Severe malaria and its management

Introduction

Malaria is a major health problem in the tropical and subtropical regions throughout the world. It is a communicable protozoa disease caused by sporozoon of the genus plasmodium and transmitted to man by species of infective female anopheles mosquito that is the vector. Plasmodium falciparum infection which is the most deadly form of disease has been found to be the major cause of malaria. In Africa, malaria kills 3,000 children under the age of five everyday (WHO FACT FILE 2014).Pregnant women are more susceptible than the general population to malaria. They are more likely to become infected, suffered a recurrence, develop complications and to die from the disease. Malaria contributes very significantly to maternal and fetal mortality with at least 10,000 maternal deaths per annum attributable in sub-Sahara Africa (Nursing Digest, 2014).Subclinical infection is common in area where natural immunity is high (e.g. sub-Sahara Africa), whereas symptomatic cases are more common in areas with low immunity e.g. Asia, South Africa (Nursing Digest, 2014). Globally, about 125 million women are at risk of malaria every year. Malaria makes a large but unquantifiable contribution to low birth weight in infant in the developing world, a major cause of morbidity and mortality in infants and children (Nursing Digest, 2014).

Malaria could be acute or chronic. When it is acute it is sudden and when chronic it is gradual. It is a worldwide disease mostly found in areas where there are mosquitoes, in tropical and sub-tropical areas and also when large populations (people) are infected, for example South Africa (Basavanthappa, 2008). It can be transmitted by the bite of infected Anopheles mosquitoes, namely, Anopheles Gambiae, Anopheles Puntulatus, Anopheles Darling and Anopheles Funestus (R.O.Mastapha, 2009).There are control and preventive measures used in reducing large number of mosquitoes and those infected people. These measures are as follows; the use of insecticide spray, skin repellant, screening and suppressive drugs (Basavanthappa, 2008). The duration of an attack of malaria is modified by the presence of the individual’s resistance or immunity to effect infection. In endemic areas, malaria is rare in young indigenous infants, but is increasingly common and severe after the first few months of life. Mosquitoes bite more in the evening and at night and all age groups are susceptible. The incubation period is usually between 12-14 days for plasmodium falciparum. In Nigeria efforts have been made in the area of eradication of malaria. The insecticide treated nets are now used in killing infected mosquitoes, which are responsible for transfer of parasite.

Definition of malaria

• Malaria can be defined as a notifiable disease caused by malaria parasite called plasmodium.
• Malaria can also be defined as a communicable disease characterized by fever, rigor caused by plasmodium parasite (Mustapha, 2009).

Causes of malaria

The cause of malaria is plasmodium parasite. There are different types of plasmodium species that cause malaria. These include:

• Plasmodium Falciparum
• Plasmodium Vivax
• Plasmodium Malaria
• Plasmodium Ovale

Plasmodium falciparum:  Plasmodium falciparum can also cause malignant tertian malaria and most serious among all types. The onset is gradual and remittent or irregular. The erythrocyte cycle takes between 36-48 hours. The clinical manifestation differs from individual to individual and they include mental confusion, anorexia, diarrhea and headache. It affects different organs such as cerebrum leading to cerebral malaria and cerebral malaria can lead to convulsion, delirium and coma.

Plasmodium vivax:   This is mainly in the tropics, subtropics and in some temperate regions. This type cause benign tertian malaria. It does not respond easily to treatment regimen. The erythrocytic cycle take 48hrs. The incubation period may be longer than that of plasmodium falciparum.

Plasmodium malariae:  This type is much less common, is especially in East and West Africa, India and Ceylon etc. It is caused by quartan malaria. The disease is commoner than tertian but responds well to treatment. Haematuria, oedema usually appear during the course (Basavanthappa, 2008).

Plasmodium ovale:   This is found regularly and common in central Africa and South America. It causes ovale malaria. The erythrocytic cycle takes 48hrs as in plasmodium vivax. Infection with this type of plasmodium ovale tend to be mild than those caused by plasmodium vivax.

Factors influencing the growth and development of mosquitoes

• Mosquitoes breed more in containers that are holding water which are found in our surrounding (around house).
• Bushes around our houses help in the growth of mosquitoes.
• Mosquitoes are found in dirty, unventilated and dark houses.
• Stagnant water around the house (Akinsola, 2003).

Mode of transmission

It is transmitted by the bites of infected female anopheles mosquitoes, which it injects sporozoites into an individual who is infected.

By the use of contaminated syringes and needles.

Congenital transmission from mother to child.

It can also be transmitted by blood of an infected person to another person.

Malaria cycle

The complete cycle of the human malaria parasite, consist principally of two stages namely (Ukwuije, 2015):

• A period of development within mosquitoes when the infective spororozoites are formed in the blood of mosquitoes by union of male and female gametocytes. This stage is called the sexual stage.
• A period of infection in man. These are cycles which involve erythrocytic cycle and exoerythrocytic cycle. It is known as asexual stage. When mosquito bites an individual with malaria it then feeds on the blood. The male and female gametocytes of plasmodium in the human blood enter the mosquito’s stomach where they unite and multiply and form sporozoites which develop in 8 – 36 hours. Sporozoites enter the insect’s salivary glands and inject into another human during mosquito bites. Sporozoites quickly enter the new hosts liver remain there for 7 – 9 days and further developed to mosquitoes. Merozoites are then liberated into blood stream and parasitize the red blood cell.

Pathophysiology of malaria

Malaria is a communicable disease characterized by rigor, fever caused by plasmodium parasite. Malaria occurs whenever the female anopheles mosquito injects the sporozoites of these parasites into the blood stream for about 30 minutes, these sporozoites then enters the liver cells to stay. In this stage it is called pre-erthrocytic phase of development. The presence of the sporozoites in the liver inflamed the cells causing hepatitis (Mustaphat, 2009). There is also proliferation of the reticulo-endothelial cell (especially in the liver, spleen and bone marrow) leading to enlargement of the liver (hepatomegally) and spleen (splenomegally) with tenderness. The liver cell then burst to release merozoites and toxins into the blood stream. Some of these merozoites enter fresh red blood cell to start up the erythrocytic phase. The red blood cells then mature to release these parasites into the blood stream. The destruction of red blood cells leads to anaemia causing tiredness and the clients complains of pain in the legs and joints due to the inflammatory phase of the parasite toxins in the body. The rigor starts with intense cold leading to a feeling of hotness and dryness of the skin. The body temperature may rise to 39.4⁰C to 40.0⁰C.This is due to parasites and their toxins acting as pyrogens and endogenous pyrogens resetting the thermostat in the in the heat regulating centre in the hypothalamus, causing more production of body heat which may lead to the irritation and poisoning of the brain tissue by parasite toxins (Mustaphat, 2009). In malaria caused by falciparum (plasmodium), the severe haemolysis can lead to jaundice, the presence of toxins along the gastrointestinal tract through the systematic circulation irritate the muscular layers causing increased peristalsis lead to diarrhea; in some people the toxins can also irritate the gastric mucosa and vomiting centre in the hypothalamus causing vomiting. In severe terminal stage, individual present with cerebral manifestation like delirium leading to coma due to blockage of the tiny cerebral blood vessels by the parasite toxins and debris of the impaired red blood cells (Mustaphat,2009).

Clinical manifestation of malaria

Malaria has different stages of manifestation which includes:

1. Hot stage
2. Cold stage
3. Seat stage

Hot stage includes:

1. Nausea and vomiting
2. Delirium
3. Convulsion

Cold stage includes the following:

1. Fever
2. Headache
3. Shivering Rigor (chills)

Sweat stage includes:

1. Profuse sweating (Diaphoresis)
2. Hypothermia
3. Diarrhea
4. Joint pain

Other clinical manifestations include the following:

1. General weakness of the body
2. Loss of appetite
3. The onset is gradual with fever
4. Slow pulse rate
5. Fast respiration
6. Cough
7. Anorexia

Complications of malaria

The complications of malaria include the following:

1. Anaemia due to destruction of red blood cells (Nursing Digest, 2014).
2. Septicaemia due to absorption of toxins into the general circulation.
3. Osteomyelitis occurs as a result of toxins affecting bones.
4. Hepatomegally due to proliferation of the reticular endothelial cells in the liver.
5. Convulsion occurs due to the resetting of the heat regulating centre in the hypothalamus in the brain.
6. Coma due to the blockage of the tiny cerebral blood vessels by parasitic toxins.
7. Febrile convulsion.
8. Malaria in pregnancy causing abortion and low birth weight.
9. Black water fever.

Diagnostic evaluation

The diagnostic evaluation is as follows:

1. Peripheral blood smear – This can reveal the presence of malaria parasite in the blood, which includes two forms mainly;
2. Dry thick smear stained with giemsal’s or field stain on the glass slide.
3. A thin smear of finger tip blood on a glass slide stained with weight’s or geimsal’s stain, which shows parasitized erythrocytes at the edge of the smear (Basavanthappa, 2008).

The morphology of the species of malaria parasite can be easily identified as follows;

1. Plasmodium Vivax: There is an enlarged pale which may contain diffused bright red cell dots (schaffner’s dots) and manifested in a wide variety of shape and size.
2. Plasmodium Ovale: This contains red blood cell parasite and it is ovale but it seems to be or resembles plasmodium vivax.
3. Plasmodium Falciparum: This is ring shape and very small, which may contain one chromatin dot and which lying against the margin of the cell.
4. Plasmodium Malariae: These Red Blood Cells are of normal size and not dots. The parasite is bound and form around central pigment.
5. Clinical manifestations: This involves the manifestation of fever, headache, nausea and vomiting, weakness and diarrhea.
6. Residence history: Is taken in the endemic area, previous attack and some exposure to blood transfusion.
7. Serologic test: Reveals the species and detects occult malaria in the blood stream. It is useful in the epidemiological study rather than diagnostic purpose.

General management of malaria

This includes:

Analgesics:   Paracetamol are prescribed to relieve pain and help for reduction of elevated temperature.

Anti-malaria:  e.g. Coartem are prescribed to inhibit the development and multiplication of malaria parasites.

Anti-biotic:  e.g. Septrin are prescribed in its condition to combat any infection which the client might be exposed to.

Drug therapy

Drug therapy of malaria is aimed at suppression, treatment of established disease or prevention of relapses and prophylaxis (Nursing Digest, 2014).

Supression

It prevents or inhibits erythrocytic stage and therapy could prevent clinical features. There are drug of choice for suppression of symptoms. Examples includes pyrimethamin (daraprim) is used in this part of the world (Basvanthappa, 2008).

Treatment of established disease

There are some drugs for the treatment of acute and chronic attack which are aimed at the inhibition of the multiplication of parasites at the erythrocytic phase thereby avoiding the clinical symptoms examples are fansidar, artemisines, quinine, artesunate e.t.c. It can be used in combination when it is chloroquine resistant malaria (plasmodium falciparum).

References

Akinsola H.A (1993), A to Z of community Health and Social Medicine in Medical and Nursing Practice, 1^st edition Ch. 4, pg. 32.

Anne W., Willson G., (2006), Anthony and Physiology in health and illness. Churchill Livinstone , 10^th edition, Ch. 15, pg 761.

Federal Ministry of Health (2005), National Guidelines and strategies for malaria prevention and Control during pregnancy.

Londermilk D., Shannon P., (2007), Maternity and Women’s Healthcare, Mosby Elseveier, 9^th, Edition, Ch. 13, pg. 328.

Mustapha R.O.(1999),A Path to Success for Student Nurses to the Final Quality Nursing Exams. Adewumi Printing Press, 1^st edition.

Nursing Digest.

Ukwuije G.C. (2005), Student’s Guide vol. 1, our Saviour Press Limited, pg.436.