MALARIA

ESSENTIALS OF DIAGNOSIS
HISTORY OF EXPOSURE IN A MALARIA-ENDEMIC AREA
PERIODIC ATTACTS OF SEQUENTIAL CHILLS, FEVER &
SWEATING, APYREXIA
HEADACHE, MYALGIA, SPLENOMEGALI, ANEMIA,
LEUKOPENIA
PARASITES IN RBC, IDENTIFIED IN THICK OR THIN
BLOOD FILMS

ETIOLOGY :
SPOROZOA GENUS PLASMODIUM
Plasmodia malaria :
Pl. vivax Mal. tertiana benigna
Pl. ovale Mal. ovale / T. benigna
Pl. falsiparum Mal. tropika / T. maligna
Pl. malariae Mal. kuartana
Life cycle of malaria parasites
Exoerytrocyter & RBC phase of
Pl. malaria
Pl. vivax
EE II (+)
Pl. ovale
EE I (+)
Pl. falcifarum
EE II (-)
Pl. malariae



PATHOGENESIS (1) Prof. Dr. Yohana Kandow
THE ASEXUAL ERYTHROCYTIC IS RESPONSIBLE FOR THE
SYMPTOMS:
- FEVER, HEADACHE, NAUSEA & MUSCULAR PAIN
AT THE TIME SCHIZONTINFECTED RBC RUPTURE
- ENDOGENEOUS PYROGEN (INTERLEUKIN-1) AND
MEDIATORS (KININS & CATHECTIN TNF) RELATED
TO PATHOGENESIS?

PATHOGENESIS (2) Prof. DR. Yohana
* ENCEPHALOPATHY:
~ RBC CONTAINING SCHIZONTS & MALARIAL
PIGMENT OBSTRUCT CEREBRAL CAPILLARIES &
VENULES
~ CEREBRAL EDEMA MAY DEVELOP AS A RESULT
OF AGONAL HYPOXIA
~ SEQUESTRATION OF PARASITIZED RBC IN BRAIN
& OTHER TISSUE RESULT FROM CYTOADHERENCE
OF KNOBLIKE PROTUBERANCE ON THE RBC TO
ENDOTHELIUM

PATHOGENESI (3) Prof. DR.
Johana
~ DECREASED DEFORMITY OF INFECTED RBC
SLUGGISH MICROVASCULAR FLOW
~ CEREBRAL ANAEROBIC GLYCOLYSIS & REDUCED
CEREBRAL OXYGEN TRANSPORT CEREBRAL
MALARIA


PATHOGENESIS (4) Prof DR Johana

- ANEMIA:
~ HEMOLYSIS OF INFECTED RBC
~ RAPID SPLENIC REMOVAL ON NONPARASITIZED
ERYTHROCYTES
~ DYSERYTHROPOISIS
- THROMBOCYTOPENIA SEQUESTRATION IN THE SPLEEN

PATHOGENESIS (5) Prof DR Johana

- ACUTE RENAL FAILURE

ACUTE TUBULAR NECROSIS

ISCHEMIA RESULTING FROM:
~ HYPOVOLEMIA
~ RENAL VASOCONTRICTION
~ MICROVASCULAR OBSTRUCTION:
* PARASITIZED RBC
* PIGMENT NEPHROPATHY SECONDARY
TO HEMOLYSIS

ACUTE RENAL FAILURE

PATHOGENESIS (6) Prof DR Johana
- THE SPLEEN IS LARGE:
~ ENGORGE & HEAVILY PIGMENTED
~ CONTAINING MANY PHAGOCYTIC CELLS
INGESTED RBC & MALARIAL PIGMENT
- EDEMATOUS LUNGS:
~ PULMONARY CAPILLARIES & VENULE ARE
PACKED WITH INFLAMMATORY CELLS
~ ENDOTHELIAL & INTESTINAL EDEMA
Cara menghitung kepadatan parasit

Jumlah parasit aseksual dalam 1 mm
3


= X x Jumlah lekosit/ mm
3

200

Di mana X= jumlah parasit aseksual per 200
leukosit
200
/ .
3
mm lekosit jumlah X

200
/ .
3
mm lekosit jumlah X

CLINICAL FINDINGS (1)

A. SYMPTOMS (1)
- SHAKING CHILLS (THE COLD STAGE)
- FEVER (THE HOT STAGE) 41C
- DIAPHORESIS (THE SWEATING STAGE)
- FATIGUE
- HEADACHE
- DIZZINESS
- MYALGIA
- ARTHRALGIA
- BACKACHE
- DRY COUGH

DINGIN DEMAM

APIREKSI KERINGAT


DI-DE-RI-TA
CLINICAL FINDNGS (2)

SYMPTOMS (2)
- GASTROINTESTINAL SYMPTOMS:
~ ANOREXIA
~ NAUSEA
~ VOMITING
~ DIARRHEA
~ ABDOMINAL CRAMPS

CLINICAL FINDINGS (3)

SYMPTOMS (3)

-THE ATTACKS PERIODICITY:
~ EVERY-DAY FALCIPARUM
~ EVERY-OTHER-DAY TERTIAN PL. VIVAX & OVALE
~ EVERY-THIRD-DAY QUARTIAN PL. MALARIAE
~ TIRED BETWEEN ATTACKS, BUT FEELS WELL
~ AFTER THIS PRIMARY EPISODE, RECURRENCE ARE
COMMON, EACH SEPERATED BY A LATENT PERIOD
GAMBARAN DEMAM TERTIANA

NORMAL
SUHU

HARI 1 2
3
GAMBARAN DEMAM KUARTANA
SUHU

HARI
NORMAL
1 2
3
4
GAMBARAN SUSTAINED FEVER
(KONTINYU)
SUHU
JAM 6
12
NORMAL
18
< 1 C
CLINICAL FINDINGS (4)
SIGNS
- SPLENOMEGALY:
APPEAR ACUTE SYMPTOMS
CONTINUED 4 DAYS
- MILDY HEPATOMEGALY
- ANEMIA
COMPLICATIONS (1):
1. CEREBRAL MALARIA:
- HEADACHE
- MENTAL DISTURBANCES
- NEUROLOGIC SIGNS
- RETINAL HEMORRHAGES
- CONVULSIONS
- DELIRIUM
- COMA

COMLICATIONS (2):
2. HYPERPYREXIA
3. HEMOLYTIC ANEMIA
4. NONCARDIOGENIC PULMONARY EDEMA
5. ACUTE TUBULAR NECROSIS & RENAL
FAILURE BLACKWATER FEVER DUE TO
>QUININE TREATMENT

COMPLICATIONS (3)
6. ACUTE HEPATOPATHY MARKED
JAUNDICE, BUT NO LIVER FAILURE
7. HYPOGLYCEMIA
8. ADRENAL INSUFFICIENCY-LIKE SYNDROME
9. CARDIAC DYSRHYTHMIAS
10, GASTROINTESTINAL SYNDROMES
11. LACTIC ACIDOSIS & HYPOGLYCEMIA
12. PNEUMONIA
13. WATER & ELECTROLYTE IMBALANCE

MANAGEMENT:
A. TREATMENT OF ACUTE ATTACKS (1)
1. ELIMINATION OF ASEXUAL ERYTHROCYTIC PARASITES
- CHLOROQUINE PHOSPHATE (SALT) 1G AT
6, 24, AND THEN 0.5 G AT 48 HOURS
HOURS 0 24 48
CHLOROQ/ GR 1 1 0.5
- MEFLOQUINE,
~ 1 x 250 MG FOR 3 DAYS, OR 750-1250 MG,
THEN 500 MG AFTER 6-8 HOURS

TREATMENT OF ACUTE ATTACKS (2)

- QUININE SULFATE (PLUS DOXYCYCLINE, CLINDAMYCIN,
OR FANSIDAR
- ATOVAQUONE 250 MG (PLUS DOXYCYCLINE 100 MG OR
PROGUANIL 100 MG)
- HALOFANTRINE,
- ARTEMISININ (QINGHAOSU), FISRT DAY 2X2 TABS,
THEN 2X1 TABLET FOR 5 DAYS

TREATMENT OF ACUTE ATTACKS (3)
IN SEVERE PATIENTS
- START ORAL THERAPY WITH CHLOROQUINE
AS SOON AS POSSIBLE
- IV QUININE DIHYDROCHLORIDE
- QUINIDINE GLUCONATE
- PARENTERAL CHLOROQUINE

TREATMENT OF ACUTE ATTACKS (4)

2. ERADICATION OF P. VIVAX OR P. OVALE
CHLOROQUINE AS ABOVE FOLLOWED BY 0.5 G ON DAYS 10
AND 17 PLUS PRIMAQUINE PHOSPHATE, 25,3 MG (SALT)
DAILY FOR 14 DAYS STARTING ABOUT DAY 4

DAYS 1 2 3 4 10 17
CHLOROQ/G 1.0 1.0 0.5 0.5 0.5
PRIMAQUINE 26.3 FOR 14 DAYS

TREATMENT OF ACUTE ATTACKS (5)

3. ELIMINATION OF PERSISTENT GAMETOCYTEMIA
- CHLOROQUINE FOR P.VIVAX, P. OVALE,
P. MALARIAE
- PRIMAQUINE SALT, SINGLE DOSE, 26.3 MG
FOR P. FALCIPARUM
TREATMENT OF ACUTE ATTACKS (6)

* TREATMENT OF FALCIPARUM MALARIA ACQUIRED
IN AREAS WHERE P. FALCIPARUM IS RESISTANT TO
CHLOROQUINE (1)
- START WITH ORAL QUININE SULFATE, 10 MG/KG 3X
DAILY FOR 3-7 DAYS, PLUS :
~ DOXYCYCLINE, 2X10 MG FOR 7 DAYS
~ CLINDAMYCIN. 3X900 MG DAILY FOR 5 DAYS
~ PYRIMETHAMINE, 2X25 MG DAILY FOR 3 DAYS
~ SULFADIAZINE, 4X500 MG DAILY FOR 7 DAYS
~ 3 TABLETS OF FANSIDAR (PYRIMETHAMIN+
SULFADOXINE)
TREATMENT OF ACUTE ATTACKS (7)
P. FALCIPARUM IS RESISTANT TO CHLOROQUINE (2).
- ALTERNATIVE DRUGS ARE:
~ MEFLOQUINE
~ HALOPHANTRINE
~ ARTESUNATE
~ ATOVAQUONE
- SEVERELY ILL:
~ IV QUININE OR QUINIDINE
~ DOCYCYCLINE OR CLINDAMYCIN
PARENTRALLY
- ORAL TREATMENT WITH QUININE PLUS THE
ANTIBIOTIC SHOULD BE AS SOON AS POSSIBLE
TREATMENT OF ACUTE ATTACKS (8)
* SPECIAL TREATMENT FOR TREATMENT OF SEVERE
P. FALCIPARUM MALARIA (1)
- MEDICAL EMERGENCY THAT REQUIRES:
~ HOSPITALIZATION
~ INTENSIVE CARE
~ IV CHEMOTHERAPY AS RAPID AS POSSIBLE
~ REQUIRING >48 HOUR OF PARENTRAL THERAPY
~ REDUCE THE QUININE OR QUINIDINE DOSE BY
ONE-THIRD TO ONE-HALF
~ DEHYDRATION SHOULD BE DONE WITH CAUTION
~ FLUID, ELECTROLYTE & ACID- BASE BALANCE
MUST BE MONITORED
TREATMENT OF ACUTE ATTACKS (9)
* SPECIAL TREATMENT FOR TREATMENT OF
SEVERE P. FALCIPARUM MALARIA (2):
~ EARLY DIALYSIS MAY BE NECESSARY FOR RENAL
FAILURE
~ BLOOD GLUCOSE LEVELS SHOULD BE MONITORED
EVERY 6 HOURS IF HYPOGLYCEMIA +,
~ 50% DEXTROSE, 1-2 ML/KG
~ MAINTENANCE 5-10% DEXTROSE

TREATMENT OF ACUTE ATTACKS (10)
* SPECIAL TREATMENT FOR TREATMENT OF SEVERE
P. FALCIPARUM MALARIA (3)
- DIC FRESH WHOLE BLOOD
- HCT < 20% TRANSFUSION
- EXCHANGE TRANSFUSION WHEN >15% RBC
ARE PARASITIZED
- SEIZURES ANTICONVULSANTS
- TEMPERATURE IS MAINTAINED <38.5 C
- BLOOD FILM SHOULD BE CHECKED DAILY UNTIL
PARASITEMIA CLEARS; WEEKLY THEREAFTER
FOR 4 WEEKS RECRUDESCENCE?
TREATMENT OF ACUTE ATTACKS (11)

B. CHEMOPROPHYLAXIX (1)
a. IN REGIONS WHERE P. FALCIPARUM AND P. VIVAX
ARE SENSITIVE TO CHLOROQUINE
~ DRUG OF CHOICE
1. CHLOROQUINE PHOSPHATE, 500 MG WEEKLY, ONE
WEEK BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEK AFTER LEAVING

TREATMENT OF ACUTE ATTACKS (12)

CHEMOPROPHYLAXIX (2)
~ ALTERNATIVE DRUGS
1. HALOFANTRINE.
2. FANSIDAR
3. AMODIAQUINE.
4. PYRIMETHAMINE
5. ARTEMISININ
6. PROGUANIL
7. QUININE

TREATMENT OF ACUTE ATTACKS (13)
CHEMOPROPHYLAXIX (3)
b. IN REGIONS WHERE P. FALCIPARUM IS RESISTANT
TO CHLOROQUININE
~ DRUGS OF CHOICE
1. MEFLOQUINE SALT, 250 MG (228 MG BASE) WEEKLY,
3 WEEKS BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING.

TREATMENT OF ACUTE ATTACKS (14)

CHEMOPROPHYLAXIX (4)
~ ALTERNATIVE:
- FIRST ALTERNATIVE: DOXYCYCLINE, 100 MG DAILY,
2 DAYS BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING
- SECOND ALTERNATIVE: MALARONE (ATOVAQUONE
250 MG + PROGUANIL 100 MG), ONE TABLET DAILY,
ONE TABLET THE DAY BEFORE ENTERING THE
ENDEMIC AREA, WHILE THERE, AND FOR 1 WEEK
AFTER LEAVING
TREATMENT OF ACUTE ATTACKS (15)

CHEMOPROPHYLAXIX (5)
- OTHER ALTERNATIVES:
DAILY PROGUANIL 200 MG + WEEKLY CHLOROQUINE
0.5 G, MORE PROTECTION THAN CHLOROQUINE
ALONE

TREATMENT OF ACUTE ATTACKS (16)
CHEMOPROPHYLAXIX (6)
c. PROPHYLAXIS FOR PREGNANT WOMEN
- THE BEST COURSE IS WEEKLY CHLOROQUINE +/
PROGUANIL
- IN AREAS OF CHLOROQUINE-RESISTANT MALARIA
MEFLOQUININE, EXCEPT IN THE FIRST TRIMESTER
- DRUGS CONTRAINDICATED ARE DOXYCYCLINE &
PRIMAQUINE
Recommendation WHO 2006 in using ACTs
Artemether+lumefantrine
Artesunate + amodiaquine
Artesunate + mefloquine
Artesunate + sulfadoxine-pyrimethamine
PROGNOSIS
- UNCOMPLICATED & UNTREATED PRIMARY ATTACK OF
P. VIVAX, P. OVALE, OR P. FALCIPARUM MALARIA USUALLY
LASTS 2-4 WEEKS; P. MALARIAE ABOUT TWICE AS LONG.
- WITH PROMPT ANTIMALARIAL THERAPY, THE PROGNOSIS
IS GENERALLY GOOD, BUT IN P. FALCIPARUM INFECTIONS,
WHEN SEVERE COMPLICATIONS DEVELOP, THE PROGNOSIS
IS POOR EVEN WITH TREATMENT