Malaria

Malaria is a world’s most life-threatening mosquito-borne blood disease. The Anopheles mosquito transmits parasite (plasmodium) to humans. These parasites cause malaria symptoms, including fever, chills, and headaches.

There are 4 common Plasmodium species of concern to humans. There is a fifth in Southeast Asia that rarely can infect humans and cause severe disease, Plasmodium know Lesi; however, this species typically causes simian malaria. The overwhelming majority of worldwide morbidity from malaria is caused by P falciparum and to a lesser degree, P vivax.

Despite the many morphologies of the parasite in its life cycle, only a few stages cause clinical disease in humans, the most severe of which are typically P falciparum and P vivax. The initial schizont broods rupture out of the liver phase, release thousands of merozoites into the bloodstream, and attempt to establish periodicity within the erythrocytic phase (time periods vary per species) where level of parasitemia increases exponentially.

For differentiation, please read Dengue fever.

Symptoms

Fever

Once the parasite concentration is high enough, a fever is mounted (pyrogenic threshold). This pyrogenic threshold may be anywhere from 0.05 to 1.25 parasites/1,000 red blood cells (0.005 – 0.125% parasitemia) – immune patients may require 0.2% parasitemia to experience fever. The most theorized mechanism for the cyclic fevers is the human immune response to the hemozoin (waste product generated from Plasmodium’s diet of hemoglobin) that bursts into the bloodstream during each cycle of asexual erythrocytic schizogony. Hemozoin is known to be a Plasmodium pathogen associated molecular pattern (PAMP) recognized by toll-like receptors (TLRs) that induces intense immune response. Other malarial toxins such as malaria glycophosphatidylinositol (GPI) likely are culpable through similar mechanisms. The temperature fluctuation with the human febrile response is expected to play a role in guiding the broods of parasites toward the classic paroxysmal fever-associated periodicity of schizont rupture.

Anemia

Severe malaria-associated anemia typically is seen in the young. Schizont rupture from erythrocytes is an obvious mechanism of anemia; however, the more profound loss of red blood cell mass is seen in the population of uninfected erythrocytes. Their decline is thought to occur via oxidative damage of the erythrocyte membranes, eventually leading to hemolysis. Another mechanism of anemia lies within bone marrow; both insufficient production and function of erythropoietin as well as possible apoptosis induction of erythrocyte precursors lead to dyserythropoiesis.

Splenomegaly

During acute malaria infection, the spleen serves as the main driver of infected erythrocyte clearance, immune cell activation, and extramedullary hematopoiesis. The extraordinary burden on the spleen causes the red pulp to become congested with infected and uninfected red blood cells, but splenomegaly also occurs by massive cellular expansion in both the red and white pulp. Impressively, the organ is able to revert back to a normal size after clearance of the infection (at least in mice). Because of P vivax’ tropism for reticulocytes (prevalent in the spleen), splenic rupture is a characteristic severe complication of P vivax, and there is evidence to suggest a separate splenic life cycle for this species.

Acidosis

End-organ damage from microvascular sequestration, respiratory depression, and production of Plasmodium lactate dehydrogenase (pLDH) by the malaria parasite all lower the pH of the blood.

Renal Injury

Cytoadherence with thrombi formation in glomeruli is a common mechanism of acute kidney injury. If anuria or hemoglobinuria (“blackwater fever”) occur, it likely is secondary to an abundance of cell-free hemoglobin that results in reduced renal perfusion. Although contributing to morbidity of the acute illness, most patients do not require long-term dialysis.

Cerebral malaria

After infecting a red blood cell, P falciparum can insert adhesive proteins into the erythrocyte membrane, thus creating a cytoadhering phenotype (further described below in ‘species specific nuances’). The ability to stick to endothelium, uninfected blood cells, and platelets causes more than 20% of brain capillaries to be filled with P falciparum parasites, resulting in vascular congestion, retinopathy, capillary leakage, thrombi, hemorrhage, axonal injury, coma, and death from cerebral malaria within 48 hours (especially in children).

Placental malaria

Occurring with highest incidence in Africa secondary to P falciparum due to its ability to form the cytoadhering phenotype, placental malaria is characterized by the accumulation of infected red blood cells within the intervillous space and ensuing infiltration of maternal macrophages. In severe cases, the resulting chronic intravillositis leads to decreased transplacental nutrient transport, fetal growth restriction and low birth weight babies, as well as increased risk for preterm birth and preeclampsia for the mother.

Overall malaria symptoms include:

fever and chills,
sweating,
headaches,
nausea and vomiting,
body aches,
weakness,
Hepatomegaly (an enlarged liver),
mild jaundice, which can cause the eyes to appear yellow,
a higher breathing rate,
a general feeling of being unwell.

The classic fever cycle of malaria usually lasts 6–10 hours and recurs every second day but this is rare, some types of Plasmodia, attacks may occur every third day.

It involves:

Chills and shivering
Fever, headaches, and vomiting, possibly with seizures in young children
Sweating stage
A return to usual temperatures that accompanies fatigue

Severe malaria

In some cases, malaria can progress and affect vital body organs. At this point, malaria parasites have affected over 5% of the red blood cells.

Symptoms include:

Severe anemia
Hematuria (bloody urine)
Changes in blood clotting
Impaired consciousness
Changes in behavior
High acidity in the blood and body fluids
Seizures
Coma.

Notably, infection with P vivax, particularly in temperate areas of India, may cause symptoms up to 6-12 months after the host leaves the endemic area. Patients infected with P vivax or P ovale may relapse after longer periods, because of the hypnozoite stage in the liver.

P malariae does not have a hypnozoite stage, but patients infected with P malariae may have a prolonged, asymptomatic erythrocytic infection that becomes symptomatic years after leaving the endemic area.

Tertian and quartan fevers are due to the cyclic lysis of red blood cells that occurs as trophozoites complete their cycle in erythrocytes every 2 or 3 days, respectively. P malariae causes quartan fever; P vivax and P ovale cause the benign form of tertian fever; and P falciparum causes the malignant form. The cyclic pattern of fever is very rare.

Complications

Possible complications of malaria include:

liver failure, which can lead to jaundice
kidney failure
unusually low blood glucose
swelling and rupturing of the spleen
shock, which includes a sudden fall in blood pressure
pulmonary edema, where fluid builds up on the lungs
acute respiratory distress syndrome, which affects breathing
dehydration.

Malaria relapses

With some types of Plasmodium, malaria can disappear but return months or years later. This occurs because the parasites have dormant stages, during which there is no disease activity. However, symptoms can occur if they reactivate.

Differential Diagnosis:

The signs and symptoms of dengue fever are similar to typhoid fever and malaria. (This can sometimes delay an accurate diagnosis).

Diagnosis

To confirm diagnosis, we have to take some Lab tests like:

Blood smear test. In a blood smear (looking blood under microscope for parasites).
Rapid diagnostic test (RDT). Rapid diagnostic test or antigen testing looks for proteins known as antigens, which are released by malaria parasites.

RDT can provide faster results than a blood smear, but a blood smear is usually needed to confirm a diagnosis.

Molecular test. Also known as polymerase chain reaction test, it can identify the type of parasite, which helps your doctor decide which drugs to prescribe. This test is a good choice if patient’s blood has low number of parasites or if the results of blood smear are vague.
Antibody test. Antibody test to find out if patient have/had malaria before. It looks for antibodies that show up in the blood after an infection.
Drug resistance test. Some malaria parasites are resistant to some drugs.

Other blood tests. Blood count and chemistry panel. This can tell us how serious patient’s infection is and if it’s causing other problems, like anemia or kidney failure etc.

Microhematocrit centrifugation

Using this method with the CBC tube is a more sensitive method for detection of malaria infection (microhematocrit centrifugation does not allow the identification of the species of Plasmodium). To determine species, a peripheral blood smear must be examined.

Fluorescent dyes/ultraviolet indicator tests

The use of a fluorescent microscope. Fluorescent /ultraviolet tests may not yield speciation information.

Polymerase chain reaction assay

PCR assay testing is a very specific and sensitive means of determining if species of Plasmodium are present in the blood of an infected individual. PCR are very effective at detecting the Plasmodium species in patients with parasitemia as low as 10 parasites/mL of blood.

Lumbar puncture

If the patient exhibits mental-status changes, and even if the peripheral smear demonstrates P falciparum, a lumbar puncture should be performed to rule out bacterial meningitis.

Rapid diagnostic tests (RDT)

Immunochromatographic tests based on antibody to histidine-rich protein-2 (PfHRP2), parasite LDH (pLDH), or Plasmodium aldolase appear to be very sensitive and specific.

Allopathic Treatment for Malaria

The allopathic treatment of malaria is predicated on the severity of the patient’s illness, the infecting species, geographic knowledge of anti-malarial drug resistance, and knowledge of prior antimalarials given to the patient (it is not recommended to use the same prophylactic medication for treatment).

Criteria for Severe Malaria (1 or more of the following):

Impaired consciousness/coma.
Severe anemia (hemoglobin < 7 g/dL).
Acute kidney injury.
Acute respiratory distress syndrome.
Circulatory collapse/shock.
Disseminated intravascular coagulation.
Acidosis.
Jaundice (along with at least one other sign of severe malaria).
Percent parasitemia of ≥5%.

Mixed infections involving more than 1 species of Plasmodium may occur in areas of high endemicity and multiple circulating malarial species. In these cases, clinical differentiation and decision making will be important; however, the clinician should have a low threshold for including the possible presence of P falciparum in the treatment considerations.

Occasionally, morphologic features do not permit distinction between P falciparum and other Plasmodium species. In such cases, patients from a P falciparum –endemic area should be presumed to have P falciparum infection and should be treated accordingly.

In patients from Southeast Asia, consider the possibility of P knowlesi infection. This species frequently causes hyper parasitemia and the infection tends to be more severe than infections with other non– P falciparum plasmodia. It should be treated as P falciparum infection.

Chloroquine treatment is still my (Dr. Qaisar Ahmed) medicine of choice for P falciparum, P vivax infection, P ovale and P malariae (chloroquine. Primaquine or tafenoquine), they eliminate the hypnozoites (liver phase).

Pregnancy

Pregnant women, especially primigravid women, are up to 10 times more likely to contract malaria than nongravid women and they have a greater tendency to develop severe malaria. Unlike malarial infection in nongravid individuals, pregnant individuals with P vivax are at high risk for severe malaria, and those with P falciparum have a greatly increased predisposition for severe malaria as well.

Many of the antimalarial and antiprotozoal allopathic drugs used to treat malaria are safe for use during pregnancy for the mother and the fetus.

Treatment options in allopathy for uncomplicated malaria in pregnant individuals are limited to mefloquine or quinine plus clindamycin. Artemether-lumefantrines effective but not safe in the treatment of malaria in pregnancy.

The use of artemether/lumefantrine as an additional treatment option for uncomplicated malaria in pregnant patients, during the second and third trimester of pregnancy at the same doses recommended for nonpregnant patients. During the first trimester of pregnancy, mefloquine or quinine plus clindamycin should be used as treatment; however, when neither of these options is available, artemether-lumefantrine should be considered.

Pediatrics

In children, malaria has a shorter course, often rapidly progressing to severe malaria. Children are more likely to present with hypoglycemia, seizures, severe anemia, and sudden death, but they are much less likely to develop renal failure, pulmonary edema, or jaundice.

Most antimalarial drugs are very effective and safe in children, provided the proper dosage is administered. Children commonly recover from malaria, even severe malaria, much faster than adults.

Pharmacologic Therapy

P falciparum or Species Not Identified from area with chloroquine resistance

Artemether/lumefantrine.
Atovaquone/proguanil.
Quinine + doxycycline (doxycycline is preferred, but tetracycline or clindamycin also are options).
Mefloquine.

P falciparum from area without chloroquine resistance or other Species Not Identified (P vivax, ovale, malariae, knowlesi)

Chloroquine.
Hydroxychloroquine.
Any regimen listed for chloroquine-resistant P falciparum malaria.

P vivax & P ovale hypnozoite eradication (must test for G6PD Deficiency)

Primaquine daily for 14 days (can start with treatment of acute infection).
Tafenoquine single dose only in patients >16 years who received chloroquine for treatment of acute infection.

Treatment recommendations for tafenoquine:

Tafenoquine, an antiplasmodial 8-aminoquinoline derivative indicated for the radical cure (prevention of relapse) of P vivax malaria in patients aged 16 years or older who are receiving appropriate antimalarial therapy for acute P vivax infection. The drug is active against all stages of the P vivax life cycle. Tafenoquine is administered as a single oral dose on the first or second day of appropriate antimalarial therapy (chloroquine) for acute P vivax malaria.

Tafenoquine increases the risk for hemolytic anemia in patients with G6PD deficiency, patients must be tested before initiating the drug. Tafenoquine is contraindicated in patients with G6PD deficiency (or unknown status), in patients who are breastfeeding an infant with G6PD deficiency (or unknown status), and hypersensitive patients.

If G6PD testing indicates deficiency, moderate deficiency can be treated with a prolonged course of reduce-dosed primaquine with close monitoring for hemolysis. If G6PD deficiency is severe, chloroquine prophylaxis may be used for a 1-year duration after acute infection given that most reactivations occur in this period.

Treatment options for severe/ complicated malaria

IV artesunate – once or twice a day (I do not recommend). The preferred interim therapy is artemether/lumefantrine, atovaquone/proguanil, quinine, and mefloquine.

After the initial course of IV artesunate, the patient can transition to a full course of oral artemether/lumefantrine if parasitemia is reduced to < 1% and the patient tolerates oral therapy.

If artemether/lumefantrine is unavailable, less preferred options are atovaquone/proguanil, quinine + doxycycline (or clindamycin), or mefloquine.

If the patient cannot tolerate oral therapy at the end of the IV artesunate course, the patient can continue receiving artesunate for a duration not to exceed a total of 7 days (severe side effects).

Post-artemisinin hemolytic anemia is a rare adverse effect and is seen to a greater degree in patients with higher initial parasitemia.

All patients who receive IV artesunate should be monitored weekly for up to 4 weeks after treatment for evidence of hemolytic anemia.

Rectal artesunate has been used for pretreatment of children in resource-limited settings as a bridge therapy until the patient can access health care facilities for definitive IV or oral therapy.

⊗ Warning: mefloquine hydrochloride includes neurologic side effects, along with the already known risk for adverse psychiatric events such as anxiety, confusion, paranoia, and depression. Vestibular symptoms, include dizziness, loss of balance, vertigo, and tinnitus, can occur. These vestibular side effects can persist long after treatment has ended and may become permanent. In addition, clinicians are warned against prophylactic mefloquine use in patients with major psychiatric disorders and are further cautioned that if psychiatric or neurologic symptoms arise while the drug is being used prophylactically, it should be replaced with another medication.

Pharmacologic treatment in pregnancy

Treatment of malaria in pregnancy include chloroquine, quinine, atovaquone-proguanil, clindamycin, mefloquine, sulfadoxine-pyrimethamine (avoid in first trimester) and the artemisinin.

Malaria Vaccine

On 6 October 2021, the WHO recommended large-scale use of the RTS,S/AS01 (Mosquirix) malaria vaccine. Research and development between GlaxoSmithKline and the US Walter Reed Army Institute, experiment is gone on children in sub-Saharan Africa and other areas with high malaria transmission based on trials involving more than 830,000 children in Ghana, Kenya, and Malawi. It is a recombinant protein vaccine based on an antigen found on the P falciparum sporozoite. If optimal access to the vaccine can be achieved, it will to be able to save the lives of Americans. (shame on them).

Homeopathic Treatment for Malaria

Homeopathy has complete treatment for all types of malarias from last more than one hundred and fifty (150) years and still is not only highly effective way of treatment but having no side effects. Experiments were don not on babies, nor on pregnant but on adults.

Here are very few of them:

Eupatorium Perfoliatum:

Known as “Boneset”, from the prompt manner in which it relieves pain in limbs and muscles that accompanies some forms of febrile disease, like malaria and influenza. Eupatorium acts principally upon the gastro-hepatic organs and bronchial mucous membrane. Back, pain in. Bilious fever. Bones, pains in. Cough. Dengue, Intermittent fever, Relapsing fever, Remittent fever, Spotted fever, Bilious fever, Jaundice, Hepatomegalia, Hepatic pain, Hepatic digestion problems. Diarrhea. Gout. Hiccough. Hoarseness. Indigestion. Influenza. Measles, Herpes zoster, Ringworms, Mouth/lips cracking. Ophthalmia. Rheumatism. Syphilitic pains. Thirst.

Gelsemium:

Sever chillness. Malaria. Pulse slow, full, soft, compressible. Chilliness up and down back. Heat and sweat stages, long and exhausting. Dumb ague, with sever muscular soreness, great prostration, and violent headache. Nervous chills. Bilious remittent fever, with stupor, dizziness, faintness; thirstless, prostrated. Chill, without thirst, along spine; wave-like, extending upward from sacrum to occiput. Cramp in muscles. Putrid taste and breath.

Bryonia Alba

Bilious attack. Bronchitis. Chlorosis. Bitter taste. Vomiting of bile and water. Enteric fever. Intermittent fevers. Miliaria eruptions. Jaundice. Hepatomegaly. Hepatic malfunctioning. Lumbago. Measles. Meningitis. Menstruation, vicarious. Milk fever. Myalgia. Painful stiffness in nape of neck and lower spine. Pulse full, hard, tense, and quick. Chill with external coldness, dry cough, stitches. Internal heat. Sour sweat after slight exertion. Easy, profuse perspiration. Rheumatic and typhoid marked by gastro-hepatic complications.

Nux Vomica

Very bitter mouth taste. Sour bitter eructation. Nausea and vomiting. Tongue rough. Extremely irritable. Cold stage predominates. Paroxysms anticipate in morning. Excessive rigor, with blueness (cyanosis) of fingernails. Aching in limbs and back, and gastric symptoms. Chilly; must be covered in every stage of fever. Perspiration sour; only one side of body. Chilliness on being uncovered, yet he does not allow being covered. Dry heat of the body. All body sever aching. Respiratory infections. Hepatomegaly.

Rhus Toxicodendron

Extreme restlessness. Dengue fever. Low appetite. Bitter taste. Nausea, vertigo, and bloated abdomen after eating. Dyspepsia. Cyanosis. Enteric fever or Typhoid. Typhus. Intermittent fever. Relapsing fever. Measles. Herpes zoster. Influenza. Pneumonia. Hepatic abscess. Scarlatina. Smallpox. Urticaria. Pain in spine, extremities. Malaria. Adynamic restless and trembling.

Iodium

Skin hot, dry, yellow and withered. Glands enlarged. Nodosities. Anasarca of cardiac disease. Fever -flushes of heat all over body. Marked fever, restlessness, red cheeks, apathetic. Profuse sweat. Malaria. Intermittent fever irregular cases, after Quinine. Hepatization spreads rapidly with persistent high temperature. Liver and spleen sore and enlarged. Jaundice. Mesenteric glands enlarged. Pancreatic disease.

Ipecacuanha

Severe headache. Nausea. Vomiting. State of vision constantly changing. Cyanotic. Coraza. Severe cough with sputum. Pleuritic effusion. Tickling all over chest. Intermittent fever. Chill, ever body pain sometimes with jerking. Dysentery. Slightest chill with much heat, nausea, vomiting, and dyspnea. Vomits food, bile, blood, mucus. Pneumonia with heigh temperature. Malaria.

Arsenic Album

Abscess. Acne rosacea. Epithelioma. Erysipelas. Eczema. Eruption Endometritis. Anemia and chlorosis. Bronchitis. Carbuncle. Cold. Coldness. Commissures soreness. Whooping-cough Cough. Pneumonia. Coxalgia. Croup. Delirium tremens. Measles. Depression of spirits. Diarrhea. Cholera. Diphtheria. Dropsy. Duodenum. Dyspepsia, Gastric ulcer. Gastritis, Vomiting, Gastrodynia. Glandular swellings.

Hodgkin’s disease, kidney diseases. Enteric fever. Malaria. Hay-fever. Cold sweats. Typhoid. Fainting. Traumatic fever. Typhus. Fever. Headache. Hectic fever. Intermittent fever. Shivering. Yellow fever. Jaundice. Neuralgia. Peritonitis. High temperature. Periodicity marked adynamic. Septic fevers.

Phosphorus

atrophy of the liver and sub-acute hepatitis. Chilly every evening. Cold knees at night. Adynamic with lack of thirst, but unnatural hunger. Hectic, with small, quick pulse; viscid night-sweats. Stupid delirium. Profuse perspiration. Malaria. Weakness. Respiratory tract infections. Liver congested. Acute hepatitis. Fatty degeneration. Jaundice. Pancreatic disease. Large, yellow spots on abdomen. Pale, sickly complexion. Hippocratic countenance.

China officinalis

Intermittent, paroxysms anticipate; return every week. Malaria – all stages well marked. Chill generally in forenoon, commencing in breast; thirst before chill. Debilitating night-sweats. Free perspiration caused by every little exertion, especially on single parts. Hay fever, watery coryza, pain in temples. Drowsiness. Unrefreshing or constant stupor. Wakens early. Protracted sleeplessness. Anxious, frightful dreams. Chillness – sweating, one hand ice cold, the other warm. Pain in limbs, spine, in kidneys. Influenza, with debility. Labored, slow respiration, constant choking. Suffocative catarrh; rattling in chest; violent, hacking cough after every meal. Hemorrhage from lungs. Dyspnea, sharp pain in lung. Asthma. Debility.

Alstonia Scholaris

Malarial with diarrhea, dysentery, anemia, feeble digestion, are the general conditions suggesting this remedy. Characteristics are the gone sensation in stomach and sinking in abdomen, with debility. A tonic after exhausting fevers. Violent purging and cramp in bowels. Heat and irritation in lower bowels. Camp diarrhea, bloody stool, dysentery; diarrhea from bad water and malaria. Painless watery stools.

Natrum Muriaticum

Heat; violent thirst, increases with fever. Fever-blisters. Coldness of the body, and continued chilliness very marked. Hydremic in chronic malarial states with weakness, constipation, loss of appetite, etc. Sweats on every exertion. Pain in back, with desire for some firm support. Arms and legs, but especially knees, feel weak. Cough from a tickling in the pit of stomach, accompanied by stitches in liver and spurting of urine. Stitches all over chest. Cough, with bursting pain in head. Shortness of breath. Whooping-cough. A great remedy for certain forms of intermittent fever, anemia, chlorosis, many disturbances of the alimentary tract and skin. Great debility: most weakness felt in the morning in bed. Coldness. Emaciation most notable in neck. Dry mucous membranes.

Baptisia Tinctoria

Baptisia in low dilutions produces anti-bodies to the bac typhus, viz, the agglutinins. Thus, it raises the natural bodily resistance to the invasion of the bacillary intoxication, which produces the typhoid syndrome. Typhoid carriers. After inoculation with anti-typhoid serum. Intermittent pulse, especially in the aged.

Septic conditions of the blood, malarial poisoning and extreme prostration. Indescribable sick feeling. Great muscular soreness. Chronic intestinal toxemias with fetid stools and eructation.

Neck tired. Stiffness and pain, aching and drawing in arms and legs. Pain in sacrum, around hips and legs. Sore and bruised. Decubitus. Sleepless and restless. Nightmare and frightful dreams. Falls asleep while answering a question. Livid spots all over body and limbs. Burning and heat in skin. Putrid ulcers with stupor, low delirium and prostration.

Chill, with rheumatic pains and soreness all over body. Heat all over, with occasional chills. Chill about 11 am. Adynamic fevers. Typhus fever. Shipboard fever.

Cedron

Periodicity is the most marked characteristic of this drug. Best in malarial affections, especially neuralgia. Voluptuous disposition, excitable, nervous temperament. Has powers of antidoting snakebites and stings of insects (tincture of pure bean scraped on wound). Mania.

Headache from temple to temple across eyes. Pain over whole right side of face, coming on about 9 am. Roaring in ears produced. Whole body seems numb with headache. Supra-orbital neuralgia periodic. Iritis, choroiditis.

Lancinating pain in joints; worse, feet and hands. Sudden pain in joint of thumb, extending up arm to shoulder. Pain in femoral joints, extending to knees. Shingles, with radiating pain. Chilliness towards evening. Red eyes. Heat, with itching of eyes, tearing in limbs, numbness of limbs.

P. S: This article is only for doctors having good knowledge about Homeopathy and allopathy, for learning purpose(s).

For proper consultation and treatment, please visit our clinic.

None of above-mentioned medicine(s) is/are the full/complete treatment but just hints for treatment; every patient has his/her own constitutional medicine.

To order medicine by courier, please send your details at WhatsApp– +923119884588

Dr. Sayyad Qaisar Ahmed (MD {Ukraine}, DHMS), Abdominal Surgeries, Oncological surgeries, Gastroenterologist, Specialist Homeopathic Medicines.

Senior research officer at Dnepropetrovsk state medical academy Ukraine.

Location: Al-Haytham clinic, Umer Farooq Chowk Risalpur Sadder (0923631023, 03119884588), K.P.K, Pakistan.

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ByDr Qaisar Ahmed