Pitfalls in the Diagnosis and Management of malaria Dr Liz Hart

1. A 34 year old man returned from Nigeria. He was an oil worker and spent 3 weeks every month in a compound near Lagos. He presented with a twenty four hour history of rigors and pyrexia up to 40°C. There were no localising features on examination blood pressure was 85/60.

Investigations

2. What about the same man who had a malaria film sent off and it was negative? What would you do differently?

false negative?

Low parasitaemia Different species Blood films are the gold standard How convinced are you? Why would we continue to do malaria films?

3. A Rheumatology consultant phones you. There is a 78 year old lady on the ward with a fever felt to be secondary to her rheumatoid arthritis treatment. She was born in Pakistan and came to the UK 50 years ago. A keen F1 sent off a malaria test that came back positive...

3. What are the causes of a false positive malaria film?

4. A GP contacts you about a positive malaria test. The patient in question has never left the country...

4.

5. The man in the first example. His blood pressure is sitting at 80/50. How much fluid should you give him?

Beware too much fluid in malaria! Capillary leak, high risk of pulmonary oedema Are they still passing urine? Is the pulse OK? Accept a systolic of 80

6. Our man from Nigeria drops his GCS and has a prolonged seizure. Parasite count comes back as 5%

‘Complicated’ malaria What constitutes complicated malaria?

Complicated malaria J, confusion, seizures Low GCS Renal impairment Acidosis Hypoglycaemia Pulmonary oedema Hb <80 Spontaneous bleeding/DIC Shock Haemoglobinuria Parasitaemia may be low with consequences in the non-immune patient whilst semi immune patients can tolerate higher parasite counts

7. Benign malaria? A 78 year old man presents with fever after a trip to Pakistan. He has CKD 4 and CCF. A malaria film is positive for Plasmodium Vivax

Evidence and Implications of Mortality Associated with Acute Plasmodium vivax Malaria J. Kevin Baird J. Kevin Baird doi: /CMR Clin. Microbiol. Rev. January 2013 vol. 26 no January 2013

Malaria parasite Cases P. falciparum1169 (73.7%)1192 (79.4%) P. vivax225 (14.2%)179 (11.9%) P. ovale130 (8.2%)78 (5.2%) P. malariae41 (2.6%)39 (2.6%) Mixed21 (1.3%)13 (0.9%)

8 A biologist returns from Malaysia. He has been working in the jungle for the last 3 months. He prevents severely unwell and a blood film for malaria is positive. How many species of malaria are there?

9. Uncomplicated falciparum malaria What will you do if your patient refuses to remain in hospital?

10. What if the treatment isn’t working?

Drug resistance Recrudescence Alternative diagnoses

11. A 29 year old woman presents to ED. She is 20/40 pregnant with her first child and has just returned from Kenya where she was visiting her husband. She did not take malaria prophylaxis because of concerns about damage to the baby

Malaria in pregnancy Plasmodium Vivax Plasmodium falciparum/mixed Chloroquine Quinine salt 10mg/Kg tds 7 days And clindamycin No primaquine until delviery, 300mg Chloroquine per week artemisinin combination therapy (ACT; three-day course) alternatives include oral artesunate plus clindamycin (seven days) or quinine plus clindamycin (seven days). artesunateclindamycinquinine 2 nd, 3 rd trimester First Trimester

12. Notification

UK malaria treatment guidelines David G. Lalloo a,*, Delane Shingadia b, Geoffrey Pasvol c, Peter L. Chiodini d, Christopher J. Whitty e, Nicholas J. Beeching a, David R. Hill d, David A. Warrell f, Barbara A. Bannister g, for the HPA Advisory Committee on Malaria Prevention in UK Travellers /$30 ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi: /j.jinf