The WHO estimations per year worldwide: About one million people lose life every year from malaria. Travelers are susceptible to malariaPathogenesis: The female anophelous gets infected when it feeds on human Blood containing malarial parasite (gametocytes) further develop in one to three weeks’ time, into schizonts. Accumulate in saliva of the mosquito.

Sporozoites disappear from the blood, enter the liver in the host. After a few days mosquitoes further multiply in the RBC (trophozoites  schizonts  )rupture releasing merozoites into the blood and cause fever P. Vivax and P. ovale may persist in the liver cells dormant forms, called hypnozoites capable of becoming merozoites months and years later. RBC prone for hemolysis. Vivax and ovale invade reticulocytes and P.malaria Invade normoblast Anemia may develop folate stores may be depleted splenomegaly can develop.

Clinical Features: Nonspecific: Travel history is helpful P. FALCIPARUM the most dangerous. Insidious malaise, headache, vomitings; Cough and mild diarrhea common Fever has no particular pattern. Jaundice is common due to hemolysis and hepatic dysfunction. The liver and spleen enlarge; may be tenderAnemia and thrombocytopenia develop rapidly.

Delirium, seizures, coma can manifest cerebral malaria (no lateralising signs)

P. Vivax, P. ovale may cause continuous fever Classical bouts of fever on alt days (Rigor->cold->104->hot , flush phase->prefuse sweating (Perspiration) gradual fall of temperature 98°f.

P. Malaria and P. know lesi infection usually mild symptoms and bouts of fever every third day (72 hrs) chronic P. Malariae infection causes AGN in children,

Investigation: Thick and thin smear need to be ExaminedRapid diagnostic tests OPTIMAL, PARASIGHT which detects (HRT) QBC Malaria test, DNA Detection PCR (mainly research)

Management: Mild Malaria

Preferred therapy: Artemether +Lumifantrine 4 tablets twice a day for 3 days (Co Artem, Riamet)

Alternate Therapy: Quinine 600mg three times daily for 1 week followed by doxycycline 2 tablets daily for a week

In Pregnency: Clindamycin 450mg three times daily. Early pregnancy : Coartenether is avoided.

Severe Malaria: Preferred therapy Artesumate 2.4 mg/ kg- IV at 0-12-24 hours and once daily for 7 days, once patient tolerates oral in take, switch 2 mg for kg orally once daily to complete the total cumulative dose 18mg /kg

Alternative Therapy: Quinine: Loading dose 20mg/kg over 4 hoursMaintenance dose 10mg/kg -4 hrs infusion 3 times daily for 2 days then twice daily up to maximum of 700mg per dose or until the patient can take orally Combine with doxycycline or clindamycin if doxy is contraindicated ECG monitoring is required on Quinine QRS duration and QT interval.Non Falciparum Malaria:

Preferred therapy: Cloroquine 600 mg base 300mg in 6 hours then 150mg twice daily for 2 days for P. Vivax, primaquine 30mg daily for two weeks For P Ovale, primaquine 15 mg daily for two weeks after confirmining G-6 PD – Negative.Patient with G6PD Deficiency (mild- moderate) cloroquine – plus primaquine 0.75mg/kg orally weekly for 8 weeks.

Cloroquine resistant P.Vivax: Coartemether (as per plasmodium, Falciparum)Prophylaxis: Mefloqunine is useful to area of multiple drug resistance. Example East Africa, Central Africa, papaunewguniea.Fit for travel.nhs.ukFansidar should not be used for chemo prophylaxis (as deaths have occurred due to agranulocytosis or stevens jhonson syndrome)

Chloroquine: Should not be used continuously more than 5 years without eye checkup because irreversible retinapathy.
In pregnancy and Lactation – may take progaunil or chloroquine safely; covering extimities sleeping under peremethrin impregnated mosquito nets.

CHLOROQUINE RESISTANCE HIGH: Mefloquine -250mg- weekly – start 3 weeks before travel and continue 4 weeks after returnDoxycycline -100mg- daily –Started 1 week before and continued 4 weeks after travel Malarone- 1 tablet daily – Started 2 days before travel and continued 4 weeks after return.

CHLOROQUINE RESISTANCE ABSENT– Chloroquine and proguanil- 300mg weekly base, 100 to 200 mg daily – Started 1 week before and continued until 4 weeks after return.