Malaria Training Course, Timika-Indonesia, 7-10 November 2016

Case Discussion

CASE 1

A 26 years old man was referred from peripheral hospital with dengue haemorhagic
fever (DHF) grade I with unconsciousness of unknown cause. The history before
admission: he had 3 day fever, Vital signs and physical examination was normal.
Laboratory results: platelets 42,000/mm3, hematocrit 43,3 %. Malaria smear negative.
Serology anti dengue IgM positive, IgG negative. On the second day platelets
decreased to 18,000 and hematocrit 30,3%. On day 4 his general condition was
getting worse, consciousness was further decreased. He was referred to the district
hospital for further care.

Question 1
What was the likely differential diagnosis?

Case 2

Male, 57 years old, admitted to hospital with fever for 7 days, chills and sweating. He
also had nausea, vomiting and headache. His skin looked yellowish since 2 days
before admission. His urine is dark coloured.

On physical examination, the patient was delirium, icteric. Blood Pressure 100/70
mmHg, temp 370C, pulse rate 88 x/min, respiratory rate 20 x/min, Heart and lung
were normal, liver and spleen were not palpable.

Laboratory findings: Hb concentration 16,4 gr/dL, Leucocyte 3,200 cells/mm3,

platellets 85,000 cells/ mm3, Ureum 40 mg/dL, creatinine 0,6mg/dL, random blood
sugar 110 mg/dL, Malaria negative. On the second day Hb.14,4 gr/dL, Leucocytes
3,900 cells/mm3, platelets 105,000 cells/mm3, Malaria : negative, SGOT 80 u/L,
SGPT 60 u/L.

Question 1
What is the most likely diagnosis/assessment in this patient?

Question 2
On day 3: Malaria smear result was Plasmodium falciparum positive.
On day 6: Malaria smear result was Plasmodium vivax.
On day 7: SGOT 173 μ/L, SGPT 126 μ/L, total bilirubin 8.93 μ/L, direct bilirubin 4.8
μ/L, indirect bilirubin 4.13 / μ L.

Question 3
What is your comment on this case?

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Question 4
On day 8: Ureum 205 mg/dL, Creatinine 5.6 mg/dL.

What is the management of this patient?

Case 3

Location: Low malaria transmission area with both P. falciparum and P. vivax are
prevalent.

Female, 28 years old came to the hospital with vomiting and sudden change of the
level of consciousness (restless and agitated). One day before admission she had fever
and the fever relieved after taking paracetamol tablet. She still could do her daily
activities. Urine color was normal.

On clinical examination it was found that the patient is agitated. BP 120/80 mmHg,
pulse rate 88x/min, respiratory rate 20x/min, body temperature 370C. Physical
findings were all within normal limit, no neck stiffness and CRT less than 2 second.

Question 1
What other questions that you should ask to this patient? What is your differential
diagnosis?

What blood tests that should be done immediately in this patient?

Question 2
If from peripheral blood smear there was PFRF 2/200 leucocytes, what is your
diagnosis?

The random blood glucose is 105 mg/dL. What action should be taken?

Question 3
What antimalarial drug should be given to this patient? What is the route of
administration?

Case 4

Male, 19 years old with body weight of 50 kg was referred from Primary Health
Clinic with diagnosis of vivax malaria. He was treated with quinine drip 2 ampoules
in 500 cc Dextrose 5% for 4 hours for 2 times due to unable to take oral medication of
antimalarial (frequent vomiting).
On admission, the patient looked lethargic, icteric and had rapid breathing. Blood
pressure is 110/60 mmHg, pulse rate 120x/min, respiratory rate 32x/min, oxygen
saturation 95% in room air, body temperature 36.80C. Physical findings revealed
icteric sclerae, liver not palpable, spleen enlarged schuffner 2 and CRT less than 2
second. Others were within normal limit. After urine catheter was administered the

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urine is dark brown colour with urine output in 2 hours of <1cc/kg/hour.

Question 1
What is your initial assessment and management? What blood tests that should be
immediately taken?

Question 2
The random blood glucose was 23 mg/dL and Malaria smear was PVRTS 120/200
leucocytes. Hb 8 g/dL, leucocyte 10,000 cells/mm3, platelets 79,000 cells/mm3.

What is your diagnosis and management of this patient? What other tests should be
taken?

Question 3
The biochemistry results: Total Bilirubin: 5.6 mg/dL, indirect bilirubin 4.3 mg/dL,
direct bilirubin 1.3 mg/dL, ureum 30 mg/dL, creatinin 1.5 mg/dL, electrolytes was
normal.

What is your assessment? What antimalarial drug should be given to this patient?
What is the route of administration?

This patient is re assessed as severe vivax malaria with jaundice and AKI dd/ATN. He
was treated with intravenous artesunate accordingly and followed with oral DHP.
During hospitalization the patient’s urine output and renal function is improving and
discharged on day 5 hospitalization.

Case 5

A boy, 2 years old taken to the hospital for having fever for 2 weeks. There was no
cough, runny nose or diarrhea. The boy vomited several times but still able to drink
plenty of water. He has been taken to a private clinic on his 3rd day of fever and was
told to have malaria and given white pulvus to be taken 3 times a day for 5 days.
However the fever persists. Since the boy can still eat and drink, the mother did not
seek any medical attention until one day before admission when she found that her
son looked pale.

On examination it was found that the HR 100 x/min, RR 24 x/min, temperature

38.90C. Physical examination was within normal limit except for anemic conjunctiva.

Laboratory findings: Hb 8.9gr/dL; Leucocyte 15,000 cells/mm3; platelets 59,000

cells/mm3; Malaria smear: P. falciparum 120/200 leucocytes, gametocyte 10/200
leucocytes.

Question 1
What is the assessment of this patient?

Question 2
What antimalarial drug should be given in this patient?

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Question 3
Any comments on the low platelets count? What it means to have gametocytes in the
peripheral blood? What is the management?

Case 6

A baby boy aged 6 months old admitted to the hospital with rapid breathing since 2
days before admission. He also had fever for 5 days. The boy was unable to beastfed
and looked pale.

On examination the HR 150 x/min, RR 60x/min, SpO2 90% in room air, body
temperature 38 0C. The baby looked very pale, there was no heart murmur and the
lung is clear. Liver and spleen were not palpable, CRT less than 2 second.

Laboratory findings: Hb: 3 gr/dL, leucocyte 4000 cells/mm3, platelets 45,000

cells/mm3. Malaria smear: P. falciparum ring form 20/1000 eritrocytes. Random
blood glucose 35 mg/dL.

Question 1
What is the possible cause of rapid breathing in this baby?

Question 2
How is the blood glucose level? How is the level of parasitaemia? What is your
assessment?

Question 3
What is the management of this patient? Does this patient need fluid resitriction?

Case 7

Location: Zero malaria transmission area, city area.

A military personnel (male, 29 years old) admitted to the hospital with yellow skin
and urine colour of black. He has just returned to the city after 2 year of service in
Papua. He had fever since 6 days ago and his skin looked yellow 5 days ago and his
urine become tea coloured. He has visited a private practice on his 3 day fever and
yellow skin and was told to have Acute Viral Hepatitis A and was given multivitamin
and was told to bed rest.

On the next day he felt extremely weak and unable to stand up and his urine become
darker. He was taken to the hospital and was diagnosed as sepsis. He was treated with
antibiotics and other supportive treatment and admitted to ICU.

On day 5 of hospitalization, the patient was checked for malaria and the result is
positive falciparum malaria. The patient was treated with intravenous artesunate

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accordingly but the condition was getting worse and he died on day 6 of
hospitalization.

Information from the family revealed that the blood culture of this patient is sterile
and the antibiotic used has been stepped up to intravenous Meropenem. The family
was told that the patient had renal failure due to overwhelming sepsis and would
require dialysis.

Question 1
What is the possible diagnostic error in this case?

Question 2
What should be the diagnosis of this patient?

Question 3
What antimalarial drug should be given in this patient? What is the management of
AKI in this patient?

Case 8

6th September 2014.

Male, 15 years old was referred from local hospital after 10 days of hospitalization
and 3 days of ICU care due to severe falciparum malaria with acute kidney injury.
Body weight: 43 kg.

History of hospitalization in referring hospital:

25th August 2014

He was diagnosed as falciparum malaria. Vital signs: BP 125/74 mmHg, HR 82
x/min, RR 14 x/min, SpO2 94% in room air. Physical examination was within normal
limit. Urine output < 1 cc/kg/hour.

Laboratory results on admission: Malaria smear: PFRF 480/200, leucocyte 16,340

cells/mm3, Hb 8.9 g/dL, platelets 56,000 cells/mm3. Total Bilirubin: 30.34 mg/dL,
direct B 8.05 mg/dL, indirect B 22.29 mg/dL, SGOT 491 U/L, SGPT 261 U/L,
Alkaline phosphatase 738 U/L, gamma GT 46 U/L, creatinine 10.77 mg/dl, ureum
338 mg/dl.

He was treated with intravenous artesunate 100 mg every 24 hours for 2 days.
Intravenous artesunate was repeated on 29th August 2014 every 12 hours 3 times. No
oral antimalarial was given. Diuretics was given to this patient.

1st September 2014

Patient looked lethargic, urine output 1 cc/kg/hour. Laboratory findings: Malaria
smear: PFRF 2/200 leucocytes. Hb 6 g/dl, leucocyte 17,280 cells/mm3. Platelets
66,000 cells/mm3, Total Bilirubin 9.34 mg/dL, direct bilirubin 2.78 mg/dL, indirect
bilirubin 6.56 mg/dL, creatinine 12.49 mg/dL, ureum 407 mg/dL.

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He was referred to another hospital for dialysis on 6th September 2014.

Clinical findings on referral hospital:

6th September 2014

The patients looked dyspneic. RR 32 x/min, HR 133 x/min, SpO2 98% with non re-
breathing mask 6-8 L/min, BP 130/70 mmHg. He was referred for dialysis.

Laboratory findings: Total bilirubin 2.26 mg/dL, Direct bilirubin 0.83 mg/dL, indirect
bilirubin 1.43 mg/dL, SGOT 24 IU/L, SGPT 36 IU/L, creatinine 14.56 mg/dL, urea
562 mg/dL. Malaria smear negative.

He was hospitalized from 6th September 2014 to 18th September 2014. He was having
2 dialysis and the final creatinin level is 1.4 mg/dL, ureum 68 mg/dL. The patient can
breathe in room air and good clinical condition. Urine output normal.

On ambulatory evaluation (22nd September 2014): patient had good clinical condition.
Laboratory finding: creatinine 0.8 mg/dL, urea 39.75 mg/dL.

2nd October 2014

He has fever for 2 days. Malaria smear PFRF 372/200 leucocytes. Hb 5 gr/dL,
leucocyte 3,910 cells/mm3, platelets 138,000 cells/mm3. Patient refused to be
hospitalized and given oral DHP 2 tablets once daily for 3 days.

6th October 2014

Patient has finished his malaria treatment but felt weak. He was hospitalized for blood
transfusion. Malaria smear negative.

Question 1
What errors can you spot in this case?

Question 2
What is the likely cause of malaria positive on 2nd October 2014? What is your
comment?

Case 9

A girl, 1 year old came to the hospital with convulsion about 10 minutes before
admission. She had fever one day before admission. She was unconscious when
admitted. Vital signs: Somnolent, HR 140 x/min, RR 30 x/min, body temp 39.80C,
BW 8.5 kg, SpO2 98% in room air. Physical examinations were within normal limit.

Laboratory findings: Malaria smear was PVRTSG 344/200 leucocytes. Hb 9.3 gr/dL,
leucocytes 7,600 cells/mm3, platelets 44,000 cells/mm3. Random blood glucose 151
gr/dL.

She was assessed as vivax malaria with cerebral complication DD/ Febrile convulsion
due to malaria. She was treated with intravenous artesunate 30 minutes after

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admission and continued with oral DHP. She regained consciousness about 60
minutes after convulsion.

Day 2: malaria smear PVRT 8/200 leucocytes. The patient was discharged on day 2
hospitalization with good condition.

Question 1
What is the most likely diagnosis of this patient?

Case 10

A girl, 10 years old came to the hospital with delirium and high fever. She had fever
for 6 days with frequent vomiting. Vital signs: confused and lethargic, body
temperature 40.2 0C; Pulse 68 x/min, RR 28 x/min and SpO2 99% in room air. Body
weight 46 kg. Physical examination is within normal limit.

Laboratory findings: PFRF 3,436/200 leucocytes and Pf schizont 4/200 leucocytes.

Leucocytes 12,000 cells/mm3, Hb 13.3 g/dL, platelets 18,000 cells/mm3. Random
blood glucose 107 mg/dL, electrolyte: natrium 127 mmol/L, K 3.8 mmol/L, Cl 92.3
mmol/L.

This patient is assessed as severe falciparum malaria with cerebral complication,

hyperparasitaemia and hyperpyrexia. Suspected sepsis and moderate dehydration. The
patient was given fluid to correct dehydration, intravenous artesunate, ampicillin and
gentamicine. On the next day she regained her consciousness. Malaria smear was
PFRF 240/200 leucocytes and gametocyte 4/200 leucocytes. Intravenous artesunate
was stop on hour 24 and continued with oral DHP.

On day 3 she can sit and mobilize. Malaria smear PFRF 12/200 leucocytes

Question 1
What is the likely cause of high fever and delirium in this patient?

Question 2
What is your comment on the parasitaemia in this patient? What is the clinical
significance Pf schizont and Pf gamet in the peripheral blood?

Question 2
What is the best way to count parasitaemia in this case?

Question 3
What is your comment on the treatment and the reduction rate of parasitaemia?

Case 11

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Male, 31 years old, works as a miners at Halmahera (Gosowo) admitted to hospital on
31st October 2009 with a complaint of fever and colds since 4 days before
hospitalization. Five days before admission he felt diarrhea once.

Past history: September 2009 suffered from vivax malaria in Halmahera and treated
with Chloroquine 2 -2 -1 tablets and primaquine 2 tab/day for 14 days. Physical
examination: Composmentis, blood pressure 130/80mmHg, pulse rate 96x/min,
temperature 40°C, not pale, not jaundice. Heart & Lung were normal. Abdomen: soft,
epigastric pain (+), liver and spleen were not palpable, bowel sound normal.

Laboratory findings: Hb. 13.1 gr%, Ht 39%; Leucocytes 4100 cells/mm3, platelets
41,000 cells/mm3, Plasmodium vivax ring +++

Working Diagnosis: Malaria Vivax relaps /recrudescence/ re-infection?

Question 1
Discuss the clinical manifestation, previous treatment, differential diagnosis of
thrombocytopenia in this patient.

Question 2
What treatment should be given to this patient?

Case 12

Female 51 years old admitted to hospital with diarrhea for 5 days, nauseated and
yellow eyes for 1 day before admission. Six days before admission, she had
experience of headache, nausea, vomiting and she had self medication with
paracetamol. Headache was disappeared however the diarrheal still exist followed
with vomiting and cramp in both legs. She was treated with antibiotic and NSAID and
the next day she was admitted to hospital. Physical examination: cmposmentis,
jaundice ++, anemic, temp 38.70C, BP 130/80 mmHg, Respiratory rate 28 x/ min,
pulse 96 x/ min. Heart and Lung were normal. Liver just palpable and spleen were not
felt. Diagnosis in emergency unit: HEPATITIS ?

Question 1
What is your comment?

Laboratory findings: Hb. 7.1 gr%, Leucocyte 7900 cells/mm3, differential leucocyte
(eos/ baso/neut/ lim/mon) 3/0/83/11/3, malaria falciparum ring +++, parasite count 7.4
%, total bilirubine 8.2 mg/dL, direct bilirubin 3.1mg/dL, SGOT 75 u/L, SGPT 54 u/L,
random blood sugar 84 mg/dL, Ureum 128 mg/dL, Creatinin 2.89 mg/dL.

Question 2
What is the diagnosis of this patient?

Question 3
Discuss the clinical presentation, microscopy results, differential diagnosis and case
management of this patient.

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Case 13

Women 55 years, history of 5 day fever, lived in malaria endemic area, referred to our
hospital by A & E doctor with GCS of 6. Laboratory findings in district hospital: total
bilirubin 24.2 mg%, direct bilirubin 19.6mg%, Ureum 290 mg%, creatinine 10.16,
Kalium 4.1 meq/L, Natrium 122 meq/L, Urine leucocyte 40 – 50/ field. Urine
production 75 cc /24 hours.

Question 1
What are your advice to your A & E doctor regarding management of this case ?

Other information: Patient was well before her illness, no history of Diabetes
Mellitus, hepatitis and tuberculosis. Vital sign: Blood pressure 80/ 60 mm Hg, pulses
110/ min, respiratory 36 x/ min. Heart & Lung: normal. No Hepatosplenomegaly.

Question 2
What are your managements?
What is your differential diagnosis?

After 2 hours in the ward, laboratory result was reported as Hb. 9 gr%, Leucocyte
21.000/ mm3, differential leucocyte : eos 3/ bas 1/ neutrofil 80/ limfo 15/ mono 1,
platelet 40,000/mm3. Random blood sugar 25 mg%. Parasite count: 3,500
parasite/200 WBC, 88 parasite/1000 RBC.

Question 3
What is your diagnosis and management?

Case 14

A man 47 years old came to hospital with fever for 3 days, the patient arrived in
Jakarta from island where malaria transmission might occur. Patient complaint of
nauseated, vomiting, cough and rhinitis. Clinical findings: Blood pressure 110/70
mmHg, pulse 80x/min, temperature 370C. Pharynx hyperaemic, other clinical findings
were normal. Laboratory findings: Hb. 12.7 gr%, Leucocyte 9300 cells/mm3, platellet
48,000/mm3, Ht 35%, LED 74 mm/hour, SGOT 30 u/L, SGPT 27 u/L, Ureum 86 mg
%, Creatinin 2 mg%, albumin 4.8 mg%. Patient was admitted and the treatment :
Ciprofloxacin 2 x 500mg, ranitidine 2 x 1 ampules, Antacida forte 3 x 1 sm, OBH 3 x
1 spoon.

Question 1
What is your comment about the treatment ?

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On day 3, the doctor reported the blood pressure 75/50mmHg, pulses 110x/min, temp
36.7 C, Respiratory rate 30x/min. The patient was sent to ICU for further
management.

Question 2
What is your diagnosis? What is your management?

The patient was treated by dopamine drip, intravenous dexamethasone 2 amp/6 hours,
urine catheter was inserted, IVFD with Normal Saline and Ringer Lactate.

Question 3
What is your comment on the above management?

On day 4, he vomited coffee ground colors about 100 cc, blood pressure 100/50
mmHg, temp 39.5C. Widal test negative, Lipase 65 u/L, amilase 87.6 u/L. USG
abdomen reported as Pankreatitis & Cystitis

Question 4
What is your diagnosis?

Blood gas analysis showed:

1st day ICU 3nd day ICU 3nd day ICU 4rd day ICU
pH 7.375 7.044 7.002 7.251
HCO3 17.9 5.0 7.3 18.6

Question 5
What is your diagnosis?

On day 5 general condition was getting worse , he became somnolent, stupor, and
convulsion. Respiratory arrest occurred, he was put on ventilator. Blood pressure
110/70 mmHg, pulse 120/min, temp 390C, urine 250 cc/day. Ureum 209 mg%, Creat
5.9 mg%, K 5.3 meq/L.

Question 5
What is your diagnosis?

On late evening day 5: the laboratory results finally showed malaria falciparum ++++,
with trophozoite form appeared. The patient was rescued with anti malaria treatment
but patient died subsequently.

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