Malaria.ppt

Yuli Hermansyah, dr, Yuli Hermansyah, dr, SpPDSpPD

MALARIA

/ intracellular obligate protozoa plasmodium gene.

P.Malariae, P.Vivax, P.Falciparum, P.Ovale

anopheles. 400 Anopheles 67 contagioused 24 (INA)

Blood transfusion / syringe. Pregnant women baby.

INTRODUCTION

Malaria

Parasitemia

Parasitemia

P.falciparum all ages of erithrocyte erithrocyte infectious rate severe complication

P.falciparum all ages of erithrocyte erithrocyte infectious rate severe complication

P.malariae older erithrocyte 1%

P.malariae older erithrocyte 1%

P.vivax reticulocyte 2% erithrocyte

P.vivax reticulocyte 2% erithrocyte

Falciparum.Pernicious.Sub tertian.Malignan.

Estivoautumnal.

P.falciparum severe & complicated malaria

Shock.Cerebral malaria.

Haemolysis.Haematologic manifestation

Pulmonary oedema.

Fatal complication

CFR severe malaria 10 – 50%.

Mortality of malaria / complication of severe malaria (P.falciparum).

WHO : Asexual stage infection of P.falciparum

with one or more complication.

DEFINITION

Severe Malaria

1. Cerebral malaria :* Coma (GCS < 11).* 30 minutes after convulsion (not caused by

another diseases).2. Severe anemia (Hb < 5 gr% or Hct <

15%).3. ARF (urine < 400ml/24 hours in adult, < 12 ml/kg BW in children)

creatinine serum > 3 mg%.

4. Pulmonary oedema / ARDS.

5. Hypoglycaemia, blood sugar < 40 mg%.

6. Circulatory collapse / shock : * systolic BP < 70 mmHg

(children 1-5 years old < 50 mmHg). * Cold sweating. * temperature skin – mucous > 1C.

7. Spontaneous bleeding : nose, gums, gastrointestinal tract + laboratory

intravascular coagulation

disturbances.

8. Repeat convulsions > 2x/24 hours.

9. Acidaemia (PH <7,25)/Acidosis (HCO3

<15mmol/L).

10.Macroscopic haemoglobinuria acute

malaria infection.

11.Post mortem confirmation of diagnosis.

Other manifestations of severe malaria 1. Impairment of conciousness less

marked than unrousable coma (GCS < 15).

2. Muscle weakness (can not sit / walk) without neurological disorder.

3. Hyperparasitemia > 5% hypoendemic area or unstable malaria area.

4. Jaundice (bil conc > 3 mg%).

5. Hyperpyrexia (rectal temp > 40C).

• 2% non immune patients. • 10% of the patients hospitalized with falciparum malaria.

• 80% of the fatal case.• Pathogenese still uncleared.

Suggestion : Erithrocyte (contain parasite) unable to pass throught capillary vessels of the brain (citoadherence and sequestration) plug capillary vessel of the brain Anoxia.

PATHOPHYSIOLOGI

1) Cerebral Malaria

30% case need transfusion.

WHO transfusion Hb < 5 gr% / Hct < 15% parasite > 10.000/mm3.

Correlated with parasitemia, skizontemia, total bilirubin serum, creatinine serum.

Acute malariadisoriented,lost of conciousness

untill coma, gallop rythm, hepatomegali and

pulmonary oedema.

Anemia : * haemolysis. * TNF-alfa.

2) Anemia

>> adult.

Sensitive indicator for severe malaria.

Mortality 45%.

<< children.

Pre-renal (dehidration) > 50%.

Acute tubular necrose 5 – 10%.

3) Acute Renal Failure

Plug capillary vessels blood flow to the kidney Anoxia

glumerular filtration rate (oliguria)

Anuria

- diffuse cortical necrosis.- progressif glumerulonephritis- arteri renal occlussion / vasculitis renal.

- hyperkalemia.- hyperphosphatemia.- hypocalcemia. - hypermagnesemia.

Acidosis metabolic.

Hyperuricaemia.

Amylase serum.

Congestive heart failure.

Aritmia.

Pericarditis.

Terminal stage uremia, GI & skin bleeding, septicemia

A R F

>> adult; << children. The most severe complication of tropica malaria †

Two types :1. Fluid overflow.2. Adult respiratory distress syndrome.

Past: * capillary membrane permeability.

* microvascullar emboli. * intra vascullar coagulation. & pulmonary microcirculair

disfunction.Recent : TNF-alfa

4) Pulmonary Oedema

Metabolic demands of the parasites.

Adult ~ tx/: quinine. Pregnancy primigravide. >> Adrenalin secretion. Failure of hepatic gluconeogenesis.

5) Hypoglicaemia

Malaria Algid. Shock with hypotension (systolic

pressure < 70 mmHg). Changes of perifer resistance. tissue perfusion. Hypotension ~ gram negative

septicemia.

6) Circulatory collapse / shock

Gums, nose, ptechiae, purpura hematome thrombocytopenia.

Intravascular coagulation disturbance rare (< 10%).

Gastrointestinal bleeding steroid.

stress ulcer. Bleeding + severe parasitemia +

uremia poor prognose.

7) Spontaneous bleeding

>> tropica malaria. Hot and dry skin, cyanosis in

extremities. Delirium coma. Temp > 38C convulsion.

Temp 39,5C - 41C delirium.Temp > 41C coma.

Endemic area heat stroke malaria.

8) Hyperpyrexia (hyperthermia)

Hyperventilation (kussmaul). Lung auscultation : N. Lactic acid . PH (< 7,25). Bicarbonat (< 15 mmol/L).

9) Metabolic acidosis

Syndrome : * acute attack.* chills.* intravascular

haemolysis.* haemoglobinemia.* haemoglobinuria.* renal failure.

Back pain. Vomiting. Diarhea. Polyuria.

10) Macroscopic haemoglobinuria

(blackwater fever)

Oliguria + ‘coca-cola’-coloured urine.

(blackwater urine) Hepatosplenomegali + anemia +

icteric. Haemolysis caused by quinine or

antibody against quinine never be proved. Deficiency of G-6-PD enzyme.

Blackwater fever

Malaria disease caused by protozoa intracellular obligate from

plasmodium genus. Human P.malariae, P.vivax, P.falciparum,

P.ovale Pathogenese still uncleared. Contagioused * mosquito bite.

* blood transfusion. * syringe. * pregnant women

baby.

SUMMARY

Plasmodium falciparum severe and complicated malaria :

* malaria falciparum.* pernicious.* sub tertian.* malignan.* estivoautumnal.

Severe malaria : infection caused by P.falciparum (asexual stage) + one/more complication : cerebral malaria, severe anemia, ARF, pulmonary oedema / ARDS, hypoglicemia, shock, spontaneous bleeding, convulsion, hyperthermia, acidosis, haemoglobinuria.

04/17/23 Kuliah Tropik Infeksi 26

Diagnosis

Anamnesis :Anamnesis : Demam, menggigil, nyeri kepala, nyeri Demam, menggigil, nyeri kepala, nyeri

otot, riwayat daerah endemik, transfusi, otot, riwayat daerah endemik, transfusi, obat malariaobat malaria

Pemeriksaan fisik :Pemeriksaan fisik : Demam, pucat, hepatomegali, Demam, pucat, hepatomegali,

splenomegali, manifestasi malaria beratsplenomegali, manifestasi malaria berat


Diagnosis

Pemeriksaan laboratorium :Pemeriksaan laboratorium : Tetes tebal & tipis ~ parasit +, spesies & Tetes tebal & tipis ~ parasit +, spesies &

stadium plasmodium, kepadatan parasit stadium plasmodium, kepadatan parasit (semikuantitatif, kuantitatif)(semikuantitatif, kuantitatif)

Pemeriksaan lain :Pemeriksaan lain : Deteksi antigen parasit malaria, metode Deteksi antigen parasit malaria, metode

imunokromatografi : HRP2, pLDHimunokromatografi : HRP2, pLDH


Diagnosis banding

Tifoid Tifoid Dengue feverDengue fever ISPAISPA Leptospirosis ringanLeptospirosis ringan Infeksi virus Infeksi virus

Meningo ensefalitisMeningo ensefalitis CVACVA Tifoid ensefalopatiTifoid ensefalopati HepatitisHepatitis Leptospirosis beratLeptospirosis berat GlomerulonefritisGlomerulonefritis SepsisSepsis DSSDSS


Pengobatan

Obat anti malaria : Obat anti malaria : Oral ~ malaria ringan tanpa komplikasiOral ~ malaria ringan tanpa komplikasi Parenteral ~ malaria berat / tak bisa Parenteral ~ malaria berat / tak bisa

minum obatminum obat Pengobatan suportif : demam, anti kejang, Pengobatan suportif : demam, anti kejang,

cairan dll.cairan dll. Pengobatan komplikasi Pengobatan komplikasi


Anti malaria, dasar mikroskopik

Falsiparum tanpa komplikasi (lini 1)Falsiparum tanpa komplikasi (lini 1) Artesunat , 4 tab hari1-3Artesunat , 4 tab hari1-3 Amodiakuin, 4 tab hari 1-3Amodiakuin, 4 tab hari 1-3 Primakuin, 4 tab hari 1Primakuin, 4 tab hari 1

Lini 2Lini 2 Kina, 3x2tab hari 1-7Kina, 3x2tab hari 1-7 Tetrasiklin, 4xi kaps hari 1-7Tetrasiklin, 4xi kaps hari 1-7 Primakuin, 3 tab hari 1 Primakuin, 3 tab hari 1


Anti malaria, dasar mikroskopik

Vivax, ovale (lini 1)Vivax, ovale (lini 1) Kloroquin , 4 tab hari1-2, 2 tab hari 3Kloroquin , 4 tab hari1-2, 2 tab hari 3 Primakuin, 1 tab hari 1-3Primakuin, 1 tab hari 1-3

Lini 2Lini 2 Kina, 3x2tab hari 1-7Kina, 3x2tab hari 1-7 Primakuin, 1 tab hari 1-14 Primakuin, 1 tab hari 1-14

Relaps Relaps Klorokuin 4 tab/minggu , 8-12 mingguKlorokuin 4 tab/minggu , 8-12 minggu Primakuin 3 tab/minggu , 8-12 mingguPrimakuin 3 tab/minggu , 8-12 minggu


Anti malaria, dasar klinis

Lini 1Lini 1 Kloroquin , 4 tab hari1-2, 2 tab hari 3Kloroquin , 4 tab hari1-2, 2 tab hari 3 Primakuin, 3 tab hari 1Primakuin, 3 tab hari 1

Lini 2Lini 2 Kina, 3x2tab hari 1-7Kina, 3x2tab hari 1-7 Primakuin, 1 tab hari 1 Primakuin, 1 tab hari 1


Malaria berat

Lini 1 Lini 1 Artesunat (60 mg); 2,4 mg/kgBB iv diikuti 1,2 Artesunat (60 mg); 2,4 mg/kgBB iv diikuti 1,2

mg/kgBB 1v jam 12, 24 ; selanjutnya 1,2 mg/kgBB 1v jam 12, 24 ; selanjutnya 1,2 mg/kgBB setiap hari sd hari 7mg/kgBB setiap hari sd hari 7

Artemether (80mg); 2 ampul im hari 1; 1 ampul Artemether (80mg); 2 ampul im hari 1; 1 ampul 1m hari 2-51m hari 2-5

Lini 2 :Lini 2 : Kina 500 mg dlm D5 selama 8 jam, diulang/8 Kina 500 mg dlm D5 selama 8 jam, diulang/8

jamjam

Malaria.ppt

Documents

Transcript of Malaria.ppt