malaria
TRANSCRIPT
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MALARIADr. DWI HANDAYANI
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MALARIAReferenceParasitology Protozoology and Helmintology Basic Clinical Parsitology: Brown & BeldingK.D. ChatterjeeClinical Parasitology: Paul Chester Beaver c.s.The immunology of Parasitic infection omar o. BarrigaFaundation of ParasitologyGerald D. Schmidt & L.S. ROBERTAtlas of Medical Helmintology & Parasitology: Jeffrey & leachModern Parasitology : Edited by F.E.G. CoxMedical Parasitology, Apractical ApproachEdited by S. H. Gillespie and P. M. HawkeyPerubahan Radidkal dalam Pengobatan Malaria di IndonesiaP.N. Harijanto. Cermin Dunia Kedokteran, 20069. Internet
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Classification of malarial parasitePhylumProtozoa
SubphylumSporozoaClassTelosporidea
SubclassHaemosporidiaFamilyPlasmodiidaeGenesPlasmodium
SpeciesP. vivax P. malariae P. falciparum P. ovale
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Monkey plasmodium
P. cynomolgi
P. knowlesi
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Morphology:- Chromatin- Cytoplasm- Pigment- Granula
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Plasmodium vivax
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Plasmodium falciparum
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Plasmodium malariae
Ring form; band form; schizont
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Plasmodium ovale
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PhysiologyLatent period in the body :-P. falciparum: shortestP. malariae: longest
Plasmodium: Hb Iron porphyrin hematin + GlobinHematin= ferrihemic acid=pigment malaria
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For survival the malarial parasitesneed: CHO; PROTEIN; FATBesides they also need:MethioninRiboflavinPara-aminobenzoic acidPanthotenic acidVit C
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Life cycle-Intrinsic phase:in the vertebrate host,asexual schizogony
Extrinsic phase:in the female anopheles mosquito,sexual sporogony
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Life cycle of malarial parasites
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Life cycle of P. vivax or P.ovaleMIKROGAMETOCYTE
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Epidemiology of malaria
2,770 m above sea levelCochabamba 400 m bellow Dead sea basinEquator
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Impact of malariaMalaria 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.
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(Epidemiology) anopheles mosquitoesVectors in indonesia:Anopheles annularisAnopheles vagusAnopheles barbirostrisAnopheles aconitusAnopheles sundaicusAnopheles maculatusAnopheles balabacensisAnopheles punctularisAnopheles subpictus Ano;heles indefinitus
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(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 malariaSporadic : cases are few and scattered
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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
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(Epidemiology)Classification of endemicity:
Hypoendemic malaria: spleen rate in age group 2-9 10%Mesoendemic malaria: 2-9: 11-50%Hyperendemic malaria: 2- 9 > 50% andadult spleen rate Holoendemic malaria: spleen rate in age group 2-9 > 75% but adult tolerance high andadult spleen rate
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Mode of infections:1. Bitten by female anopheles2. Congenital3. Transfusion4. Organ transplantationPathologyVascular blockade of vascular by parasistized rbc.Anoxia (organ)Deposition of pigments
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Incubation period:P malariae: 12-14 daysP. falciparum: 10-12 daysP. ovale: 10-12 daysP. vivax: 14-17 days
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SymptomatologyThe 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)
Secondary anemia3.splenomegaly
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The attack of paroxysmP. vivax and P. ovale : 48 hoursP. falciparum : 24-48 (36-48) hoursP. malariaae : 72 hours
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Diagnosis Thick film (DDRThin filmQ.B.C. (Quantitative Buffy Coat)I.R.M.A. (Immunoradiometric assay)Elisa for Ag p. falcliparum(HRP-2 = histidine Rich Protlein-2)RNA probeDNA HybridizationRapid Manuel test (P.falciparum)HRP-IIalso available for vivax
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(Diagnosis of malaria) 9. Indirect fluorescence Assay (IFA)
10. Polymerase Chain Reaction (PCR)
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Pernicious manifestationWarning signs:asexual parasitemia 5%, 10 % with multiple rings in red cells and schizonts in peripheral blood
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Pernicious manifestation:Cerebral malariaMalaria with jaundiceDiarrhoea, dysenteryRenal failurePulmonary edemaBlack water feverAlgid malaria, shock Hyperpyrexia
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Algic malariaA 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.
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(Algic malaria)Two types:
Gastric: with persistent vomiting Dysenteric: with bloody, diarrheic stools containing enormous numbers of parasites.
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Definition of severe malaria (WH0)One or more of the following criteria + the presence of asexual parasitaemia defines severe malaria
Cerebral malaria/unarousable comaSevere anaemiaRenal failurePulmonary oedema/adult respiratory distress syndrome (ARDS)
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[Definition of severe malaria (WH0)]HypoglycaemiaHypotension/shockBleeding/disseminated intravascular coagulation (DIC)Convulsion Acidosis/ Acidaemia Macroscopic haemoglobinuria
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Pathophysiology of Cerebral malaria:It is exactly not knownProposed hypotheses:Permeability hypothesis (Maegraith and fletcher)Toxic/cytokine hypothesisMechanical hypothesis
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Black water feverHaemoglobinuriafeverNausia & vomitusIcterus Pamaquinequinine(qinghousu)Death due to Renal failure
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Treatment 1. Non-specific treatment:symptomatic and supportive measures according to the clinical manifestation2. 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
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ChemoprophylaxisChloroquine: 300 mg base weeklySulfadoxine 1 g + Pyrimethamine 50 mgevery two weeksSulfadoxine .1.5 g + Pyrimethamine 70 mgevery four weeksMefloquine: 5 mg/kg BB/weekly(250 mg/tablet base)
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Suppressive treatment:Chloroquine: 0.5 g weekly
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Early treatment failure: One or two condition occur as bellow within the first 3 days of treatmentParasitemia with complication of severe malaria on day 1, 2 and 3.Parasitemia on day 2 > that on day 0Parasit count on day 3 > 25% of day 0Or the axial temperature: > 37.5
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Late treatment failure:if the following conditions occur on day 4 28, divided into 2 sub group:
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.
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Late treatment failureLate Parasitological Failure (LPF)Parasitemia (the same species with day 0)on day 7, 14 or 28 without rising of the axial temperature (< 37 C)
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Resistance of asexual parasites (P. falciparum) to schizontocidal drugs (4-aminoquinolines)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.
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Immunologi of malaria innatePlasmodium: host specificP. vivax
P. berghei In the liver of man:In liver of chimpanse:sporozoiteWell developedNot developThe liver of mouse: 1%In the liver of a tree rodent: 50%sporozoite
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The immunity of malariaThe combination of those mechanisms which:Prevent infectionPrevent reinfectionPrevent super infectionWith the outcome of:Destruction of the malarial parasitesHindrance of their multiplication,Modification of their effects andHelping specifically for the repairing of tissues.
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(Immunity)P. falciparum : infection disappears within a year
P. vivax : 1-1 years.P. Malariae : infection persists until 20-30 years
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(Immunity of malaria)innate:Such as: - G6PD deficiency- Duffy factor negative- Sickle cell anemia- Thallasemia Hb & Hb E- Hb foetus of human- ATP deficiency
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(immunity of malaria)Acquired
- Passive- Active: 1. concomitant2. residual
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(Immunity of malaria):Non specificRESSpecific: Gamma globulinlysinAgglutininPrecipitinOpsoninAblastinComplement-fixingCytoplasm-modifying
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In high endemic area of malaria:
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Receptor : glycoprotein
Duffy factorGenotype:
Fy, Fy
RBC
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Premunision: a specific immune response clinical recovery & resistant to super infection.
Tolerant
Immunities: - species specific- strain specific
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P. falciparum TNFPatologiHigh levelLow levelProtection Inhibition of parasites in:The liver &RBCDyserythropoisis-Erythro phagocytosis
AnemiaCytoadherenceAdherence of parasitized rbc to vascular endotheliumClinical manfestations:Such as: Headache Fever Chill etc.
Macrophage