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Anwar Wardy

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Malaria Threatens

40% world population

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From Near Extinsion in 1976

India contributes 85% of casesin South East Asia1st clinical description HippocratesElaborated CelsusPeruvian Bark in therapy 17th CenturyQuinine 1820Man to Mosquito Cycle Sir Ronald Ross 1998-99

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Definition Complication of

plasmodium

falciparum Unarousable

coma more than30 mts

Exclusion of othercauses

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Aetio Pathogenesis

Sequestration ofCerebral Capillaries

and Venules

Ring like lesions in the Brain

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Mechanical Hypothesis

P. falciparum parasites in brain capillary

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Section of brain showing blood vessels

blocked with developing

P. falciparum parasites

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Selective Cytoadherance results in rosetting

Reduction of Microvascular Blood flow

Hypoxia

Dose not explain selective absence of Neurological Deficits

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Humoral Hypothesis

Malaria Toxin

Stimulates Production of TNF- alpha &Cytokines

Stimulate Endothelial cells

Uncontrolled production of NO COMA

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c

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CLINICAL MANIFASTATIONS

The seasonal Trend

0

1

3

4

7

6

12

13

17

11

17

11

0

1

2

3

4

5

6

7

8

9

10

11

1213

14

15

16

17

Jan Fe b Mar Apr May June July Aug Sept Oct Nov Dec

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Earliest Manifestations - Fever

Loss of Appetite

Vomiting Cough

Specific for Cerebral Malaria

Impaired consiousness Gen. Convulsion with Sequelae

Coma

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Coma Scale for ChildrenBest Motor response Localizes painful stimulus 2

Withdraws limb from pain 1

Non-specific or Absent

response 0

Verbal Response Appropriate Cry 2Moan or Inappropriate cry 1

None 0

Eye Movements Directed 1

(e.g. follows mothers face)Not directed 0

Total 0-5

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Associated Presentation

Hypoglycaemia

Metabolic Acidosis

Shock Neurological

deficits

Other forms canCo-exist

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LABORATORY

DIAGNOSIS

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Diagnosis of Falciparum Malaria

Conventional Microscopy

Giemsa Stain

Field Stain

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Stages of P. falciparum

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LABORATORY DIAGNOSIS

Contd. Fluorescence Microscopy (QBC)

Nucleic Acid Staining with acridine

Parasite Count = (TLC / Cuml X Parasite /100 WBC) / 100 = Parasite / Cuml of Blood

Serology

Anti body detection

Antigen detection (HRP) Biochemical Test - Optimal test (Parasite

LDH)

PCR & Culture

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CEREBRAL

INVOLVEMENT

Clinical

CSF - Increased Lactic Acid

CT, MRI

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THOUGHTS AT BEDSIDE

Haemoglobin

Urobilinogen

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THERAPEUTIC OPTIONS

CHEMOTHERAPY

QuinineArtemisinins - Artesunate

- Arte- ether - Arte - mether

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SUPPORITIVE &

ADJUNCTIVE THERAPY Nursing Care Catherization Nasogastric tube

Fluid & Electrolyte Monitor level of coma & vital signs Antipyretics Anticonvulsants

Reduction in ICT Correction of Hypoglycaemia Exchange Transfusion IncreaseMicrocirculatory Flow - Pentoxyfylline Desferrioxamine Correction of - Anaemia, Acidosis,

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NEWER HORIZON

Inhibition of Endothelial Activity - LMP 420 - Decrease of TNF alpha& LT activity

Vaccine Development

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