anemia,Metabolic Acidosis,Bacterial Infections ( Gm -ve ) Acute Pulmonary Odema, Acute Renal Failure • Sequele • Hemiplegia,Cortical Blindness,Ataxia • Behavioral Disturbances,Tremors • Polyneuropathy,GB syndrome

  36. 934 N: 534 Source NC Mathur Hyderabad Cerebral Manifestations Ceb. Encph. 98% Asymptomatic 20% Cr. Nr.6% Pyramidal10% Psychiatry2% Cerebellar5% Hemiplegia4% Peripheral Neurit5% Spinal disorders 5% Extra Pyramidal5%

  37. N= 534 Mortality in cerebral malaria • Majority do well • Overall mortality 14.36% (81) • 0-1 : 41.6% (19) • 1-5 : 23.5% (28) • 6-12 : 8.5% (34) 0-1 yr 1-5 yrs 6-12 yrs Source NC Mathur Hyderabad

  38. NC mathur 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% contd… Source NC Mathur Hyderabad

  39. Mortality higher in contd…. • Travellers : 20.6% • Hyperparasitemia (> 5% or > 25000/microlit) • PCV < 20% • Hb% < 7 gm% • Hypoglycemia : < 60mg/dl • Malnutrition • Fever > 3 days at admission

  40. Lactic acid peak N-acetyl acetate peak subdude Thalamic infarcts Nc mathur n= 534 MRI & MRS Source NC Mathur Hyderabad

  41. N=534 nc mathur Source Dr NC Mathur Hyderabad MRI(Magnetic Resonance Imaging) Thalamic infarcts 29 Sep 28 Aug

  42. 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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