Ringkasan Malaria

Agustin Iskandar,dr, Mkes, SpPK

LOGO
Causal Agent: Plasmodium

P. vivax

P. ovale

P. malariae

P. falciparum

P. knowlesi
 Plasmodium Life Cycle

• Sexual cycle in mosquito

• Asexual cycle in vertebrate host
• Comprises two cycles of replication - in
liver and then in blood
• Synchrony in erythrocytic infection gives
rise to periodicity of fever
• P.malariae (72h), P.vivax, P.ovale, (48h)
P. falciparum (36-48 h)
Life Cycle of Plasmodium
Life Cycle of P. falciparum
 Clinical Manifestation
 Cardinal Signs / Trias Malaria

Paroxysm •Cold period (15-60 minutes)

•Fever period 39 - 41 C (2-4 hours)

al Fever •Sweating period (2-4 hours)

Anemia
•Often occurs in endemic areas, esp in pregnant women & children
•Caused by RBC destruction, erythropoesis inhibition, immunological
haemolysis, eryhtrophagocytosis, reticulocyte inhibition

Splenome •Acute phase  Increased RES function

•Chronic phase  determines endemicity
galy
In endemic areas  often no cardinal signs present
Malaria Fever Chart
 Falciparum Malaria (Malign Tertian Malaria) – P.
Falciparum
 Cause of fatal cases/deaths
 Sequestration: rosetting, plasmodium not common seen on blood smear
(indicate severe infection)
 recrudesence
 Tertian Malaria (Benign T M)- P. vivax & P. ovale
 Rarely fatal- relapses common
 Prodrome: myalgia, headache, chilliness, low grade irregular fever
 Spleen palpable 10-14 days
 P. ovale milder with shorter initial attacks
 Regularized to a two-day cycle (tertian)
 Recurrence  hypnozoits
 Quartan Malaria - P. Malariae
 Paroxysms every third day
 Mildest and most chronic of the 4 species
 immune complex nephropathy
Malaria P. vivax
Clinical pattern
Malaria P. falciparum
Clinical pattern
 Complications (WHO 2000)

 hyperparasitemia > 5% parasitaemia

 Cerebral Malaria
 Severe anemia
 Renal failure
 pulmonary edema
 hypoglycemia
 relative hypovolemic shock
 bleeding  thrombocytopenia
 metabolic acidosis
 hyperpirexia
 black water fever  rapid intravascular haemolysis 
haemoglobinuria  coffee ground appearance
Complication (Indonesia)

Cerebral •Coma
malaria •Mortality 5-12%

Severe •Hemoglobin < 5 g/dL

•3-12%
malarial •Short supply of blood
anemia •Unsafe blood supply

Acute •> 50% pre renal (relative

hypovolemia)
Renal •Oliguria  anuria (<100 cc/24 j)
•haemodialysis/peritoneal dialysis

failure mortality <10%

 Diagnosis

Clinical/Working Diagnosis:
History & clinical manisfestation  cardinal signs

Microscopic/Confirmed Diagnosis:
thin & thick smear

Immunologic Diagnosis:
Rapid Diagnostic Test (RDT)/ICT using monoclonal Ab
detecting HRP-2

Biomolecular Diagnosis:
PCR  Numerous P.falciparum kits are available with
>95% sensitivity
Thin & Thick Smear
 P. falciparum on thin blood films

Only ring forms and gametocytes can be found in P. falciparum infection.

Other stages of P. falciparum do not appear in the blood. (they hide in deep tissues)
Ring forms or
trophozoites; many red
cells infected – some
with more than one
parasite

Gametocytes (sexual stages);

After a blood meal, these
forms will develop in the
mosquito gut http://phil.cdc.gov/phil/quicksear
ch.asp
 Plasmodium falciparum
Thin
smear

Schizont gametocyte
Ring form

Thick
smear

18
 Plasmodium vivax
In peripheral blood, every erythrocytic
stages can be found in P. vivax and P.
malariae infections.

ringform
Amoeboid form or
trophozoites of P. vivax

Schizont of P. vivax Ring form of P. vivax

 Gametocytes of P. vivax

Male gametocyte Female gametocyte

Note: compact cytoplasm and absence of

nuclear division.
 Parasite Count
 Quantitative:

Parasite count = N X jumlah lekosit/mm3 darah

(thick smear) 200

Parasite count = N X jumlah eritrosit/mm3 darah

(thin smear) 1000

 Semi-quantitative:
+ = 1 – 10 parasites/100 lp
 ++ = 11 – 100 parasites/100 lp
 +++ = 1 – 10 parasites/lp
 ++++ = 11 – 100 parasites/lp  severe
Classification of Antimalaria Drug
 The kind and degree of resistance

S (sensitive)
All asexual stage diminish on 7 days

R1 : All asexual stage diminish on 7 days

but there is recrudense during 14-28 days

R2 : The amount of parasit in erythrocyte decrease (

75%) but not eliminated

R3 : There is no decreasing of parasitemia

 Sensitive (S)

Late R I

Early R I

R II

R III

0 1 2 3 4 5 6 7 14 21
28
 Recommendations for drug therapy in
Indonesia
 CHLOROQUINE: Is no longer recommended
 ACT provided in Indonesia:

Artesunate + Amodiakuin (AS+AQ)

Combination

Artemether – Lumefantrine (AL)

Combination
 Some failures may be due to emerging
previous ACT resistance, e.g in Papua 
other ACT (DHP)

Dihydroartemisinin-
Piperaquine (DHP)
Combination
 ACT: AS + AQ

1 tablet Artesunate 50 mg & 1 tablet amodiaquin 200 mg (~153 mg

base)
AS+AQ is quite effective for P.falciparum & P.vivax, failure of
treatment (> 20%) has been reported only in a few areas, like
Papua, Lampung, North Sulawesi Utara, Nusatenggara
 ACT: A-L (Coartem)

Artemeter 20 mg and lumefantrine 120 mg.

Coartem is available as fixed dose combination.
 ACT: DHP

Dihydroartemisinin : 2-4 mg/kg BB

Piperakuin : 16-32 mg/kg BB
Primakuin : 0.75 mg/kgBB
Treatment Follow Up
 Treatment Follow Up
Early Treatment Failure
(Development of 1 or more
of the following condition in
the first 3 days)
•Paracytemia with clinical
complication of severe malaria
on day 1, 2, 3
•Paracytemia on day 2 > day 1
•Paracytemia on day 3 (>25%
from day 0)
•Paracytemia on day 3 still (+)
with T >37.5oC
Late Treatment Failure
(Development of 1 or
more of the following
condition on day 4 - 28)
•Late clinical (and parasitological
failure) (LCF):
•Paracytemia (of the same species)
after day 3 with severe malaria
complications
•T >37.5oC with paracytemia on day
4-28
•Late parasitological failure (LPF):
•Paracytemia (of the same species)
on day 7-28 without an increasing T
>37.5oC
 Line II Treatment

 Primaquin should not be given for infants and pregnant women

 Dossage is given based on body weight: Primaquin : 0,75
mg/Kg/single dose for P. falciparum and 0.25 mg/kg/day for
14 days for P.vivax
 In pregnancy & children <11 y.o: clindamycin 10 mg/kg twica
a day for 7 days
 Prophylaxis (Indonesia)

Doksisiklin 2 mg/kg once Daily, for not

daily more than 12
weeks
Should not be given for children <8 years and
during pregnancy
 Prophylaxis (WHO)

Chloroquine Children 5 mg/kg Adult 300mg

weekly weekly
Proguanil Children Adult 200mg
3,5 mg/kg daily daily
Mefloquine Children Adult 250 mg
5 base/kg/weekly base weekly
Primaquine Children Adult 50mg
0,5 mg/kg daily daily