PROBLEM CASE

Dr MUHAMMAD TAUSEEF
MCPS Resident
Unit 1
 ●9 year old female weight 19 kg came via ER with
complain of
Presenting ● fever 4months
Complain: ● pallor 2months

●
 Pt was in USOH 4 months back
when he developed fever which
was low grade (100-101F)
intermittent more at night some
times associated with rigor and
HOPC chills temporarily relived by
medicine antipyretics.
2months later he developed
pallor pt also had nasal bleed for
1week ago .vitamin K given
Past medical hx : 2yrs ago pt had
loose stools and fever
According to attendent pt had
decrease white blood 11000
Surgical HX : not significant
BirthHX : Via a SVD 8months of
gestation mecounim aspiration at birth
no NICU admission
Vaccination hx : only oral vaccines
given
Transfusion hx: multiple
transfusion of pcv and platelets
Family hx: cousingeneous marriage
4 siblings no other siblings have any
significant disease
Sociaeconomic : father is a
 ●Pale looking child lying on bed with Iv canula on left hand with
vitals of
●HR= 104 Bpm
●RR= 25 bpm
General ●BP=93/56( 50th centile)
Physical ●RBS= 72mg/dl

Examinatio ●Temp= A/F

n: ●Sats= 94%(room air)

●SUB VITALS
●A++,J-,Cy-,Ed+ pedal pitting , D-,LN+ve multiple left cervical lymph
nodes 1-2 small bilateral inguinal lymph nodes
Anthropometri
c ●Weight: 18Kg (-2.83 SD)
measurements ●Height: 122cm (-1 SD)
:
 ●ABDOMEN:
inspection:
Umblicus centrally placed, no visible vein
, pulsation, scar marks or swelling.
Systemic palpation:
Examinatio Guarding , tenderness on deep palpation ,non
n: distended , liver and spleen palpable liver is 3cm
spleen 3cm .
No fluid thrill and shifting dullness appreciated.
auscultation:
Gut sounds audible.
●RESPIRATORY:
Bilateral equal air entry, normal
vesicular breathing. Tachypnea left
middle lobe and right middle
and lower lobe crepts audible
●CVS:
Apex beat palpable at 5th intercostal
space, midclavicular line.
both heart sounds audible with no added
sounds.
Peripheral pulses palpable.
●CNS:power=5/5 in all limbs
●Tone= normal in all limbs
●Reflexes=+2
GCS= 15/15
Well oriented
 ● Autoimmune hemolytic anemia
● Chronic malaria with hemolytic
Differential
diagnosis:
anemia
● Leishmaniasis
● Acute leukemia
INVESTIGATIONS
 CBC 7-11-24 16-11-23 19-11-24
Hb 6 6.3 6.8
Rbc 2.24 2.2 2.5
Hct 18.6 17.7% 20%
MCV 83 78 79
MCH 26.8 27.9 27
CBC TLC 2.4 2 1.8
N 20 17.5 23.6
L 71 77.5 72
PLT 5 54 30
CBC 25-11-24
Hb :10.1
RBC: 3.7
Hct: 30
WBc :1.7
N: 21.9
L:73
PLT: 37
 12-11-24 16-11-24
SODIUM 130 130
POTASSIUM 3.3 3.3
CHLORIDE 91 101
BICARBONATE
T.BILIRUBIN 37
UCE & DIRECT BILIRUBIN 0.3

LFTS: SGPT 21 Gama GT: 289

ALP 1085
ALBUMIN 2.7
UREA 18
CREATININE 0.3
MPI-CT
M

Negative
BLOOD
C/S : No
Growth ●Dengue
serology
Negative
FINAL DIAGNOSIS

Malaria with bone

marrow supression
 ●Patient was orally allowed.
●Inj ceftriaxone 75mg/kg IV OD
●Inj Provas 23ml IV TDS
TREATMENT ●Inj risek 20 mg IV OD
GIVEN IN ●Injection GenM 2.4mg at 0,12,24hrs followed by IV OD for 3 days.
WARD ●PCV transfused with 10ml/kg at hb of 6 mg/dl undercover of Lasix.
●Tab primaquine 0.5mg/kg once daily for 14days.
Discussion
Definition :
malaria is an acute and chronic
illness ,characterized by paroxysms of the
fever,chills,sweats,fatigue,anaemia and
splenomegaly.

Causative organisms:
plasmodium falciparum(m.virulent)
plasmodium vivax (m.common)
plasmodium malariae
plasmodium ovale
plasmodium knowlesi
Life cycle:
WHO criteria species Incubation Fever
for severe period paroxysyms
Malaria: p.falciparum 9-14days Variable Malignant
impaired 24 or 48hrs tertian fever
consciousness p.vivax 12-17days 48hrs Tertian fever
prostration p.ovale 16-18days 48hrs Tertian fever
resp.distress p.malaraie 18-40days 72hrs Quartan fever
multiple seizures
jaundice
heamoglobinuria
abnormal Mode of transmission :
bleeding Standing water
severe anaemia Warm climate
circulatory Infected blood transfusion
collapse Contaminated needles
pulmonary Congenital malaria
edema.
 ●1.Clinical history & Examination (triad of
fever,anaemia and splenomegaly)
DIAGNOSIS: ●2.Thick and Thin film smears .
●3.PCR
●4.RDT or immuonochromatographic assay.
 ●1.Cerebral Malaria
●Presence of coma in a child with p.falciparum
parasitemia and absence of other reasons for coma.
Complicatio Manifests as headache ,ALOC,prolonged seizures or
ns coma.
●2. Tropical splenomegaly syndrome
● chronic complication of p.falciparum. persistence
of massive splenomegaly even after treatment of
acute infection due to impaired immune response to
malarial antigens.
●3. Black water fever
●blackwater fever, also called malarial
hemoglobinuria, rare, yet dangerous, complication of
malaria. It occurs almost exclusively with infection from
the parasite Plasmodium falciparum.

●Symptoms of blackwater fever include a rapid pulse, high

fever and chills, extreme prostration, a rapidly
developing anemia, and the passage of urine that is
black or dark red in colour (hence the disease’s
name). The distinctive colour of the urine is due to
the presence of large amounts of hemoglobin,
released during the extensive destruction of the patient’s
red blood cells by malarial parasites. Patients frequently
develop anemia because of the low numbers of red blood
cells. The presence of blood pigments in the blood serum
usually produces jaundice early in the course of the
disease
SUSPECTED MALARIA

Malaria should be suspected in any patient with history

of fever >37.5 C OR in children with palmar pallor OR Hb
concentration of <8 gm/dl.
-In all settings, suspected malaria should be confirmed by
parasitological test.

UNCOMPLICATED MALARIA

Patient who presents with symptoms of malaria and

positive parasitological test (microscopy OR RDT), but
with no features of severe malaria.
WHO GUIDELINES FOR
SEVERE FALCIPARUM
MALARIA
Definitions
Severe falciparum malaria:
severe falciparum malaria is defined as one or more of the
following, occurring in the absence of an identified alternative
cause and in the presence of P. falciparum asexual
parasitaemia.
• Impaired consciousness: A Glasgow coma score < 11 in
adults or a Blantyre coma score < 3 in children
• Prostration: Generalized weakness so that the person is
unable to sit, stand or walk without assistance
• Multiple convulsions: More than two episodes within 24 h
• Acidosis: A base deficit of > 8 mEq/L or, if not available, a
plasma bicarbonate level of < 15 mmol/L or venous
plasma lactate ≥ 5 mmol/L. Severe acidosis manifests
clinically as respiratory distress (rapid, deep, laboured
breathing).
• Hypoglycaemia: Blood or plasma glucose < 2.2 mmol/L (<
40 mg/dL)
• Severe malarial anaemia: Haemoglobin concentration ≤ 5
g/dL or a haematocrit of ≤ 15% in children < 12 years of
age (< 7 g/dL and < 20%, respectively, in adults) with a
parasite count > 10 000/µL
 Cont
…
Renal impairment: Plasma or serum creatinine > 265
µmol/L (3 mg/dL) or blood urea > 20 mmol/L
• Jaundice: Plasma or serum bilirubin > 50 µmol/L (3 mg/
dL) with a parasite count > 100 000/ µL
• Pulmonary oedema: Radiologically confirmed or oxygen
Desirable effects:
• Chloroquine prophylaxis reduced recurrent P. vivax malaria in pregnant women
(moderate-quality evidence).
saturation < 92% on room air with a respiratory rate > 30/
min, often with chest indrawing and crepitations on
auscultation
Cont
…
Significant bleeding: Including recurrent or prolonged
bleeding from the nose, gums or venepuncture sites;
haematemesis or melaena
• Shock: Compensated shock is defined as capillary refill
≥3
s or temperature gradient on leg (mid to proximal limb),
but no hypotension. Decompensated shock is defined as
systolic blood pressure < 70 mm Hg in children or < 80
mmHg in adults, with evidence of impaired perfusion
(cool
peripheries or prolonged capillary refill).
• Hyperparasitaemia: P. falciparum parasitaemia > 10%
. In high-transmission settings, blood transfusion
is generally recommended for children with a haemoglobin
level of < 5 g/100 mL (haematocrit < 15%). In low-transmission
settings, a threshold of 20% (haemoglobin, 7 g/100 mL) is
recommended
TREATMENT OF UNCOMPLICATED
MALARIA
PRIMAQUINE AND G6PD
DEFICIENCY
 ●SUPPORTIVE CARE:
●Volume depletion should be corrected.
●Analgesics and Antipyretics are given
●Blood Transfusion if hb <6mg/dl
●SPECIFIC TREATMENT:
●Treatment of Uncomplicated Malaria
TREATMENT: (plasmodium falciparum)
From Nelson:
Chloroquine sensitive
Chloroquine phosphate 10mg base/kg PO immediately
followed by 5mg base /kg PO at 6,24 and 48hrs.
Hydroxychloroquine 10mg base/kg PO immediately
followed by 5mg base /kg PO at 6,24 and 48hrs.
●Chloroquine resistance:
●A.Atovaquon+proguanil (tab 250mg+100mg) (ped
tab62.5mg+25mg)
●5-8kg. 2ped tab PO qid for 3days
●9-10kg. 3ped tab PO qid for 3days.
●11-20kg 1 adult tab PO qid for 3days.
●21-30kg. 2adult tab PO qid for 3days.
●31-40kg 3adult tab PO qid for 3days.
●>40kg. 4adult tab PO qid for 3days.
●B.Artemether-lumifantarine(20/120mg)
●5-15kg 1tab PO b.d for 3days
●15-25kg 2tab PO b.d for 3days
●25-35kg. 3tab PO b.d for 3days
●>35kg. 4tabs PO b.d for 3days
●PO 12-quinine Sulphate plus one of the following
(Doxycycline, Clindamycin or tetracycline)
●Quinine sulphate 8.3mg base/kg (=10mg salt/kg) PO
tid for 3or 7days
●Doxycycline 2.2mg/kg PO 12hourly for 7days
●Tetracycline 25mg/kg /day PO divided qid for 7days
●Clindamycin 20mg Base /kg/day PO divided tid for
7days
●D.Mefloquine 13.7mg base/kg(=15mg base/kg)PO as
initial dose followed by 9.1mgbase/kg (=10mg
salt/kg) po given 6-12hrs after initial dose.
●Treatment of Uncomplicated malaria
(p.Malariae or knowlesi)
●Chloroquine Phosphate or hydroxychloroquine
●Treatment of Uncomplicated malaria
(P.malariae/ Ovale or vivax)
●Suspected chloroquine resistance
● chloroquine phosphate Plus primaquine phosphate
(0.5mgbase/kg
●PO OD for 14days
●Hydroxychloroquine Plus primaquine phosphate.
●Chloroquine resistance:
Quinine sulphate plus doxycycline or Tetracycline Plus
primaquine phosphate .
Atoquone
THANKYOU :)