• Malaria is an acute and chronic disease,

caused by the protozoa of the genus

Plasmodium with clinical manifestations of
fever, anemia and enlarged spleen. Definition
according to WHO, cerebral malaria can be
found in patients who have symptoms:
 Cannot find a painful stimulus
 There is asexual P. Falciparum in peripheral blood
 Absence of other causes of encephalopathy
Etiologi
Plasmodium falciparum
falciparum malaria (also called tropical malaria), is the heaviest or most
severe type of malaria, the highest level of parasitemia

Plasmodium vivax
Causes malaria tertiana. Without treatment: ends within 2-3 months. 50%
relapse in a few weeks - 5 years after the initial disease.
Plasmodium malariae
Causes malaria quartana. Asymptomatic for long times.

Plasmodium ovale
This type is rarely found, mostly in Africa and the Western Pacific. Often
heal without treatment.
Vektor malaria
Anopheles mosquito acts as a malaria vector.
In Java and Bali, An. Sundaicus and An.
Aconitus is the main malaria vector, and An.
Subpicus and An. Maculates as a secondary
vector.
Anopheles Sundaicus
Anopheles Aconitus
Siklus hidup Plasmodium falciparum
Clasifications
Types of malaria based on the type of
plasmodium include the following:
Malaria Tropika (Plasmodium Falcifarum)
Malaria Kwartana (Plasmoduim Malariae)
Malaria Ovale (Plasmodium Ovale)
Malaria Tersiana (Plasmodium Vivax)
Epidemiology
Sulawesi Utara
Malaria is most common among 10 diseases with
complications of cerebral malaria> 3%.
Ujung Pandang
273 patients diagnosed as malaria, 78 patients
(28.57%) were tropical malaria, 7 of them were
cerebral malaria (8.97%).
Total cases: 30 million / year,
100,000 / year mortality.
– The mortality of cerebral
malaria in Indonesia is quite
high: 0.9 - 50%. Children
12.5% ​and adults 17.5%.
– incidence: children and
adults> 16% of severe
malaria, and> 4% experienced
complications of cerebral
malaria.
Patogenesis dan Patofisiologi
 Clinical manifestations
Incubation period
• The incubation period usually lasts 8-37 days depending on the
parasite species (the shortest for P. falciparum and the longest
for P. malariae), the severity of infection and in previous
treatment or on the degree of host resistance

Prodromal Periods
Prodromal syntoms can occur before the occurrence of fever,
including: malaise, lethargy, headache, spinal pain, pain in bones
and muscles, anorexia, unpleasant stomach, mild diarrhea and
sometimes feeling cold on the back
 Common symptoms
Common classic symptoms of trias malaria (proxym
malaria) are sequentially called malaria trias, namely
cold stage
This stage lasts + 15 minutes to 1 hour. Starting with shivering and feeling
very cold, teeth cracking, pulse fast but weak, pale bluish lips and fingers

hot stage
This stadium lasts + 2-4 hours. Patients feel hot. Red face, dry skin, headache
and frequent vomiting. The pulse becomes strong again, feels very thirsty and
body temperature can increase to 41oC or more

sweating stage
This stadium lasts + 2-4 hours. People who sweat profusely. Body temperature
drops again, sometimes below normal.
Clinical manifestations
Serebral Malaria
Definition according to WHO, cerebral malaria
can be found in patients who have symptoms:
 Cannot find a painful stimulus
 There is asexual P. Falciparum in peripheral
blood
 Absence of other causes of encephalopathy
In addition, it can also
occur:
 History of fever
 Blantyre coma score (BCS) ≤ 2
 Impairment in various levels, including delirium, anxiety,
apathy, coma. Prolonged coma is associated with
abnormal seizures and postures.
 Repeated seizures
 Headache Meningeal excitatory signs Abnormal
posture, which is associated with age ≥ 3 years and
accompanies intracranial increase in funduscopy.
There is an abnormal corneal reflex Cheyne-
Stokes or Kussmaul breathing.
Respiratory Distress is significantly associated
with hyperlactatemia and cerebral malaria.
Abnormal view Retinal bleeding Papiledema
(as an indicator of poor results) Increased
intracranial pressure (a risk factor for severe
death or neurologic sequelae).
Laboratoriums Diagnostic
• Thick preparations are more sensitive to detect parasites, but thin
preparations are needed to identify Plasmodium and allow estimating the
degree of parasitemia in peripheral blood. Plasmodium falciparum can be
distinguished from all three other plasmodium with parasitemia that
exceeds 2-5% of red blood cells.

• Promising new diagnoses for malaria include 10 minutes of

immunochromatographic tests for P. falciparum histidine-rich protein
(HRP2). HRP2 is only for P. Falciparum, it cannot detect other malaria
species.
Diagnosis
The diagnosis of cerebral malaria is found: Clinical symptoms: malaria
trias (fever, chills and sweating), headaches, mental disorders, neck
pain, muscle stiffness and general seizures.

Physical examination:
 Splenomegaly and hepatomegaly are often found.
 Impaired consciousness or coma (usually 24 - 72 hours)
 adult GCS <11 and children Blantyre coma score <3.
 On thick and thin blood smear examination, an asexual
form of Plasmodium falciparum was found.
 No other infections were found.
 Hypoglycemia, hyponatremia, hypophosphatemia,
pleocytosis up to 80 cells / micron3, lymphocytes up to
15 cells / micron.
 Analysis of cerebrospinal fluid lymphocytes> 15 / ul.
 CT and MRI ser cerebral edema.
 Treatment of Malaria Without
Complications.
– Malaria Falsiparum
The first line of treatment for falciparum malaria is as listed below:
• First Line= Artesunat + Amodiakuin + Primakuin
•

• Each package of Artesunat + Amodiakuin consists of 2 blisters, namely

blister amodiakuin consisting of 12 tablets @ 200 mg = 153 mg
amodiakuin alkaline, and artesunate blister consists of 12 tablets @ 50
mg. Combination drugs are given orally for three days with a single daily
dose as follows:
• Second-line treatment of falciparum malaria is
given, if first-line treatment is not effective
where it is found: clinical symptoms do not
worsen but asexual parasites do not decrease
(persistently) or recur (rekrudesensi).

• Second Line = Kina + Doksisiklin atau

Tetrasiklin + Primakuin
 Cerebral Malaria
Artesunate
Dosage: 2.4mg / kg, given every 12 hours until the patient is aware or improving. If
you are conscious of being changed to oral with a dose: 2 mg / kg until day 7. To
prevent recrudence use clindamycin 2x 150 mg / day for 7 days.

Artemisin
suppositories (others: artesunate, dihydroartemisin) which can be used as a severe
anti-malaria drug especially in children, cases of vomiting or other conditions that do
not allow parenteral administration.

Artemeter
Dosage: 3.2 mg / kg i.m loading dose divided by 2 doses (every 12 hours), followed by
1.6 mg / kg / 24 hours for 4 days.
Kina (kina HCl / Kinin Antipirin)
• The loading dose is 20mg / kg of quinine HCl
in 100-200 ml of Dextrose 5% (or NaCl 0.9%)
for 4 hours, followed by 10mg / kgbb in 200ml
dextrose 5% in 4 hours, then the dose is the
same every 8 hours

• Can be given intramuscularly if it is not possible Intravein infutions.

The loading dose is 20mg / kg divided into 2 injection sites, followed
by 10mg / kg every 8 hours until the patient can drink orally
Kinidin
• Isomer of quinine that is quite safe and
effective as an anti-malaria with a loading
dose of 15 mg base / kg dissolved in 250 ml of
isotonic fluid in 4 hours, continued 7.5 mg
alkaline / kg in 4 hours, every 8 hours
Klorokuin
• Dosis loading : klorokuin 10mg basa/kgbb
dilarutkan 500 ml cairan isotonis diberikan
dalam 8 jam dan dilanjutkan dengan dosis 5
mg basa/kgbb per infus selama 8 jam diulang
3 kali (dosis total 25mg/kgbb selama 32 jam)
Prognosis
• Poor prognosis with high mortality if left untreated. Despite
treatment, 15% of children and 20% of adults who become
cerebral malaria die.
• Eighty percent of deaths occur within the first 24 hours of
management. However, if diagnosed as early as possible and
treated properly, the prognosis will be good.