DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MALARIA| Tutorial E-2 TM

130110110177|Gabriella Chafrina| 05/09/14

DIAGNOSIS
History Taking
Chief complaint in malaria is fever, chills, sweating, headache, nausea, vomiting, diarrhea and muscle pain. In history
taking, it should be ask about:
a) Travelling history to endemic place
b) Residential history in endemic place
c) Past medical history for malaria/fever
d) Medication history for malaria drugs for last 1 month
e) blood transfusion

Physical Examination
- Intermittent fever (>37,5
o
C axilla)
- Conjunctiva or palms anemic
- Splenomegaly
- Hepatomegaly
- Clinical manifestation for severe malaria can be unconsciousness, high fever, anemic conjunctiva, and icteric,
oliguria, black brown colored urine (Black Water Fever), convulsion and very weak (prostration)
- In severe anemia condition: GCS<11, temp >40
o
C, blood pressure and pulse rate decreasing, weak, neurologic
symptoms positive

Lab Examination
1) Microscopic examination
Microscopic examination is a gold standard for malaria. Microscopic
examination is done by do thick and thin blood smear examination.
Thick and thin blood smear examination in hospital/puskesmas for
deciding:
- If there is any parasitic malaria (positive or negative)
- Species and stadium Plasmodium
- Parasitic quantity

THICK BLOOD SMEAR for screening and examine parasite quantity
a) Semi quantitative
(-) : negative (no parasitic in 100 HPF)
(+) : positive 1 (found 1-10 parasitic in 100 HPF)
(++) : positive 2 (found 11-100 parasitic in 100 HPF)
(+++) : positive 3 (found in 1-10 parasitic in 1 HPF)
(++++) : positive 4 (found >10 parasitic in 1 HPF)

In correlation between parasitic quantity with mortility:
- Parasitic quantity <100.000/ul, so mortality <1%
- Parasitic quantity >100.000/ul, so mortality >1%
- Parasitic quantity >500.000/ul, so mortality >50%

b) Quantitative
Parasitic count can be count /ul for thick blood smear (leukocyte) or thin blood smear (erythrocyte)
Example:
If we found 1500 parasite in 200 leukocyte, while leukocyte count is 8000/ul, so we count parasite = 8000/200
x 1500 parasite = 60.000 parasite/ul
If we found 50 parasite in 1000 erythrocyte = 5%. If erythrocyte count is 4.500.000, so we count erythrocyte =
4.500.000/1000 x 50 = 225.000 parasite/ul

THIN BLOOD SMEAR to identify the type of plasmodium with giemsa staining
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MALARIA| Tutorial E-2 TM

130110110177|Gabriella Chafrina| 05/09/14

2) Rapid Diagnostic Test (RDT)
Mechanism for this test is based on detection for malaria parasite antigen by using immunochromatography
methods. This test is used in emergency room, in outbreak cases, and in area without microscopic laboratory
facility.
The most important thing which have to be concerned is before RDT can be used, we must read the manual book
first to ensure the accuracy from the result that we get. In this moment, the RDT using by Program Pengendalian
Malaria is which can identify P. falciparum and P. non falciparum

3) Polymerase Chain Reaction (PCR) and DNA Sequencing
This examination can be done in available facility. This examination
is important to distinguish between re-infection and recrudescence
in P. falciparum. Besides that, it can be used to identify Plasmodium
species which have low parasitic count or below microscopic
borderline. Examination that using CPR also very important in
eliminating malaria because it can be used to distinguish between
import and indigenous parasite.

4) Besides those examination above, in severe malaria supportive
examination that should done are:
a) Hemoglobin and hematocrit count
b) Leukocyte and thrombocyte count
c) Other blood chemistry (blood glucose, bilirubin serum, SGOT
and SGPT, alkaline phosphatase, albumin/globulin, ureum,
creatinine, sodium and potassium, blood gas analysis)
d) Urinalysis

















DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MALARIA| Tutorial E-2 TM

130110110177|Gabriella Chafrina| 05/09/14

DIFFERENTIAL DIAGNOSIS
Clinical manifestation for malaria is varied from mild to severe symptoms, especially with diseases below:
1) Malaria without complication must be differ with other infectious disease such as:
a. Typhoid fever
Fever more than 7 days with headache, abdominal pain (diarrhea and constipation), relative bradycardia, rose
spot, leukopenia, relative lymphocytosis, serologic test and culture
b. Dengue fever
Continuous fever for 2-7 days with headache, prostration, bone pain, vomiting, tourniquet test positive,
thrombocyte count decrease and hemoglobin and hematocrit increasing in dengue hemorrhagic fever,
serologic test (antigen and antibody)
c. Leptospirosis
High fever, headache, myalgia, abdominal pain, nausea, vomiting, and conjunctival injection, serologic
examination Microscopic Agglutination Test (MAT) or serologic test positive
2) Severe malaria differentiate with other infectious disease such as:
a. Brain infection
Fever patient with progressive headache, unconsciousness, nuchal rigidity, convulsion, and other neurologic
symptoms. In patients can be done CSF exam and brain imaging
b. Stroke (cerebrovascular disturbance)
Unconsciousness, lateralization neurologic symptoms (hemiparesis or hemiplegia), without fever and there is
underlying condition (hypertension, diabetes mellitus, and others)
c. Typhoid encephalopathy
Typhoid fever symptoms begin with unconsciousness and other signs (special characteristic is there are
abdominal sign like abdominal pain and diarrhea), supported by supporting examination
d. Hepatitis A
Hepatitis prodromal (fever, nausea, vomiting, cant eat followed by icteric without fever), eyes or skin
jaundice, and tea-colored urine. ALT and AST increasing >5-fold without clinical manifestation or increasing >3-
fold with clinical manifestation
e. Severe leptospirosis (Weils Disease)
Fever with Icteric, pain in calf and bone, occupational history that supported leptospirosis transmission,
leukocytosis, and kidney failure. Incidence for this disease commonly arising after flood
f. Acute glomerulonephritis
Acute kidney failure symptoms with negative blood examination result to malaria
g. Sepsis
Fever with clearly local infection, unconsciousness, circulation disturbance, leukocytosis with toxic granule
that supported by microbiology culture
h. Dengue Hemorrhagic Fever or Dengue Shock Syndrome
High fever continuously for 2-7 days, accompanied by shock or without shock with headache, bone pain,
bleeding manifestation (epistaxis, petechiae, purpura, hematoma, hematemesis, and melena), vomiting,
thrombocyte count decreasing, hemoglobin and hematocrit count increasing, and serologic test positive
(antigen and antibody)