Diagnosis Malaria dan eliminasi

Inge Sutanto
 DIAGNOSIS MALARIA
• Sediaan darah tebal & tipis parasit malaria
• Rapid test malaria antigen malaria spesifik
• PCR DNA atau RNA parasit malaria
Subjektif dengan sensitivity 40 parasit/mikroliter
 Pemeriksaan Rapid diagnostic test
• Prinsip
“imunokromatografi”
yaitu cairan akan
bermigrasi pada
membran nitro-selulosa

• Antibodi monoklonal
akan membawa dan
mengikat antigen spesifik
pada darah penderita
 Antigen malaria in rapid test
• Three antigens used in rapid test:
- PfHrp2 (P. falciparum specific),
- pan-aldolase: Pf, Pv, Pm
- pan-lactate dehydrogenase: Pf, Pv, Pm
Sensitivitas rapid test ditentukan jumlah parasit
Sensitivitas untuk Pf lebih tinggi dari pada Pv
 RAPID DIAGNOSTIC TEST FOR PLACENTAL
MALARIA
Peripher Peripher Placental Placental
al Sens al Spec Sens Spec

Peripher ---- ---- 82% 86%

al micros

Peripher 96% 67% 95% 61%

al RDT

Placental ---- ---- 95% 72%

RDT

Rapid malaria test dapat mendeteksi parasite yang bersekuestrasi

Singer LM et al. Am J Trop Med Hyg 2004; 70: 481 - 485

 Rapid tetap positive walaupun parasite sudah tidak
terdeteksi dengan pemeriksaan mikroskop

Jamshaid Iqbal et al. Persistent Histidine-Rich Protein 2, Parasite Lactate Dehydrogenase, and Panmalarial Antigen
Reactivity after Clearance of Plasmodium falciparum Monoinfection. JOURNAL OF CLINICAL MICROBIOLOGY, Sept.
2004, p. 4237–4241 Vol. 42, No. 9
 Non immune patients
• Sensitivity of the RDTs at low level of
parasitemia remains a problem
• Less sensitive compared to microscopic
examination ( 50 parasites/µl)
• In non immune individuals, symptomatic
malaria can occur at parasite densities that are
below the detection threshold of currently
available RDTs
 False negative
• Have been observed even in severe
malaria with parasitemia < 40.000
• A negative RDT result should be confirmed
by microscopy
 False negativity
• Since malaria falciparum is a potentially
lethal disease, it has been suggested that in
such cases, 1 in 10 dilution of a negative
sample with 0.9% NaCl may help to exclude
the prozone phenomenon.
 False negativity

• This has been attributed to possible genetic

heterogeneity of PfHRP2 expression,
deletion of HRP-2 gene, presence of
blocking antibodies for PfHRP2 antigen or
immune-complex formation, prozone
phenomenon at high antigenemia
Delesi gen PfHrp2 menyebabkan rapid test negatif
 False positive

• Gametocytemia (young stage) of

P. falciparum
• Persistent viable asexual-stage parasitemia
below the detection limit of microscopy
(probably due to drug resistance)
 False positive
• Persistent of antigens due to sequestration
and incomplete treatment
• Delayed clearance of circulating antigen
(free or in antigen-antibody complex)
• Cross reaction with non falciparum antigen
or rheumatoid factor
 Rheumatoid Hepatitis C
arthritis (ICT False ( ICT False +)
+)
RF 18/50 6/17

ANA 3/25 0/2

RF + ANA 6/25 2/5

Neg RF & ANA 0 0/1

Total 27/100 8/25

Iqbal J et al. J Clin Microbiol Rev 2000; 38: 1184 - 86

 Nucleid acid detection (PCR)
• Very sensitive technique (1-5 parasites/l)
• require sophisticated equipment and supplies
• highly trained personnel, impractical for
routine diagnosis
 Nucleid acid detection

• could detect the

four species of
human plasmodium,
but could not
differentiate the
stages
PCR mendeteksi penderita malaria asimtomatik
PCR lebih sensitif dari pada rapid test
Kesalahan pembacaan spesies mikroskopik
Diagnosis yang lebih sensitif dari mikroskopik diperlukan untuk
mendeteksi asimtomatik malaria
PCR MERUPAKAN SATU SATUNYA DIAGNOSTIC TOOL YANG DAPAT MEDETEKSI
ADANYA MALARIA SEJUMLAH 2 PARASIT PER MICROLITR
 Kesimpulan
• Diperlukan pemeriksaan diagnosis yang lebih
sensitif dari mikroskopik dalam era eliminasi
malaria
• Pengembangan diagnosis malaria yang tidak
invasif mungkin perlu dipikirkan