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7/30/2019 Cerebral Malaria New
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Anwar Wardy
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Malaria Threatens
40% world population
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From Near Extinsion in 1976
India contributes 85% of casesin South East Asia1st clinical description HippocratesElaborated CelsusPeruvian Bark in therapy 17th CenturyQuinine 1820Man to Mosquito Cycle Sir Ronald Ross 1998-99
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Definition Complication of
plasmodium
falciparum Unarousable
coma more than30 mts
Exclusion of othercauses
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Aetio Pathogenesis
Sequestration ofCerebral Capillaries
and Venules
Ring like lesions in the Brain
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Mechanical Hypothesis
P. falciparum parasites in brain capillary
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Section of brain showing blood vessels
blocked with developing
P. falciparum parasites
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Selective Cytoadherance results in rosetting
Reduction of Microvascular Blood flow
Hypoxia
Dose not explain selective absence of Neurological Deficits
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Humoral Hypothesis
Malaria Toxin
Stimulates Production of TNF- alpha &Cytokines
Stimulate Endothelial cells
Uncontrolled production of NO COMA
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c
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CLINICAL MANIFASTATIONS
The seasonal Trend
0
1
3
4
7
6
12
13
17
11
17
11
0
1
2
3
4
5
6
7
8
9
10
11
1213
14
15
16
17
Jan Fe b Mar Apr May June July Aug Sept Oct Nov Dec
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Earliest Manifestations - Fever
Loss of Appetite
Vomiting Cough
Specific for Cerebral Malaria
Impaired consiousness Gen. Convulsion with Sequelae
Coma
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Coma Scale for ChildrenBest Motor response Localizes painful stimulus 2
Withdraws limb from pain 1
Non-specific or Absent
response 0
Verbal Response Appropriate Cry 2Moan or Inappropriate cry 1
None 0
Eye Movements Directed 1
(e.g. follows mothers face)Not directed 0
Total 0-5
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Associated Presentation
Hypoglycaemia
Metabolic Acidosis
Shock Neurological
deficits
Other forms canCo-exist
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LABORATORY
DIAGNOSIS
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Diagnosis of Falciparum Malaria
Conventional Microscopy
Giemsa Stain
Field Stain
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Stages of P. falciparum
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LABORATORY DIAGNOSIS
Contd. Fluorescence Microscopy (QBC)
Nucleic Acid Staining with acridine
Parasite Count = (TLC / Cuml X Parasite /100 WBC) / 100 = Parasite / Cuml of Blood
Serology
Anti body detection
Antigen detection (HRP) Biochemical Test - Optimal test (Parasite
LDH)
PCR & Culture
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CEREBRAL
INVOLVEMENT
Clinical
CSF - Increased Lactic Acid
CT, MRI
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THOUGHTS AT BEDSIDE
Haemoglobin
Urobilinogen
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THERAPEUTIC OPTIONS
CHEMOTHERAPY
QuinineArtemisinins - Artesunate
- Arte- ether - Arte - mether
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SUPPORITIVE &
ADJUNCTIVE THERAPY Nursing Care Catherization Nasogastric tube
Fluid & Electrolyte Monitor level of coma & vital signs Antipyretics Anticonvulsants
Reduction in ICT Correction of Hypoglycaemia Exchange Transfusion IncreaseMicrocirculatory Flow - Pentoxyfylline Desferrioxamine Correction of - Anaemia, Acidosis,
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NEWER HORIZON
Inhibition of Endothelial Activity - LMP 420 - Decrease of TNF alpha& LT activity
Vaccine Development
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