NURUL QOMARIYAH

DEFINISI:
Penyakit infeksi akut atau kronis
Disebabkan oleh Plasmodium malariae
Ditularkan melalui gigitan nyamuk Anopheles
Ditandai dengan:
Demam paroksismal
Anemia
Splenomegali

ETIOLOGI:
Plasmodium:
Falciparum
Vivax
Malariae
Ovale

Malaria transmission cycle from mosquito to human

White NJ, Breman JG. Malaria and babesiosis: Diseases caused by red blood cell parasites.
In Harrisons Principles of Internal Medicine. 16th ed. NY: MacGraw-Hill Co. 2005: 1220

Characterictics of Plasmodium species infecting humans

Finding for indicated species
Characteristic

P. falciparum

P. vivax

P. ovale

P. malariae

Duration of
intrahepatic phase
(days)

5,5

15

Number of
merozoites released
per infected
hepatocyte

30.000

10.000

15.000

15.000

Duration of
erythrocytic cycle
(hours)

48

48

50

72

Red cell prference

Younger cells (but

can invade cells of
all ages)

Red cells up to 14
days old

Reticulocytes

Older cells

Morphology

Usually only ring

forms; bananashaped
gametocytes

Irregularly shaped
large rings and
tropozoites;
enlarged
erythrocytes;
Schuffners dots

Infected
erythrocytes,
enlarged and oval
with tufted ends;
Schuffners dots

Band or rectangular
forms of
trophozoites
common

Pigment color

Black

Yellow-brown

Dark brown

Brown-black

Ability to cause
relapses

No

Yes

Yes

No

White NJ, Breman JG. Malaria and babesiosis: Diseases caused by red blood cell parasites.
In Harrisons Principles of Internal Medicine. 16th ed. NY: MacGraw-Hill Co. 2005: 1220

Faktor manusia dikaitkan dengan kerentanan

terserang penyakit malaria:

Ras atau suku bangsa

Populasi dengan HBS

perkembangan P. falciparum terhambat

Kekurangan enzim tertentu

G6PD

memberikan perlindungan terhadap infeksi Plasmodium

Imunitas
Mencegah masuknya Plasmodium
Menekan perkembangan parasit

ANAMNESIS:
Riwayat demam intermiten atau terus-menerus
Riwayat dari atau pergi ke daerah endemik malaria
Trias malaria: menggigil, demam, banyak keringat
Di daerah endemik malaria, trias malaria mungkin
tidak dijumpai diare dapat merupakan gejala
utama

MANIFESTASI KLINIS:
Konjungtiva pucat
Sklera ikterik
Splenomegali

Manifestation of severe Falciparum malaria

Signs

Manifestation

Major
Unarousable
coma/cerebral malaria

Failure to localize or respond appropriately to noxiuos stimuli; coma persisting

for > 30 min after generalized convulsion

Acidemia/acidosis

Arterial pH < 7,25 or plasma bicarbonate level of < 15 mmol/L; venous lactate
level breathing, often termed respiratory distress

Severe normochromic,
normocytic anemia

Hematocrit of < 15% or hemoglobin level of < 50 g/L (<5g/dL) with

parasitemia of > 100.000/L

Renal failure

Urine output (24 h) of < 400 mL in adults or < 12 mL/kg in children; no

improvement with rehydration; serum creatinine level of > 265 mol/L (> 3,0
mg/dL)

Pulmonary
edema/ARDS

Noncardiogenic pulmonary edema, often aggravated by overhydration

Hypoglycemia

Plasma glucose level of < 2,2 mmol/L (< 40 mg/dL)

Hypotension/shock

Systolic blood pressure of < 50 mmHg in children 1-5 years or < 80 mmHg in
adults; core/skin temperature difference of > 100C

Bleeding/DIC

Significant bleeding and haemorrhage from the gums, nose, and

gastrointestinal tract and/or evidence of disseminated intravascular
coagulation

Convulsions

More than 2 generalized seisures in 24 h

Hemoglobinuria

Macroscopic black, brown, or red urine; not associated with effects of oxidant
drugs and red blood cell enzyme defects (such as G6PD deficiency)

Sign

Manifestations

Other
Impaired conciousness

Obtunded but arousable

Extreme weakness

Prostration; inability to sit unaided

Hyperparasitemia

Parasitemia level of > 5% in nonimmune patients (> 20% in any patient)

Jaundice

Serum bilirubin level of > 50 mmol/L (> 3.0 mg/dL) if combined with other
evidence of vital-organ dysfunction

Features indicating a poor prognosis in severe falciparum malaria

Clinical
Marked agitation
Hyperventilation (respiratory
distress)
Hypothermia (<36,50C)

Bleeding
Deep coma
Repeated convulsions

Anuria
Shock

Laboratory
Biochemistry
Hypoglycemia (<2,2 mmol.L)
Hyperlactatemia (>5 mmol/L)
Acidosis (arterial pH <7,3; serum HCO3 <15 mmol/L)
Elevated serum creatinine (>265 mol/L)
Elevated total bilirubin (> 50 mol/L)

Elevated liver enzymes (AST/ALT 3 times upper

limit of normal, 5-nucleotidase )
Elevated muscle enzymes (CPK , myoglobin )
Elevated urate (> 600 mol/L)

Hematology
Leukocytosis (>12.000/L)
Severe anemia (PCV < 15%)
Coagulopathy
Decreased platelet count (< 50.000/L)
Prolonged prothrombin time (> 3s)
Prolonged partial thromboplastin time
Decreases fibrinogen (< 200 mg/dL)

Parasitology
Hyperparasitemia
Increased mortality at > 100.000/L
High mortality at > 500.000/L
> 20% of parasites indentified as pigment-containing trophozoites and schizonts
> 5% of neutrophils with visible pigment

COMPLICATON OF SEVERE MALARIA

Cerebral malaria (death rate 20% in adults; 15% in children)
Hypoglycemia (usual hypoglycemia signs e.g. sweating, tachycardia
(-))

Lactic acidosis (correlates with hypoglycemia; failure in excretion lactic

acid via liver and kidney)

Non-cardiogenic pulmonary edema (mortality rate > 80%)

Renal impairment (related with erythrocytes sequestration
microcirculatory flow). Early HD good prognosis

Hematologic abnormalities (severe anemia, dyserythropoiesis, slight

coagulation abnormalities, mild thrombocytopenia)

Liver dysfunction mild hemolytic jaundice

Patients with falcifarum may develop deep jaundice with
hemolytic, hepatitic, and cholestatic components

Related incidence of severe complication of falcifarum malaria

Complications

Nonpregnant
adults

Pregnant
women

Children

Anemia

++

+++

Convulsion

+++

Hypoglycemia

+++

+++

Jaundice

+++

+++

Renal failure

+++

+++

++

+++

Pulmonary edema

DIFFERENTIAL DIAGNOSIS

Viral infection
Toxic typhoid fever
Fulminant hepatitis
Leptospirosis
Encephalitis

PENATALAKSANAAN MALARIA TANPA KOMPLIKASI

Jumlah tablet per hari, dosis tunggal
Tiap tablet klorokuin 250mg setara dengan 150 mg klorokuin
basa
Menurut WHO

Menurut Depkes RI

Hari 1

Hari 2

Hari 3

Hari 4-5

Hari 1

Hari 2

Hari 3

<1

14

1+

58

2+1

9 15

3+1

> 15 /
dewasa

4+2

PEDOMAN PENGGUNAAN OBAT UNTUK MALARIA PARAH

Nama obat

Dosis permulaan

Dosis lanjutan

Kuinin

20 mg/kg BB kuinin dalam 100-200 cc D

5% / NaCl selama 4 jam, dianjutkan
dengan 10 mg/kg BB dilarutkan dalam
200 cc D 5% selama 4 jam

10 mg/kg BB dilarutkan dalam 200 cc D 5%

setiap 8 jam. Bila penderita sudah sadar,
diberikan kinin oral, 600 mg 3x sehari,
sampai hari ke 7

Kuinidin

15 mg basa/kg BB dilarutkan dalam 250

cc cairan isotonik selama 4 jam

7.5 mg basa/kg BB dalam 250 cc cairan

isotonik selama 4 jam, setiap 8 jam,
dilanjutkan per oral setelah penderita sadar

10 mg/kg BB dalam 500 cc larutan

isotonik selama 8 jam

5 mg basa/kg BB dalam 500 cc larutan

isotonis selama 8 jam, diulang 3 kali (total
15 mg/kg BB)

Artesunate
(IV)

250 mg drip dalam larutan isotonik

100 mg/hari selama 14 hari

Artemeter

160 mg suntikan (IM)

80 mg IM selama 14 hari

Klorokuin

(untuk

yang masih
sensitif)

PROFILAKSIS

Obat antimalaria

Perorangan: baju panjang, insektisida, kasa/kelambu

Vaksin malaria:
Antisporozoit (pra-eri)
Stadium aseksual / eritrositik
Stadium seksual / transmisi (-)