Anwar Wardy

Malaria Threatens 40% world population

From Near Extinsion in 1976 India contributes 85% of cases in South East Asia 1st clinical description Hippocrates Elaborated Celsus Peruvian Bark in therapy 17th Century Quinine 1820 Man to Mosquito Cycle Sir Ronald Ross 1998-99

Definition
Complication of plasmodium falciparum Unarousable coma more than 30 mts Exclusion of other causes

Aetio Pathogenesis
Sequestration of Cerebral Capillaries and Venules

Ring like lesions in the Brain

Mechanical Hypothesis

P. falciparum parasites in brain capillary

Section of brain showing blood vessels blocked with developing P. falciparum parasites

Selective Cytoadherance results in rosetting Reduction of Microvascular Blood flow Hypoxia Dose not explain selective absence of Neurological Deficits

Humoral Hypothesis
Malaria Toxin Stimulates Production of TNF- alpha & Cytokines Stimulate Endothelial cells Uncontrolled production of NO COMA

CLINICAL MANIFASTATIONS
The seasonal Trend
17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0

17

17

13 12 11 11

7 6 4 3 1 0
Jan Fe b Mar Apr May June July Aug Sept Oct Nov Dec

 Earliest Manifestations Fever Loss of Appetite Vomiting Cough

Specific for Cerebral Malaria

Impaired consiousness Gen. Convulsion with Sequelae Coma

Coma Scale for Children

Best Motor response Localizes painful stimulus Withdraws limb from pain Non-specific or Absent response Appropriate Cry Moan or Inappropriate cry None Directed (e.g. follows mothers face) Not directed 2 1 0 2 1 0 1

Verbal Response

Eye Movements

Total

0-5

Associated Presentation
Hypoglycaemia Metabolic Acidosis Shock Neurological deficits Other forms can Co-exist

LABORATORY DIAGNOSIS

Diagnosis of Falciparum Malaria

Conventional Microscopy Giemsa Stain Field Stain

Stages of P. falciparum

LABORATORY DIAGNOSIS
Contd.
Fluorescence Microscopy (QBC) Nucleic Acid Staining with acridine Parasite Count = (TLC / Cuml X Parasite / 100 WBC) / 100 = Parasite / Cuml of Blood Serology Anti body detection Antigen detection (HRP) Biochemical Test - Optimal test (Parasite LDH) PCR & Culture

CEREBRAL INVOLVEMENT
Clinical CSF - Increased Lactic Acid CT, MRI

THOUGHTS AT BEDSIDE
Haemoglobin

Urobilinogen

THERAPEUTIC OPTIONS

CHEMOTHERAPY
Quinine Artemisinins - Artesunate
- Arte- ether - Arte - mether

SUPPORITIVE & ADJUNCTIVE THERAPY

Nursing Care Catherization Nasogastric tube Fluid & Electrolyte Monitor level of coma & vital signs Antipyretics Anticonvulsants Reduction in ICT Correction of Hypoglycaemia Exchange Transfusion IncreaseMicrocirculatory Flow - Pentoxyfylline Desferrioxamine Correction of Anaemia, Acidosis,

NEWER HORIZON
Inhibition of Endothelial Activity
- LMP 420 - Decrease of TNF alpha & LT activity

Vaccine Development