Travel Related OI Flashcards
Most serious species of malarial infection?
Plasmodium falciparum
Who is at highest risk of malarial infection in UK?
Those of African and south Asian ethnicity
‘Visiting family from country of origin’
Presentation of malaria?
Fever, headache, arthralgia, myalgia, diarrhoea, sometimes features of bacterial infection
Complications of malaria?
Hyperparasitaemia, acute renal failure, hypoglycaemia, DIC, lactic acidosis, fulminant hepatic failure, cerebral malaria
Affect of malaria in pregnancy?
Anaemia, infants with LBW, prematurity and infant mortality due to Malarial parasites preferentially binding to placenta
When to consider malaria diagnosis?
Anyone with fever returning from endemic area - usually present within 3/12
How to diagnose malaria?
Thick and thin blood film
Thick - diagnose and estimate percentage of parasitaemia
Thin - for speciation
Highly sensitive and specific dipsticks also available
How is treatment for malaria chosen?
Species and severity of infection
Amodiaquine CANNOT be given with efavirenz
Treatment of uncomplicated falciparum malaria?
Oral artemether-lumefantrine (co-artem)
If weight >35kg four tablets at 0, 8, 24, 36, 48 and 60h
Alternatives - oral quinine (reacts with ritonavir so hold PI while on) for 7/7 plus doxy for 7:7
Or malarone (atovaquone proguanil) four tablets daily for 3/7
What constitutes severe falciparum malaria?
Shock, renal impairment, acidosis, pulmonary oedema, ARDS, impaired consciousness or seizures, hypoglycaemia, very low Hb (<5), haemaglobinuria, DIC
When is parenteral regime for malaria treatment used?
Severe/complicated falciparum malaria or parasitaemia >2
Parenteral treatment for falciparum malaria
IV artesunate 2.4mg/kg daily (0,12,24hr then daily 7/7) with doxycycline 20mg OD
IV quinine an alternative option with cardiac monitoring and regular glucose monitoring
What is risky about quinine?
Prologs QRS and QT intervals and can induce hypoglycaemia
What is the treatment for non-falciparum malaria?
3 days oral chloroquine (600mg stat, 300mg after 6-8hrs then 300mg daily for 2/7) followed by 14/7 primaquine to eradicate liver stages
Primaquine not needed if p.malariae
Test for G6PD and lower primaquine dose for longer if positive
Who should receive malaria prophylaxis?
All HIV+ travellers to endemic areas as they are at higher risk of severe illness
What is the ABCD of malaria prevention?
Advice for all travellers to endemic areas
Awareness of risk
Bite prevention
Chemoprophylaxis
Prompt Diagnosis and treatment
Also recommend >20% DEET, covering up, permethrin coated mosquito nets
What chemoprophylaxis is given against malaria?
Depends where you are going, for how long, national travel health network and centre can give specialist advice
Cotrimoxazole can help but patients on this should still receive standard prophylaxis
Main options - mefloquine 250mg once weekly, malarone (atovaquone proguanil) OD, doxycycline 100mg OD
Start one week prior to travel and continue 4 weeks on return
Malarone 1-2 days before travel and continue 1 week after return
Mefloquine 3-4 weeks prior to travel in case need to switch due to neuropsychiatric side effects
What are the three types of disease caused by leishmania?
- Visceral (kala azar) - systemic features fever, weight loss, helatosplenomegaly, with or without bone marrow involvement
- Mucocutaneous - destructive lesions of mucous membranes of nose or mouth
- Cutaneous - skin ulcers on limbs and face
How does cutaneous leishmaniasis present?
Papule that progresses to chronic ulcer
How is visceral leishmaniasis diagnosed?
Parasitological diagnosis may be made by microscopy, culture or PCR from-
Splenic aspirate (high sensitivity but only by practitioner trained in this technique)
Bone marrow aspirate
Biopsy specimens such as LN or skin
Histology - liver, bone marrow, LN, skin
Serological - direct agglutination, ELISA to detect antibodies to recombinant k39 antigen
How is cutaneous leishmaniasis diagnosed?
Parasitological or histological diagnosis - preferably both - may be made from skin biopsy
Raised edge of ulcer where parasites are present
Treatment of visceral leishmaniasis?
Coordinate with local tropical medicine service
Ambisome 4mg/kg for 10 doses given on days 1-5, 10, 17, 24, 31 and 38
What is the secondary prophylaxis for visceral leishmaniasis?
Pentamidine 4mg/kg every 2 weeks IV or
Ambisome iv 5mg/kg every 3 weeks
Few data of when to stop
Some authors recommend stopping if stable on ARVs and CD4 >200-350 for 3-6 months
Treatment of cutaneous leishmaniasis?
Depending on species
Discussed with tropical diseases team
Local infiltration of sodium stibogluconate - limited experience of this in HIV+ individuals
Systemic treatment