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MALARIA
Reference
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Parasitology Protozoology and Helmintology Basic Clinical Parsitology: Brown & Belding K.D. Chatterjee Clinical Parasitology: Paul Chester Beaver c.s. The immunology of Parasitic infection omar o. Barriga Faundation of Parasitology Gerald D. Schmidt & L.S. ROBERT Atlas of Medical Helmintology & Parasitology: Jeffrey & leach Modern Parasitology : Edited by F.E.G. Cox Medical Parasitology, Apractical Approach Edited by S. H. Gillespie and P. M. Hawkey Perubahan Radidkal dalam Pengobatan Malaria di Indonesia P.N. Harijanto. Cermin Dunia Kedokteran, 2006 Internet
Monkey plasmodium
P. cynomolgi
P. knowlesi
Plasmodium vivax
Plasmodium falciparum
Plasmodium ovale
Physiology
Latent period in the body : - P. falciparum : shortest - P. malariae : longest Plasmodium: Hb Iron porphyrin hematin + Globin Hematin= ferrihemic acid=pigment malaria
Life cycle
- Intrinsic phase: in the vertebrate host, asexual schizogony
- Extrinsic phase:
Female anopheles
merozoite
oocyst
in RBC
TROPHOZOITE
SCHIZONT
MEROZOITE
ookinete
MAKROGAMETOCYTE
makrogamete
zygote
MIKROGAMETOCYTE
mikrogamete
Epidemiology of malaria
60o
Equator 30o
2,770 m above sea level Cochabamba 400 m bellow Dead sea basin
Impact of malaria
Malaria causes about 350-500 million infections in humans and approximately one to three million deaths annually. The vast majority of cases occur in children under the age of 5. Pregnant women are also especially vulnerable.
Vectors in indonesia: Anopheles annularis Anopheles vagus Anopheles barbirostris Anopheles aconitus Anopheles sundaicus Anopheles maculatus Anopheles balabacensis Anopheles punctularis Anopheles subpictus Ano;heles indefinitus
(Epidemiology)
Endemic : connotes natural transmission in an area so that there are autochthonous, locally contracted cases Imported malaria: is acquired outside the area Introduced malaria : cases derived from Imported malaria Sporadic : cases are few and scattered
Malaria endemicity:
The prevailing frequency and intensity of endemic malaria. Classification of endemicity: Based on spleen index (%) of children in age group 2-9, and the spleen rate of adult
(Epidemiology)
Classification of endemicity:
Hypoendemic malaria: spleen rate in age group 2-9 10% 2. Mesoendemic malaria : 2-9: 11-50% 3. Hyperendemic malaria : 2- 9 > 50% and adult spleen rate 4. Holoendemic malaria : spleen rate in age group 2-9 > 75% but adult tolerance high and adult spleen rate
1.
Incubation period:
P malariae P. falciparum P. ovale P. vivax : 12-14 days : 10-12 days : 10-12 days : 14-17 days
Symptomatology
1.
The febrile paroxysm may be divided into 3 clinical stages: - cold stage (15-16 minutes) - host stage (about 2 hours: 39-40o C) - sweating stage (about 1 hour)
Diagnosis
Thick film (DDR Thin film Q.B.C. (Quantitative Buffy Coat) I.R.M.A. (Immunoradiometric assay) Elisa for Ag p. falcliparum (HRP-2 = histidine Rich Protlein-2) 6. RNA probe 7. DNA Hybridization 8. Rapid Manuel test (P.falciparum)HRP-II also available for vivax
1. 2. 3. 4. 5.
(Diagnosis of malaria)
9. Indirect fluorescence Assay (IFA) 10. Polymerase Chain Reaction (PCR)
Pernicious manifestation
Warning signs: asexual parasitemia 5%, 10 % with multiple rings in red cells and schizonts in peripheral blood
Pernicious manifestation:
Cerebral malaria Malaria with jaundice Diarrhoea, dysentery Renal failure Pulmonary edema Black water fever Algid malaria, shock Hyperpyrexia
Algic malaria
A condition analogous to cerebral malaria, except that the gut and other abdominal viscera are involved. The skin is cold and clammy, but internal temperature is high.
(Algic malaria)
Two types: Gastric Dysenteric : with persistent vomiting : with bloody, diarrheic stools containing enormous numbers of parasites.
Cerebral malaria/unarousable coma Severe anaemia Renal failure Pulmonary oedema/adult respiratory distress syndrome (ARDS)
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7 8 9
10
Hypoglycaemia Hypotension/shock Bleeding/disseminated intravascular coagulation (DIC) Convulsion Acidosis/ Acidaemia Macroscopic haemoglobinuria
Treatment
1. Non-specific
treatment:
symptomatic and supportive measures according to the clinical manifestation 2. Specific treatment: Blood schizontocide: - Chloroquine - sulfadoxine & pyrimethamine (SP) - quinine; Mefloquine - Artemisinin/Qinghausu (artesunate; artemeter; dihidroartemisinin) - Artemisinin based combination therapy (ACT): e.g.: Artesdiaquine (Artesunate 50 mg + amodiaquine 200 mg). - Non Artemisinin based bcombination therapy (NON-ACT): e.g. Quinine + SP Chloroquine + teteracycline /doxicycline Gametocytocide : Primaquine
Chemoprophylaxis
Chloroquine: 300 mg base weekly Sulfadoxine 1 g + Pyrimethamine 50 mg every two weeks Sulfadoxine .1.5 g + Pyrimethamine 70 mg every four weeks
Suppressive treatment:
Chloroquine: 0.5 g weekly
Late Clinical (and parasitological) Failure (LCF) - Parasitemia (the same species with that of day 0) complicated with severe malaria after day 3. - The axial temperature > 37 C with parasitemia between day 4 - 28.
Resistance: The ability of a parasite strain to survive and /or to multiply despite the administration and absorption of a drug given in doses equal to or higher than those usually recommended but within the limits of tolerance of the subject.
Immunologi of malaria
innate Plasmodium: host specific
In the liver of man:
Well developed
P. vivax
In liver of chimpanse:
Not develop
P. berghei
In the liver of a tree rodent: 50%
(Immunity)
P. falciparum : infection disappears within a year P. vivax P. Malariae years : 1-1 years. : infection persists until 20-30
(Immunity of malaria)
1. innate:
Such as: - G6PD deficiency - Duffy factor negative - Sickle cell anemia - Thallasemia Hb & Hb E - Hb foetus of human - ATP deficiency
(immunity of malaria)
2. Acquired
(Immunity of malaria):
Non specific R ES 2. Specific: Gamma globulin lysin Agglutinin Precipitin Opsonin Ablastin Complement-fixing Cytoplasm-modifying
1.
4 months- 3 10 -15 years adult years High Low parasite Low parasite parasite rate rate rate
Receptor : glycoprotein
Merozoite
RBC
Premunision: a specific immune response clinical recovery & resistant to super infection.
Tolerant Immunities: - species specific - strain specific
Macrophage
P. falciparum
TNF
Patologi
Protection Inhibition of parasites in: The liver & -Dyserythropoisis Cytoadherence --Erythro phagocytosis Adherence of parasitized rbc to vascular Anemia endothelium Clinical manfestations: Such as:
RBC
- Headache
- Fever - Chill etc.