MALARIA

Yuli Hermansyah, dr, SpPD

INTRODUCTION
 / intracellular obligate protozoa  plasmodium gene.  P.Malariae, P.Vivax, P.Falciparum, P.Ovale  anopheles.  400 Anopheles 67 contagioused 24 (INA)  Blood transfusion / syringe.  Pregnant women  baby.

Malaria

malariae  older erithrocyte  1% P.Parasitemia P.vivax  reticulocyte  2% erithrocyte P.falciparum  all ages of erithrocyte  erithrocyte infectious rate   severe complication .

Estivoautumnal.falciparum  severe & complicated malaria Falciparum. Malignan. .P. Sub tertian. Pernicious.

Cerebral malaria. Haemolysis. Haematologic manifestation Pulmonary oedema.Shock. Fatal complication .

Mortality of malaria  / complication of severe malaria (P.CFR severe malaria  10 – 50%. .falciparum).

* 30 minutes after convulsion (not caused by another diseases). 2. Cerebral malaria : * Coma (GCS < 11). 3. Severe anemia (Hb < 5 gr% or Hct < 15%).falciparum with one or more complication. 1. ARF (urine < 400ml/24 hours in adult. < 12 ml/kg BW in children)  creatinine serum > 3 mg%.DEFINITION Severe Malaria WHO : Asexual stage infection of P. .

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blood sugar < 40 mg%. Hypoglycaemia. Pulmonary oedema / ARDS. Spontaneous bleeding : nose.4. 7. 6. * temperature skin – mucous > 1C. gastrointestinal tract + laboratory  intravascular coagulation disturbances. Circulatory collapse / shock : * systolic BP < 70 mmHg (children 1-5 years old < 50 mmHg). 5. gums. * Cold sweating. .

10.8.Macroscopic haemoglobinuria  acute malaria infection.25)/Acidosis (HCO3 <15mmol/L).Post mortem confirmation of diagnosis. 11. . 9. Acidaemia (PH <7. Repeat convulsions > 2x/24 hours.

Muscle weakness (can not sit / walk)  without neurological disorder. 4. Impairment of conciousness less marked than unrousable coma (GCS < 15). 5. Hyperpyrexia (rectal temp > 40C). Jaundice (bil conc > 3 mg%).Other manifestations of severe malaria 1. . 3. Hyperparasitemia > 5% hypoendemic area or unstable malaria area. 2.

• 10% of the patients hospitalized with falciparum malaria. . • Pathogenese still uncleared. • 80% of the fatal case.PATHOPHYSIOLOGI 1) Cerebral Malaria •  2% non immune patients. Suggestion : Erithrocyte (contain parasite)  unable to pass throught capillary vessels of the brain (citoadherence and sequestration)  plug capillary vessel of the brain  Anoxia.

*  TNF-alfa. gallop rythm. creatinine serum.2) Anemia  30% case need transfusion. skizontemia.  Acute malariadisoriented.  Anemia : * haemolysis. hepatomegali and pulmonary oedema. .  Correlated with parasitemia. total bilirubin serum.000/mm3.  WHO  transfusion  Hb < 5 gr% / Hct < 15% parasite > 10.lost of conciousness untill coma.

 Mortality 45%.  Acute tubular necrose  5 – 10%.  Sensitive indicator for severe malaria.3) Acute Renal Failure  >> adult. .  << children.  Pre-renal (dehidration)  > 50%.

.Plug capillary vessels   blood flow to the kidney  Anoxia  glumerular filtration rate  (oliguria) Anuria . hypocalcemia. hypermagnesemia. hyperkalemia. .diffuse cortical necrosis. hyperphosphatemia.arteri renal occlussion / vasculitis renal.progressif glumerulonephritis .

 Aritmia. GI & skin bleeding.A R F  Acidosis metabolic. Terminal stage  uremia.  Pericarditis.  Hyperuricaemia.  Congestive heart failure.   Amylase serum. septicemia .

 The most severe complication of tropica malaria  † Two types : 1. Adult respiratory distress syndrome. 2. * intra vascullar coagulation.4) Pulmonary Oedema  >> adult. Recent :  TNF-alfa . << children. & pulmonary microcirculair disfunction. * microvascullar emboli. Fluid overflow. Past: *  capillary membrane permeability.

 Shock with hypotension (systolic pressure < 70 mmHg). .  Adult ~ tx/: quinine.   tissue perfusion.  Changes of perifer resistance.  >> Adrenalin secretion. 6) Circulatory collapse / shock  Malaria Algid.  Pregnancy  primigravide.  Hypotension ~ gram negative septicemia.  Failure of hepatic gluconeogenesis.5) Hypoglicaemia   Metabolic demands of the parasites.

ptechiae.7) Spontaneous bleeding  Gums.  Bleeding + severe parasitemia + uremia  poor prognose. nose. stress ulcer. purpura hematome  thrombocytopenia.  Intravascular coagulation disturbance  rare (< 10%). .  Gastrointestinal bleeding steroid.

9) Metabolic acidosis  Hyperventilation (kussmaul).  Endemic area  heat stroke  malaria.25).5C .41C  delirium.  Bicarbonat (< 15 mmol/L).  PH  (< 7.8) Hyperpyrexia (hyperthermia)  >> tropica malaria.  Temp > 38C  convulsion.  Hot and dry skin. Temp 39.  Delirium  coma.  Lung  auscultation : N.  Lactic acid . cyanosis in extremities. . Temp > 41C  coma.

 Polyuria. * intravascular haemolysis.  Vomiting. .  Diarhea. * chills. * renal failure. * haemoglobinemia. * haemoglobinuria.10) Macroscopic haemoglobinuria (blackwater fever)  Syndrome : * acute attack.  Back pain.

Blackwater fever  Oliguria + ‘coca-cola’-coloured urine.  Haemolysis caused by quinine or antibody against quinine never be proved. (blackwater urine)  Hepatosplenomegali + anemia + icteric.  Deficiency of G-6-PD enzyme. .

falciparum.vivax.malariae. * syringe. Human  P.ovale Pathogenese still uncleared. * pregnant women  baby. Contagioused  * mosquito bite. P.SUMMARY Malaria  disease caused by protozoa intracellular obligate from plasmodium genus. . P. * blood transfusion. P.

hyperthermia. acidosis. shock. convulsion. severe anemia. spontaneous bleeding. hypoglicemia. * sub tertian.falciparum (asexual stage) + one/more complication : cerebral malaria. haemoglobinuria. * pernicious. ARF. pulmonary oedema / ARDS.Plasmodium falciparum  severe and complicated malaria : * malaria falciparum. . Severe malaria : infection caused by P. * malignan. * estivoautumnal.

transfusi. manifestasi malaria berat  11/14/2013 Kuliah Tropik Infeksi 26 .Diagnosis Anamnesis :  Demam. hepatomegali. nyeri otot. pucat. menggigil. riwayat daerah endemik. nyeri kepala. splenomegali. obat malaria  Pemeriksaan fisik :  Demam.

Diagnosis Pemeriksaan laboratorium :  Tetes tebal & tipis ~ parasit +. metode imunokromatografi : HRP2. pLDH  11/14/2013 Kuliah Tropik Infeksi 27 . kepadatan parasit (semikuantitatif. kuantitatif)  Pemeriksaan lain :  Deteksi antigen parasit malaria. spesies & stadium plasmodium.

Diagnosis banding      Tifoid Dengue fever ISPA Leptospirosis ringan Infeksi virus         Meningo ensefalitis CVA Tifoid ensefalopati Hepatitis Leptospirosis berat Glomerulonefritis Sepsis DSS 28 11/14/2013 Kuliah Tropik Infeksi .

anti kejang.  Pengobatan komplikasi  11/14/2013 Kuliah Tropik Infeksi 29 .Pengobatan Obat anti malaria :  Oral ~ malaria ringan tanpa komplikasi  Parenteral ~ malaria berat / tak bisa minum obat  Pengobatan suportif : demam. cairan dll.

Anti malaria. 4 tab hari 1-3  Primakuin. 4 tab hari 1 Lini 2  Kina. 4xi kaps hari 1-7  Primakuin. 3 tab hari 1 Kuliah Tropik Infeksi 30 11/14/2013 . 4 tab hari1-3  Amodiakuin. dasar mikroskopik   Falsiparum tanpa komplikasi (lini 1)  Artesunat . 3x2tab hari 1-7  Tetrasiklin.

2 tab hari 3  Primakuin. 1 tab hari 1-3 Lini 2  Kina. dasar mikroskopik    Vivax. ovale (lini 1)  Kloroquin .Anti malaria. 3x2tab hari 1-7  Primakuin. 8-12 minggu  Primakuin 3 tab/minggu . 8-12 minggu Kuliah Tropik Infeksi 31 11/14/2013 . 1 tab hari 1-14 Relaps  Klorokuin 4 tab/minggu . 4 tab hari1-2.

1 tab hari 1  11/14/2013 Kuliah Tropik Infeksi 32 . 3 tab hari 1  Lini 2  Kina. dasar klinis Lini 1  Kloroquin . 2 tab hari 3  Primakuin.Anti malaria. 3x2tab hari 1-7  Primakuin. 4 tab hari1-2.

4 mg/kgBB iv diikuti 1.2 mg/kgBB setiap hari sd hari 7  Artemether (80mg). 2.2 mg/kgBB 1v jam 12. 1 ampul 1m hari 2-5 Lini 2 :  Kina 500 mg dlm D5 selama 8 jam.Malaria berat   Lini 1  Artesunat (60 mg). 24 . diulang/8 jam Kuliah Tropik Infeksi 33 11/14/2013 . 2 ampul im hari 1. selanjutnya 1.