Transcript N=234 Malaria Swati Y Bhave Imm Past President IAP N=234 Indian Scenario Malaria cases in millions 64 1954 Malaria eradication programme initiated 1 1961-70 1971-80 1981-90 1991-2000

N=234
Malaria
Swati Y Bhave
Imm Past President IAP
N=234
Indian Scenario
Malaria cases in millions
7
6
5
4
3
1954 Malaria
eradication
programme
initiated
2
1
0
1961-70
1971-80
1981-90
1991-2000
N=234
Indian Scenario
Delhi, Bombay, Madras,
Calcutta, Ahmedabad,
Bhopal, Baroda, Hyderabad,
Jaipur, Lucknow, &
Bangalore
80% of malaria cases
in the country
(11 major cities)
New Delhi
Hyderabad
N=234
MATERIAL & METHODS
• Between 1994 - 1998 hospitalized 234 cases
of malaria in Bombay Hospital & MRC
• Divided in the age group of < 1 yr, 1-5 yrs, 612 yrs and 13-17 yrs.
• Complete clinical examination & Laboratory
parameters
• Analysis of drug resistance
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
SMEAR POSITIVITY
AGE & SEX
DISTRIBUTION
39.31
72.23
32.05
Smear -ve
26.49
Vivax
31.62
20.94
8.11
< 1yr
6-12 yrs
1-5 yrs
13-17 yrs
27.77
MALE
FEMALE
8.11
Mixed
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
41.45
Falciparum
N=234
Clinical signs & symptoms of
Malaria
Classical: Fever with chills,
Anemia, Hepatospleenomegaly,
Multisystem involvement
Varied manifestations
Hematological, GI, Renal, Resp,CNS
General symptoms:
Malaise, headache,bodyache,
anorexia, failure to thrive,weight loss
N=234
Presenting Symptoms
70
60
50
40
30
20
10
0
GI SYMP.
RESP.
SYMP.
HEADACHE
ICTERUS
MYALGIA
• GI: abd pain,
vomiting,diarrhea
• Icterus: hepatitis
• Resp: Cough URI,
Pnem, ARDS
• CNS : alter sensorium,
neur deficits
• Renal, electrolyte,
metabolic
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
Diagnosis of malaria
Peripheral smear : diagnostic
Correct technique, expertise,
Repeated smears; at least 6
Malaria antigens
Malaria antibodies
Bone marrow
N=234
Malarial fever in children
Any type of fever can occur in malaria
Type of fever depends upon/:
Age, immune status, first attack, species
Can mimic TB , typhoid
Rule out malaria in all cases of fever
specially PUO
NO FEVER: neonates, chronic
N=234
FEVER PROFILE
High
Low
FEVER PROFILE
Moderate
High
100
90
Medium
Low
100%
80
80%
PERCENTAGE
70
60
60%
50
40
40%
30
20
20%
10
0
0%
< 1 Year
1-5 Year
6-12 Year
13-17 Year
Falciparum
Vivax
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
Smear -ve
N=234
Hepato-spleenomegaly
Depends upon age, duration,
type,
pre-existing pathology: iron
def anemia,
only spleen more common
than only liver
No organomegaly
N=234
Hepatosplenomegaly
Splenomegaly
Smear -ve
Hepatomegaly
Vivax
Falciparum
45
40
PERCENTAGE
35
30
Hepatosplenomegaly
25
20
Splenomegaly
15
10
Hepatomegaly
5
0
< 1 Yr
1-5 Yr
6-12 Yr
13-17 Yr
0
10
20
30
40
Percentage
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
50
N=234
Hepatic dysfunction
Mimic hepatitis
DD: typhoid
Viral ( higher range of
enzymes)
Hepatic dysfunction &
fever :
malaria needs to be ruled
out
N=234
Hepatic dysfunction
SGPT
25
SGPT
Bilirubin
40
BILI
SGOT
SGOT
35
20
30
15
25
10
20
15
5
10
Vivax
Smear -ve
Falciparum
Vivax
Smear -ve
Falciparum
Vivax
Smear -ve
Falciparum
0
5
0
< 1 Yr
1-5 Yr
6-12 Yr
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
13-17 Yr
N=234
Other lab tests
•
•
•
•
Renal profile done in all cases
Serum electrolytes - normal in 99%
Only one case of acute renal failure
Routine urine done in all, abnormal in 37 (15.81%)
60%
54.05%
50%
40%
30%
18.19%
20%
10%
13.51%
5.4%
8.1%
0%
Culture +ve
Proteins +
Granular Casts
Urobilinogen
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
Pus cells
N=234
False Positive Widal in malaria
Many reports of widal positive in malaria
Sometimes malaria is seen in typhoid patients on
treatment hence dual infection can exist
But more often this is false positive widal
proved by negative blood culture, non changing titre
most cases lower than diagnostic titre &
Fever responding to antimalarials
N=234
WIDAL TEST
Titres
O
H
O & H Total
17.54%
•
•
Falciparum
10%
0%
10%
20%
Vivax
10%
10%
10%
30%
Smear –ve
30%
20%
10%
50%
Widal test done in 57 (24.35%) & was +ve in 17.54%, none with significant
titres.
Blood culture done in 78 (33.33%) cases with fever > 7 days and hepatospleenomegaly, showed no growth.
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
Anemia in malaria
Depends upon
Age
Duration
severity of attack,
Degree of hemolysis :
Falciparum
Pre-existing state of
anemia
N=234
Hemoglobin in malaria
N=234
N=234
Hb
Haemoglobin - gm %
<< 55
5-8
5-8
8-11
8-11
11-15
11-15
70
70
60
60
11-15
8-11
<5
5-8
PERCENTAGE
34 %
50
50
40
40
30
30
20
20
3%
48 %
10
10
15 %
00
<< 11 Yr
Yr
1-5
1-5 Yr
Yr
6-12
6-12 Yr
Yr
13-17
13-17 Yr
Yr
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
WBC count in Malaria
Any type of count can occur
Leucopenia, leucocytosis,leukemoid reaction,
Respiratory symptoms
leucopenia viral
leucocytois esp neutrophilia : bacterial
Monocytosis ? Indirect evidence
N=234
WBC count
WBC
Falciparum
Vivax
Smear -ve
PERCENTAGE
60
50
40
30
20
10
0
<5000
6000-10000
11000-15000
>15000
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
Falciparum
Vivax
Smear -ve
50
PERCENTAGE
45
40
35
30
25
20
15
10
5
0
Neutrophila
Monocytosis
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
Platelet count
• THROMBOCYTOPENIA
< 40,000
Falciparum
Vivax
Smear –ve
11.11%
>40,000 to
1 lakh
22.22%
Total
33.22%
0%
11.11%
11.11%
22.22%
33.33%
55.55%
• VERY GOOD EVIDENCE
OF MALARIA
• BLEEDING RARE
• CROWDING OF BONE
MARROW BY PARASITE
• QYICKLY RETURNS TO
NORMAL ON TREATEMENT
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
Falciparum
Vivax
Smear -ve
50
PERCENTAGE
45
40
35
30
25
20
15
10
5
0
Neutrophila
Monocytosis
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
INDIRECT EVIDENCE OF MALARIA
60
• What to do in Smear -ve
50
cases?
40
• Indirect evidence of malaria
30
raised LDH, raised retic
count, mild hepatic
20
dysfunction, monocytosis &
10
thrombocytopenia.
0
LDH
RETIC
FALCIPARUM
PLATELET
VIVAX
MONOCYTES
SMEAR -VE
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
Drug resistance
Falciparum resistance to Chloroquine
increasing reports all over the country
also reports of resistance to second line drugs
S/P & mefloquine
Timely use of quinine & artemsinine derivatives
reduce mortality of cerebral malaria
some reports of vivax resistance to chloroquine
& second line drugs
N=234
YEAR WISE ANALYSIS OF
CHLOROQUINE RESISTANCE
CHLOROQUINE RESISTANCE
Falciparum
Vivax
Smear -ve
100%
90
90%
PERCENTAGE
80
80%
70
70%
60
60%
50
50%
40
40%
30
30%
20
20%
10
10%
0%
0
<1
1-5
6-12
13-17
1994
1995
1996
Falciparum
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
1997
Vivax
1998
Sm
N=234
Analysis of Chloroquine resistance
WHO gradation
DRUG RESISTANCE TO
FALCIPARUM
Resistance
90%
70
80%
60
70%
50
PERCENTAGE
60%
50%
40%
30%
40
30
20
20%
10
10%
0%
0
R1
R2
R3
Chloroquine
S/P
Mefloquine
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
Q uinine
Art. Deri.
N=234
PATTERN OF DRUG RESISTANCE
120
RESISTANT
SENSITIVE
NOT USED
100
80
60
40
20
0
F V S
F V S
CHLORO
QUINE
S/P
F V S
F V S
MEFLO
QUINE
QUININE
F V S
ART. DERI.
Bhave S. Y, Joshi S. V , Warad Vijay , Dhar H. L , Bombay Hospital & MRC
N=234
CONCLUSION
 In our series
 Falciparum cases had more GI symptoms, whereas
 Vivax had more Resp symptoms
 The age group of 6-12 had maximal symptoms and
good chloroquine sensitivity
Malaria can be missed unless high index of
suspicion.
N=234
CONCLUSION (contd..)
 Leucocytosis, Neutrophilia with respiratory
symptoms can be misdiagnosed as bacterial
infection.
 Leucopenia with respiratory symptoms can be
misdiagnosed as viral infection.
 Gastroenteritis with persistent fever needs malaria
smear examinations.
 Hepatitis dysfunction : Generally mild unlike viral
hepatitis
N=234
Cerebral Malaria
• Unaurousable coma
• Exclusion of other encphalopathies
• Confirmation of P. falciparam
(undiagnosed coma with neurological
manifestations of any degree are treated as
cerebral malaria)
N=234
Pathophysiology
• Capillary Blockade
* Agglutination
* RBC Heavy – Parasite load
* Trophozoites & Gametocytes
* Capillary endothelium too sticky
• Rupture of RBC- Schizont
Merozoites, Hemozoin pigments, RBC proteins, Malaria Toxins
(Pyrogenic, Hemolytic, Endotheliotoxic, Histo-toxic)
N=234
Modes of Presentation
•
•
•
•
Recurrent Seizures, Hyperthermia,Hypoglycaemia
Renal Failure / Renal Dysfunction
Hepatic Dysfunction & Icterus
Fluid, Electrolyte & Acid Base Disturbance
•
•
•
•
Pulmonary Odema, Circulatory Collapse
Black Water Fever ,(Intravascular Haemolysis)
DIC & Bleeding Diathesis,Migraine,Sciatica
Cough, Aphonia,Anorexia,Abdominal Pain
•
Psychiatric Disorder,Excessive Crying
..
N=234
Complications & sequele
• Complications
• Hypoglycemia,Severe Anemia,Metabolic Acidosis,Bacteria
Infections ( Gm -ve )
Acute Pulmonary Odema, Acute Renal Failure
• Sequele
• Hemiplegia,Cortical Blindness,Ataxia
• Behavioral Disturbances,Tremors
• Polyneuropathy,GB syndrome
•
N=234
934
Source NC Mathur Hyderabad
N: 534
Cerebral Manifestations
Ceb. Encph.
98%
Asymptomatic
20%
Psychiatry
2% Cerebellar
5%
Peripheral
Spinal
Neurit
disorders
5%
5%
Hemiplegia
4%
Extra
Pyramidal
5%
Pyramidal
10%
Cr. Nr.
6%
N=234
Mortality in cerebral malaria
N= 534
• Majority do well
• Overall mortality
14.36% (81)
0-1 yr
1-5 yrs
6-12 yrs
• 0-1
: 41.6% (19)
• 1-5
: 23.5% (28)
• 6-12 : 8.5% (34)
Source NC Mathur Hyderabad
NC mathur
N=234
n=534
Poor Prognosis
Mortality higher in
• Comatose Children who present
< 72 hrs : 21.1%
> 72 hrs : 47.6%
• with Seizures : 32.4%
• with Decerebrate Rigidity : 57.2%
Source NC Mathur Hyderabad
contd…
N=234
Mortality higher in
contd….
• Travellers : 20.6%
• Hyperparasitemia
(> 5% or > 25000/microlit)
• PCV < 20%
• Hb% < 7 gm%
• Hypoglycemia : < 60mg/dl
• Malnutrition
• Fever > 3 days at admission
N=234
Nc mathur
n= 534
MRI & MRS
Lactic acid peak
N-acetyl acetate
peak subdude
Thalamic
infarcts
Source NC Mathur Hyderabad
N=234
N=534
nc mathur
Source Dr NC Mathur Hyderabad
MRI
(Magnetic Resonance Imaging)
Thalamic
infarcts
28 Aug
29 Sep
N=234
Conclusions
• Malaria is increasing global problem and high index
of suspicion is required for diagnosis
• in cerebral malaria, complications are less and
Survival is good if diagnosed early and treatment
initiated
• Physician should be well versed with multisystem,
varied and rare manifestations
• and be aware of the available drugs and pattern of
drug resistance in the area