Management of Childhood Malaria Flashcards by Iseoluwa Ojo

Malaria is a clinical entity following the __________ of ______________ by species of ______________.

invasion of red blood cells

Plasmodia.

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P. falciparum (——-% of infection, approx. ______% of mortality)

P. _________
P. _________
P. _________
P. _________ (South East Asia)

It is transmitted by the _________ ___________ mosquito.

95% ; 100%
P. malariae
P. ovale
P. vivax
P. knowlesi (South East Asia)
female Anopheles mosquito.

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Majority of the cases (88%), deaths (90%) and reduction in malaria-deaths occur in _____________

It is a common cause of morbidity and mortality in children in _______

sub-Saharan Africa

Africa

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Endemicity
Amount of malaria in a community or region
1.Based on use of _________ and __________ rates children 2-9years
2. Based on ___________ rates

spleen and parasite

transmission

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spleen

Hypoendemicity :parasite and splenic rate _______%
Mesoendemicity :parasite and splenic rate _______%
Hyperendemicity :parasite and splenic rate persistently >_____%

adult spleen rate >_____ %

Holoendemicity :parasite and splenic rate persistently >_____%

adult spleen rate >_____% with low adult spleen rate

0- 10

11- 50

50; 75

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Transmission rates
High transmission stable >___ case per 1000 population
all year round, seasonal variation
Partial immunity in older children/adult likely to have severe malaria
Low transmission <___ case /1000 population, intermittent transmission
annual biannual or variable . Immunity is _____

low

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Severe disease and death occur in children less than _______

Parasitemia and symptomatic in _______ age

Decreasing parasite density prevalence and acquisition of immunity in older groups

5 years

School

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Cell mediated immunity and humoral immunity
Presence of Hb ———- , ———- deficiency
Hb ———- ,Hb ———-, ———- genotype

All reduce ability of parasite to to penetrate red cell reduce severity of acute and chronic malaria

Hb S , G6PD deficiency

HbF ,HbE thalassemia , Duffy -negative genotype

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Pathogenesis of malaria
Infected red cells exhibit ________ on their surfaces that allow them to ____________________ and also to the ________ of small vessels such as arterioles, venules and capillaries

Also infected red cells are less ________

Both features promote ________ of infection red cells in deep vessels and subsequent _______________

__________________ and impaired ________ are the hallmarks of severe malaria. Little ________ is known to occur

Infected red cells rupture releasing both ________ and ________ which activates monocytes and macrophages causing the release of pro-inflammatory cytokines

knobs ;adhere to one another

endothelial wall ;deformable

sequestration ;vascular occlusion

Microvascular obstruction ; perfusion

inflammation ;parasite

host cells metabolites

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Economics of malaria
It has been estimated that the direct and indirect costs of malaria is more than ___________ per year.

Malaria-afflicted families are able to harvest only _____% of their crops compared to healthy families.

Malaria slows economic growth in African countries by about _____% every year.
Clearly malaria is closely linked to poverty.

$2 billion

40; 1.3

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Malaria and Children
Malaria affects children in the following ways:
■Causes __________ and ______________ among babies born to women living in endemic regions.
■Congenital Malaria (____% in Lagos and ____% Ife)
■Anaemia leading to _____________ function (poor school performance).
■____________ (from recurrent illnesses).

prematurity and low birth weight

15;47

poor cognitive

Poor growth

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Risk factors for malaria in Nigeria (High Transmission area)
Young children
▪ ___________ visitors
▪ Children with ________
__________ or __________

Non-immune

HIV/AIDS

Asplenia or hyposplenism

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Two forms of clinical Presentation

_____________________ malaria

_______________________ malaria

Acute uncomplicated

Severe (complicated)

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Uncomplicated malaria

Symptoms

Fever (often ________ grade and __________ )
__________
Malaise
__________
Anorexia
________ or ________
________ pain
Diarrhoea

high; intermittent

Vomiting; Headaches

Myalgia or Arthralgia

Abdominal

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In most cases the physical examination reveals no significant finding.
Fever
_______
_____________ megaly
No localising signs
Lymphadenopathy is ____________

pallor

Hepato or Spleno

NOT a feature

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Severe (Complicated) Malaria
•_____________ manifestation (clinical or laboratory)
• Presence of ________ form of P. _________ or ________
• Exclusion of other causes
• Evidence of _____________________ is the hallmark of severe malaria

Life threatening

asexual

falciparum or vivax

vital organ dysfunction

Forms of Severe Malaria
__________ Malaria
__________ (generalized weakness so that the child is unable to sit, stand or walk unaided)
Pulmonary __________ & __________
Multiple __________ (> _____ episodes within 24hr)
Severe __________

Cerebral
Prostration
Pulmonary oedema
Respiratory Distress Syndrome
Convulsions ; 2
anaemia

Forms of Severe Malaria

Shock (systolic BP<______mmHG)
______________ injury
Abnormal ______________
Hyper ______________
______________ nuria
Hyper ______________

50mmHG
Acute kidney
bleeding
Hyperbilirubinaemia
Haemoglobinuria
Hyperpyrexia

Forms of Severe Malaria

_______glycaemia (serum glucose <____mmol/L)
Metabolic _________ (serum HCO3- <15mmol/L )
Hyper__________ (serum lactate >5mmol/L) Hyper___________

Hypoglycaemia (serum glucose <2.2mmol/L)
Metabolic acidosis (serum HCO3- <15mmol/L )
Hyperlactaemia (serum lactate >5mmol/L)
Hyperparasitaemia

Severe Malaria: Cerebral Malaria Fever
Loss of consciousness > ____________ or altered sensorium
_____ CSF abnormality
No other cause of ______________
Commonest cause of malaria deaths
Other features of severe malaria such as severe anaemia and metabolic acidosis are commonly co- existing in the same child

30 minutes

No CSF abnormality
encephalopathy

Pathogenesis of cerebral malaria

__________ of __________ in the brain by _____________ and ____________

Cerebral oedema is (common or rare?) in children

Occlusion

small vessels

parasitized and non-parasitized red cells

Common

Blantyre coma scale

Eye:

_______
_________

Directed
Not directed

Blantyre coma scale

Verbal:

________
________
__________

Appropriate cry
Moan or inappropriate cry
None

Blantyre coma scale

Motor :

Localizes painful stimuli
Withdrawal from pain
Nonspecific or absent response

Severe Malaria: Severe Anaemia Fever Pallor (PCV <_____%) with or without evidence of decompensation No evidence of other causes

Pathogenesis of severe Anaemia _______________________ of parasitized and non-parasitized red cells ________ of parasitized red cells during schizogony ___________ erythropoiesis ___________. partly as a result of thrombocytopaenia and coagulation defects NB: the diagnosis of malaria should be queried in the absence of thrombocytopaenia

Acute splenic removal Rupture; Ineffective Mild bleeding

Diagnosis Diagnosis can be difficult. “Gold standard” is ____________ and finding ____________ in thick and thin blood film Rapid Diagnostic Tests: based on detection of •_________________ (specific for _________): as good as microscopy •_______________: for _________ and __________ •__________: less sensitive Non rapid non-microscopic based tests: counter- immunoelectrophoresis, polymerase chain reaction

blood microscopy asexual parasitaemia Histidine rich protein ; falciparum Lactate dehydrogenase ; falciparum and vivax Aldolase

Other Investigations ________ with _______ __________ Electrolytes ,Urea & creatinine Blood PH and gases Blood glucose Lumbar Puncture (where necessary)

Full Blood Count with ESR Hb genotype

Treatment of Uncomplicated malaria Goals: cure, prevention of severe forms and drug resistance ________________________ is the recommended treatment It is the simultaneous use of at least _____ drugs with different modes of action; which are still effective as monotherapy; and one of which must be _______________.

Artemisinin-combination therapy (ACT) 2; an artemisinin derivatives

For Nigeria examples of ACT include: • ____________ -____________ • ____________-____________ • ____________-____________ • Dihydroartemisinin-Piperaquine

For Nigeria examples of ACT include: • Artemisinin-Lumefantrine • Artesunate-amodiaquine • Artesunate-mefloquine • Dihydroartemisinin-Piperaquine

Initial management of severe malaria (cerebral malaria) Clear and maintain _______ Position _________ or on the side Weigh patient and calculate dosage Make rapid clinical assessment Start ______ chemotherapy: start with parenteral _______therapy and once child is able to take, complete a course of _______ Exclude or treat _________________ Assess state of hydration Measure and monitor urine output

airway semi-prone; antimalarial mono; ACT hypoglycaemia

Initial management of severe malaria 2 Take _______ for diagnostic smear (serially), monitor blood sugar, PCV and other laboratory tests Plan first ________ of fluids (diluents of drugs, glucose and Blood transfusions) Antipyretics if core temperature exceeds _____oC _____________ to exclude meningitis. Consider other infections. Anticonvulsants and other drugs as indicated

blood 8 hours 39; Lumbar puncture

Treatment of Severe Malaria (The goal is prevention of _______) The 3 recommended options are ___________,_____________, and ______________ (in decreasing order of preference) artesunate 2.4 mg/kg ___ or ____ given on admission (time = 0), then at 12 h and 24 h, then once a day; (In children weighing less <20 kg, —— mg/kg should be used instead) artemether 3.2 mg/kg ____\ given on admission then 1.6 mg/kg. It should only be used if none of the alternatives are available as its _________ may be erratic. quinine 20 mg salt/kg in on admission (———infusion) then 10 mg/kg every 8 h(The quinine should be added to 10ml/kg of isotonic solution and run over 2-4 hours)

death ARTESUNATE, ARTHEMETHER & QUININE IV or IM;3 IM; absorption IV

Malaria and Children: Control • _____________ net • Regular indoor spraying of ———— • Clearing of _______ in the neighbourhood • Removal of __________ in the neighbourhoods • Intermittent preventative treatment of young children

Insecticide-treated insecticides; bushes water puddles

A vaccine with ~____% efficacy was licensed for use in children in 2015!

____________ and ___________ resistance is widespread rendering these medications ineffective ____________ is the most effective antimalarial for severe malaria

Chloroquine and sulphadoxine-pyrimethamine Artesunate