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Nurul Ilyani bt Jamaluddin 41216

A disease caused by the presence of the sporozoan Plasmodium in human transmitted by the bite of an infected female Anopheles mosquito that previously sucked the blood from a person with malaria. 4 important species of Plasmodium:
Plasmodium falciparum Plasmodium vivax Plasmodium malariae Plasmodium ovale

In Malaysia, Mainly in Perak, Pahang, Kelantan, Sabah and Sarawak. But the incidence gradually declining over the year.

Sporozoites (infective form) transmitted during the bloodmeal feeding of a female Anopheles mosquito on a human. The sporozoites invade and reside within hepatocytes where they multiply to large numbers.

An. maculatus An. balabacensis An. donaldi

P. Malaysia Sabah Sarawak

1 . uncomplicated malaria (all species)


Fever, chill, headache, malaise and myalgia Malarial paroxysm: rigor and fever followed by profuse diaphoresis and exhaustion occuring at regular interval tertian, quartan etc are seldom seen.

3 Phases Total duration 8 - 12 hours 1) Cold, chill stage 15 60 min, rigors and chattering teeth. 2) Hot 2-6 hours temp 39 41 0C 3) Sweating 2-4 hours drenching, profuse, fever declines, symptoms diminish and exhaustion.

Vivax\Ovale

The fever paroxysm corresponds to the period of erythrocyte rupture and merozoite invasion.

Severe anemia DIVC ARF


Urine < 0.5ml/kg/hr, failing to improve after rehydration and creatinine > 265mmol/L

Pulmonary oedema ARDS Hypoglycemia


Quinine and quinidine can induce hyperinsulinemia

Severe metabolic acidosis

Hyperkalemia (K >5.5 mmol/l) Cerebral malaria

Repeated generalized convulsion Algid malaria

Dexamethasone and mannitol are contraindicated

Hypotension (systolic < 70mmhg), cold clammy skin.. CVP, fluid resus, inotrope ? Possibility of complicating septicemia if + persistent hypotension > bld C+S and antiobiotic If pt is on IV quinine or quinidine, consider drug induced cardiac depression.

Hyperparasitemia
P.falciparum in peripheral blood > 5% of erythrocytes or > 250,000/ul Worse prognosis, need IV chemotx or exchange tranfusion

Hyperpyrexia
Rectal temp > 40c Tx : sponging, rectal PCM 0.5-1g every 4 hour

Jaundice
Se.bilirubin > 50umol/l

Visualization of parasite on Giemsa-stained thin and thick smears. May be undetected initially as parasitized red cells are often sequestered from the blood stream Require repeated smears twice daily for 3/7 to fully exclude malaria

FBC, ESR, BUSE, LFT, RP ABG, CXR, UFEME G6PD screened before the use of primaquine Blood c+s UPT

Chloroquine

Primaquine

10mg base/kg of BW (not exceed 600mg) followed by 5mg/kg 6-8 hr later and 5mg for next 2/7 Usual adult regime : 600mg followed by 300mg 6hr later and 300mg/day for next 2/7. In resistence case, add doxycyline/tetracycline plus primaquine
Eradicate hypnozoite Usual adult dose : 15 mg daily for 2/52 G6PD deficeincy pt : 30-45mg weekly for 8/52 Contraindicated in pregnancy

Chloroquine (as above) Fansidar


SDX/PYR (sulfadoxine 500mg/ pyrimethamine 25mg per tab) given single dose, usually 3 tabs Contraindicated in prengnant women n infant

Primaquine
30-45mg single dose in adult with normal G6PD for gametocidal action

Quinine (600mg tds for 1/52) with either;


Fansidar : 3tabs as single dose Doxycycline: 100mg salt daily for 1/52 Tetracycline: 250mg qid for 1/52

Primaquine (as above)

Loading dose: IVI 20mg/kg quinine salt over 4 hour Initial maintaince: 10mg/kg quinine salt over 4hr tds Adjustment consideration:
Pt remains seriously ill after 3/7 (reduce dose by 30-50%) QT interval prolonged by 25% Liver or renal impairment Hypotension n arrthymia Good oral intake give oral quinine

Repeat blood smear daily (BD in severe infx) Within 48-72 hr after starting tx, pt usually become afebrile and clinically improved upon recovery, blood film should be repeated once/month to ensure no recrudescence.

Leptospirosis is a zoonosis of worldwide distribution High-risk areas include south-east asia. Seasonal outbreaks associated with changes in local water levels have been described; -flood Recreation; water sports, ingestion of water and food contaminated with leptospirosis. Inoculation through skin abrasions

Caused by Leptospira interrogans (gram ve). Appears to be ubiquitious in wildlife and many domestic animals, most frequent hosts are rodents. The bacterium persists in convoluted tubules of the kidney and are shed into the urine in massive numbers

Incubation period averages 1-2 weeks. In 90% of cases, leptospirosis manifests as an acute febrile illness with a biphasic course. 1st phase- Septicaemic phase 2nd phase- immune phase

Occurs during the 1st week of infection Characterized by


Sudden onset of high and remittent fever with chills and rigors (38-40c) Retro-orbital headache Conjuctival congestion Myalgia (paraspinal, calf and abdominal muscle) Maculopapular skin rash vomiting

Usually 1st phase symptoms improve first (defervescence) before going into the next phase Occurs 1-4 weeks after infection Immune phase characterized by aseptic meningitis (50%), and in severe cases Weils disease. Systemic manifestation is common such as nephritis, hepatitis, myocarditis and ARDS Mortality : 10-15%

Pallor Conjuctival congestion Jaundice Muscle tenderness Rashes Hepatosplenomegaly lymphadenopathy

Serum/urine C & S test

Microscopic examination

Can be cultured from blood during 1st week of illness and from urine 2-4 weeks of illness
Thick smears stained by Giemsas technique will be positive

Serology detection of leptospira antibodies

TW maybe normal or as high as 50,000/ul. Thrombocytopenia is uncommon Ufeme: urine may contain bile, protein, cast and red cells LFT: bilirubin and liver enzymes RP: creatinine in 50% of case CSF: polymorphonuclear or lymphocytic pleocytosis with [protein] and normal glucose

General
Close T, BP, PR, RR and I/O charting
Adequate hydration, keep temp < 38c

Antibotics for 1/52


Mild dz: Doyclycline 100mg bd or Ampicillin/amoxicllin 1g qid Severe dz: IV Penicillin G 1.5 mU qid or Ceftriaxone 1g OD Beware of Jarisch-Herxheimer rxn

Supportive
Dialysis, ventilatory support etc

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