MALARIA

ESSENTIALS OF DIAGNOSIS

HISTORY OF EXPOSURE IN A MALARIA-ENDEMIC AREA

PERIODIC ATTACTS OF SEQUENTIAL CHILLS, FEVER &

SWEATING, APYREXIA IMPORTANT/ DIDERITA

HEADACHE, MYALGIA, SPLENOMEGALI, ANEMIA,

LEUKOPENIA

PARASITES IN RBC, IDENTIFIED IN THICK OR THIN

BLOOD FILMS

ETIOLOGY :
SPOROZOA GENUS PLASMODIUM
Plasmodia malaria :
Pl. vivax
Mal. tertiana benigna
Pl. ovale Mal. ovale / T. benigna
Pl. falsiparum Mal. tropika / T. maligna
Pl. malariae
Mal. kuartana

Life cycle of malaria parasites

live-cycle P.falciparum

Exoerytrocyter & RBC phase of

Pl. malaria

Pl. vivax
Pl. ovale
Pl. falcifarum
Pl. malariae

EE II (+)

EE I (+)

EE II (-)

PATHOGENESIS (1)
THE ASEXUAL ERYTHROCYTIC IS RESPONSIBLE FOR THE
SYMPTOMS:
- FEVER, HEADACHE, NAUSEA & MUSCULAR PAIN

AT THE TIME SCHIZONTINFECTED RBC RUPTURE

- ENDOGENEOUS PYROGEN (INTERLEUKIN-1) AND
MEDIATORS (KININS & CATHECTIN TNF) RELATED

TO PATHOGENESIS?

PATHOGENESIS (2)
* ENCEPHALOPATHY:
~ RBC CONTAINING SCHIZONTS & MALARIAL
PIGMENT OBSTRUCT CEREBRAL CAPILLARIES &
VENULES
~ CEREBRAL EDEMA MAY DEVELOP AS A RESULT
OF AGONAL HYPOXIA

~ SEQUESTRATION OF PARASITIZED RBC IN BRAIN

& OTHER TISSUE RESULT FROM CYTOADHERENCE
OF KNOBLIKE PROTUBERANCE ON THE RBC TO

ENDOTHELIUM

PATHOGENESI (3)
~ DECREASED DEFORMITY OF INFECTED RBC
SLUGGISH MICROVASCULAR FLOW
~ CEREBRAL ANAEROBIC GLYCOLYSIS & REDUCED

CEREBRAL OXYGEN TRANSPORT CEREBRAL

MALARIA

PATHOGENESIS (4)
- ANEMIA:
~ HEMOLYSIS OF INFECTED RBC
~ RAPID SPLENIC REMOVAL ON NONPARASITIZED
ERYTHROCYTES
~ DYSERYTHROPOISIS
- THROMBOCYTOPENIA SEQUESTRATION IN THE SPLEEN

PATHOGENESIS (5)
- ACUTE RENAL FAILURE

ACUTE TUBULAR NECROSIS

ISCHEMIA RESULTING FROM:

~ HYPOVOLEMIA
~ RENAL VASOCONTRICTION
~ MICROVASCULAR OBSTRUCTION:
* PARASITIZED RBC
* PIGMENT NEPHROPATHY SECONDARY
TO HEMOLYSIS

ACUTE RENAL FAILURE

PATHOGENESIS (6)
- THE SPLEEN IS LARGE:
~ ENGORGE & HEAVILY PIGMENTED
~ CONTAINING MANY PHAGOCYTIC CELLS
INGESTED RBC & MALARIAL PIGMENT
- EDEMATOUS LUNGS:
~ PULMONARY CAPILLARIES & VENULE ARE
PACKED WITH INFLAMMATORY CELLS

~ ENDOTHELIAL & INTESTINAL EDEMA

X . jumlah lekosit / mm 3
200

Cara menghitung kepadatan parasit

Jumlah parasit aseksual dalam 1 mm3
= X x Jumlah lekosit/ mm3
200

Di mana X= jumlah parasit aseksual per 200

leukosit

CLINICAL FINDINGS (1)

A. SYMPTOMS (1)
- SHAKING CHILLS (THE COLD STAGE)
- FEVER (THE HOT STAGE) 41C
- DIAPHORESIS (THE SWEATING STAGE)
- FATIGUE

TRIAS
MALARIA

- HEADACHE
- DIZZINESS
- MYALGIA

DINGIN

DEMAM

- ARTHRALGIA
- BACKACHE

APIREKSI

KERINGAT

- DRY COUGH

DI-DE-RI-TA

CLINICAL FINDNGS (2)

SYMPTOMS (2)

- GASTROINTESTINAL SYMPTOMS:
~ ANOREXIA
~ NAUSEA

~ VOMITING
~ DIARRHEA
~ ABDOMINAL CRAMPS

CLINICAL FINDINGS (3)

SYMPTOMS (3)
-THE ATTACKS PERIODICITY:
~ EVERY-DAY FALCIPARUM

~ EVERY-OTHER-DAY TERTIAN PL. VIVAX & OVALE

~ EVERY-THIRD-DAY QUARTIAN PL. MALARIAE
~ TIRED BETWEEN ATTACKS, BUT FEELS WELL
~ AFTER THIS PRIMARY EPISODE, RECURRENCE ARE
COMMON, EACH SEPERATED BY A LATENT PERIOD

GAMBARAN DEMAM TERTIANA

SUHU

HARI

NORMAL

GAMBARAN DEMAM KUARTANA

SUHU
HARI

NORMAL

GAMBARAN SUSTAINED FEVER

(KONTINYU)

< 1 C

NORMA

SUHU
JAM 6

12

18

CLINICAL FINDINGS (4)

SIGNS
- SPLENOMEGALY:
APPEAR ACUTE SYMPTOMS
CONTINUED 4 DAYS
- MILDY HEPATOMEGALY
- ANEMIA

COMPLICATIONS (1):
1. CEREBRAL MALARIA:
- HEADACHE
- MENTAL DISTURBANCES
- NEUROLOGIC SIGNS
- RETINAL HEMORRHAGES
- CONVULSIONS
- DELIRIUM

- COMA

COMLICATIONS (2):
2. HYPERPYREXIA

3. HEMOLYTIC ANEMIA
4. NONCARDIOGENIC PULMONARY EDEMA
5. ACUTE TUBULAR NECROSIS & RENAL

FAILURE BLACKWATER FEVER DUE TO

>QUININE TREATMENT

COMPLICATIONS (3)
6. ACUTE HEPATOPATHY MARKED
JAUNDICE, BUT NO LIVER FAILURE
7. HYPOGLYCEMIA
8. ADRENAL INSUFFICIENCY-LIKE SYNDROME

9. CARDIAC DYSRHYTHMIAS
10, GASTROINTESTINAL SYNDROMES
11. LACTIC ACIDOSIS & HYPOGLYCEMIA

12. PNEUMONIA
13. WATER & ELECTROLYTE IMBALANCE

MANAGEMENT:
A. TREATMENT OF ACUTE ATTACKS (1)
1. ELIMINATION OF ASEXUAL ERYTHROCYTIC PARASITES
- CHLOROQUINE PHOSPHATE (SALT) 1G AT
0, 24, AND THEN 0.5 G AT 48 HOURS

HOURS

24

48

CHLOROQ/ GR

0.5

- MEFLOQUINE,
~ 1 x 250 MG FOR 3 DAYS, OR 750-1250 MG,
THEN 500 MG AFTER 6-8 HOURS

TREATMENT OF ACUTE ATTACKS (2)

- QUININE SULFATE (PLUS DOXYCYCLINE, CLINDAMYCIN,
OR FANSIDAR
- ATOVAQUONE 250 MG (PLUS DOXYCYCLINE 100 MG OR
PROGUANIL 100 MG)
- HALOFANTRINE,
- ARTEMISININ (QINGHAOSU), FISRT DAY 2X2 TABS,
THEN 2X1 TABLET FOR 5 DAYS

TREATMENT OF ACUTE ATTACKS (3)

IN SEVERE PATIENTS
- START ORAL THERAPY WITH CHLOROQUINE

AS SOON AS POSSIBLE
- IV QUININE DIHYDROCHLORIDE
- QUINIDINE GLUCONATE

- PARENTERAL CHLOROQUINE

TREATMENT OF ACUTE ATTACKS (4)

2. ERADICATION OF P. VIVAX OR P. OVALE

CHLOROQUINE AS ABOVE FOLLOWED BY 0.5 G ON DAYS 10

AND 17 PLUS PRIMAQUINE PHOSPHATE, 25,3 MG (SALT)
DAILY FOR 14 DAYS STARTING ABOUT DAY 4
DAYS
CHLOROQ/G

PRIMAQUINE

1
1.0

10

17

1.0

0.5

0.5

0.5

25,3 FOR 15 DAYS

TREATMENT OF ACUTE ATTACKS (5)

3. ELIMINATION OF PERSISTENT GAMETOCYTEMIA

- CHLOROQUINE FOR P.VIVAX, P. OVALE,
P. MALARIAE
- PRIMAQUINE SALT, SINGLE DOSE, 26.3 MG
FOR P. FALCIPARUM

TREATMENT OF ACUTE ATTACKS (6)

* TREATMENT OF FALCIPARUM MALARIA ACQUIRED
IN AREAS WHERE P. FALCIPARUM IS RESISTANT TO
CHLOROQUINE (1)
- START WITH ORAL QUININE SULFATE, 10 MG/KG 3X
DAILY FOR 3-7 DAYS, PLUS :

~ DOXYCYCLINE, 2X100 MG DAILY FOR 7 DAYS

~ CLINDAMYCIN. 3X900 MG DAILY FOR 5 DAYS
~ PYRIMETHAMINE, 2X25 MG DAILY FOR 3 DAYS

~ SULFADIAZINE, 4X500 MG DAILY FOR 7 DAYS

~ 3 TABLETS OF FANSIDAR (PYRIMETHAMIN+
SULFADOXINE)

TREATMENT OF ACUTE ATTACKS (7)

P. FALCIPARUM IS RESISTANT TO CHLOROQUINE (2).
- ALTERNATIVE DRUGS ARE:
~ MEFLOQUINE
~ HALOPHANTRINE
~ ARTESUNATE
~ ATOVAQUONE
- SEVERELY ILL:
~ IV QUININE OR QUINIDINE
~ DOCYCYCLINE OR CLINDAMYCIN
PARENTRALLY
- ORAL TREATMENT WITH QUININE PLUS THE
ANTIBIOTIC SHOULD BE AS SOON AS POSSIBLE

TREATMENT OF ACUTE ATTACKS (8)

* SPECIAL TREATMENT FOR TREATMENT OF SEVERE
P. FALCIPARUM MALARIA (1)
- MEDICAL EMERGENCY THAT REQUIRES:
~ HOSPITALIZATION
~ INTENSIVE CARE
~ IV CHEMOTHERAPY AS RAPID AS POSSIBLE
~ REQUIRING >48 HOUR OF PARENTRAL THERAPY
~ DEHYDRATION SHOULD BE DONE WITH CAUTION
~ FLUID, ELECTROLYTE & ACID- BASE BALANCE
MUST BE MONITORED

TREATMENT OF ACUTE ATTACKS (9)

* SPECIAL TREATMENT FOR TREATMENT OF

SEVERE P. FALCIPARUM MALARIA (2):

~ EARLY DIALYSIS MAY BE NECESSARY FOR RENAL
FAILURE

~ BLOOD GLUCOSE LEVELS SHOULD BE MONITORED

EVERY 6 HOURS IF HYPOGLYCEMIA +,
~ 50% DEXTROSE, 1-2 ML/KG
~ MAINTENANCE 5-10% DEXTROSE

TREATMENT OF ACUTE ATTACKS (10)

* SPECIAL TREATMENT FOR TREATMENT OF SEVERE
P. FALCIPARUM MALARIA (3)

- DIC FRESH WHOLE BLOOD

- HCT < 20% TRANSFUSION
- EXCHANGE TRANSFUSION WHEN >15% RBC

ARE PARASITIZED
- SEIZURES ANTICONVULSANTS
- TEMPERATURE IS MAINTAINED <38.5 C
- BLOOD FILM SHOULD BE CHECKED DAILY UNTIL
PARASITEMIA CLEARS; WEEKLY THEREAFTER
FOR 4 WEEKS RECRUDESCENCE?

TREATMENT OF ACUTE ATTACKS (11)

B. CHEMOPROPHYLAXIX (1)
a. IN REGIONS WHERE P. FALCIPARUM AND P. VIVAX
ARE SENSITIVE TO CHLOROQUINE
~ DRUG OF CHOICE
1. CHLOROQUINE PHOSPHATE, 500 MG WEEKLY, ONE
WEEK BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEK AFTER LEAVING

TREATMENT OF ACUTE ATTACKS (12)

CHEMOPROPHYLAXIX (2)
~ ALTERNATIVE DRUGS

1. HALOFANTRINE.
2. FANSIDAR
3. AMODIAQUINE.
4. PYRIMETHAMINE
5. ARTEMISININ

6. PROGUANIL
7. QUININE

TREATMENT OF ACUTE ATTACKS (13)

CHEMOPROPHYLAXIX (3)
b. IN REGIONS WHERE P. FALCIPARUM IS RESISTANT
TO CHLOROQUININE
~ DRUGS OF CHOICE

1. MEFLOQUINE SALT, 250 MG (228 MG BASE) WEEKLY,

1-3 WEEKS BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING.

TREATMENT OF ACUTE ATTACKS (14)

CHEMOPROPHYLAXIX (4)
~ ALTERNATIVE:
- FIRST ALTERNATIVE: DOXYCYCLINE, 100 MG DAILY,
2 DAYS BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING
- SECOND ALTERNATIVE: MALARONE (ATOVAQUONE
250 MG + PROGUANIL 100 MG), ONE TABLET DAILY,

ONE TABLET THE DAY BEFORE ENTERING THE

ENDEMIC AREA, WHILE THERE, AND FOR 1 WEEK
AFTER LEAVING

TREATMENT OF ACUTE ATTACKS (15)

CHEMOPROPHYLAXIX (5)
- OTHER ALTERNATIVES:
DAILY PROGUANIL 200 MG + WEEKLY CHLOROQUINE
0.5 G, MORE PROTECTION THAN CHLOROQUINE

ALONE

TREATMENT OF ACUTE ATTACKS (16)

CHEMOPROPHYLAXIX (6)
c. PROPHYLAXIS FOR PREGNANT WOMEN
- THE BEST COURSE IS WEEKLY CHLOROQUINE +/
PROGUANIL

- IN AREAS OF CHLOROQUINE-RESISTANT MALARIA

MEFLOQUININE, EXCEPT IN THE FIRST TRIMESTER
- DRUGS CONTRAINDICATED ARE DOXYCYCLINE &

PRIMAQUINE

Recommendation WHO 2006 in using

Artemisinin-base Combination Therapy (A.C.Ts)

Artemether+lumefantrine

Artesunate + amodiaquine

Artesunate + mefloquine

Artesunate + sulfadoxine-pyrimethamine

PROGNOSIS
- UNCOMPLICATED & UNTREATED PRIMARY ATTACK OF
P. VIVAX, P. OVALE, OR P. FALCIPARUM MALARIA USUALLY
LASTS 2-4 WEEKS; P. MALARIAE ABOUT TWICE AS LONG.
- WITH PROMPT ANTIMALARIAL THERAPY, THE PROGNOSIS
IS GENERALLY GOOD, BUT IN P. FALCIPARUM INFECTIONS,
WHEN SEVERE COMPLICATIONS DEVELOP, THE PROGNOSIS

IS POOR EVEN WITH TREATMENT