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Problems In Management Of Severe Malaria

机译：严重疟疾管理中的问题

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Malaria has become a major global problem affecting more than 2000 million population and causing 1.5 million deaths annually 1. In India the problem is enormous and almost half of the population is exposed to this dreadful disease. During the last decade, there has been a resurgence of malaria in India which has affected the economic growth by denting the national exchequer as well as causing deaths in thousands2. Malaria in India usually affects mostly patients who are at the prime of their life. It is a matter of great concern that the country is losing these people who could have been saved by prevention of malaria transmission, by early diagnosis or by instituting early therapy. Whenever, a case of malaria is adequately and successfully treated, malaria does not usually have a residual deficit and these patients recover fully. Introduction Malaria, particularly pernicious malaria (falciparum malaria) poses a diagnostic dilemma at early stage as the disease can mimic many other conditions1. Even after proper diagnosis, it can pose problem due to associated complications which unless anticipated earlier or diagnosed at proper stage can cause death. The aim of WHO's Roll Back Malaria programme has been early diagnosis and prompt treatment to reduce the mortality to a great extent. There is a great need for early diagnosis and recognition of the complications of malaria at local centre, and if warranted, to be sent to a higher centre for management of the complications at an early stage to avoid mortality due to complications. There are certain difficulties in the diagnosis and management of malaria. We like to make a brief review of these issues. Difficulty In The Diagnosis And Treatment Of Malaria Diagnosis is the most important part of management. Diagnosis of malaria may be missed purely for technical reasons 1 inadequate smear faulty microscopy faulty staining dirty slides wrong buffer pH contaminated or deteriorating stain inexperienced technical hands inadequate time spent in examining the slide faulty storage of the blood before preparation of slide anticoagulants may interfere in interpretation Difficulty in identifying falciparum parasites in mixed infection ( vivax and falciparum) There may be cleared parasitemia from the peripheral blood due to treatment posing difficulty in establishing diagnosis. In this circumstance immunochromatographic tests may be useful 3. If the patients come at a later stage of the disease when there is a peripheral clearance of parasites but complications like acute renal failure or acute lung injury has set in. Malaria may be missed clinically in the presence of epidemics of dengue, meningitis, viral hepatitis, in patients with haemoglobinopathy, heat hyperpyrexia, alcoholic liver diseases etc 1,2. At times coexisting conditions like cerebrovascular accidents, pneumonia, aspiration pneumonia, meningitis and hepatic coma , diabetic ketoacidosis can often be missed if one is not careful enough. Difficulty in getting the laboratory facility where it is most wanted, like rural or suburban areas; and even if facility is available, the quality of most of the laboratories is questionable. Difficulty in getting biochemical test done at odd hours. Non-oliguric renal failure cannot be diagnosed without a biochemical test. Failure to take a travel history – this aspect is forgotten by the patients as well as physicians. It can lead to missing the diagnosis of malaria. When a patient goes to a high transmission area from a low one, he is at an increased risk of developing severe malaria. If a person leaves an endemic area for a prolonged period, he is at a higher risk to suffer from severe malaria on return. Patients who present to a center without expertise in tropical medicine may receive suboptimal treatment. Improvements in recognition, diagnosis, and treatment of malaria are essential to prevent morbidity and death among travelers 4 . At times there is underestimation of the severity of the di
机译：疟疾已成为影响全球超过20亿人口，每年造成150万人死亡的主要全球性问题。1.在印度，这一问题十分严重，几乎一半的人口都患有这种可怕的疾病。在过去的十年中，印度的疟疾再次流行，这通过削弱国家财政状况并造成成千上万人的死亡，影响了经济增长。印度的疟疾通常会影响大多数处于生命高峰期的患者。令人严重关切的是，该国正在失去这些本来可以通过预防疟疾传播，早期诊断或采取早期治疗而得救的人。只要一例疟疾得到适当和成功的治疗，疟疾通常就不会有残留的缺陷，这些患者可以完全康复。引言疟疾，特别是恶性疟疾（恶性疟疾）在早期阶段就构成了诊断难题，因为该疾病可以模仿许多其他疾病1。即使经过适当的诊断，它也可能由于相关的并发症而引起问题，除非提前预计或在适当的阶段进行诊断，否则可能导致死亡。世卫组织遏制疟疾计划的目标是早期诊断和及时治疗，以在很大程度上降低死亡率。迫切需要在当地中心对疟疾的并发症进行早期诊断和识别，如果有必要，应尽早将其送往上级中心进行并发症的处理，以避免因并发症而导致死亡。疟疾的诊断和管理存在一定困难。我们希望对这些问题进行简要回顾。疟疾的诊断和治疗困难诊断是管理中最重要的部分。可能仅由于技术原因而无法诊断出疟疾1涂片不足，显微镜检查不足，载玻片染色不正确，缓冲液pH值被污染或污渍恶化，技术人员经验不足，在制备载玻片抗凝剂之前检查载玻片血液的时间不足可能会干扰解释混合感染（间体和恶性疟）中恶性疟原虫的鉴定困难。由于治疗难以确诊，可能从外周血中清除了寄生虫病。在这种情况下，免疫色谱法检测可能会有用。3.如果患者在疾病的后期进入，但周围有寄生虫清除，但出现了急性肾衰竭或急性肺损伤等并发症。临床上可能会漏诊疟疾患有血红蛋白病，热性高热，酒精性肝病等患者的登革热，脑膜炎，病毒性肝炎流行1,2。有时并存的疾病如脑血管意外，肺炎，吸入性肺炎，脑膜炎和肝昏迷，如果不足够小心，往往会错过糖尿病性酮症酸中毒。无法获得最需要的实验室设施，例如农村或郊区;即使有设施，大多数实验室的质量也值得怀疑。难以在几小时完成生化测试。如果没有生化检查，则不能诊断出非少尿性肾功能衰竭。未能记录旅行史–患者和医生都忘记了这一方面。它可能导致错过对疟疾的诊断。当患者从低传播区进入高传播区时，他患严重疟疾的风险增加。如果一个人长时间离开流行区，返回时患严重疟疾的风险就更高。在没有热带医学专业知识的情况下到中心就诊的患者可能会得到次优治疗。改善对疟疾的认识，诊断和治疗对防止旅行者发病和死亡至关重要4。有时低估了疾病严重程度

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