Nonspecific - flulike illness - HA - fatigue - diarrhea - fever - malaise - muscle aches PT is very ill

17 - Malaria Flashcards by michael english

Definition of malaria?

Infectious disease characterized by:

chills
Fever
sweating

Caused by protozoa of the genus plasmodium in the RBC
Transmitted by female anopheles mosquito

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Malaria is found?

90% is africa

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Most malaria deaths are caused by?

P. Falciparum - sub saharan africa

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Who dies the most from P. Falciparum?

Kids under 5

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Types of malaria?

Plasmodium falciparum
- tropics/subtropics
Plasmodium vivax
- widespread
Plasmodium ovale
- W. Africa
Plasmodium malariae
- tropics/subtropics

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Phases of malaria?

Infection
Liver phase
- Sporozites migrate to hepatocytes 
Erythrocyte phase
- infects the erythrocytes
- erythrocytes rupture and spread disease

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A small % of the malaria parasite:

Turn into gametocytes

sexual reproduction
get picked up by mosquito

“Its the circle, the circle of life”

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Malaria relapse?

P. Vivax and P. Ovale have relapses
- they have a hypnozite stage that can stay in the liver and come back

P. Malariae doesnt have a hypnozite stage
- can still live in the RBC for years

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Malaria incubation phase?

Vary by species

P. Falciparum: 12 days
P. Vivax: 14 days
P. Ovale: 17 days
P. Malariae: 28 days

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Periodicity or paroxysm of fever?

48hrs:

p. Falciparum
p. Vivax
p. Ovale

72hrs
- p. Malariae

Fever is not a reliable clue to diagnosis

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Febrile stages of malaria pics?

Slide 15

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S/s of malaria?

Nonspecific

flulike illness
HA
fatigue
diarrhea
fever
malaise
muscle aches

PT is very ill

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Asymptomatic malaria?

If pts are immune or partially immune (non-sterile) they will be asymptomatic or only have mild anemia

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Most severe malaria?

P. Falciparum

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What makes p. Falciparum so bad?

It is a microvascular sequestration/disease

It targets all RBCs
- others only target the reticulocytes

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P. Falciparum causes?

Severe anemia

rapid development in the non-immune population
HCT decreases by 8-10% in 48hrs

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Sever manifestations of malaria of malaria?

Cerebral malaria
- coma

Sever anemia
- P. Falciparum infection

Renal failure

Pulmonary edema

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Why does malaria cause renal failure?

RBCs adhere to the renal microvasculature

Oliguric renal failure

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Which malaria causes nephrotic syndrome?

Chronic P. Malariae

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Pregnancy and malaria?

Like oil and water…

Increased risk of morbidity and mortality

low birth rate
fetal loss
prematurity

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Vivax and ovale can cause this late complication after 2-3 months?

Spleinic rupture

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Ddx for malaria?

Anemia
Babesiosis
Dengue fever

Non-diagnostic malaria labs?

Hemolysis 
- Anemia
- Increased lactic acid
- Decreased haptoglobin
- Thrombocytopenia 
NO eosinophilia
Acute renal failure
- proteinuria
- elevated serum Cr
- hemoglobinuria 
Bilirubinemia
- hemolysis 
Hypoglycemia

Warning signs of a poor prognosis?

Biochemical

Renal imparment (Cr>3)
Acidosis (bicarb <15)
Jaundice (bili >2.5)
Hyperlactemia (lactate >5)
Hypoglycemia (<40)
aminotranserase (>3x normal)

Hematologic
- parasitemia - >5% neutrophils contain malaria pigment

Diagnostic labs for malaria?

Thick and thin smears - 3 smears 12-24hrs apart - Thick smears 20x more sensitive - Thin smears - specification is easier Parasitemia = number of parasites/1000RBC

What is the best time (highest yield) time to get the thick and thin smears?

Soon after the fever spike

How are thick and thin smears collected?

Some lab guy just smears your bloody finger on a slide and then looks at it - one heavy drop - one smeared spot

Alternate diagnostic tests?

Rapid dipstick test - detects bi-product (LDH) of parasite - specific to P. Falciparum DNA, PCR, etc (W p. Falciparum they may be dead before it comes back)

Rapid malaria test?

BinaxNOW - p. Falciparum 95% sens 94% specific - P. Vivax: 69% sens 100% specific Confirm w thick/thin smears

BinaxNOW cannot be used for?

Monitoring therapy response, it cant detect non-viable organisms

Malaria prevention?

Dont go to africa Barring that: - wear your ppe - mosquito repellant (30-35% deet) - permethrin impregnated - pants

Malaria vaccine?

Some in the works but nothing yet

Malaria prevention drugs?

``` Chloroquine - q wk - CNS side effects Mefloquine - q wk $ - CNS side effects Doxycycline - qd Atovaquone/proguanil - qd $$ Primaquine - qd ```

Starting and stopping malaria drugs?

1-2 wk before and 4 wk after - Chloroquine, mefloquine, doxy 1-2 wk before 7 after - atovaquone/proguanil 14 days after (shorter run up too i think) - primaquine

Why doesnt malaria prophylaxis work?

People dont take it, only - 60% of service members surveyed were compliant her: “My head still hurts” Him: “did you take the tylenol i gave you?” Her: “NO” Him: “Hmm”

How can you eradicate persisten hypnozoites?

During the liver stage of P. Vivax or P. Ovale you can take | - primaquine phosphate

With primaquine phosphate you need to monitor?

G-6-PD status

PART?

Presumptive anti-relapse tx - primaquine to prevent relaps from hypnozites w P. Vivax Again noncompliance was an issue (only 1 in 5 did it)

Indications for malaria tx?

``` Determine species - must treat falciparum Magnitude of parasitemia Impaired consciousness Renal failure Pulmonary edema Antimalarial resistance ```

Malaria pts must be protected from?

Further bites in malaria endemic environment

Tx for uncomplicated malaria?

Prophylaxis drug - different dose than prophylaxis

Chloroquine sensitive malaria?

Give them chloroquine (aralen) PO

Chloroquine resistant malaria?

PO: - coratem (artethemer and lumefantrine) - malarone (atovaquone+proguanil) Quinine sulfate + doxy

How is P. Falciparum treated?

Quinidine gluconate IV + Doxy or clinda

Where do you get the meds for p. Falciparum?

Eli lilly stoped making quinidine gluconate IV Artesunate is available through the CDC

Treatment monitoring?

Thick and thin blood smears q 6-12 hrs until parasitemia falls below 1% If its not falling its not working If it doesnt fall by 75% in 48hrs or not gone by 7 days your tx isnt working, change it up

___ makes malaria worse?

Steroids

Things to monitor/manage during malaria tx?

Control glucose Monitor - acidosis - pulmonary - renal failure - seizures - edema

CDC no longer recommends?

Exchange transfusions

Reoccurrence

Relapse - hypnozoite (p. Vivax and p. Ovale) Recrudescence - incomplete tx Reinfection - Most commonly p. Falciparum Low level infection - p. Malariae - below detectable levels

Sickle cell and malaria?

SCD is not a protective factor | - malaria is one of the top precipitating factors of a sickle cell crisis

Malaria is not a US problem right?

Nope: 2000 cases in 2011 A lot of it was brought back by service members (not the coast guard) (slide 52)

Malaria meme?

Really not any good ones | - sorry i tried