this malaria slides are prepared based on latest WHO guidelines.... hope it helps u all in understanding the treatment

1. TREATMENT OF
MALARIA
- Dr.Akif A.B

2. Chloroquine
sensitive malaria
Chloroquine 10mg/kg bw stat dose followed by
10mg/kg on 2nd day
f/b
5mg/kg bw on 3rd day
or
Chloroquine 10mg/kg bw
f/b
5mg/kg at 6hr,24 hrs & 48hrs
Add Primaquine 0.25-0.5mg/kg bw/ day for 14 days only if
G6PD levels are normal
This chloroquine level resides for about 2-3 weeks in blood, thus prevents the first
Relapse of P.vivax which generally occurs at 3wks after onset of primary illness.
So relapses begin after 5-6wks of illness if not treated with Primaquine.

5. CHLOROQUINE
S/E:
- It is generally well tolerated in therapeutic doses of malaria
- Large doses used in treatment of Rheumatoid Arthritis are usually associated
with higher frequency of side effects
- Pruritis is a common side effect and is more severe in darkly skinned
individuals.
- Other rare side effects : 1) elevated liver enzymes
2) GI disturbances
3) convulsions, retinopathy and arrhythmias
Overdosages can be dangerous and can lead to death within hours.
Pt. may progress from feeling dizzy and drowsy with headache and gi upset to
sudden visual loss, convulsions, hypokalemia, hypotension and cardiac
arrhythmias

6. The most important side effect of Primaquine is hemolysis in G6PD deficient
Patients
Amount of hemolysis depends on dosage, duration of exposure and degree
of G6PD Deficiency
Primaquine is rapidly eliminated from the body. So hemolysis will stop once
the drug is stopped.
So Pt. being treated with Primaquine should be looked for anemia, red or black
urine and should be stopped immediately if present.
A single dose of 0.25mg/kg bw Primaquine as Gametocidal will not lead to
hemolysis even in G6PD deficient pt.
So it is not necessary to check G6PD status for single dose administration as
given in Falciparum malariae.

8. FALCIPARUM MALARIA

9. ACT should be given for 3 days.

14. 1) Hypersensitivity
reactions
2) GI Diturbances
3) Cough
4) Rash
5) Arthralgia
6) Delayed hemolysis

15. SEVERE FALCIPARUM
MALARIA

16. SEVERE MALARIA
Impaired consciousness
Prostration
Multiple convulsions
Acidosis
Hypoglycemia
Anemia
Jaundice
Pulmonary edema
Significant bleeding
Shock

18. ARTESUNATE > ARTEMETHER > QUININE irrespective of whether patient is
A infant or pregnant or a lactating female.
Mortality from untreated severe malaria is almost 100%.
With effective treatment mortality reduces to 10-20%
If a pt. presents with severe anemia , there are more chances of survival as
compared to acidosis
Therapeutic objective : is to prevent the patient from dying
Artesunate Dosage : 2.4mg/kg
Studies have shown that artesunate dosage between 1.5-4mg/kg dose is not
associated with any toxicity

21. Artesunate and Post Treatment Hemolysis
- Starts 7days after treatment with Artesunate
- Between 2010 and 2012, there were 6 reports involving a total of 19 European
travellers with severe malaria who were treated with artesunate injection
and developed delayed hemolysis. Out of 6 , 1 was adult
Artesunate rapidly kills ring stages parasites
Taken out of RBCs by Spleen
This infected RBCs have a shorter life span
Leads to hemolysis

22. ARTESUNATE ARTEMETHER QUININE
- Water soluble and can
be given Intavenously
- Oily solution
- Should be given only
I.M
I.V or I.M both are
equally effective
Rapidly converts into
Dihydroartemisnin, the
active form.
Converts slowly Loading dose : 20mg/kg
f/b
10mg/kg every 8hrly
Artesunate powder is
diluted with 5ml of 5%D
and given I.V or I.M
Only I.M / Oral If no improvement in
48hrs, dose reduced to
10mg/kg every 12hrly
2.4mg/kg bw / dose 3.2mg/kg stat
f/b
1.6mg/kg daily
Shouldn’t be infused
rapidly.
- Dilute in 5%D and
infuse over 4hrs ( not
>5mg/kg/hour)
Dose adjustment is not required for Artemisnin derivatives in Liver or Kidney
diseases.

23. FOLLOW ON TREATMENT
- 24hrs parenteral f/b complete ACT
- In ACT, Artemisnin + Mefloquine should be avoided in Pt. presenting with
unconsciousness or altered consciousness.
- If ACT not available : Artesunate/Quinine + Doxycycline(7d)
or
Artesunate/Quinine + Clindamycin(preferred in Pregnancy)

24. MANAGEMENT OF COMPLICATIONS OF
SEVERE FALCIPARUM MALARIA
Coma
Hypoglycemia
Convulsions
Hyperpyrexia
Pulmonary edema
Severe anemia
Acute kidney injury
Coagulopathy
Metabolic acidosis
shock

26. TREATMENT OF
SEVERE FALCIPARUM MALARIA
IN PREGNANCY
- Artesunate > artemether > quinine
- 2nd & 3rd trimester > 1st trimester
- Hypoglycemia and pulmonary edema
- Risk of mortality 50% more in pregnant > non pregnant
- Fetal demise and premature labor
- Teratogenic effects : decreases embryonic erythroblasts, cardiac myopathy
delay in limb and tail development

27. SEVERE VIVAX MALARIA
- Very rare
- Anemia, thrombocytopenia , acute pulmonary edema are common
TREATMENT
Parenteral Artesunate > Artemether > Quinine for 24hrs
f/b
ACT or Chloroquine

29. 1) There is no liver stage since parasite directly enters blood
2) Hypnozoites are not found
3) Hence there is no relapse
4) No need for Primaquine

30. 1) Infective form to man = Sporozoites present in salivary glands of
Mosquito
2) Infective form to man in case of
blood transfusion
3) Infective form to mosquito = Gametocytes
- To infect mosquito, Gametocyte must be mature, viable, count >12per cubic mm.
merozoites

31. P.Vivax P.Falciparu
m
P.Malariae P.Ovale
Relapse(Hypn
ozoites)
seen Not seen Not seen Seen
Recrudescene
ce
Not seen seen seen Not seen
Incubation
period
14days 12days 28days 17days
Erythrocytic
cycle
48hrs 48hrs 72hrs 48hrs

32. Recrudescence is due to persistence of drug resistant parasite.
In Falciparum : Disease appears after 2-3weeks of completion of treatment
In Malariae ; Disease appears very late almost after 60yrs.
-due to hypnozoites
-May reappear after2-3yrs
-Seen in P.vivax and ovale.

33. Species Disease Periodicity
P.Vivax Benign tertian 48hrs
P.Falciparum Malignant tertian 48hrs
P.Ovale Ovale tertian 48hrs
P.Malariae Quartian 72hrs
P.Knowlesi Quotidian 24hrs

34. Plasmodium spcies Type of RBC
P.Vivax Young RBCs
P.Falciparum RBCs of all age
P.Ovale Reticulocytes /Young RBCs
P.Malariae Old RBCs

35. Sickle cell trait Protective from P.falciparum
Thallasemia trait Protective from P.falciparum
Fetal Hb Protective from P.falciparum
G6PD deficiency Protective from P.falciparum
Ovalocytosis Protective from P.falciparum
Duffy negative RBCs Protective from P.vivax

36. -It is a parasite of monkey but can also affect humans
-Early trophozoite resembles to P.falciparum
-Late trophozoite resembles to P.malariae
-Quotidian malariae

37. P.Vivax P.Falciparu
m
P.Malariae P.ovale
Forms seen
in
peripheral
blood smear
Early and late
trophozoites,
gametocytes
and schizonts
Ring forms
(early
trophozoites)
and
gametocytes
Similar to that
of vivax
Ring forms are
known as
Band forms.
Similar to that
of vivax
Gametocye Spherical,
almost
occupies RBC
Banana
shape, larger
than RBC
Similar to that
of vivax
Similar to that
of vivax
RBC size Enlarged Normal Normal enlarged
Stippling Schuffner’s
dots ( small
red dots)
Maurer’s
cleft( large
red spots)
Ziemann’s
dots
James dots

40. Gameto
cytes

41. Thin smear = for species identification
Thick smear = for quantification

42. -pLDH and Aldolase = common to all plasmodium species
-HRP-2 Ag detection = specific for P.falciparum

43. -DR.AKIF A.B

44. -Most potent and fastest acting schizonticidal drugs
-But have short duration of action, hence cant be used singly and has to be
combined with slower acting drugs
- Acts by producing free radicals and toxic heme products
-Since they produce free radicals, free radicals have teratogenic effect. Hence C.I
in 1st trimester. Can be given in 2nd and 3rd trimester
-Oral drugs : Artesunate, Artemether, Dihydroartemisnin
-Only i.v drug : Artesunate
ARTEMISNISNIN GROUP DRUGS

45. -I.V Artesunate is DOC in severe falciparum malaria
-Oral artesunate 200mg for 3 days is preferred in Chloroquine resistant malaria
-Not used for prophylaxis since it has short duration of action
-S/E:
GI side effects: Nausea, vomiting, Diarrehea
ARTEMISNISNIN GROUP DRUGS

46. -Enters vacuole of plasmodium and binds with haem and produces toxic heme
products which is cidal for plasmodium
-Resistance is due to efflux of drug from vacuole
-DOC for treatment and prophylaxis of malaria except falciparum
-It has high volume of distribution and hence loading dose has to be given.
-Other uses : Giardiasis
Amebiasis,
Infectious mononucleosis,
SLE,
RA
CHLOROQUINE

47. S/E:
C - Convulsions
H - Hemolysis in G6PD deficient pt.
L - Low blood pressure
O -Ocular : Bull’s eye maculopathy
R - qRs and T wave abnormalities
CHLOROQUINE

48. •Fast acting schizonticidal drugs
•Used in severe falciparum malaria and chloroquine resistant malaria
•Derived from bark of cinchona plant
QUININE and QUINIDINE

49. •Cinchonism : headache + tinnitus +Visual disturbance
•Hypotension : Due to Alpha-1 blocking effect
•Hypoglycemia : Due to insulin release. Hence given with
dextrose
•Black water fever : Inadequate therapy leads to
hypersensitivity
QUININE and QUINIDINE
S/E

50. •Used in treatment and prophylaxis of vivax
•Used along with artesunate in severe falciparum malaria
•S/E : Neuropsychiatric
MEFLOQUINE

51. •Hemolysis in G6PD deficiency
•Methemoglobinemia
•Anemia
• Leukocytosis
PRIMAQUINE S/E

52. •Pregnancy
•Lactation
• Infants
PRIMAQUINE C.I