Tutor by : dr. Tirza Gwendoline M, Sp.

PD
Yosui Eka K. Tobing (04-028)
Definition
• Malaria is a parasite disease caused by
plasmodium which attack erythrocyte and
signed by finding the asexual form in blood
• Malaria is a protozoan disease transmitted by
the bite of infected Anopheles mosquitoes
Etiology
Four species of the genus Plasmodium
• P. falciparum  Tropica malaria (Malignan)
• P. vivax  Tertiana malaria (Benign)
• P. ovale  Ovale malaria
• P. malariae  Quartan malaria
Pathogenesis
 Characteristics of Plasmodium
Species Infecting Humans
Characteristic P. Falciparum P. Vivax P. Ovale P. Malariae
Duration of 5.5 8 9 15
intrahepatic phase
(days)
Number of 30,000 10,000 15,000 15,000
merozoites released
per infected
hepatocyte
Duration of 48 48 50 72
erythrocytic cycle
(hours)
Red cell preference Younger cells Reticulocytes Reticulocytes Older cells
(but can invade and cells up
cells of all ages) to 2 weeks
old
 Characteristics of Plasmodium
Species Infecting Humans
Characteristic P. Falciparum P. Vivax P. Ovale P. Malariae
Morphology Usually only Irregularly Infected Band or
ring formsa; shaped large erythrocytes, rectangular
banana-shaped rings and enlarged and forms of
gametocytes trophozoites; oval with trophozoites
enlarged tufted ends; common
erythrocytes; Schüffner's
Schüffner's dots
dots
Pigment color Black Yellow-brown Dark brown Brown-black
Ability to cause No Yes Yes No
relapses
Epidemiology
• Malaria occurs throughout most of the tropical regions of the
world
• P. falciparum predominates in Africa, New Guinea, and Haiti
• P. vivax is more common in Central America
• The prevalence of these two species is approximately equal in
South America, the Indian subcontinent, eastern Asia, and
Oceania
• P. malariae is found in most endemic areas, especially
throughout sub-Saharan Africa, but is much less common
• P. ovale is relatively unusual outside of Africa and, where it is
found, comprises <1% of isolates.
Epidemiology
 Paracyte Factor :
Social and Geographic
-Medicine resistance
Factor :
-Velocity of multiply
Host Factor : -Access to gain
-Invade method
-Imunity treatment
-Cytoadherence
-Cytokine proinflamation -Culture n economy
-Rosetting
-Genetic factors
-Antigenic Polimorfism
-Gestational age -Politic stability
-Antigenic variety
-Intensity of insect
-Malaria toxin
transmission

Clinical Manifestastion

Asymptomatic Fever Severe malaria Death

(spesific)
Clinical Features
1. Periodic fever
2. Anemia
3. Splenomegaly
Prodromal Symptom
• Fatigue
• Malaise
• Headache
• Back Pain
• Bone and joint pain
• Mild fever
• Anorexia
• Mild diarrhea
Trias Malaria
• Cold period (15-60 min) : shiver, follow with
increasing temperature.
• Hot period : blushing face, rapid pulse, the
temperature still increase and begins to sweat
• Sweat period : lots of sweat and decreasing
temperature, feel healthy.
Plasmodium Incubation Fever Type Relapse Recrudence Clinical Manifestation
Period (day) (hour)
Falciparum 12 (9-14) 24, 36, 48 (-) (+) GI symptoms; haemolysis,
anemia, icterus,
haemoglobinuria, shock,
algid malaria, cerebral
symptom, lung edema,
hypoglicemic, pregnancy
disturbance, retina
disorder, death.
Vivax 13 (12-17) 48 (++) (-) Chronic anemia,
 12 bulan splenomegaly, lien
rupture.
Ovale 17 (16-18) 48 (++) (-) Same with vivax
Malariae 28 (18-40) 72 (-) (+) Recrudense until 50 years,
permanent splenomegaly,
nefrotic syndrome
Diagnose
• Anamnesis
• Physical examination
• Laboratory
Anamnesis
• Type of fever
• Patients origin area whether from the malaria
endemic area or not
• History about travelling to malaria endemic area
• History of curative and preve treatment
 Supporting Examination
• Stained peripheral-blood smears
Demonstration of asexual forms of the parasite
Diagnose malaria (-)  3 times examination with negative
result
▫ Bold blood smears  best way to find parasite of malaria
Count number of asexual parasites per 200 WBCs (or per
500 at low densities). Count gametocytes separately.
▫ Thin blood smears  identify the species of Plasmodium
Count number of RBCs containing asexual parasites per
1000 RBCs. In severe malaria, assess stage of parasite
development and count neutrophils containing malaria
pigment.e Count gametocytes separately.
• Antigen Test : P-F test (Rapid Test)
Detection the antigen of P. falciparum
• Serology test
Detection specific antigen of malaria in minimal value
of parasite
Can examine few days after parasitemia
• PCR (Polymerase Chain Reaction)
High sensitivity and specivity
Differential Diagnose
• Dengue Fever
• Typhoid Fever
• Typhoid fever with hepatitis
• Meningitis
• Encephalitis
• Typhoid encephalopaty
 Treatment
Uncomplicated Malaria
Known chloroquine-sensitive Chloroquine (10 mg of base/kg stat followed by 5 mg/kg at 12,
strains of Plasmodium vivax, 24, and 36 h or by 10 mg/kg at 24 h and 5 mg/kg at 48 h) or
P. malariae, P. ovale, Amodiaquine (10–12 mg of base/kg qd for 3 days)
P. falciparum
Radical treatment for P. vivax In addition to chloroquine or amodiaquine as detailed above,
or P. ovale infection primaquine (0.25 mg of base/kg qd; 0.375–0.5 mg of base/kg qd
in Southeast Asia and Oceania) should be given for 14 days to
prevent relapse
Sensitive P. falciparum Artesunatec (4 mg/kg qd for 3 days) plus sulfadoxine (25
malaria mg/kg)/pyrimethamine (1.25 mg/kg) as a single dose or
Artesunatec (4 mg/kg qd for 3 days) plus amodiaquine (10 mg of
base/kg qd for 3 days)
Multidrug-resistant P. Either artemether-lumefantrinec (1.5/9 mg/kg bid for 3 days with
falciparum malaria food) or artesunatec (4 mg/kg qd for 3 days) plus
Mefloquine (25 mg of base/kg—either 8 mg/kg qd for 3 days or
15 mg/kg on day 2 and then 10 mg/kg on day 3)
Uncomplicated Malaria
Second-line Either artesunatec (2 mg/kg qd for 7 days) or quinine (10
treatment/treatment of mg of salt/kg tid for 7 days)
imported malaria plus 1 of the following 3:
1. Tetracyclinee (4 mg/kg qid for 7 days)
2. Doxycyclinee (3 mg/kg qd for 7 days)
3. Clindamycin (10 mg/kg bid for 7 days)
Or
Atovaquone-proguanil (20/8 mg/kg qd for 3 days with
food)
 Severe Malaria
Artesunatec (2.4 mg/kg stat IV followed by 2.4 mg/kg at 12 and 24 h and then daily if
necessary)g
or
Artemetherc (3.2 mg/kg stat IM followed by 1.6 mg/kg qd)

or
Quinine dihydrochloride (20 mg of salt/kgh infused over 4 h, followed by 10 mg of
salt/kg infused over 2–8 h q8hi)

or
Quinidine (10 mg of base/kgh infused over 1–2 h, followed by 1.2 mg of base/kg per
houri with electrocardiographic monitoring)
 Properties of Antimalarial Drugs
Drug(s) Antimalarial Activity Minor Toxicity Major Toxicity
Quinine, Acts mainly on "Cinchonism": tinnitus, Hypoglycemia; more
Quinidine trophozoite blood stage; high-tone hearing loss, cardiotoxic
kills gametocytes of P. nausea, vomiting,
vivax, P. ovale, and P. dysphoria, postural
malariae (but not P. hypotension
falciparum); no action on
liver stages
Chloroquine As for quinine but acts Nausea, dysphoria, Hypotensive shock
slightly earlier in asexual pruritus in dark-skinned (parenteral), cardiac
cycle patients, postural arrhythmias,
hypotension neuropsychiatric
reactions
Amodiaquine As for chloroquine Nausea (tastes better than Agranulocytosis;
chloroquine) hepatitis, mainly with
prophylactic use
Mefloquine As for quinine Nausea, giddiness, Neuropsychiatric
dysphoria, fuzzy thinking, reactions,
sleeplessness, nightmares, convulsions,
sense of dissociation encephalopathy
 Properties of Antimalarial Drugs
Drug(s) Antimalarial Activity Minor Toxicity Major Toxicity
Tetracycline. Weak antimalarial activity; Gastrointestinal Renal failure in patients
Doxycycline should not be used alone intolerance, deposition with impaired renal
for treatment in growing bones and function (tetracycline)
teeth, photosensitivity,
moniliasis, benign
intracranial
hypertension
Halofantrine As for quinine Diarrhea Cardiac conduction
disturbances;
atrioventricular block;
ECG QTc interval
prolongation; potentially
lethal ventricular
tachyarrhythmias
Artemisinin Broader stage specificity Reduction in Anaphylaxis, urticaria,
and and more rapid than other reticulocyte count (but fever
derivatives drugs; no action on liver not anemia)
(artemether, stages; kills all but fully
artesunate) mature gametocytes of P.
falciparum
 Properties of Antimalarial Drugs
Drug(s) Antimalarial Activity Minor Toxicity Major Toxicity
Pyrimethamine For blood stages, acts Well tolerated Megaloblastic anemia,
mainly on mature forms; pancytopenia, pulmonary
causal prophylactic infiltration
Proguanil Causal prophylactic; not Well tolerated; mouth Megaloblastic anemia in
(chloroguanide) used alone for treatment ulcers and rare renal failure
alopecia
Primaquine Radical cure; eradicates Nausea, vomiting, Massive hemolysis in
hepatic forms of P. vivax diarrhea, abdominal subjects with severe G6PD
and P. ovale; kills all pain, hemolysis, deficiency
stages of gametocyte methemoglobinemia
development of P.
falciparum
Atovaquone Acts mainly on Not identified Not Identified
trophozoite blood stage
Lumefantrine As for quinine Not identified Not Identified
Complications
• Acute Renal Failure
• Acute Pulmonary Edema
• Hypoglycemia
• Other complications
Prevention
• Personal Protection Against Malaria
avoidance of exposure to mosquitoes at their peak
feeding times (usually dusk and dawn) and throughout
the night :
- use of insect repellents containing DEET
- suitable clothing
- insecticide-impregnated bed nets
• Chemoprophylaxis
 Drugs Used in the Prophylaxis of Malaria
DRUG USAGE ADULT COMMENT
DOSE
Atovaquone/ Prophylaxis in areas 1 adult Begin 1–2 days before travel to
proguanil (Malarone) with chloroquine- or tablet PO malarious areas. Take daily at
mefloquine-resistant the same time each day while in
Plasmodium falciparum the malarious area and for 7
days after leaving such areas
Chloroquine Prophylaxis only in 300 mg of Begin 1–2 weeks before travel
phosphate (Aralen) areas with chloroquine- base (500 to malarious areas. Take weekly
sensitive P. falciparum mg of salt) on the same day of the week
PO once while in the malarious areas and
weekly for 4 weeks after leaving such
areas
Doxycycline Prophylaxis in areas 100 mg PO Begin 1–2 days before travel to
with chloroquine- or qd malarious areas. Take daily at
mefloquine-resistant P. the same time each day while in
falciparum the malarious areas and for 4
weeks after leaving such areas
Hydroxychloroquine alternative to 310 mg of Begin 1–2 weeks before travel
sulfate (Plaquenil) chloroquine for primary base (400 to malarious areas. Take weekly
 Drugs Used in the Prophylaxis of Malaria
DRUG USAGE ADULT DOSE COMMENT
Mefloquine Prophylaxis in areas with 228 mg of base Begin 1–2 weeks before travel
(Lariam) chloroquine-resistant P. (250 mg of salt) to malarious areas. Take weekly
falciparum PO once weekly on the same day of the week
while in the malarious areas and
for 4 weeks after leaving such
areas
Primaquine An option for prophylaxis in 30 mg of base Begin 1–2 days before travel to
special circumstances (52.6 mg of malarious areas. Take daily at
salt) PO qd the same time each day while in
the malarious areas and for 7
days after leaving such areas
Primaquine Used for presumptive 30 mg of base This therapy is indicated for
antirelapse therapy (terminal (52.6 mg of persons who have had
prophylaxis) to decrease risk salt) PO qd for prolonged exposure to P. vivax
of relapses of P. vivax and P. 14 days after and/or P. ovale
ovale. departure from
the malarious
area
 History of Present Illness
16 days 13 days 9 days
before before before

Fever, Headache, Patient got Patient

whole muscle & joint treated for 4 discharged
body, pain, nausea (+), days in a good
intermittent cough with recovery
, especially phlegm, vomit
in the (+), yellow eyes,
evening ‘tea like’ urine,
went to clinic in
Jambi and got
refered to Tebet
hospital, Jakarta
 5 days
before

Fever, Epigastric History have

whole pain (+), a trip to
body, nausea (-), uptown
shiver vomit (-), (Jambi)
(+), urinate and
sweaty defecate
(+), normal,
period of
fever :
every 2-
3 days.
History of Past Illness
• History of malaria (+), has been treated for a few times.
Patient get Cloroquin every 2 weeks.

History of Family Illness

• DM history denied
• Asthma history denied
• Hypertension history denied
• Heart disease history denied

Social-Economy and Habit

• History travelling out of town (Jambi)
• Consuming alcohol
• Smoking history (clove cigarette) in 10 years
 Physical Examination
General condition : moderate illness Pulmo : BND vesicular (-), Rh (-)
Consciousness : compos mentis Wh (-)
Height : 171 cm Cor : Heart sound I-II reg,
Weight : 62 kg Murmur (-), gallop (-)
BMI : 21,2 Abdomen : flat, supple, tenderness
BP : 120/80 mmHg (-), bowel sound (+) normal
HR : 104 x/ minute 4 x/ minute, hepar and
spleen didn’t feel enlarged
RR : 22 x / minute
Extremity : warm extremity,
Temperature : 38,90C
edema -/-
Eyes : anemic conj +/+
icterus sclera -/-
Neck : JVP 5-3 cmH2O
 Laboratory (14/06/2010)
Examination Result
HEMATOLOGY
Malaria 1 Positive
-P. vivax, shape: trofozoit, Infected of
Erythrocytes 0,02 %
- P. falciparum, shape : trofozoid and
gametocyte, infected if erythrocytes
0,24 %
IMUNOSEROLOGY
ICT Malaria Positive
 Laboratory
HEMATOLOGY RESULT
Hb 11,7 g/dl
Ht 32.8 %
Trombocyte 149.000/ul
Leucocyte 5510/ul
Erythrocyte 4.050.000/ul
LED 55
Basofil 1%
Eosinofil 1%
Segment 0%
Stem 50 %
Lymphocyte 34 %
Monocyte 14 %
MCV 81.1 fL
MCH 28.9 pg
MCHC 35.6 %
 Laboratory
HEMATOLOGY RESULT
GDS 95 mg/dl
BUN 5 mg/dl
Creatinin 0,8 mg/dl
SGOT 15 U/L
SGPT 19 U/L
Na 138,2 mmol/L
K 3,27 mmol/L
Cl 101,7 mmol/L
Bacteria Negative
Crystal Negative
Fungal Negative
Trichomonas Negative
Problem List
• Periodic fever
• History of Malaria
• Anemia
Diagnose
• Malaria vivax et falciparum
Differential Diagnose
• Dengue Fever
• Typhoid fever
Treatment
• Patient hospitalize
• Diet 2200 kal
• IVFD II RL/ 24 jam
• MM/: 1. Paracetamol 3 x 500 mg
2. Primaquine 1 x 15 mg
3. OBH 3 x 1 C
4. Bromhexine HCl 3 x 1 C
5. Prednisone 3 x 5 mg
6. Diazepam 1 x 2 mg (at night)
 1st day treatment (15/06/2010)
S : fever (+) , shooting pain (+), cough with phlegm (+), fatigue (+)
O:Gen Con: Moderate illness ; Cons: CM
BP : 120/80 mmHg; HR: 66x/min; RR: 24x/min; T: 38,2 ‘C
Eyes: CA +/+ Neck : JVP normal
Thorax :
Insp : movement of chest wall is simetric Perc : sonor right = left
Palp : Vocal fremitus simetric Ausc : BBS vesicular, Rh -/-, Wh
Abdomen:
Insp : look flat Perc : tympani , tap pain (-)
Ausc : Bowel sound (+) 4 x /minute Palp : supple, epigastric tenderness +
A: Malaria vivax et falciparum
P: Diet 2200 kal
IVFD: II RL / 24 hours
MM/ 1. Kloroquin phosphat 1000mg – 500 mg – 500 mg
2. Primaquin e1 x 15 mg
3. Paracetamol 3 x 500 mg
4. OBH 3 x 1C
5. Bromhexine HCl 3 x 1C
6. Prednisone 3 x 5 mg 7. Diazepam 1 x 2 mg (at night)
 Lab 15/06/2010
Examination Result
HEMATOLOGY
Malaria 2 Positive
- P. falciparum, shape : trofozoid and
gametocyte, infected if erythrocytes
0,12 %
 Laboratory
URINE RESULT
Colour Yellow
Purity Clear
pH 6.00
BJ 1030
Protein Negative
Reduksi Negative
Bilirubin Negative
Urobilinogen 0,2
Keton Negative
Blood Negative
Lekosit Negative
Nitrit Negative
 2nd day treatment (16/06/2010)
S : had fever last night, this morning the temp. normal, shooting pain (+), cough (+),
narrow(-)
O:Gen Con: Moderate illness ; Cons: CM
BP : 120/70 mmHg; HR: 64/min; RR: 20/min; T: 37,2 ‘C
Eyes: CA +/+ Neck : JVP normal
Thorax :
Insp : movement of chest wall is simetric Perc : sonor right = left
Palp : Vocal fremitus simetric Ausc : BBS vesicular, Rh -/-, Wh
Abdomen:
Insp : look flat Perc : tympani , tap pain (-)
Ausc : Bowel sound (+) 4 x /minute Palp : supple, epigastric tenderness +
A: Malaria falciparum
P: Diet 2200 kal
IVFD: II RL / 24 hours
MM/ 1. Kloroquin phosphat 1000mg – 500 mg – 500 mg
2. Primaquin e 1 x 45 mg (3 tab)
3. Paracetamol 3 x 500 mg
4. OBH 3 x 1C
5. Bromhexine HCl 3 x 1C
6. Prednisone 3 x 5 mg 7. Diazepam 1 x 2 mg (at night)
 3rd day treatment (17/06/2010)
S : fever (-), cough (+), lose appetite, defecate normal, urinate normal , color yellow
O:Gen Con: Moderate illness ; Cons: CM
BP : 120/80 mmHg; HR: 72/min; RR: 22/min; T: 37 ‘C
Eyes: CA +/+ Neck : JVP normal
Thorax :
Insp : movement of chest wall is simetric Perc : sonor right = left
Palp : Vocal fremitus simetric Ausc : BBS vesicular, Rh -/-, Wh
Abdomen:
Insp : look flat Perc : tympani , tap pain (-)
Ausc : Bowel sound (+) 5 x /minute Palp : supple, epigastric tenderness (-)
A: Malaria falciparum
P: Diet 2200 kal
IVFD: II RL / 24 hours
MM/ 1. Kloroquin phosphat 500 mg/24 hr
2. Primaquin e 1 x 45 mg (3 tab)
3. Paracetamol 3 x 500 mg if neccesary
4. OBH 3 x 1C
5. Bromhexine HCl 3 x 1C
6. Prednisone 3 x 5 mg
 4th day treatment (18/06/2010)
S : fever (-), nausea (+), cough with phlegm (+), lose appetite, defecate normal, urinate normal ,
color yellow
O:Gen Con: Moderate illness ; Cons: CM
BP : 110/80 mmHg; HR: 68/min; RR: 18/min; T: 36,5 ‘C
Eyes: CA -/- Neck : JVP normal
Thorax :
Insp : movement of chest wall is simetric Perc : sonor right = left
Palp : Vocal fremitus simetric Ausc : BBS vesicular, Rh -/-, Wh
Abdomen:
Insp : look flat Perc : tympani , tap pain (-)
Ausc : Bowel sound (+) 4 x /minute Palp : supple, epigastric tenderness (-)
A: Malaria falciparum
P: Diet 2200 kal
IVFD: II RL / 24 hours
MM/ 1. Kloroquin phosphat 500 mg/24 hr
2. Primaquin e 1 x 45 mg (3 tab)
3. Paracetamol 3 x 500 mg if necessary
4. OBH 3 x 1C
5. Bromhexine HCl 3 x 1C
6. Prednisone 3 x 5 mg
 Lab 18/06/2010
HEMATOLOGY RESULT
Hb 11.6 g/dl
Ht 32.6 %
Trombocyte 169.000/ul
Leucocyte 6430/ul
Erythrocyte 4.030.000/ul
LED 55
Basofil 1%
Eosinofil 0%
Segment 0%
Stem 52 %
Lymphocyte 36 %
Monocyte 11 %
MCV 81 fL
MCH 28.8 pg
MCHC 35.5 %
 5th day treatment (19/06/2010)
S : fever (-), nausea (+) <<, cough with phlegm (+), llimp body
O:Gen Con: Moderate illness ; Cons: CM
BP : 110/70 mmHg; HR: 70/min; RR: 22/min; T: 36,3 ‘C
Eyes: CA -/- Neck : JVP normal
Thorax :
Insp : movement of chest wall is simetric Perc : sonor right = left
Palp : Vocal fremitus simetric Ausc : BBS vesicular, Rh -/-, Wh
Abdomen:
Insp : look flat Perc : tympani , tap pain (-)
Ausc : Bowel sound (+) 3x /minute Palp : supple, epigastric tenderness (-)
A: Malaria falciparum
P: Diet 2200 kal
IVFD: II RL / 24 hours
MM/ 1. Kloroquin phosphat 500 mg/24 hr
2. Primaquin e 1 x 45 mg (3 tab)
3. Paracetamol 3 x 500 mg if necessary
4. OBH 3 x 1C
5. Bromhexine HCl 3 x 1C
6. Prednisone 3 x 5 mg
 6th day treatment (20/06/2010)
S : fever (-), nausea (+) <<, limp body, cough with phlegm (+), lose appetite <<
O:Gen Con: Moderate illness ; Cons: CM
BP : 120/80 mmHg; HR: 68x/min; RR: 22x/min; T: 36,5 ‘C
Eyes: CA -/- Neck : JVP normal
Thorax :
Insp : movement of chest wall is simetric Perc : sonor right = left
Palp : Vocal fremitus simetric Ausc : BBS vesicular, Rh -/-, Wh
Abdomen:
Insp : look flat Perc : tympani , tap pain (-)
Ausc : Bowel sound (+) 4 x /minute Palp : supple, epigastric tenderness (-)
A: Malaria falciparum
P: Diet 2200 kal
IVFD: II RL / 24 hours
MM/ 1. Kloroquin phosphat 500 mg/24 hr
2. Primaquin e 1 x 45 mg (3 tab)
3. Paracetamol 3 x 500 mg if necessary
4. OBH 3 x 1C
5. Bromhexine HCl 3 x 1C
6. Prednisone 3 x 5 mg
 7th day treatment (21/06/2010)
S : fever (-), appetite good, cough (-)
O:Gen Con: Moderate illness ; Cons: CM
BP : 110/80 mmHg; HR: 68x/min; RR: 18x/min; T: 36,5 ‘C
Eyes: CA -/- Neck : JVP normal
Thorax :
Insp : movement of chest wall is simetric Perc : sonor right = left
Palp : Vocal fremitus simetric Ausc : BBS vesicular, Rh -/-, Wh
Abdomen:
Insp : look flat Perc : tympani , tap pain (-)
Ausc : Bowel sound (+) 4 x /minute Palp : supple, epigastric tenderness (-)
A: Malaria falciparum
P: Diet 2200 kal
IVFD: II RL / 24 hours
MM/ 1. Kloroquin phosphat 500 mg/24 hr
2. Doxycyclin 2 100 mg
3. Paracetamol 3 x 500 mg if necessary
4. Prednisone 3 x 5 mg  tappering off
 Laboratory 21/06/2010
HEMATOLOGY RESULT
Malaria 3 Negative
Not found
• 21/06/2010  Patient discharged