Malaria:
It is the commonest parasitic infection
Live cycle:sporozites occur in the salivary glands of mosquitoafter a mosquito takes a blood meal
these sporozites injected in the blood and go to the liver then emerge in the bloodstream as
merozoites these merozoites enter RBCsthen RBCs ruptured and give gametocytesthese
gametocytes are taken by mosquito in a blood meal then go to the salivary glands of
mosquito and change into sporozites.
The whole pathology occurs within the RBCs.
Pathophysiology:-the whole pathophysiology takes place within the RBCs.
-When the malaria parasite enter the RBCs:1. It reacts with HB & the component of RBCs & releases cytokines which produces TNF
which is responsible of fever… (Cytokines also increases the capillary permeability).
2. It lead to release of cytoadherent which change the RBCs into knobs.
)‫)تبقى زي الصمغ وتلصق مع بعض‬
Cytoadherent attack the normal and abnormal RBCsclump together.
3. Rouset formation: It's due to clumping of infected RBCs (RBCs gather and make lines) these RBCs can
obstruct blood vessels.
This rouset formation is responsible for cerebral malaria & pulmonary edema (also
may be due to increased capillary permeability caused by cytokines).
Presentation:A. Muscles:Myalgia (muscle pain) malaria parasite causes damage of the muscles lead to
release of CDK (creatinine phosphokinase) lead to myalgia.
B. Lungs:Pulmonary edema  edema due to increased capillary permeability.
C. Kidney:Renal failure malaria lead to tubular necrosis & damage the glomeruli (so malaria
doesn’t cause HTN)
D. GIT:(Can cause everything in GIT)
1.
Abdominal pain.
2.
Vomiting & diarrhea.
3.
Malabsorption.
4.
Hypoglycemia
Prevent sugar absorption
Stimulate pancreas to release insulin
E. Brain: Brain edema
 Cerebral malaria "unknown mechanism"
F. Orthostatic hypertension:Pt can't maintain his normal bp when standing up which lead to dizziness &
syncope.
G. Severe metabolic acidosis:lactic acidosis.
1.
2.
3.
4.
*Laboratory indicators of severity of malaria (indicate poor\bad prognosis):
Low blood sugar
Increased cpk
Lactic acidosis
Low HB
 Diagnosis:1. Blood film:-by seeing Trophozoites inside the RBCs (ring stage)blue
Chromatinpink
-it’s the definitive diagnostic tools
-Advantages of BF: Cheap.
 Tell you about response to treatment.
 Tell about the degree of parasitaemia.
-Disadvantages of BF: The minimal number of …. That should be seen to diagnose malaria is
200 …….
 need honest technician .
1 cross (+) in BF = in every 100 film10 parasites
2 crosses (++) you see from 10-100 parasites
BF also show you the type parasite:-P.falciparum 90% of cases
-P.vivax10-12% of cases
-P.malariaenone in Sudan
-P.ovale none
2. ICT



Rapid test .
Tell you if there is malaria or not but doesn’t tell the degree of
parasitemia.
Contain antibodies for Vivax & Falciparum  tells you which one is
positive but doesn’t tell the degree of parasitemia.
Malaria is divided clinically into:1. Simple malaria
2. Complicated malaria
Simple malaria:Its characterized by:1. Fever : the most important feature & sometimes simple malaria is called malaria fever.
2. Headache.
3. Convulsion (febrile convulsion).
4. Malaise.
5. Aches & pain.
6. Diarrhea & vomiting.
7. Coughs.
Complicated malaria: Severe complicated malaria is a medical emergency, and if the patient not treated
properly ,the patient will die in few hours.
 Criteria of complicated malaria :1. Cerebral malaria Repeated convulsion & coma.
2. Hyperpyrexia :temp>41
3. Hypoglycemia
It’s a serious complication
It's more common in children & pregnant women
4. Pulmonary edema .
5. Renal failure.
6. Hypotension. Can't be treated unless you treat malaria
doesn’t respond to fluids & if you give the patient large amount if
fluidsincreased risk of fluid overload P.edema.
7. Acidosis.
8. Severe anemia
Sudden & very low HB.
9. DIC
10. Jaundice (more in adult).
11. Hyperparasitemia
………………………………………………….
 If you find one or more this is complicated malaria.
 The commonest presentation of complicated malaria
1. Cerebral malaria (coma).
2. Anemia HF.
3. Hypoglycemia
4. Hyperpyrexia associated with
hyperparasitemia.
Investigation for complicated malaria:
1. CBC for anemia
2. Urea & electrolytes for RF
3. Chest X-ray for
pulmonary edema
to exclude severe pneumonia :because its DD for malaria
4. RBG for hypoglycemia
5. ABG for acidosis
6. Urine general
7. Lumbar puncture if you suspect meningitis as DD for convulsion and fever.
Treatment of malaria:1. First you have to diagnose malaria
2. Classify it simple or complicated(both are dangerous because simple malaria can
change to complicated within few hours)
3. Give medication according to the national protocol:
first line: coartem
second line: DHAP
third line: quinine\artesunate (iv\im)
*Coartem= artemether + lumefantrine
*DHAP= dihydroartemesinin+piperaquine
For simple malaria start with the first linecoartem
If no response give DHAP
Also yet no response give quinine or artesunate
For complicated start with the third line: either quinine or artesunate iv\im
Coartem
6doses
Given at……….,then after 8 hours then after 12 hours
Artesunate
: ‫ فتايل‬3 ‫يجي في شكل‬
Powder, NaHCO3, NS
powder has 3 concentrations:
30, 60,120mg
)‫ازرق‬,‫اصفر‬,‫)اخضر‬
Dose
Weight ≤20kg3mg\kg
Weight>20kg2.4mg\kg
How do you give it?
1. You dissolve the powder in NaHCO3 (pour NaHCO3 in the powder till it become crystal
clear & don’t start with NS because powder doesn’t dissolve in it)
2. Then add NS
this dose should be given within 30 minutes ,because after 30 minute it becomes unstable.
give it IV (preferred) but you can give it IM (we don’t prefer im )
SE: no SE unless you give a large dose (eg.80\kg)this causes severe hemolysis.
how many doses? 3doses
When do you give it?
At….time then after 12 hours & then after 24 hours
if you come after 24 hours & you find the pt has improved clinically (no symptoms)
&laboratory (-ve BF) you have to give him coartem before discharge (take the pills home)
if you come after 24 hours & you find that the pt is febrile & not improved , what shall you
do?
Give him another dose of artesunate , yet not improved  give another dose  till you reach
7 doses & don’t give more than 7 doses. (Dx may be wrong ). (max is 7 doses).
Quinine:You can give quinine but recommended is artesunate iv
dose : 10mg\kg\dose
Dissolve it in D5%
1mg in 1ml of d5% to avoid hypoglycemia (e.g.mg200in200ml)
Give it slowly within 3hours
3doses\day: every 8hours.
you can give quinine im (deep im 60 mg in 1ml NS or d5%)
Duration of Rx:
3doses \day usually for 48 hours (pt usually improve after 48 hours ,no symptoms) & then the
pt can tolerate quinine tablets  so give him the same dose 8 hourly tabs for another 7
daystotal duration quinine is 9days at least .
SE:
1. HYPOGLYCEMIA
2. Arrhythmia
3. Hypotension
‫تسبب الموت لوالدرب مشى سرعة‬123
4. Tinnitus\deafness
5. Blindness
Malaria vivax:
‫الحمى الحبشية‬
account for 12% OF malaria parasite cases.
cause malaria parasite resistant .
also can cause :
1.
2.
3.
4.
Hyperparasitemia + fever
Thrombocytopenia
Coma
Relapsing fever characteristic for vivax because merozoites of vivax can stay in the liver
for 70 years.
So once you treated vivax you have to eradicate merozoites from the liver by giving
primaquine daily at least for 2-3 weeks otherwise you get relapsing fever
p.malariae can cause nephrotic syndrome.
)‫)غرب أفريقيا‬
if the pt is splectomized give fansider +artesunate as prophylaxis
in simple malaria ,quinine is contraindicated, you have to follow the protocol.
if you give the pt quinine & after 3 days three days there is no improving it is most likely
other diagnosis or quinine resistant
‫ما عندنا في السودان‬
Other DD for malaria
1. Typhoid fever
2. Severe pneumonia
3. Brucellosis
4. meningitis
5. Hepatitis
6. Kalazar
7. Leukemia
Congenital malaria:
1.
2.
3.
4.
5.
Neonates presented with criteria:Fever
Jaundice
Anemia
Splenomegaly
+ve BFFM
Treatment :
Quinine im 10mg \kg for 5-6days PD.
Give sugar through NG tube because these are very sensitive to low blood sugar.
prognosis :is very good
Malaria with –ve BFFM:-don’t allow pt in Sudan die with fever unless you give antimalarial drugs because it's an
endemic area
‫في غانا في ناس ماتوا وبعد الوفاة لقوا ادمغتهم مالنه طفيليات بالرغم من ان التحاليل كانت سلبية‬
Prognosis of cerebral malaria is good & we rarely lose pt due to cerebral malaria.
Quinine IM
Deep IM
Instead of 1mg in 1ml of d5% when you give quinine IVhere 60 mg in 1ml of NS or
d5% due to absorption is less.