SHIVERING FEVER

1. Why the patient gets fever for a week and the periodic
high fever preceded by shivering and followed by a
spontaneus decrease in temperature with profuse
sweating ?



2. What is the correlation between 3 months stayed in
Papua with the dissease ?

Areas with high clinical cases in Indonesia:
Papua, NTT, Maluku, Sulawesi Tenggara, West Kalimantan, Bangka Belitung, Bengkulu and
Riau, and Timor Timur is an area with endemic malaria plasmodium vivax and plasmodium
falcifarum.
Sumber : repository.usu.ac.id/

Mosquito bites risk factor
Typeof plasmodium :
P. Falcifarum
P. Vivax
P. Malariae
P. Ovale



Aseksual reproduktion
When the female anopheles mosquito (which contains malaria parasites) bite
humans, will be out sporozoites from mosquito salivary glands into the blood and
liver tissue. In the life cycle of the malaria parasite in the tissue forming cells sizon
stage liver (exo-eritrositer stage). Once the liver cells burst, merozoites are going out
/ kriptozoit into erythrocytes established in erythrocytes sizon stage (stage
eritrositer). There began to shape young troposit until sizon old / mature to
erythrocytes rupture and merozoites exit.

Most of the merozoites enter erythrocytes and reinjected into fraction form male
and female gametocytes that are ready to be sucked by the female malaria mosquito
and continue its life cycle in the mosquito's body (stage sporogoni). In the mosquito
stomach, occurred the marriage of male gamete cells (micro gametes) and the
female gamete cells (macro-gametes) is called a zygote. Zygote turns into ookinet,
then go into the stomach wall of the mosquito turns into oocysts. Once mature
oocysts then broke, out sporozoites which migrate to the mosquito salivary glands
and is ready to be transmitted to humans.
Seksual reproduction
Happens in the body when the mosquito Anopheles female mosquito sucks blood
containing gametocytes. Gametocytes that are not digested with blood. At
makrogamet (male) chromatin divides into a moving core 6-8 kepinggir parasites.
The edge of a whip-like filaments formed and actively move called mikrogamet.
Fertilization occurs due to the entry into makrogamet mikrogamet to form a zygote.
Zygote short change shape like a worm called ookinet that can penetrate the
epithelial layer of the stomach wall and basement membrane. This place ookinet
enlarged and called oocysts. Formed thousands of sporozoites within the oocysts
and sporozoites penetrate several glands mosquito and when the mosquito bites /
man stabbed the sporozoites enter the blood and start the cycle pre eritrositik.

3. Why does the patient icteric ?

Jaundice is common in falciparum malaria infection, possibly due to sequestration
and sitoadheren which causes microvascular obstruction. Jaundice due to hemolytic
frequent. Severe jaundice due to P. Falciparum often adult patients this because
hemolysis, hepatocyte damage. There is also hepatomegaly, hyperbilirubinemia,
decreased levels of serum albumin and a slight increase in serum transaminase and 5
nukleotidase. Disruption of liver function may lead to hypoglycemia, lactic acidosis,
impaired drug metabolism.

Sumber : Sudoyo A. W. dkk, 2007. Buku Ajar Ilmu Penyakit Dalam Jilid I Edisi IV . Jakarta
: EGC

4. What is the type of fever ?


a. Septic fever: The temperature gradually rose to very high levels during the night
and went back down to levels above normal in the morning. Disertia frequent
complaints chills and sweating. If high fever went down to normal levels is also
called fever hektik.
b. Remittances Fever: Temperature weight every day but never reached normal
body temperature.
c. Intermittent fever: body temperature dropped to normal levels for several hours
in a day. When a fever like this happens once every two days and called tertian
case two fever-free days in between two bouts of fever called kuartana.
d. Continuous fever: body temperature during fever have no significant variation
(less than one degree). When high continuous fever then called hyperpyrexia

Sumber : repository.usu.ac.id/

Pola demam Penyakit
Kontinyu Demam tifoid, malaria falciparum malignan
Remitten Sebagian besar penyakit virus dan bakteri
Intermiten Malaria, limfoma, endokarditis
Hektik atau septik Penyakit Kawasaki, infeksi pyogenik
Quotidian (sub
intermiten,periodik24
jam
Malaria karena P.vivax
Double quotidian
(2 demam
bersamaan)
Kala azar
a disease caused by protozoan parasites of the
Leishmania genus, arthritis gonococcal, juvenile
rheumathoid arthritis, beberapa drug fever (contoh
karbamazepin)
Relapsing atau
periodik
Malaria tertiana atau kuartana, brucellosis
Demam rekuren Familial Mediterranean fever

7. Cunha BA. The clinical significance of fever patterns. Inf Dis Clin North Am
1996;10:33-44

5. Why does the patient splenomegaly ?



Splenomegaly often seen in people with malaria, the spleen is palpable after 3 days
of attacks of acute infection, a swollen spleen, pain and hyperemia. The spleen is an
organ retikuloendothelial, where plasmodium cells destroyed by macrophages and
lymphocytes. The addition of these inflammatory cells will cause the spleen to
enlarge.

Sumber : Harijanto, dr. P. N. 2000. Malaria : Epidemiologi, Patogenesis, Manifestasi Klinis
dan Penanganan. Penerbit Buku Kedokteran EGC. Jakarta.

6. What is the correlation between abnormal erytrocyt in
blood peripheral blood smear test with the result of
physical exam ?

7. Why the patient has pale palpebra conjunctiva ?
According to another expert opinion, the pathogenesis of malaria is associated
with mulitifaktorial and the following:
a) The destruction of erythrocytes
Phagocytosis not only in erythrocytes containing parasites but also against
erythrocytes do not contain parasites that cause anemia and tissue anoxia. In the
severe intravascular hemolysis can occur hemoglobinuria (black water fever) and
can cause kidney failure.
b) The mediator of endotoxin-macrophage
At the time skizogoni, erythrocytes containing parasites endotoxin sensitive trigger
macrophages to release a variety of mediators. Endotoxin may originate from the
gastrointestinal tract and the malaria parasite itself can release tumor necrosis
factor (TNF). TNF is a monokin found in the blood circulation of humans and
animals infected with the malaria parasite. TNF and other cytokines cause fever,
hypoglycemia and respiratory disease syndrome in adults.
c) sequestration of infected erythrocytes
Erythrocytes infected with P. falciparum advanced stage can form protrusions
(knobs) on its surface. The bulge contains antigens and antibodies react with
malaria and is associated with affinity erythrocytes containing P. falciparum to the
endothelium of blood capillaries in the tool, so skizogoni circulation takes place in
the tool. Infected erythrocytes attached to the endothelium and forming clots that
stem capillary leak and cause tissue anoxia and edema
PARASITOLOGI KEDOKTERAN
Anemia. On malaria anemia may occur. The degree of anemia depends on the
species of parasite that causes it. Anemia was particularly marked during falciparum
malaria with a rapid destruction of erythrocytes in malaria and severe and chronic.
Types of hemolytic anemia in malaria is, normokrom and normocytic. In the acute
attack hemoglobin levels dropped suddenly.
Anemia caused by several factors:
a. Destruction of erythrocytes containing parasites and does not contain parasites
that occur in the spleen, in this case an auto immune factors play a role.
b. Reduced survival time, that does not mean normal erythrocytes containing
parasites can not live long.
c. Diseritropoesis the disturbance in the formation of erythrocytes due to depressed
erythropoiesis in the bone marrow, reticulocytes can not be released in the
peripheral blood circulation.

Sumber : repository.usu.ac.id/

8. What is rapid test ? How about the procedure and
interpretation ?

9. Why the doctor gives recommendation a preventive
medication ? what kind of preventive medication ?

Tempat tidur diberi kelambu
Semprot obat serangga
Olesi tangan dan kaki dengan lotion anti nyamuk
Letak tempat tinggal diusahakan jauh dari yempat ternak
Hindari keadaan rumah yg lembab,gelap,kotor dan pakaian yg
bergelantungan serta genangan air

10. What are the differential diagnoses ?

a. Malaria
- Definisi
Malaria is a contagious infectious disease caused by parasites of the genus
Plasmodium, which is transmitted through the bite of the Anopheles
mosquito with an overview of the disease include frequent periodic fever,
anemia, an enlarged spleen and a different set of symptoms because of its
effect on several organs such as the brain, liver and kidneys.

- Etiologi
Malaria is a contagious infectious disease caused by parasites of the genus
Plasmodium
Plasmodium is a protozoan parasite belonging vilum, sporozoa class. There
are four species of Plasmodium in humans, namely: Plasmodium vivax
malaria vivax cause (mild tertian malaria). Falcifarum Plasmodium cause
malaria falsifarum (severe tertian malaria), and Blackwater faver pernicious
malaria. Plasmodium malariae malaria cause kuartana, ovale and
Plasmodium ovale malaria cause.

- Patofisiologi
After going through the liver tissue, releasing 18-24 plasmodium falciparum
merozoites into the circulation. Merozoites are released will go into the RES cells in
the spleen and undergo phagocytosis and filtration. Merozoites escape filtration and
phagocytosis in the spleen would invade erythrocytes. Form of asexual parasites in
erythrocytes is responsible jawabdalam the pathogenesis of malaria in humans.
Pathogenesis of falciparum malaria and parasite factors are influenced by host
factors (host). Are included in the parasite factor is the intensity of transmission,
parasite density and parasite virulence. While that is a host of factors including the
level of local endemitas, shelter, genetic, age, nutritional status and immunological
status.
Parasites in erythrocytes (EP) in outline having two stages, namely the 24-hour ring
stage I and stage II mature at 24 hours. EP-stage surface antigens RESA ring displays
(ring-erithrocyte surgace antigen) which disappeared after the parasite entered the
mature stage. EP membrane surface protrusion will experience a mature stage and
form a knob with histidine rich protein-1 (HRP-1) as the main components.
Furthermore, if the experience merogoni EP will be released in the form of GPI
malaria toxin that is glikosofosfatidilinositol that stimulate the release of TNF-a and
interleukin-1 (IL-1) from macrophages,
Sitoadherensi is the mature stage of attachment between the EP on the vascular
endothelial surface. Attachment occurs by way of adhesive molecules located on the
surface of vascular endothelium. Sitoadherensi cause no circulating mature EP back
in circulation. Parasites that live in mature erythrocytes in microvascular networks
are experiencing mature EP called sequestration. Only experienced plasmodium
falciparum sequestration, because the other plasmodium whole cycle occurs in the
peripheral vasculature. Sequestration was highest in the brain, followed by liver and
kidney, lungs, heart, intestines, and skin. Sequestration is thought to play a major
role in the pathophysiology of severe malaria.

- Clinical manifestation

- Pemeriksaan fisik

1. Fever ( 37.5 measurements with thermometers C)
2. Conjunctiva or pale palms
3. Enlarged spleen (splenomegaly)
4. Liver enlargement (hepatomegaly)

Severe malaria was found on the suspect clinical signs as follows:
1. Rectal temperature 40 C
2. Rapid and weak pulse
3. Systolic blood pressure> 70 mm Hg in adults and in children <50> 35x/menit in
adults or> 40x/menit in infants, children under 1 year> 50x/menit.
5. Decrease the degree of awareness of the Glasgow coma scale (GCS) <11> 100
parasites per 1 field of view equivalent to 40 000 parasites / uL

- Pemeriksaan penunjang
1. Examination drops of blood for malaria
a. Drops of blood preparations thick. Is the best way to find the malaria
parasite
b. Thin trickle of blood preparations. Used to identify the type of
plasmodium
2. Antigen test: p-f test
Which detects antigens of P. falciparum (Histidine Rich Protein II). Rapid
detection of only 3-5 minutes, does not require special training, good
sensitivity, does not require special tools. For antigen detection vivaks
already in the market, namely the ICT method.
3. Serology tests
techniques using indirect fluorescent antibody test. This test is useful to
detect the presence of specific antibodies against the malaria parasite or
in circumstances where very minimal.
4. PCR (Polymerase Chain Reaction)
This examination is considered to be very sensitive to DNA amplification
technology, when used reasonably fast and high sensitivity and
specificity. Advantages this test although the number of parasites is very
little to give positive results. This test is only used as a means of research
and not for routine examination.

- Treatment
1. falciparum malaria
The first line = artesunate + amodiaquine + primaquine
Primaquine is given orally with a single dose of 0.75 mg base / kg given on the first
day.
Second-line treatment of falciparum malaria is given, if the first-line treatment is not
effective which found no worsening of clinical symptoms but not reduced asexual
parasites (persistent) or comes back (rekrudesensi)
Second line = quinine + doxycycline or tetracycline + primaquine
Quinine given orally, 3 times daily at a dose of 10 mg / kg for 7 days.
Doxycycline is given 2 times per day for 7 days, with a dose of 4 mg / kg

2. Treatment for Malaria vivax and ovale
The first line = chloroquine + primaquine
This combination is used as the primary choice for the treatment of malaria vivax
and ovale malaria. Chloroquine treatment aims to kill the asexual and sexual stage
parasites.
Chloroquine was given 1 time per day for 3 days, with a total dose of 25 mg / kg
Primaquine was given for 14 days at a dose of 0.25 mg / kg

3. Treatment of chloroquine resistant vivax Malaria
Second line = quinine + primaquine
Quinine given orally 3 times daily at a dose of 10 mg / kg for 7 days.
Primaquine is also given together with chloroquine every week at a dose of 0.75 mg
/ kg

4. Treatment for Malaria malariae
Malariae malaria treatment with chloroquine given enough 1 time per day for 3
days, with a total dose of 25 mg base / kg

- Komplikasi
Malaria patients with kompikasi generally classified as severe malaria
according to WHO defined as P. falciparum infection with one or more of the
following complications:
1. Cerebral malaria (coma) that is not caused by another disease or more
than 30 minutes after the seizure, the degree of impairment of
consciousness should be assessed based on the GCS (Glasgow Coma
Scale) is below or equal to 7 soporous clinical circumstances.
2. Acidemia / acidosis;
3. Severe anemia
4. Acute renal failure
5. Non-kardiogenik/ARDS pulmonary edema (adult respiratory distress
syndrome).
6. Circulatory failure or shock
7. Spontaneous bleeding from the nose or gums, gastrointestinal and
laboratory abnormalities accompanied by intravascular coagulation
disturbances

b. Demam Tifoid
- Definisi
Typhoidal fever is an acute infectious disease that is usually found in the
gastrointestinal tract (small intestine) with symptoms of fever a week or more with
disorders of the gastrointestinal tract and with or without impaired consciousness
- Etiologi
Typhoid fever is caused by the bacterium Salmonella typhi or Salmonella paratyphi
of the genus Salmonella. These bacteria are rod-shaped, gram-negative, spore-
forming, motile, capsulated and have flagella (hair moves with trill).
- Patogenesis
Salmonella typhi and Salmonella paratyphi enter the human body through food
contaminated with germs. Most germs destroyed by stomach acid and some into
the small intestine and multiply.
When the humoral immune response of intestinal mucosal IgA deficient will
penetrate the germ cells, especially epithelial M cells and subsequently into the
lamina propria. In the lamina propria breed bacteria and removed by phagocytic
cells mainly by macrophages. Germs can live and multiply in macrophages and
subsequently taken to the distal ileum Peyeri plaque and then to the mesenteric
lymph nodes. Furthermore, through the duct torasikus germs contained in these
macrophages into the circulation of the blood (bacteremia cause asymptomatic first)
and spread throughout the reticuloendothelial organs of the body, especially the
liver and spleen. In these organs germ leave phagocyte cells and then multiply
outside the cell or a sinusoid and then enter into the blood circulation resulting in
bacteremia again the second time, accompanied by the signs and symptoms of
systemic infection, such as fever, malaise , myalgia, headache and abdominal pain
- Clinical manifestation
- Pemeriksaan fisik
- Pemeriksaan penunjang
a. Widal test
Widal test is an agglutination reaction between antigen and antibody
(agglutinin). Agglutinin specific for Salmonella typhi present in the serum
of patients with typhoid fever, in people who had contracted Salmonella
typhi and the people who never get typhoid fever vaccine.
b. Uji Enzym-Linked Immunosorbent Assay (ELISA)
- Anamnesis
- Komplikasi
Complications of typhoid fever can be divided into two parts, namely
a. Komplikasi Intestinal
Perforasi Usus , perdarahan usus

b. Komplikasi Ekstraintestinal

a. Cardiovascular complications: peripheral circulatory failure (shock, sepsis),
myocarditis, thrombosis and thrombophlebitis.
b. Complications Blood: Hemolytic anemia, thrombocytopenia, disseminated
intravascular koaguolasi, and hemolytic uremic syndrome.
c. Pulmonary complications: pneumonia, empyema, and pleurisy
d. Liver and bladder complications: hepatitis and cholelithiasis
e. Renal complications: glomerulonephritis, pyelonephritis, and perinefritis
f. Bone complications: osteomyelitis, periostitis, spondylitis, and arthritis
g. Neuropsychiatric complications: delirium, meningismus, meningitis,
peripheral polineuritis, psychosis, and catatonia syndrome
c. Demam Berdarah
- Definisi
acute febrile disease caused by the dengue virus
- Etiologi
acute febrile disease caused by the dengue virus, which enters the human
bloodstream by mosquitoes of the genus Aedes, such as Aedes aegypti or Aedes
albopictus.
- Patofisiologi
- Patogenesis
- Clinical manifestation
- Pemeriksaan fisik
- Pemeriksaan penunjang
- Anamnesis
- komplikasi