A 20-year old male patient was admitted to the male medicine ward with complaints of fever with chills since 1 week, headache, abdominal pain, nausea, vomiting, yellowish sclera, yellowish urine, anorexia, general weakness since 10 days.

1. A CASE STUDY ON MALARIA
(PLASMODIUM FALCIPARUM) WITH
ACUTEVIRAL HEPATITIS
Ajita Sadhukhan
- Pharm D. 3rd year
- Roll No. : 1
- Enrolment No. : 150821207001

2. • MALARIA (PLASMODIUM FALCIPARUM): MALARIA IS A POTENTIALLY
LIFE-THREATENING DISEASE CAUSED BY INFECTION WITH
PLASMODIUM PROTOZOATRANSMITTED BY AN INFECTIVE FEMALE
ANOPHELES MOSQUITO.
• ACUTEVIRAL HEPATITIS IS DEFINED AS INFLAMMATION OF LIVER
CAUSED MAINLY BY HEPATITIS A, B,C OR EVIRUS.
DEFINITION:
2

3. IPD No.: 17015066
Age: 20 years
Weight :56 kg
Department: Male Medicine Ward
Sex: Male
Unit: I
Date of Admission: 27/11/17
Date of Discharge: 1/12/17
Patient Demographics
3

4. C/O FEVER WITH CHILLS SINCE 1WEEK, HEADACHE, ABDOMINAL PAIN,
NAUSEA,VOMITING,YELLOWISH SCLERA,YELLOWISH URINE,
ANOREXIA, GENERAL WEAKNESS →ALL SINCE 10 DAYS
Family Hx : NAD
Social Hx: NAD
Pregnancy Status: NAD
ALLERGIES : NAD
Reason for admission
4

5. PHYSICAL EXAMINATION:
• R: 21/min
• SPO2: 98%
• CVS: S1 S2 AUDIBLE
• RS: AEBE B/L CREPTS
• CNS: NAD
• BP: 100/60 mm Hg
• PR: 100/min
• TEMP: 98 F
• PA: Soft
OBJECTIVES
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6. LABORATORY PARAMETERS OBSERVEDVALUE NORMAL RANGE UNIT
Hb 9.4 11.5-18 g%
WBC 12110 4000-11000 Cells/cu mm
Neutrophils 47 40-70 %
Eosinophils 03 1-6 /cu mm
Lymphocytes 46 20-40 /cu mm
Monocytes 04 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 4.79*10^12 3.8-5.8*10^12 /cu mm
MCH 19.6 27-31 pg
PCV 30.1 40-54 %
MCHC 31.2 32-36 g/dL
MCV 62.9 78-100 fL
Se. Na+ 129 130-145 mEq/L
Se. K+ 4.2 3-5 mEq/L
Se. CREATININE 0.5 0.4-1.5 Mg/dL
Lab. Investigation reports [first day]
6

7. LABORATORY PARAMETERS OBSERVEDVALUE NORMAL RANGE UNIT
PLATELETS 43000 1.5-4*10^5 CELLS/CU MM
AST 118 UPTO 40 IU/L
ALT 116 UPTO 40 IU/L
SER. ALP 63 44-147 IU/L
BILI.TOTAL 12.5 0.2-1.1 Mg/dl
BILI. DIRECT 7.0 0-0.25 Mg/dl
TOTAL PROTEIN 4.9 6-8 g/dl
ALBUMIN 2.7 3.5-5 g/dl
BILI. INDIRECT 5.5 0-0.4 Mg/dl
Lab. Investigation reports [first day contd.]
7

8. LABORATORY PARAMETERS OBSERVEDVALUE NORMAL RANGE UNIT
Hb 8.1 11.5-18 g%
WBC 10620 4000-11000 Cells/cu mm
Neutrophils 47 40-70 %
Eosinophils 03 1-6 /cu mm
Lymphocytes 45 20-40 /cu mm
Monocytes 05 2-10 /cu mm
RBC 3.97*10^12 3.8-5.8*10^12 /cu mm
MCH 20.4 27-31 pg
PCV 25.1 40-54 %
MCHC 32.3 32-36 g/dL
MCV 63.2 78-100 fL
Se. Na+ 129 130-145 mEq/L
Se. K+ 3.9 3-5 mEq/L
platelets 80000 1.5-4*10^5 Cells/cu mm
Lab. Investigation reports [3rd day]
8

9. LABORATORY PARAMETERS OBSERVEDVALUE NORMAL RANGE UNIT
Hb 7.5 11.5-18 g%
WBC 9710 4000-11000 Cells/cu mm
Neutrophils 49 40-70 %
Eosinophils 02 1-6 /cu mm
Lymphocytes 45 20-40 /cu mm
Monocytes 04 2-10 /cu mm
RBC 3.72*10^12 3.8-5.8*10^12 /cu mm
MCH 20.2 27-31 pg
PCV 25.1 40-54 %
MCHC 32.1 32-36 g/dL
MCV 63.4 78-100 fL
Lab. Investigation reports [4th day]
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10. Others:
• Abd. USG: liver size 168 mm hepato, splenomegaly, perocholecystic oedema
• G6PD enzyme: 21.5 (4.6-13.5 U/g Hb)
• PT: 14.7 sec (12.1-17.3)
• INR: 1.08 (0-2)
• APTT: patient’s value: 32.0 sec (30-40) ; control : 29.4 sec
• PS for MP: P. falciparum ring form is seen (heavy parasitaemia)
• Widal test: -ve
• Sickling test: -ve
• Urine analysis: pus cells and RBCs normal
Protein: +1
Bilirubin: +1
Blood: +1
10

11. MALARIA
PROVISIONAL DIAGNOSIS
11

12. • A 20 year old male patient was admitted to Med. ward-1 with complaints of
fever with chills since 1 week, headache, abdominal pain, nausea, vomiting,
yellowish sclera, yellowish urine, anorexia, general weakness → all since 10
days.
• Based on lab report, patient’s Hb, neutrophils (borderline), MCHC, MCH,
MCV, PCV, albumin and serum sodium (borderline) levels are abnormally
decreased. AST, ALT, direct,total and indirect bilirubin, platelets,
lymphocytes, RBC count (increased on 1st day and borderline on the 3rd and
4th days), WBC count (increased on 1st day and borderline on 3rd and 4th
days) and G6PD enzyme are abnormally increased. USG detected hepato,
spleenomegaly and pericholecystic 0edema. PS for MP detected P.
falciparum ring form (heavy parasitaemia).Protein, blood and bilirubin were
detected in urine analysis (+1). Hence, patient was diagnosed with malaria
(Plasmodium falciparum) with acute viral hepatitis. 12

13. FINAL DIAGNOSIS:
MALARIA (PLASMODIUM FALCIPARUM)
WITHACUTEVIRAL HEPATITIS
13

14. ➢ FOR MALARIA :
• To reduce transmission of infection to others by cleansing the infectious
reservoirs.
• To prevent emergence and spread of resistance of anti-malarial
medicines.
➢FOR ACUTEVIRAL HEPATITIS:
To prevent progression of the disease, particularly cirrhosis, liver failure
and hepatocellular carcinoma.
GOALS OFTREATMENT
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15. DAY 1
T: 98 F
P: 100/min
R: 20/min
B.P.: 100/60 mmHg
SPO2: 98 %
RS: AEBE B/L crepts
CVS,CNS, PA: NAD
C/O high grade fever, headache, bodyache, vomiting, abdominal pain, yellowish sclera,
reddish urine, generalised weakness
ADV: CBC, Ser. Creatinine, Na+, K+, G6PD, CXR
15

16. Day 1 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Artenusate 120 mg Stat I.V. 1-0-0 To treat malaria
Tab. Primaquine 45 mg P.O. stat To treat malaria
Tab. Mefloquin 20 mg P.O. Stat To treat malaria
Inj. Pantoprazole 40 mg I.V. 1-0-1 Gastric disturbance
Inj. Ondansetron 4 mg I.V. 1-1-1 To prevent emesis
Tab. Folic Acid 5 mg P.O. 1-0-1 Folate deficiency
Tab. Paracetamol 500 mg P.O. SOS To treat fever
Glucose Powder - P.O. - To provide energy
Inj. NaCl + Multivitamin 1 pint @ 40 ml/hr I.V. 1-0-1 To maintain osmolarity
Inj. Leucovorin 2 cc in 100 ml NS I.V. 1-0-0 Folate deficiency

17. DAY 2
T: 99 F
P: 112/min
R: 28/min
B.P.: 120/80 mmHg
SPO2: 97%
RS: AEBE clear
CVS: S1, S2 +
CNS: NAD
PA: Spleenomegaly, Hepatomegaly
C/O fever, headache, abdominal pain
ADV: full diet (FD)
17

18. Day 2 Medication chart
18
Tab. Primaquine 45 mg P.O. stat To treat malaria
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Artenusate 120 mg Stat I.V. 1-0-0 To treat malaria
Syp. Lactulose 5 ml P.O. 1-0-1 Laxative
Tab. Mefloquin 20 mg P.O. Stat To treat malaria
Inj. Pantoprazole 40 mg I.V. 1-0-1 Gastric disturbance
Inj. Ondansetron 4 mg I.V. 1-1-1 To prevent emesis
Tab. Folic Acid 5 mg P.O. 1-0-1 Folate deficiency
Tab. Paracetamol 500 mg P.O. SOS To treat fever
Glucose Powder - P.O. - To provide energy
Inj. NaCl + Multivitamin 1 pint @ 40 ml/hr I.V. 1-0-1 To maintain osmolarity
Inj.Leucovorin 2 cc in 100 ml NS I.V. 1-0-0 Folate deficiency

19. DAY 3
T: normal
P: 84/min
R: 29/min
B.P.: 110/70 mmHg
SPO2: 95%
RS, CVS, CNS: NAD
PA: Spleenomegaly, Hepatomegaly
ADV: full diet (FD)
19

20. Day 3 Medication chart
20
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Artenusate 120 mg Stat I.V. 1-0-0 To treat malaria
Tab. Primaquine 45 mg P.O. stat To treat malaria
Tab. Mefloquin 20 mg P.O. Stat To treat malaria
Inj. Pantoprazole 40 mg I.V. 1-0-1 Gastric disturbance
Inj. Ondansetron 4 mg I.V. 1-1-1 To prevent emesis
Tab. Folic Acid 5 mg P.O. 1-0-1 Folate deficiency
Glucose Powder - P.O. - To provide energy
Inj. Leucovorin 2 cc in 100 ml NS I.V. 1-0-0 Folate deficiency

21. DAY 4
T: 93.8 F
P: 74/min
R: 20/min
B.P.: 160/100 mmHg
SPO2: 94%
RS, CVS, CNS: NAD
PA: Spleenomegaly, Hepatomegaly
After urination, B.P.: 110/70 mm Hg
ADV: Monitor B.P. every hour
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22. Day 4 Medication chart
22
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Artenusate 120 mg Stat I.V. 1-0-0 To treat malaria
Tab. Primaquine 45 mg P.O. stat To treat malaria
Tab. Mefloquin 20 mg P.O. Stat To treat malaria
Inj. Pantoprazole 40 mg I.V. 1-0-1 Gastric disturbance
Inj. Ondansetron 4 mg I.V. 1-1-1 To prevent emesis
Tab. Folic Acid 5 mg P.O. 1-0-1 Folate deficiency
Glucose Powder - P.O. - To provide energy
Inj. Leucovorin 2 cc in 100 ml NS I.V. 1-0-0 Folate deficiency

23. DAY 5
T: normal
P: 80/min
R: 19/min
B.P.: 140/90 mmHg
SPO2: 98%
RS, CVS, CNS, PA: NAD
ADV: Discharge
23

24. Day 5 Medication chart
24
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Artenusate 120 mg Stat I.V. 1-0-0 To treat malaria
Inj. NaCl + Multivitamin 1 pint @ 40 ml/hr I.V. 1-0-1 To maintain osmolarity
Inj. Pantoprazole 40 mg I.V. 1-0-1 Gastric disturbance
Inj. Ondansetron 4 mg I.V. 1-1-1 To prevent emesis
Tab. Folic Acid 5 mg P.O. 1-0-1 Folate deficiency
Glucose Powder - P.O. - To provide energy
Syp. Lactulose 5 ml P.O. 1-0-1 Laxative

25. DISCHARGE MEDICATIONS
25
DRUG DOSE FREQUENCY NUMBER OF DAYS
Tab. Rbson D (Rabeprazole + Domperidone) - 1-0-1 15
Tab. Diavnerv (Multivitamin) - 1-0-1 15
Tab. FolicAcid 5 mg 1-0-0 15

26. TREATMENT PLAN:
26
• NON-PHARMACOLOGICALTREATMENT:
➢FOR MALARIA:
✓Wear long sleeves, long pants, and fully closed shoes and socks after
dark.
✓Use permethrin-treated mosquito nets.
✓Repellent containing 30-50% DEET should be applied to exposed areas of
skin every 4-6 hours.
➢FOR ACUTEVIRAL HEPATITIS:
✓Vaccination.
✓Liver transplantation.
✓Complete bedrest.
✓Avoid fatty and fried foods.
✓Plenty of fluid.

27. • PHARMACOLOGICALTREATMENT:
➢FOR MALARIA:
WHO recommends arteminism based combination therapies (ACTs). A single dose
of primaquine should be added to reduce transmission of infection.
➢FOR ACUTEVIRAL HEPATITIS:
✓Urodeoxycholic acid 300mg 1-0-1 before food
✓Glucose powder 2tsf 4-6 times a day
✓Laxative

28. ➢DIAGNOSTICTESTS FOR HEPATITIS NOT DONE.
➢SERIOUS → USE ALTERNATIVE:
MEFLOQUINE + ONADANSETRON: BOTH INCREASE QT INTERVAL. AVOID
OR USE ALTERNATIVE DRUG. ECG MONITORING IS RECOMMENDED.
POINTSTO BE INTERVENED WITHTHE DOCTOR
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29. PATIENT COUNSELING
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ABOUT DISEASE
• Malaria (Plasmodium falciparum): malaria is a potentially life-threatening
disease caused by infection with plasmodium protozoa transmitted by an
infective female anopheles mosquito. It has high mortality but on early
diagnosis it is easily curable. Once cured, it does not reoccur.
• Acute viral hepatitis is defined as inflammation of liver caused mainly by
hepatitis A, B, C or E virus. It is curable on early prognosis, otherwise is fatal
and may lead to severe chronic conditions like liver cirrhosis, liver failure, etc.

30. About Medications:
• Dose of drugs
• Frequency of dose
• Route of administrations such as I.V, I.M., t/d, s/c, P.O., S/L.
• Counselling regarding overdose (may cause toxicity), underdose (submaximal or no
response) and missing of dose of medication. E.G. If a dose is missed, then the patient is to
be advised to go for the next dose, otherwise toxicity of drug may occur.
• Contraindications
• Drug interactions (drug-drug, drug-food)
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31. ✓Wear long sleeves, long pants, and fully closed shoes and socks after dark.
✓Use permethrin-treated mosquito nets.
✓Repellent containing 30-50% DEET should be applied to exposed areas of
skin every 4-6 hours.
✓Eat a balanced diet, mainly iron rich foods.
✓Avoid alcohol.
✓Regular exercise.
✓Lead a healthy and hygienic life.
✓Avoid fatty and fried foods.
✓Plenty of fluids.
Life Style Modifications
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