MALARIA

Muhammad ulul amrie, s.kep

 INTRODUCTION

Malaria
 / 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.
 Parasitemia
Parasitemia

P.vivax  reticulocyte
P.vivax   2%
reticulocyte  2% erithrocyte
erithrocyte

P.malariae  older
P.malariae  older erithrocyte  1%
erithrocyte  1%

P.falciparum
P.falciparum  all
all ages
ages of
of erithrocyte
erithrocyte
 erithrocyte
erithrocyte infectious
infectious rate
rate  

severe
severe complication
complication
P.falciparum  severe & complicated malaria

Falciparum.
Pernicious.
Sub tertian.
Malignan.
Estivoautumnal.
 Shock.
Cerebral malaria.
Haemolysis.
Haematologic manifestation
Pulmonary oedema.

Fatal complication
CFR severe malaria  10 – 50%.

Mortality of malaria  / complication of

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

5. Hypoglycaemia, blood sugar < 40 mg%.

6. Circulatory collapse / shock :

* systolic BP < 70 mmHg
(children 1-5 years old < 50 mmHg).
* Cold sweating.
* temperature skin – mucous > 1C.

7. Spontaneous bleeding : nose, gums,

gastrointestinal tract + laboratory 
intravascular coagulation disturbances.
8. Repeat convulsions > 2x/24 hours.

9. Acidaemia (PH <7,25)/Acidosis (HCO3

<15mmol/L).

10.Macroscopic haemoglobinuria  acute

malaria infection.

11.Post mortem confirmation of diagnosis.

Other manifestations of severe malaria
1. Impairment of conciousness less marked
than unrousable coma (GCS < 15).

2. Muscle weakness (can not sit / walk) 

without neurological disorder.

3. Hyperparasitemia > 5% hypoendemic area

or unstable malaria area.

4. Jaundice (bil conc > 3 mg%).

5. Hyperpyrexia (rectal temp > 40C).

 PATHOPHYSIOLOGI
1) Cerebral Malaria
•  2% non immune patients.
• 10% of the patients hospitalized with
falciparum malaria.
• 80% of the fatal case.
• Pathogenese still uncleared.

Suggestion :
Erithrocyte (contain parasite)  unable to
pass throught capillary vessels of the brain
(citoadherence and sequestration)  plug
capillary vessel of the brain  Anoxia.
2) Anemia
 30% case need transfusion.

 WHO  transfusion  Hb < 5 gr% / Hct

< 15% parasite > 10.000/mm3.

 Correlated with parasitemia, skizontemia,

total bilirubin serum, creatinine serum.

 Acute malariadisoriented,lost of conciousness

untill coma, gallop rythm, hepatomegali and
pulmonary oedema.

 Anemia : * haemolysis.
*  TNF-alfa.
3) Acute Renal Failure
 >> adult.

 Sensitive indicator for severe malaria.

 Mortality 45%.

 << children.

 Pre-renal (dehidration)  > 50%.

 Acute tubular necrose  5 – 10%.

Plug capillary vessels   blood flow to
the kidney  Anoxia  glumerular
filtration rate  (oliguria)
Anuria

- diffuse cortical necrosis.

- progressif glumerulonephritis
- arteri renal occlussion /
vasculitis renal.

- hyperkalemia.
- hyperphosphatemia.
- hypocalcemia.
- hypermagnesemia.
 A R F  Acidosis metabolic.

 Hyperuricaemia.

  Amylase serum.

 Congestive heart failure.

 Aritmia.

 Pericarditis.
Terminal stage  uremia, GI & skin bleeding,
septicemia
4) Pulmonary Oedema
 >> adult; << children.
 The most severe complication of
tropica malaria  †

Two types :
1. Fluid overflow.
2. Adult respiratory distress syndrome.

Past: *  capillary membrane permeability.

* microvascullar emboli.
* intra vascullar coagulation.
& pulmonary microcirculair disfunction.
Recent :  TNF-alfa
5) Hypoglicaemia
  Metabolic demands of the parasites.
 Adult ~ tx/: quinine.
 Pregnancy  primigravide.
 >> Adrenalin secretion.
 Failure of hepatic gluconeogenesis.

6) Circulatory collapse / shock

 Malaria Algid.
 Shock with hypotension (systolic pressure
< 70 mmHg).
 Changes of perifer resistance.
  tissue perfusion.
 Hypotension ~ gram negative septicemia.
7) Spontaneous bleeding
 Gums, nose, ptechiae, purpura hematome
 thrombocytopenia.
 Intravascular coagulation disturbance 
rare (< 10%).
 Gastrointestinal bleeding steroid.
stress ulcer.
 Bleeding + severe parasitemia + uremia 
poor prognose.
8) Hyperpyrexia (hyperthermia)
 >> tropica malaria.
 Hot and dry skin, cyanosis in extremities.
 Delirium  coma.
 Temp > 38C  convulsion.
Temp 39,5C - 41C  delirium.
Temp > 41C  coma.
 Endemic area  heat stroke  malaria.
9) Metabolic acidosis
 Hyperventilation (kussmaul).
 Lung  auscultation : N.
 Lactic acid .
 PH  (< 7,25).
 Bicarbonat (< 15 mmol/L).
10) Macroscopic haemoglobinuria
(blackwater fever)
 Syndrome : * acute attack.
* chills.
* intravascular haemolysis.
* haemoglobinemia.
* haemoglobinuria.
* renal failure.
 Back pain.
 Vomiting.
 Diarhea.
 Polyuria.
 Blackwater fever

 Oliguria + ‘coca-cola’-coloured urine.

(blackwater urine)
 Hepatosplenomegali + anemia + icteric.
 Haemolysis caused by quinine or antibody

against quinine never be proved.

 Deficiency of G-6-PD enzyme.
 SUMMARY

Malaria  disease caused by protozoa

intracellular obligate from
plasmodium genus.
Human  P.malariae, P.vivax, P.falciparum,
P.ovale
Pathogenese still uncleared.
Contagioused  * mosquito bite.
* blood transfusion.
* syringe.
* pregnant women  baby.
Plasmodium falciparum  severe and
complicated malaria :
* malaria falciparum.
* pernicious.
* sub tertian.
* malignan.
* estivoautumnal.
Severe malaria : infection caused by
P.falciparum (asexual stage) + one/more
complication : cerebral malaria, severe anemia,
ARF, pulmonary oedema / ARDS, hypoglicemia,
shock, spontaneous bleeding, convulsion,
hyperthermia, acidosis, haemoglobinuria.
 Diagnosis
 Anamnesis :
 Demam, menggigil, nyeri kepala, nyeri

otot, riwayat daerah endemik, transfusi,

obat malaria
 Pemeriksaan fisik :
 Demam, pucat, hepatomegali,

splenomegali, manifestasi malaria berat

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 Diagnosis
 Pemeriksaan laboratorium :
 Tetes tebal & tipis ~ parasit +, spesies &

stadium plasmodium, kepadatan parasit

(semikuantitatif, kuantitatif)
 Pemeriksaan lain :
 Deteksi antigen parasit malaria, metode

imunokromatografi : HRP2, pLDH

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 Diagnosis banding
 Tifoid  Meningo ensefalitis
 Dengue fever  CVA
 ISPA  Tifoid ensefalopati
 Leptospirosis ringan  Hepatitis
 Infeksi virus  Leptospirosis berat
 Glomerulonefritis
 Sepsis
 DSS
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 Pengobatan
 Obat anti malaria :
 Oral ~ malaria ringan tanpa komplikasi

 Parenteral ~ malaria berat / tak bisa

minum obat
 Pengobatan suportif : demam, anti kejang,
cairan dll.
 Pengobatan komplikasi

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 Anti malaria, dasar mikroskopik
 Falsiparum tanpa komplikasi (lini 1)
 Artesunat , 4 tab hari1-3

 Amodiakuin, 4 tab hari 1-3

 Primakuin, 4 tab hari 1

 Lini 2
 Kina, 3x2tab hari 1-7

 Tetrasiklin, 4xi kaps hari 1-7

 Primakuin, 3 tab hari 1

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 Anti malaria, dasar mikroskopik
 Vivax, ovale (lini 1)
 Kloroquin , 4 tab hari1-2, 2 tab hari 3

 Primakuin, 1 tab hari 1-3

 Lini 2
 Kina, 3x2tab hari 1-7

 Primakuin, 1 tab hari 1-14

 Relaps
 Klorokuin 4 tab/minggu , 8-12 minggu

 Primakuin 3 tab/minggu , 8-12 minggu

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 Anti malaria, dasar klinis
 Lini 1
 Kloroquin , 4 tab hari1-2, 2 tab hari 3

 Primakuin, 3 tab hari 1

 Lini 2
 Kina, 3x2tab hari 1-7

 Primakuin, 1 tab hari 1

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 Malaria berat
 Lini 1
 Artesunat (60 mg); 2,4 mg/kgBB iv diikuti 1,2

mg/kgBB 1v jam 12, 24 ; selanjutnya 1,2

mg/kgBB setiap hari sd hari 7
 Artemether (80mg); 2 ampul im hari 1; 1 ampul

1m hari 2-5
 Lini 2 :
 Kina 500 mg dlm D5 selama 8 jam, diulang/8

jam

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