W.S. 6.

7
DIAGNOSIS & TATALAKSANA
MALARIA

PAUL
HARIJANTO
MANAGEMENT SEVERE
MALARIA
SUSPECTED CASE

 EARLY IDENTIFICATION & DIAGNOSIS

 SPECIFIC TREATMENT
◦ ANTI MALARIAL DRUGS
 MANAGEMENT & DETECTION VITAL ORGAN
FAILURE :
◦ Hemodynamic changes ( shock )
◦ Causes of Decresing Concious level ( hypoglycaemia )
◦ Respiratory failure ( breathless, rate > 30x/ minute )
 Early identification & Diagnosis
 Failed to take a proper history ( travel
history, location of living )
 Availablity microscopic examinations/
RDT
 Misleading diagnosis Malaria : (
Dengue, Typhoid, URTI )
 Misleading diagnosis complications :
Coma : sepsis, meningitis, stroke
Jaundice : Hepatitis, cholecystitis
Renal failure : dehydration, acute
gastroenteritis, Intoksication
Early assesment/ warning sign :

 Development/ worsening of coma

 Convulsion
 Respiratory depression/ arrest
 Edema paru/ respiratory insufficiency
 Hemodinamiccally unstable
 Sepsis
 Acute Kidney Injury
 General danger signs suggesting severe febrile
illness as criteria for referral from peripheral
health facilities
IMAI for adolescent & adults in areas of malaria transmission
 Fever or history of fever in the past 24 h plus one or more of
the following danger signs:
◦ Very weak or unable to stand
◦ Convulsions
◦ Lethargy
◦ Unconsciousness
◦ Stiff neck
◦ Respiratory distress
◦ Severe abdominal pain
IMAI : Integrated Management of Adolescent and Adult Illness
 SEVERE MALARIA 2015

DEFINITION : Patients with plasmosium asexual parasitemia,with

one or more CLINICAL or LABORATORY FEATURES :
PROSTRATION
IMPAIRED CONSCIOUSNESS ( GCS SEVERE ANAEMIA ( Hb <5
<11, Blantyre < 3 ) PADA ANAK <12TH DAN
RESPIRATORY DISTRESS Hb<7 pd dewasa
HYPOGLYCAEMIA( < 40 )
MULTIPLE CONVULSIONS ( > 2/ 24 hrs)
ACIDOSIS (base def <8,
CIRCULATORY COLLAPSE / SHOCK ( HCO3 <15/ Pl. Lactate >5)
cap refil>3 or temp gradient on leg (mid to RENAL IMPAIRMENT ( >3,
prox limb), no hypotension; sys <80 blood urea > 20 mmol/L)
adults, 70 in children + impaired perfuss) HYPERPARASITEMIA, >10%
PULMONARY EDEMA (CX-Ray/ O2
sat<92% room air + resp >30/min)
ABNORMAL BLEEDING WHO: Guidelines for the
JAUNDICE ( > 3 mg/dL + par >100.000) Treatment of Malaria 2015
LABORATORY TEST MALARIA
 MIKROSKOPIK MALARIA ( Giemsa )
◦ Tetes Tebal
◦ Hapusan Tipis
◦ Hitung Parasit
 Rapid Diagnostic Test (RDT) – Tes Cepat
◦ Paracheck
◦ PF test
◦ ICT
◦ Optimal
Interpreting Thick and Thin Films
 THICK FILM  THIN FILM
◦ lysed RBCs
◦ larger volume
◦ 0.25  l blood/100 fields
◦ blood elements more
concentrated
◦ good screening test
◦ positive or negative
◦ parasite density
◦ more difficult to diagnose
species
◦ fixed RBCs, single layer
◦ smaller volume
◦ 0.005  l blood/100 fields
◦ good species
differentiation
◦ requires more time to read
◦ low density infections can
be missed
 50
45
40
35
30
25
20
Pf test
15
10
5 SD
0
0 1 2 3 4 5 6 7
HARI

Persisten parasitemia dibandingkan dengan persisten antigenemia

Case 1

 Wanita 37 tahun dengan demam ulang-ulang 5

hari, sakit kepala, badan agak kuning, belum bab.
 KU Cukup, sadar, tek. Darah 100/60, nadi 116,
temp 38 C, makan baik, tidak muntah.
 Cor/ pulmo : tak ada kelainan
 Hepar teraba 2 jari
 Diagnosa : Suspek Hepatitis
 Apa Differential Diagnosisnya ?
 Laboratorium

 Hb. 8.5 gr%, leuko 4900/ mm3, trombo 81.000/mm3

 Total bil : 4,4 mg%, direk 1.97 mg%, indirek 2,4 mg%,
SGOT 55u/L, GPT : 55 u/L, gamma-GT 61,4 u/L,
alk.PO4 : 174 u/L, urea 27.5, creat. 1.3, gula darah
148 u/L, Na 135, K 3.3
 Bagaimana Diagnosa penderita ini ?
 Apa masih perlu pemeriksaan lain untuk diagnosa ?
Lab
 Ig M dengue negatif, Ig G dengue positif
 NS1 : negatif
 Tubex M : + 4
 Widal tes : + 1/80
 Diagnosa ??
Malaria : Fal ring : +++, 380 par/ 200 Leuko,
2 par/ 1000Eri

 Apa pengobatannya ?
 Dosis ARTEMISININ PADA MALARIA
BERAT

0 JAM 12.J 24.J 48.J 72.J Max 7 hari

48.J 72.J

2.4 2.4 2.4 2.4 2.4

Mg/ Mg/ Mg/ Mg/ Mg/
KgBB KgBB KgBB KgBB KgBB

ARTESUNATE I.V/ I.M

• ARTEMETER , hanya I.M , 3,2 mg/hr1, lanjut dosis

• 1,6 mg/kg BB hari berikutnya
 Kasus 2
Anamnesa:
Laki-laki, 34 tahun tinggal di Tomohon,
datang ke RS dengan demam sudah 3 hari.
Penderita baru tiba dari Papua 2 hari lalu
dan sudah merasa tidak sehat
P. Fisik : tensi 80/60 mmHg, Temp 38.5 C
Cor/ Pulmo : taa
Abd : taa
 Apa tatalaksana awal kasus ini ??
MANAGEMENT & DETECTION VITAL ORGAN FAILURE :

Hemodynamic changes ( shock )

Assesement Fluid requirement : individually
Keep the fluid requirement : “ slightly dry “ ,
using NaCl 0.9%, NOT LACTATE
Prone developed Lung edema
Giving bolus IV fluid either Colloid or Crystaloid
is CONTRA-INDICATED
Clinical monitoring is important : development
breathless,JVP, respiration rate, rales in
auscultation, urine production
 Suggested fluid management for adult with severe
malaria
Hypotension : MAP < 65 mmHg with
Evidance decreased perfusion or Hb < 7gr/dL
NO
APO/Urine < 0,5 YES
ml/Kg/hour

Hb<7gr/dL MAP<65 mmHg

NO
YES Cautious fluid
Transfuse bolus : 5 ml/Kg
IV crystalloid PRC/ whole Vasopressor
1-2 ml/Kg/hour Anuria Urine < 0,5 APO blood Exclude
Titrate against ml/Kg/hour bleeding
BP & Urine RRT Empiric broad
output No IV fluid/O2
Fluid Bolus Diuretic Spect. AB
trial/ RRT ventilator

Hansonn J, Anstey NM, Bikan D, et al. Critical Care 2014 ; 18 : 642

 Laboratorium
6/10/2011
5/10/2011 Malaria : (-)
• Hb: 8,0
• Bil.direct: 1,2
• Leuko : 8,300
• Ht: 27% • Bil.indirect:
• Segmen 90% 2,4
• Limfosit 10% • Bil.total: 3,6
• SGOT: 51
• Malaria: Fal.ring (+), Fal.gamet (+)
• SGPT: 16
200 lp: 4200 parasit
1000 lp: 25 parasit • Ureum: 68
• Creatinin 2,8
 TATALAKSANA
1. Apa pemberian obat malaria nya ?
2. Perlu tindakan lain nya/ pemeriksaan ?
3. Pengobatan tambahan/ lainnya ?
Case 3

 Male 26 years old, referred by peripheral hospital(PH) with

fever for 3 days. Lab . : platelets was 42.000, 18.000. Ht
43.3% then 30.3%. Ig.G positif, IgM negatif.
DIAGNOSIS
??
Because his condition getting worse, developed loss of
concious, he had been referred to district hosp.

Why ??
E.D.S
Expanded
Dengue
Syndrome
In District Hospital :

Examination in DH : afebrile, pale, GCS :

E4M1V2, no Hepatosplenomegaly, no
neurological defisit, Lab : Hb 12 gr%, WBC
14750/ mm3, granulocyte 90%, thrombocyte
30.000 mg/dL, Random blood sugar 26 mg/dL,
SGOT 300 IU, SGPT 325 IU.
Diagnosis ??

malaria falcip +4 (15.000 per 200 leuco),

parasite count 1.050.000/uL
 Was treated with artesunate 120 mg on 0 hr, 12
hrs and 24 hrs, also 40% dextrose 75cc was
given intravenously. Six hours later he
developed breathless, kussmaul breathing was
noted, fever 39C, patient was referred to ICU.
 Parasite count 12000/200WBC, bl.glucose 103
mg%, SGOT 597IU, SGPT 259 IU, Bilirubin total
18.05 U/dL, direct bill 13.8 U/dl. WBC
20.370/mm3.
What’s your management ?
 On the second day he developed
convulsion, parasite count 6910/200
wbc, 110 par/ 1000 rbc. 6hours later
the parasite count 4175/ 200 wbc,
SGOT 470u/L , SGPT 345 u/L. GCS
E1/M2/V2, oliguria and furosemide
was given.
 On the third day, bleeding in the
sclera, BP 90/60, Kussmaul, CVP was
inserted, the patient go to cardiac
arrest and died.
Case 4
 Wanita 55 thn rujukan dari RS perifer, demam 5 hari,
tinggal di daerah malaria, dilaporkan TS dengan tidak
sadar (GCS 6), dari surat rujukan Bilirubin total 24,2 mg%,
bil.dir.ek 19,6mg%. Ureum 290, creatinin 10,16. Kalium 4,1
Na 122. Urine leuk. 40 - 50. Urine produksi 75 cc per 24
jam.

Diagnosenya & apa tindakan saudara ?

Data
selanjutnya…….
 Penderita ini tidak dijumpai riwayat sakit sebelumnya
seperti DM, Hpt, TB. Pada pemeriksaan : Tekanan darah
80/ 60 mm Hg, nadi 110/ menit, resp 36 x/ menit. Jantung
paru : normal. Hepatosplenomegali.
 Pertanyaan : Apa penanganannya ?
A. Pemberian loading NaCl 20 ml/kg BB/ jam
B. Pemberian NaCl 20 ml/kg/BB yg di observasi
C. Pemberian Ringer laktat 500cc/ 1jam
D. Pemberian cairan koloid 40 tetes/ menit
E. Pemberian cairan dextran 500 ml/ 1 jam
Parasit malaria ditemukan Falciparum ring +++.

Pertanyaan , diagnosenya :
A. Malaria Berat
B. Malaria Ringan/ uncomplicated
C. Bukan Malaria
D. Hepato-renal syndrome dgn malaria ringan
E. Sepsis
F. Perlu informasi lain
KASUS 5
Seorang laki - laki 62 tahun, dengan riwayat panas-dingin 3 hari, sakit kepala, mual.
Pemeriksaan :K.U. baik, febris, tidak anemi, sadar. Tensi, nadi, resp. normal. Jantung
dan paru normal. Hepar dan lien : normal
Diagnosa : observasi malaria.
Laboratorium : Darah malaria : Falciparum ring + . Hb. 12 gr %, Leuko 8600 / mm3.
Hitung jenis leukosit eos/baso/neutro/limfo/mono : -/-/2/93/3/2. LED : 16 / 1 jam. Urine
mikroskopik : normal
Pengobatan: artesunate+ amodiaquine. Penderita K.U baik dan tidak muntah.
Follow up :
Pada hari ke-4, keluhan sakit kepala masih, penderita muntah, hiccup + +, tidak bisa
makan.Malaria : falcip ring +; vivax +. Hari IV : Gula darah 61 mg % ; ureum 313 mg % ;
kreatinin 7,35 mg %,Se. natrium 114 meq / L; kalium 3,4 meq / L, berat jenis Urine 1,012.

Pertanyaan :
1. Apa penderita ini termasuk gagal pengobatan ?
2. Apakah insuffisiensi ginjal (ureum 313 mg % ; kreatinin 7,35 mg %) dapat
disebabkan karena penyakit ginjal sebelumnya (glomerulonefritis) ?

30
Kasus 10-b

Hari ke V :
Jaundice pada sklera, Hb. 11. gr %, leuko 18.100, Se. Bilirubin total 4,46 mg % ;
indirek 2,98 mg % ; direk 1,48 mg %, S.G.O.T 43 u / L, S.G.P.T 59 u / L, Gamma -GT
256,7 u / L, Alk. fosfatase 300 u / L, albumin 3,18 gr %, globulin 3,90 gr %.

3. Apa diagnosa saudara ?

4. Apa pengobatan penderita ini ?
4. Pemeriksaan apa saja yang masih diperlukan ?

31
Kasus 10-c

Setelah pengobatan dengan artesunate , maka pada hari ke XVI, keadaan umum
membaik, panas hilang, akan tetapi penderita tampak pucat. Tidak ditemukan tanda
perdarahan. Hb. 6.9 gr %, retikulosit 9,3 %, trombosit 252.000 / mm3. Diberikan tranfusi
darah 2 bag(1000cc), Hb menjadi 7,9 gr %, hari ke XV penderita pulang Hb 8,2 gr %
Retik 0,6 %, ureum 87 mg %, kreatinin 2,18 mg %.

Pertanyaan :
6. Apa penyebab anemianya ?

32
PAKATUAN WO PAKALAWIREN
Sampai Baku Dapa !
Dr. Paul Harijanto, Sp.PD-KPTI
Div. Penyakit Tropik & Infeksi
SMF/ Bag. Penyakit Dalam
FK UNSRAT/ RSUP Manado
RSU Bethesda -Tomohon

Telp.:
0431-351024/046 ( RSU Bethesda)
0812-430-2869 ( HP)
0431-351187 (Res)
E-mail : paulharijanto@gmail.com