1. What is new in Malaria Management ? Dr. PC Bhattacharyya Sr. Consultant Physician down town hospital Guwahati,Assam

2. Current Scenario No significant development in management since the advent of artemisinin. Many new drugs are in experimental stage Various combination of different drugs are tried with variable success Newer investigations contributed much towards the successful management

3. Newer Investigations 1.Serological Tests : 2.Molecular biological techniques DNA Probes RNA probes 3.Transcript amplification system and target amplification by PCR 4.Probe amplification ring Q beta replicase 5.Compound or ‘Christmas tree’ Probes 6.Fluorescence microscopy

4. Serological tests Test Current applicationSource of antigens (or antibodies) Antibodies Identified ImmunoprecipitationEpidemiological studies & research Erythrocytic scizonts & soluble antigens IgG IgM ImmunofluroscenceEpidemiological studies research & aid to diagnosis Erythrocytic scizonts IgG IgM IgA Indirect haemagglutination Epidemiological surveysAntigen coated erythrocytes IgG ELISA Epidemiological studies and aid to diagnosis Soluble antigen or antibodies igG (IgM) RIA ResearchSoluble antigensIgG IgM Merozoite inhibition in culture ResearchMerozoite from erythrocytic schizonts IgG IgM

5. Management (i) 1.Immediate general management 2.Immediate admission in ICU 3.Resuscitation 4.Airway/Circulation by ALS technique 5.ABG/Serum electrolyte estimation 6.Coagulation profile 7.Detection of pulmonary oedema and ARDS & ventilatory support

6. Management (ii) 8. Hypoglycaemia 9. Circulatory collapse 10.Renal shutdown- Dialysis 11. Anaemia – blood transfusion 12. Haemoglobinuria 13. Hyperpyrexia 14. Jaundice & exchange transfusion

7. Newer Drugs - I  TETRACYCLENE : Doxycycline, Cotrimoxazol Clindamycin  NAPHTHOQUINONE : (Atovaquone or BW 566 C80),  VINYL SULPHONES : Inhibit cystesine proteinase ).  WR 238,605 : New 8 aminoquinolone,  SULPHONES/ BIGUANIDES

8. NEWER DRUGS - II  AZITHROMYCIN  DESFERRIXAMINE  DRUGS WHICH REVERSE CHLOROQUINE RESISTANCE Calcium channel blocker.  MISCELLANEOUS Pyronaridine, Benflumentol, Hydroxy Piperaquine, Trioxane. Teraoxanes, Hydroxynaphthoquinones & Pyridianomenthanols.  Dapsone, Ketoconazole, Miconazole, Ampho-B

9. Exchange Transfusion Rationale Rapid reduction of parasite load Improving rheology Reduction of microcirculatory sludge Correction of anaemia Buying time for optimum action of drugs

10. Exchange Transfusion Indications Parasitaemia >30% without organ dysfunction Parasitaemia > 10% with organ dysfunction Pregnancy Patient >60 yrs. of age

11. Exchange transfusion Technique Through Femoral/brachial vein Patients blood exchanged in small quantity Volume exchanged- 2000ml- parasitaemia >10% 3000ml – parasitaemia >11-20% 4000ml – parasitaemia >20%

12. Exchange transfusion Our experience in DTH Number of cases 9 Exchange transfusion 3 cases 2 had ARDS, All survived Without exchange transfusion 6 cases 5 cases died (4 cases had ARDS)