Malaria ke Types, Symptoms aur Treatment
Malaria ke Main Types
Malaria chheh Plasmodium species se hota hai jo humans ko infect karte hain: P. falciparum, P. vivax, P. ovale (wallikeri aur curtisi), P. malariae, aur P. knowlesi 1. In mein se P. falciparum sabse zyada dangerous hai aur severe malaria ka main cause hai, jo 90% malaria deaths ke liye responsible hai 2.
Species-wise Classification:
- P. falciparum: Sabse severe form, sub-Saharan Africa mein predominant, rapidly progressive complications cause karta hai 2
- P. vivax: "Benign tertian malaria" kehte the, lekin ab pata chala hai ki ye bhi severe ho sakta hai 3
- P. ovale (wallikeri aur curtisi): Liver hypnozoites form karta hai, relapse cause kar sakta hai 1
- P. malariae: Chronic infection cause karta hai 1
- P. knowlesi: Simian malaria, Southeast Asia mein humans ko infect karta hai 1
Symptoms aur Clinical Differentiation
Uncomplicated Malaria ke Symptoms:
Malaria ke symptoms non-specific hote hain: fever, headache, chills, nausea, vomiting, aur diarrhea 1. Fever ki presence likelihood ratio 5.1 hai diagnosis ke liye, jabki absence mein malaria unlikely ho jata hai (LR 0.12) 1.
Common laboratory findings:
- Thrombocytopenia (sabse common - all species mein) 3
- Mild anemia 1
- Hyperbilirubinemia 3
- Normal ya mildly elevated WBC 1
Severe (Complicated) Malaria ke Criteria:
WHO criteria ke according, ek bhi criterion present hone par severe malaria diagnose hota hai 1. P. falciparum severe malaria ka main cause hai, lekin P. vivax aur P. knowlesi bhi severe disease cause kar sakte hain 1.
Clinical Criteria:
- CNS involvement: Glasgow Coma Scale <11, multiple convulsions (>2 in 24h), prostration 1
- Cardiovascular: Shock (BP <80 mmHg systolic) 1
- Respiratory: Pulmonary edema, ARDS (PaO2 <60 mmHg ya SpO2 <92%) 1
- Renal: Acute renal failure (creatinine >3 mg/dL, urine output <400 mL/24h) 1
- Bleeding: Recurrent bleeding from nose, gums, venipuncture sites 1
Laboratory Criteria:
- Severe anemia: Hemoglobin <7 g/dL with parasite count >10,000/mL 1
- Acidosis: pH <7.35 ya bicarbonate <15 mmol/L 1
- Hyperlactatemia: Venous lactate >5 mmol/L 1
- Hypoglycemia: Blood glucose <40 mg/dL 1
- Hyperparasitemia: >5% (non-immune), >10% (semi-immune) 1
- Jaundice: Bilirubin >3 mg/dL with parasite count >100,000/mL 1
Species-specific Differences:
- P. vivax: Same criteria as P. falciparum, lekin specific parasite density threshold nahi hai 1
- P. knowlesi: Jaundice threshold >20,000/mL parasite density, severe disease >100,000/mL 1
Treatment Regimens
Uncomplicated P. falciparum Malaria:
First-line treatment artemisinin-based combination therapy (ACT) hai - artemether-lumefantrine (AL) ya dihydroartemisinin-piperaquine (DP) 4, 5.
Artemether-Lumefantrine (AL):
- Dosing: 4 tablets at 0 hours, 4 tablets at 8 hours (day 1), phir 4 tablets twice daily days 2-3 4, 5
- Critical: Fatty meal ke saath lena mandatory hai adequate absorption ke liye 4, 5
- Efficacy: 96-98.4% cure rate 5
- Side effects: Headache, vertigo, digestive disorders, QTc prolongation 6
Dihydroartemisinin-Piperaquine (DP):
- Dosing: 3 tablets daily for 3 days (36-75 kg) ya 4 tablets daily for 3 days (>75 kg) 4, 5
- Critical: Fasting condition mein lena hai 4, 5
- Advantage: P. vivax recurrence prevention mein AL se better (RR 0.32) 4
Second-line Options:
- Atovaquone-proguanil: 4 tablets daily for 3 days, fatty meal ke saath 4, 5
- Quinine sulfate + doxycycline: Quinine 648 mg (2 capsules) every 8 hours for 7 days + doxycycline 100 mg twice daily for 7 days 7
Important Caveat: Quinine Southeast Asia se acquired P. falciparum ke against use nahi karna chahiye resistance ki wajah se 5. Quinine serious adverse effects cause karta hai including cinchonism, hypoglycemia, thrombocytopenia 5, 7.
Uncomplicated P. vivax, P. ovale, P. malariae:
Chloroquine-sensitive regions mein chloroquine first-line hai: total dose 25 mg base/kg over 3 days 4, 8.
Critical: P. vivax aur P. ovale ke liye, blood schizontocidal treatment ke saath 8-aminoquinoline (primaquine ya tafenoquine) dena mandatory hai liver hypnozoites eliminate karne ke liye 1, 4.
Primaquine Dosing:
- G6PD testing mandatory hai before starting 4, 6
- Standard dose for radical cure 4
- Mild-moderate G6PD deficiency (30-70% activity) mein: 45 mg once weekly for 8 weeks 4
- Pregnancy mein contraindicated 4
Severe Malaria:
Intravenous artesunate first-line treatment hai for all severe malaria 4, 5.
IV Artesunate Protocol:
- Dosing: 2.4 mg/kg IV at 0,12, and 24 hours, phir daily until parasite density <1% 4, 5
- ICU admission mandatory 1
- Monitoring: Parasitemia every 12 hours until <1%, phir every 24 hours until negative 1
- Transition: Jab patient clinically improve ho aur oral medication le sake, tab full course oral ACT complete karo 4, 5
Post-treatment Monitoring:
Post-artemisinin delayed hemolysis (PADH) monitoring mandatory hai days 7,14,21, and 28 par 4, 6, 5. PADH 37.4% patients mein hota hai 4.
If IV Artesunate Unavailable:
- IV Quinine: 20 mg salt/kg over 4 hours (loading dose), phir 10 mg/kg over 4 hours every 8 hours 5
Pregnancy Mein Treatment:
Artemether-lumefantrine all trimesters mein safe hai WHO aur CDC ke according 4, 5. Multiple trials mein congenital malformations ya miscarriage ka association nahi mila second/third trimester mein 4.
Common Pitfalls aur Caveats:
AL ke saath fat intake ensure karna: Failure to do so subtherapeutic levels aur treatment failure cause karta hai 4, 6, 5
Delayed diagnosis: P. falciparum ka delayed diagnosis mortality significantly increase karta hai 5
QTc prolongation: Both AL aur DP QTc prolong karte hain - patients at risk ya QTc prolonging medications le rahe hain unme avoid karo 4, 6, 5
G6PD testing: Primaquine/tafenoquine dene se pehle G6PD deficiency test karna mandatory hai severe hemolysis prevent karne ke liye 4, 6
Parasitemia thresholds: Different guidelines 2-5% threshold use karte hain severe malaria define karne ke liye - non-endemic regions se patients mein lower threshold (2%) use karo 1
P. vivax ko benign mat samjho: Clinical features aur complications P. vivax mein P. falciparum jitne severe ho sakte hain 3