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Microsoft word - 5-mode of presentation and susceptibility to treatment of malaria in children at thal, a remote area of kp

Mode of Presentation and Susceptibility to Treatment of Malaria in Children at Thal, …
Mode of Presentation and
Khawar Kamal*
Mahmood ur Rahman**
Farwa Rizvi***

Susceptibility to Treatment of
Malaria in Children at Thal, a *Combined Military Hospital (CMH)
Remote Area of KP, Pakistan
**Prof. and HOD, Community Med., Army Medical College, Rawalpindi ***Assistant Professor, Community Medicine, Islamabad Medical and ABSTRACT:

Dental College, Bahria University, To determine the mode of presentation and susceptibility to treatment Islamabad
of malaria in children at Thal, a remote area of KP, Pakistan.
Study Design: A descriptive study.
Place and Duration: The study was carried out at Combined Military Hospital Department
(CMH) Thal from Sep 2008 to Aug 2009.
Materials and Methods: A total of 202 children suffering from malaria (diagnosis Pakistan Institute of Medical
confirmed by positive slide examination for malarial parasites by qualified Sciences Islamabad
hematologist) selected by consecutive sampling, were in the study including 138 ****Head of ENT Department
(68%) males and 64 (32%) females with mean age of 7.2 years. Statistics regarding Sciences Islamabad
age, gender, fever duration, clinical signs and response to treatment were
Results: Out of 202, Plasmodium falciparum was detected in 67 (33.2%) cases,
Plasmodium vivax in 135 (66.8%) cases. Fever was present in 100% of cases and
the mean duration prior to diagnosis was 6.7 days. Major symptoms included
vomiting, headache and diarrhea. Splenomegaly was present in majority of cases
(182 out of 202). Artemether was first line therapy in Plasmodium falciparum with
100% success. Chloroquine was given in Plasmodium vivax with 12% failure (all Address for Correspondence
responded to subsequent Artemether).
Dr Farwa Rizvi, Assistant Professor, Community Medicine, Conclusion: Malaria is prevalent in children in Thal and response to standard Islamabad Medical and Dental
treatment remains satisfactory.
Key words: Malaria, Plasmodium vivax, Plasmodium falciparum, Chloroquine, Islamabad.
later in those who have taken anti malarial medications Introduction
as prevention.5Initial manifestations of the disease are similar to flu-like symptoms,6 and can resemble other Malaria is a protozoal disease caused by infection with conditions such as septicemia, gastroenteritis, and viral parasites of the genus plasmodium and transmitted to man by certain species of infected female anopheline mosquito.1 Malaria causes symptoms that typically vomiting, hemolytic anemia, jaundice, hemoglobin in include fever and headache, which in severe cases can the urine, retinal damage,7 and convulsions. Malaria is progress to coma or death. The disease is widespread the major health hazard in Pakistan. There is a lot of in tropical and subtropical regions in a broad band dormant water after heavy rains in the country, providing around the equator, including much of Sub-Saharan a perfect setting for mosquito reproduction. In Pakistan, Africa, Asia, and the Americas.2 In many settings of malaria is prevalent from July to November.8 stable malaria transmission, the presence of According to reports, an estimated 247 million malaria asymptomatic malaria parasite carriers is common and cases among 3.3 billion people were at risk in 2006, the definition of clinical malaria remains uncertain.3 The causing a million deaths, mostly children under 5 years signs and symptoms of malaria typically begin 8–25 and 109 countries were endemic for malaria in 2008. 9, 10 days following infection;4 however, symptoms may occur Mode of Presentation and Susceptibility to Treatment of Malaria in Children at Thal, … In Indian sub continent the majority of malaria infections clinically palpable in 182 (90%) cases whereas are contributed by P. falciparum and P. Vivax.11, 12 significant hepatomegaly was detected only in 32 In Pakistan Southern Punjab, Baluchistan and Sind are (15.8%) cases. Clinically pallor was present in 73 (36%) endemic areas. This study was carried out to determine cases (67 out of 67 falciparum infection and 6 out of 135 the mode of presentation and susceptibility to treatment of vivax infections). Presence of Splenomegaly and pallor are graphically shown in Fig 1 and 2 respectively. Materials and Methods
This descriptive study was carried out from Sep 2008 to Aug 2009 at the Department of Pediatrics, Combined Military Hospital (CMH) Thal. Study population comprises of 202 children who were diagnosed as cases of malaria at children ward of our hospital. Informed consent was taken from parents of the children (patients). Principles of respect for the person, beneficence and justice were strictly observed. Detailed history from parents and patients especially history of fever, rigors and chills, vomiting, headache, generalized body aches, convulsions, cough and diarrhea was recorded on specifically designed Performa. The age range was 2-12 years with mean age of 7.2 years. After history and complete clinical examination, three consecutive blood samples for thick and thin peripheral Figure 1: Splenomegaly in cases
blood smears were analyzed. Patients with positive results were included in the study. The thick smear was stained by Giemsa's stain and thin smear by Leishman's stain. The slide was then studied under oil immersion lens (x1000) of the microscope. The parasites were quantified by independently counting asexual and sexual stages of both P. falciparum and P. vivax parasites against 300 white blood cells (WBCs) on the thick smear. Parasite density was done to classify the patients as mild, moderate, high and very high parasite density. First line of treatment was Chloroquine in cases with Plasmodium vivax whereas Artemether in cases with Plasmodium falciparum. Response to treatment was also recorded meticulously, and a total of three a febrile days and disappearance of other symptoms were Total 202 children were included in this study over a Figure 2: Presence of anemia in malaria cases
period of one calendar year. Study population comprised 68% male and 32% female with mean age of Anemia and thrombocytopenia were detected in majority 7.2 (2-12) years. Plasmodium falciparum was detected of cases with P. falciparum as shown in table I. in 67 (33.2%) cases whereas Plasmodium vivax in 135 Artemether was given as first line therapy in cases with (66.8%) cases. No case of mixed smear was detected. Plasmodium falciparum with 100% success. Fever was present in 100% of cases with mean duration Chloroquine was given as first line drug in cases with before diagnosis was 6.7 days and range was 1-25 Plasmodium vivax with 12% failure (all responded to days. Chills and rigors were present in 77 (38.1%) subsequent Artemether). Fever, chills, and rigors were cases. Other major symptoms included vomiting 44 settled initially followed by vomiting, diarrhea, headache (21.8%), headache 39 (19.3%), body aches 39 (19.3%) and body aches. The duration of response to treatment and diarrhea 35 (17.3%) cases. Only 5 (2.5%) cases was short except in those cases that were resistant to presented with fever and fits, diagnosed subsequently chloroquine. There was no adverse effect of treatment as cases of cerebral malaria. Splenomegaly was Mode of Presentation and Susceptibility to Treatment of Malaria in Children at Thal, … Table I: Blood counts in cases
nausea, vomiting, and diarrhea may also occur. The classic symptom of malaria is cyclical occurrence of sudden coldness followed by rigors, fever and sweating lasting four to six hours, occurring every two days in P. vivax and P. ovale infections, while every three days for P. malariae.18 In this study fever was present in 100% of cases. Chills and rigors were present in 77 (38.1%) cases. Vomiting 44 (21.8%), headache 39 (19.3%), body aches 39 (19.3%) and diarrhea 35 (17.3%) cases. Only 5 (2.5%) cases presented with fever and fits, diagnosed subsequently as cases of cerebral malaria caused by P. falciparum. P falciparum can have recurrent fever every 36–48 hours or an almost continuous fever. Malaria causes hemolysis with anemia and jaundice. Plasmodium falciparum, may cause renal failure, seizures, mental confusion, coma, and death.13 Discussion
A study in Uganda revealed that one in four children develop cognitive abnormalities after cerebral malaria.14 Malaria is a cause of mortality and morbidity in The presentation of malaria is similar in endemic areas developing countries, where children and pregnant but there may be divergent symptoms in migrant people. women are the primary target. Malaria is a mosquito- This may lead to misdiagnosis when splenomegaly is borne disease caused by the Plasmodium parasite 13. not obvious, or when diarrhea, vomiting or cough is Malaria is a major health problem in Pakistan and areas adjoining Afghanistan-Pakistan border due to inefficient Confirmed diagnosis of malaria is microscopic use of anti-malarial drugs, misdiagnosis and inadequate examination of blood films as each of the four major parasite species has distinguishing characteristics. Thin The study was carried out at Thal city, the last out post films allow species identification as the parasite's of settled area. The patients were received from khost appearance is best preserved in this preparation. Thick province of Afghanistan, kurram, orakzai, South films allow screening larger amount of blood and are Waziristan agencies and district Hangu. A 12 month eleven times more sensitive than the thin film, so picking study was conducted based on positive blood slides for up low levels of infection is easier on the thick film, but parasitemia. Plasmodium vivax was the predominant the appearance of the parasite is much more indistinct organism throughout the study period with no seasonal and therefore distinguishing between the different species can be trickier. It is vital to utilize both smears The studies carried out in Uganda, Ghana and other parts of the world revealed that the maximum Of all anti malarial drugs, Chloroquine has been the hematological deterioration occurs in malaria caused by drug of choice for many years in the world. However, plasmodium falciparum14 and the same was the result in resistance of Plasmodium falciparum to Chloroquine has our study. Chloroquine resistance was absolute in P. spread from Asia to Africa, making it ineffective against the most hazardous Plasmodium strain in parts of the Each year 350-500 million cases of malaria occur world. In areas where Chloroquine is still effective it worldwide and over one million people die, most of them remains the first choice. Extracts of Artemisia Annua, are young children in Africa. 13A study carried out by containing the compound artemisinin or semi-synthetic Snow RW etal revealed that in 2005, there were almost derivatives offer over 90% efficacy rates. We used 515 million cases of P. falciparum malaria in 2002.15 Chloroquine as first line treatment in cases with P vivax Both Plasmodium vivax and falciparum are prevalent in (12% failure subsequently treated with Artemether) and Pakistan.16 In this study P. falciparum was diagnosed in Artemether in cases with P. falciparum with 100% 67 (33.2%) cases and P. vivax was diagnosed in 135 success. Five cases of cerebral malaria were also (66.8%) cases. According to a recent report Chloroquine successfully treated with intramuscular Artemether. remains the drug of choice in P. vivax malaria in the Cerebral malaria is usually treated with IV Quinine or IM region of south Asia. 17In this study the cases of P. vivax Artemether. A study carried out in Pakistan revealed malaria were treated by chloroquine as the drug of that there was 11% mortality in cases of cerebral choice and the failure rate was only in 12% of cases malaria, treated with IV quinine but in our study mortality who were treated with Artemether successfully. rate was 0% as all the five cases of cerebral malaria Symptoms of malaria include fever, flu-like illness, chills, headache, muscle aches, and tiredness. Cough, Mode of Presentation and Susceptibility to Treatment of Malaria in Children at Thal, … Drug resistance, lack of compliance in children, multiple 8. Khadim MT. Malaria a menace at Zhob Garrison. Pak Armed Forces drug therapy, cross-resistance, positive selection and genetic influence of drugs are primary hurdles in 9. Farooq MA, Salamat A, Iqbal MA. Malaria – An Experience at CMH Khuzdar (Baluchistan). J Coll Physicians Surg Pak 2008; 18:257-8. treatment.22 Artemether and Quinine are commonly 10. World Malaria report 2008. Available at used for treating severe malaria caused by P.
falciparum. There was 100% success for Artemether in our study in treating P. falciparum malaria and as rescue 11. Dhiman S, Goswami D, Rabha B, Gopalakrishnan R, Baruah I, Singh therapy in P. vivax malaria. In view of its good L. Malaria epidemiology along Indo-Bangladesh border in Tripura performance by intramuscular injection, Artemether state, India. Southeast Asian J Trop Med Public Health. 2010; appears to be an excellent alternative for treatment of severe malaria and cerebral malaria in areas with poor 12. Sharma SK, Chattopadhyay R, Chakrabarti K, Pati SS, Srivastava VK, Tyagi PK, Mahanty S, Mishra SK, Adak T, Das BS, Chitnis C. Epidemiology of malaria transmission and development of natural Conclusion
immunity in a malaria- endemic village, San Dulakudar, in Orissa state, India. Am J Trop Med Hyg. 2004; 71(4):457–465. 13. Malaria. Available at Cited on 28 feb 2009 Presentation of malaria in this region is similar to 14. Cserti-Gazdewich C, Dhabangi A, Musoke C, Nabukeera-Barungi N, other endemic areas and resistance to drugs is Ddungu H, Mpimbaza A, Ssewanyana I et al. Hematologic Findings and Transfusion Therapy in Severe Pediatric Plasmodium Falciparum Malaria: Results from a Prospective Observational Study in Uganda. References
December 8, 2008, 50th ASH annual meeting and exposition, San Francisco. 1. Park K. Park’s text book of preventive and social medicine, Banarsidas 15. Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI. The global Bhanot Publisher, Prem Nagar, Jabalpur,2010;222. distribution of clinical episodes of Plasmodium falciparum malaria. 2. Nayyar GML, Breman JG, Newton PN, Herrington J (2012). "Poor- quality anti malarial drugs in southeast Asia and sub-Saharan 16. Khan MA, Smego RA, Rizvi ST, Beg MA. Emerging drug-resistance Africa". Lancet Infectious Diseases 12 (6): 488–96. and guidelines for treatment of malaria. J Coll Physicians Surg Pak 3. Mabunda S, Aponte J J, Tiago A, Alonso P. A country-wide malaria survey in Mozambique. II. Malaria attributable proportion of fever and 17. Leslie T, Mayan MI, Hasan MA, Safi MA, Klinkenberg E, Whitty CJ et establishment of malaria case definition in children across different al. Sulfadoxine-Pyrimethamine, hlorproguanil-Dapsone, or Chloroquine epidemiological settings. Malaria Journal 2009, 8:74. for the Treatment of Plasmodium vivax Malaria in Afghanistan and 4. Fairhurst RM, Wellems TE (2010). "Chapter 275. Plasmodium species Pakistan: A Randomized controlled Trial. JAMA 2007;297:2201-9 (malaria)". In Mandell GL, Bennett JE, Dolin R (eds). Mandell, 18. Malaria life cycle & pathogenesis. Malaria in Armenia. Available at. Douglas, and Bennett's Principles and Practice of Infectious Cited on December 2008. (7th ed.). Philadelphia, Pennsylvania: Churchill 19. Jamal MM, Ara J, Ali N. Malaria in pediatric age group: a study of 200 cases. Pak Armed Forces Med J:2005;55:74-7. 5. Nadjm B, Behrens RH (2012). "Malaria: An update for physicians”. 20. White NJ. Antimalarial drug resistance. J Clin Invest 2004;113:1084– Infectious Disease Clinics of North America 26 (2): 243–59. Bartoloni A, Zammarchi L (2012). "Clinical aspects of uncomplicated Din JU, Khan SA, Ally SH. Malaria in children: study of 160 cases at a and severe malaria". Mediterranean Journal of Hematology and private Clinic in Mansehra. Ayub Med Coll Abbottabad 2006;18:44-5 Infectious Diseases 4 (1): 2012-026 22. John CC, Bangirana P, Byarugaba J, Opoka RO, Idro R, Jurek AM et al. Cerebral Malaria in Children Is Associated With Long-term Beare NA, Taylor TE, Harding SP, Lewallen S, Molyneux ME (2006). "Malarial retinopathy: A newly established diagnostic sign in Cognitive Impairment. Pediatrics 2008:122;e92-e9 American Journal of Tropical Medicine and


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