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Case Studies

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?
• 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 2
What is your comment on this case?
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 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?
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?
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 restriction?
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
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.

• 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 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
• 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: composmentis, 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.
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 ?
• 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 results

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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