W.S. 6.7 DIAGNOSIS & TATALAKSANA MALARIA Paul Harijanto - WS MALARIA-PIN... · Wanita 55 thn rujukan dari RS perifer, demam 5 hari, tinggal di daerah malaria, dilaporkan TS dengan

W.S. 6.7

DIAGNOSIS & TATALAKSANA

MALARIA

PAUL

HARIJANTO

MANAGEMENT SEVERE MALARIA SUSPECTED CASE

EARLY IDENTIFICATION & DIAGNOSIS

SPECIFIC TREATMENT

◦ ANTI MALARIAL DRUGS

MANAGEMENT & DETECTION VITAL ORGAN

FAILURE :

◦ Hemodynamic changes ( shock )

◦ Causes of Decresing Concious level ( hypoglycaemia )

◦ Respiratory failure ( breathless, rate > 30x/ minute )

Early identification & Diagnosis

Failed to take a proper history ( travel history, location of living )

Availablity microscopic examinations/ RDT

Misleading diagnosis Malaria : ( Dengue, Typhoid, URTI )

Misleading diagnosis complications :Coma : sepsis, meningitis, stroke

Jaundice : Hepatitis, cholecystitis

Renal failure : dehydration, acute gastroenteritis, Intoksication

Early assesment/ warning sign :

Development/ worsening of coma

Convulsion

Respiratory depression/ arrest

Edema paru/ respiratory insufficiency

Hemodinamiccally unstable

Sepsis

Acute Kidney Injury

IMAI for adolescent & adults in areas of malaria transmission

Fever or history of fever in the past 24 h plus one or more of

the following danger signs:

◦ Very weak or unable to stand

◦ Convulsions

◦ Lethargy

◦ Unconsciousness

◦ Stiff neck

◦ Respiratory distress

◦ Severe abdominal pain

General danger signs suggesting severe febrile

illness as criteria for referral from peripheral

health facilities

IMAI : Integrated Management of Adolescent and Adult Illness

SEVERE MALARIA 2015

DEFINITION : Patients with plasmosium asexual parasitemia,with

one or more CLINICAL or LABORATORY FEATURES :

PROSTRATION

IMPAIRED CONSCIOUSNESS ( GCS

<11, Blantyre < 3 )

RESPIRATORY DISTRESS

MULTIPLE CONVULSIONS ( > 2/ 24 hrs)

CIRCULATORY COLLAPSE / SHOCK (

cap refil>3 or temp gradient on leg (mid to

prox limb), no hypotension; sys <80

adults, 70 in children + impaired perfuss)

PULMONARY EDEMA (CX-Ray/ O2

sat<92% room air + resp >30/min)

ABNORMAL BLEEDING

JAUNDICE ( > 3 mg/dL + par >100.000)

SEVERE ANAEMIA ( Hb <5

PADA ANAK <12TH DAN

Hb<7 pd dewasa

HYPOGLYCAEMIA( < 40 )

ACIDOSIS (base def <8,

HCO3 <15/ Pl. Lactate >5)

RENAL IMPAIRMENT ( >3,

blood urea > 20 mmol/L)

HYPERPARASITEMIA, >10%

WHO: Guidelines for the

Treatment of Malaria 2015

LABORATORY TEST MALARIA

MIKROSKOPIK MALARIA ( Giemsa )

◦ Tetes Tebal

◦ Hapusan Tipis

◦ Hitung Parasit

Rapid Diagnostic Test (RDT) – Tes Cepat

◦ Paracheck

◦ PF test

◦ ICT

◦ Optimal

Interpreting Thick and Thin Films

THICK FILM

◦ lysed RBCs

◦ larger volume

◦ 0.25 l blood/100 fields

◦ blood elements more concentrated

◦ good screening test

◦ positive or negative

◦ parasite density

◦ more difficult to diagnose species

THIN FILM

◦ fixed RBCs, single layer

◦ smaller volume

◦ 0.005 l blood/100 fields

◦ good species

differentiation

◦ requires more time to read

◦ low density infections can

be missed

0

5

10

15

20

25

30

35

40

45

50

0 1 2 3 4 5 6 7

HARI

Pf test

SD

Persisten parasitemia dibandingkan dengan persisten antigenemia

Case 1

Wanita 37 tahun dengan demam ulang-ulang 5 hari, sakit kepala, badan agak kuning, belum bab.

KU Cukup, sadar, tek. Darah 100/60, nadi 116, temp 38 C, makan baik, tidak muntah.

Cor/ pulmo : tak ada kelainan

Hepar teraba 2 jari

Diagnosa : Suspek Hepatitis

Apa Differential Diagnosisnya ?

Laboratorium

Hb. 8.5 gr%, leuko 4900/ mm3, trombo 81.000/mm3

Total bil : 4,4 mg%, direk 1.97 mg%, indirek 2,4 mg%, SGOT 55u/L, GPT : 55 u/L, gamma-GT 61,4 u/L, alk.PO4 : 174 u/L, urea 27.5, creat. 1.3, gula darah148 u/L, Na 135, K 3.3

Bagaimana Diagnosa penderita ini ?

Apa masih perlu pemeriksaan lain untuk diagnosa ?

Lab

Ig M dengue negatif, Ig G dengue positif

NS1 : negatif

Tubex M : + 4

Widal tes : + 1/80

Diagnosa ??

Malaria : Fal ring : +++, 380 par/ 200 Leuko, 2 par/ 1000Eri

Apa pengobatannya ?

Dosis ARTEMISININ PADA MALARIA BERAT

0 JAM 12.J 24.J 48.J 72.J Max 7 hari

2.4 Mg/KgBB

2.4 Mg/KgBB

2.4 Mg/KgBB

2.4 Mg/KgBB

2.4 Mg/KgBB

ARTESUNATE I.V/ I.M

• ARTEMETER , hanya I.M , 3,2 mg/hr1, lanjut dosis• 1,6 mg/kg BB hari berikutnya

48.J 72.J

Kasus 2

Anamnesa:

Laki-laki, 34 tahun tinggal di Tomohon, datang ke RS dengan demam sudah 3 hari. Penderita baru tiba dari Papua 2 hari laludan sudah merasa tidak sehat

P. Fisik : tensi 80/60 mmHg, Temp 38.5 C

Cor/ Pulmo : taa

Abd : taa

Apa tatalaksana awal kasus ini ??

MANAGEMENT & DETECTION VITAL ORGAN FAILURE :

Hemodynamic changes ( shock )Assesement Fluid requirement : individually

Keep the fluid requirement : “ slightly dry “ , using NaCl 0.9%, NOT LACTATE

Prone developed Lung edema

Giving bolus IV fluid either Colloid or Crystaloidis CONTRA-INDICATED

Clinical monitoring is important : development breathless,JVP, respiration rate, rales in auscultation, urine production

Suggested fluid management for adult with severe

malaria

Hansonn J, Anstey NM, Bikan D, et al. Critical Care 2014 ; 18 : 642

Hypotension : MAP < 65 mmHg with

Evidance decreased perfusion or Hb < 7gr/dL

NO

Urine < 0,5

ml/Kg/hour

Anuria

YES

Fluid Bolus

trial/ RRT

Cautious fluid

bolus : 5 ml/Kg

Vasopressor

Exclude

bleeding

Empiric broad

Spect. AB

IV crystalloid

1-2 ml/Kg/hour

Titrate against

BP & Urine

outputRRT No IV fluid/O2

Diuretic

ventilator

MAP<65 mmHg Hb<7gr/dL

Transfuse

PRC/ whole

blood

APO/Urine < 0,5

ml/Kg/hour

YES

APO

NO

Laboratorium

5/10/2011

• Hb: 8,0

• Leuko : 8,300

• Ht: 27%

• Segmen 90%

• Limfosit 10%

6/10/2011

Malaria : (-)

• Bil.direct: 1,2

• Bil.indirect:

2,4

• Bil.total: 3,6

• SGOT: 51

• SGPT: 16

• Ureum: 68

• Creatinin 2,8

• Malaria: Fal.ring (+), Fal.gamet (+)200 lp: 4200 parasit1000 lp: 25 parasit

TATALAKSANA

1. Apa pemberian obat malaria nya ?

2. Perlu tindakan lain nya/ pemeriksaan ?

3. Pengobatan tambahan/ lainnya ?

Case 3

Male 26 years old, referred by peripheral hospital(PH) with

fever for 3 days. Lab . : platelets was 42.000, 18.000. Ht

43.3% then 30.3%. Ig.G positif, IgM negatif.

DIAGNOSIS

??

Because his condition getting worse, developed loss of

concious, he had been referred to district hosp.

Why ??

E.D.S

Expanded

Dengue

Syndrome

Examination in DH : afebrile, pale, GCS :

E4M1V2, no Hepatosplenomegaly, no

neurological defisit, Lab : Hb 12 gr%, WBC

14750/ mm3, granulocyte 90%, thrombocyte

30.000 mg/dL, Random blood sugar 26 mg/dL,

SGOT 300 IU, SGPT 325 IU.

In District Hospital :

malaria falcip +4 (15.000 per 200 leuco),

parasite count 1.050.000/uL

Diagnosis ??

Was treated with artesunate 120 mg on 0 hr, 12

hrs and 24 hrs, also 40% dextrose 75cc was

given intravenously. Six hours later he

developed breathless, kussmaul breathing was

noted, fever 39C, patient was referred to ICU.

Parasite count 12000/200WBC, bl.glucose 103

mg%, SGOT 597IU, SGPT 259 IU, Bilirubin total

18.05 U/dL, direct bill 13.8 U/dl. WBC

20.370/mm3.

What’s your management ?

On the second day he developed

convulsion, parasite count 6910/200

wbc, 110 par/ 1000 rbc. 6hours later

the parasite count 4175/ 200 wbc,

SGOT 470u/L , SGPT 345 u/L. GCS

E1/M2/V2, oliguria and furosemide

was given.

On the third day, bleeding in the

sclera, BP 90/60, Kussmaul, CVP was

inserted, the patient go to cardiac

arrest and died.

Case 4 Wanita 55 thn rujukan dari RS perifer, demam 5 hari,

tinggal di daerah malaria, dilaporkan TS dengan tidak

sadar (GCS 6), dari surat rujukan Bilirubin total 24,2 mg%,

bil.dir.ek 19,6mg%. Ureum 290, creatinin 10,16. Kalium 4,1

Na 122. Urine leuk. 40 - 50. Urine produksi 75 cc per 24

jam.

Diagnosenya & apa tindakan saudara ?

Data

selanjutnya……. Penderita ini tidak dijumpai riwayat sakit sebelumnya

seperti DM, Hpt, TB. Pada pemeriksaan : Tekanan darah80/ 60 mm Hg, nadi 110/ menit, resp 36 x/ menit. Jantungparu : normal. Hepatosplenomegali.

Pertanyaan : Apa penanganannya ?

A. Pemberian loading NaCl 20 ml/kg BB/ jam

B. Pemberian NaCl 20 ml/kg/BB yg di observasi

C. Pemberian Ringer laktat 500cc/ 1jam

D. Pemberian cairan koloid 40 tetes/ menit

E. Pemberian cairan dextran 500 ml/ 1 jam

Pertanyaan , diagnosenya :

A. Malaria Berat

B. Malaria Ringan/ uncomplicated

C. Bukan Malaria

D. Hepato-renal syndrome dgn malaria ringan

E. Sepsis

F. Perlu informasi lain

Parasit malaria ditemukan Falciparum ring +++.

30

KASUS 5Seorang laki - laki 62 tahun, dengan riwayat panas-dingin 3 hari, sakit kepala, mual.

Pemeriksaan :K.U. baik, febris, tidak anemi, sadar. Tensi, nadi, resp. normal. Jantung

dan paru normal. Hepar dan lien : normal

Diagnosa : observasi malaria.

Laboratorium : Darah malaria : Falciparum ring + . Hb. 12 gr %, Leuko 8600 / mm3.

Hitung jenis leukosit eos/baso/neutro/limfo/mono : -/-/2/93/3/2. LED : 16 / 1 jam. Urine

mikroskopik : normal

Pengobatan: artesunate+ amodiaquine. Penderita K.U baik dan tidak muntah.

Follow up :

Pada hari ke-4, keluhan sakit kepala masih, penderita muntah, hiccup + +, tidak bisa

makan.Malaria : falcip ring +; vivax +. Hari IV : Gula darah 61 mg % ; ureum 313 mg % ;

kreatinin 7,35 mg %,Se. natrium 114 meq / L; kalium 3,4 meq / L, berat jenis Urine 1,012.

Pertanyaan :

1. Apa penderita ini termasuk gagal pengobatan ?

2. Apakah insuffisiensi ginjal (ureum 313 mg % ; kreatinin 7,35 mg %) dapat

disebabkan karena penyakit ginjal sebelumnya (glomerulonefritis) ?

31

Hari ke V :

Jaundice pada sklera, Hb. 11. gr %, leuko 18.100, Se. Bilirubin total 4,46 mg % ;

indirek 2,98 mg % ; direk 1,48 mg %, S.G.O.T 43 u / L, S.G.P.T 59 u / L, Gamma -GT

256,7 u / L, Alk. fosfatase 300 u / L, albumin 3,18 gr %, globulin 3,90 gr %.

3. Apa diagnosa saudara ?

4. Apa pengobatan penderita ini ?

4. Pemeriksaan apa saja yang masih diperlukan ?

Kasus 10-b

32

Setelah pengobatan dengan artesunate , maka pada hari ke XVI, keadaan umum

membaik, panas hilang, akan tetapi penderita tampak pucat. Tidak ditemukan tanda

perdarahan. Hb. 6.9 gr %, retikulosit 9,3 %, trombosit 252.000 / mm3. Diberikan tranfusi

darah 2 bag(1000cc), Hb menjadi 7,9 gr %, hari ke XV penderita pulang Hb 8,2 gr %

Retik 0,6 %, ureum 87 mg %, kreatinin 2,18 mg %.

Pertanyaan :

6. Apa penyebab anemianya ?

Kasus 10-c

PAKATUAN WO PAKALAWIREN

Dr. Paul Harijanto, Sp.PD-KPTI

Div. Penyakit Tropik & Infeksi

SMF/ Bag. Penyakit Dalam

FK UNSRAT/ RSUP Manado

RSU Bethesda -Tomohon

Telp.:

0431-351024/046 ( RSU Bethesda)

0812-430-2869 ( HP)

0431-351187 (Res)

E-mail : [email protected]

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