2. history 1 ½ y boy Fever –2 weeks –Intermittent –39.5 –Chills and rigor –sweating

3. history ? URTI Oral antibiotic( amoxicillin ), ( cefixime)

4. history Pallor, family history of G6PD Normal urine No cough,SOB No vomiting, diarrhea, Normal appetite No jaundice No skin rash No abnormal movement

5. Examination Pale Febrile No LAP ENT : N RS: N CVS: N ABD: N CNS: N

7. investigation CBC –WBC: 8.2 –NEUT: 36 –LYMPH: 45 –HB : 7.2 –PLAT: 70 Retic: high G6PD: 6 ( 6-10) ??

9. investigation Malaria smear : +ve ( 1% parasitemia)

10. Hospital course Mefloquine ( 15 mg/kg then 10 mg /kg 12 later)

11. Hospital course Repeated malaria smear x3 : +ve

12. Hospital course !!?

13. WHO Malaria is the most significant parasitic infection in the world Approximately 2 billion people live in malaria-endemic areas malaria causes an estimated 300 to 500 million cases of acute illness each year

14. WHO responsible for at least 20 percent of the mortality in young children approximately 3000 deaths per day Malaria has been estimated to cost Africa more than $12 billion US yearly

15. antimalarial drugs the quinolines and arylaminoalcohols the antifols the artemisinin derivatives the hydroxynaphthaquinones Antibacterial agents

16. Quinolines and arylaminoalcohols chloroquine, amodiaquine, quinine, quinidine, mefloquine, halofantrine, primaquine, tafenoquine, lumefantrine, piperaquine, pyronaridine

17. Antifols pyrimethamine, proguanil, chlorproguanil, trimethoprim

18. Artemisinin derivatives artemisinin, dihydroartemisinin, artemether, artesunate

19. Hydroxynaphthaquinones atovaquone

20. Artemisinins

21. derived from a plant called sweet wormwood reported to have antipyretic properties more than 1500 years ago In 1971, a highly active chemical was obtained and is now called artemisinin Chin Med J (Engl) 1979;92:811–16

22. Artemisinins sweet wormwood

23. Artemisinins Artemisinin is a highly crystalline compound that does not dissolve in oil or water Semisynthetic derivatives that have been chemically modified at the C10 position to produce artesunate, artemether, arteether, dihydroartemisinin, and artelinic acid

24. ANTIMALARIAL PROPERTIES Artemisinins kill all species of plasmodium that infect humans The asexual stages of infection are the most susceptible artemisinins are active against the large ring stage of infection artemisinins also target tiny ring stages of infection J Antimicrob Chemother 2002;50:751–4

25. ANTIMALARIAL PROPERTIES Artemisinins inhibit metabolism of parasites more quickly than other antimalarials Potential benefit Artemisinins do not interfere with hepatic stages of parasite development no causal prophylactic value J Infect Dis 1996;173:691–8

26. ANTIMALARIAL PROPERTIES kill early gametocyte stages of development potential to interfere with mosquito transmission Lancet 2000;355:352–7

27. MECHANISM OF ACTION free radicals inhibition of the malarial parasite’s calcium ATPase J Med Chem 2004;47:2945–64

28. CLINICAL APPLICATIONS treatment of uncomplicated and severe malaria pregnant women study of over 500 women treated with artemisinins in Thailand  no increase in rate of abortion, congenital abnormality, or stillbirth Clin Infect Dis 2001;33:2009–16 no evidence of significant resistance in clinical isolates Postgrad Med J 2005;81:71–78

29. Severe malaria Quinine vs Artemisinins narrow therapeutic ratio hyperinsulinaemic hypoglycaemia (more frequent and severe in pregnancy) prolongs the QTc interval evidence of resistance in south east Asia Rapid parasitic clearance Trans R Soc Trop Med Hyg 2001;95:637–50

30. Severe malaria Intravenous artesunate is the drug of choice for severe malaria, particularly if acquired in Asia Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005967

31. Rectal administration

32. A study of 898 children with severe P falciparum malaria –Rectal quinine (20 mg/kg diluted to 30 mg/ml in water solution) VS intramuscular quinine (12.5 mg/kg) efficacy outcomes did not differ BMJ. 2006 May 6;332(7549):1055-9

33. Rectal administration A study of 110 children aged 6 months to 5 years who had cerebral malaria. –Patients were randomized to receive either intrarectal or intravenous quinine there was no difference in –the clinical and parasitological outcomes –coma recovery time, – fever clearance time – parasite clearance time. –Mortality was similar in both groups Clin Infect Dis. 2007 Dec 1;45(11):1446-52.

34. Rectal administration a comparative study with parenteral quinine, rectal artesunate was efficacious in African children with moderate-severe malaria Lancet 2004;363:1598–605 rectal formulation of artesunate lead to rapid falls in parasitaemia that were indistinguishable from those seen after intravenous artesunate Antimicrob Agents Chemother 2001;45:509–16

35. Rectal administration Intrarectal quinine or artesunate are efficacious and could be used as an alternative in the treatment of childhood cerebral malaria, especially in situations in which intravenous therapy is not feasible.

36. Reversed chloroquines

37. Chlorpheniramine was assayed for in vitro antimalarial activity against multidrug- resistant Plasmodium falciparum chlorpheniramine exerts marked synergistic action on chloroquine against P. falciparum Chlorpheniramine also potentiated antimalarial action of mefloquine, quinine chlorpheniramine antagonism with artesunate was obtained Parasitol Int. 2006 Sep;55(3):195-9.

38. Reversed chloroquines A standard treatment CQ, alone or in combination with CP, to 117 semi-immune Nigerian children with P. falciparum observed for 28 days Treatment with CQ-CP combination resulted in a shorter parasite clearance time (2.0 +/- 0.5 days) and a higher cure rate (87.5%) compared to treatment with CQ alone (3.5 +/- 0.5 days; 66.7%) Afr J Med Med Sci. 2004 Mar;33(1):77-81

39. Reversed chloroquines five children who failed CQ and/or AQ treatment, were subsequently retreated and cured with a combination of AQ plus CP »Mem Inst Oswaldo Cruz, Rio de Janeiro, Vol. 102(3), June 2007

40. Is it the time to recommend CQ-CP combination in KSA??!!

41. KSA and malaria

42. KSA 1 st report of CQ resistant was in 1991 J Egypt Soc Parasitol. 1991 Aug;21(2):591-2

43. KSA P. falciparum isolates from malaria-endemic area of Jazan showed CQ resistance rate (89.5%) the highest percentage of chloroquine resistance ever recorded in Saudi Arabia 10.5% of isolates showed a PYR-SDX resistant J Egypt Soc Parasitol. 2007 Apr;37(1):17-30.

44. In Yemen : –Chloroquine resistance was found in 47% of isolated P. falciparum – Mefloquine resistance was found in 5.2% Ann Saudi Med. 2007 Nov-Dec;27(6):432-6

45. Malaria treatment guideline in Saudi Arabia !!!??????!!! THANK YOU