MALARIA

Yuli Hermansyah, dr, SpPD

INTRODUCTION
/ 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.

Malaria

Parasitemia
P.vivax reticulocyte 2% erithrocyte P.malariae older erithrocyte 1%
P.falciparum all ages of erithrocyte erithrocyte infectious rate severe 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 > 1C. 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 > 40C).

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 malariadisoriented,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 > 38C convulsion. Temp 39,5C - 41C delirium. Temp > 41C 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 Dengue fever ISPA Leptospirosis ringan Infeksi virus

Meningo ensefalitis CVA Tifoid ensefalopati Hepatitis 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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