Case Studies

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 erithrocytes. 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 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?