malaria.ppt
DESCRIPTION
pptTRANSCRIPT
/ 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
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.
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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
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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
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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
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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
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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
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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
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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
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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