MALARIA

ESSENTIALS OF DIAGNOSIS
SYMPTOMS
 HISTORY OF EXPOSURE IN A MALARIA-ENDEMIC AREA
 PERIODIC ATTACTS OF SEQUENTIAL CHILLS, FEVER & SWEATING, APYREXIA 
DIDERITA
 HEADACHE, MYALGIA,
SIGNS
- SPLENOMEGALI, ANEMIA
LABORATOTIES
- LEUKOPENIA
- PARASITES IN RBC  IDENTIFIED IN THICK OR THIN BLOOD FILMS
 ETIOLOGY :
SPOROZOA GENUS PLASMODIUM

Plasmodia malaria :
 Pl. vivax  Mal. tertiana benigna
 Pl. ovale  Mal. ovale / T. benigna
 Pl. falciparum  Mal. tropika / T. maligna
 Pl. malariae  Mal. kuartana
 Erytrocytic & Exo-RBC phase

 Pl. vivax


EE II (+)
 Pl. ovale
EE I (+)



Pl. falcifarum

Pl. malariae
 EE II (-)
PATHOGENESIS (1)  Prof. Dr. Yohana Kandow
THE ASEXUAL ERYTHROCYTIC IS RESPONSIBLE FOR THE
SYMPTOMS:
- FEVER, HEADACHE, NAUSEA & MUSCULAR PAIN
 AT THE TIME SCHIZONTINFECTED RBC RUPTURE
- ENDOGENEOUS PYROGEN (INTERLEUKIN-1) AND
MEDIATORS (KININS & CATHECTIN (TNF)  RELATED
TO PATHOGENESIS?
 PATHOGENESIS (2)  Prof. DR. Yohana
* ENCEPHALOPATHY:
~ RBC CONTAINING SCHIZONTS & MALARIAL
PIGMENT OBSTRUCT CEREBRAL CAPILLARIES &
VENULES
~ CEREBRAL EDEMA MAY DEVELOP AS A RESULT
OF AGONAL HYPOXIA
~ SEQUESTRATION OF PARASITIZED RBC IN BRAIN
& OTHER TISSUE RESULT FROM CYTOADHERENCE
OF KNOBLIKE PROTUBERANCE ON THE RBC TO
ENDOTHELIUM
 PATHOGENESI (3)  Prof. DR.
Johana
~ DECREASED DEFORMITY OF INFECTED RBC 
SLUGGISH MICROVASCULAR FLOW
~ CEREBRAL ANAEROBIC GLYCOLYSIS & REDUCED
CEREBRAL OXYGEN TRANSPORT  CEREBRAL
MALARIA
 PATHOGENESIS (4)  Prof DR Johana

- ANEMIA:
~ HEMOLYSIS OF INFECTED RBC
~ RAPID SPLENIC REMOVAL ON NONPARASITIZED
ERYTHROCYTES
~ DYSERYTHROPOISIS
- THROMBOCYTOPENIA  SEQUESTRATION IN THE SPLEEN
PATHOGENESIS (5)  Prof DR Johana
- ACUTE RENAL FAILURE

ACUTE TUBULAR NECROSIS

ISCHEMIA RESULTING FROM:

~ HYPOVOLEMIA
~ RENAL VASOCONTRICTION
~ MICROVASCULAR OBSTRUCTION:
* PARASITIZED RBC
* PIGMENT NEPHROPATHY SECONDARY
TO HEMOLYSIS

ACUTE RENAL FAILURE

 PATHOGENESIS (6)  Prof DR Johana
- THE SPLEEN IS LARGE:
~ ENGORGE & HEAVILY PIGMENTED
~ CONTAINING MANY PHAGOCYTIC CELLS
INGESTED RBC & MALARIAL PIGMENT
- EDEMATOUS LUNGS:
~ PULMONARY CAPILLARIES & VENULE ARE
PACKED WITH INFLAMMATORY CELLS
~ ENDOTHELIAL & INTESTINAL EDEMA
CLINICAL FINDINGS (1)
A. SYMPTOMS (1)
- SHAKING CHILLS (THE COLD STAGE)
- FEVER (THE HOT STAGE)  ≥41ºC
- DIAPHORESIS (THE SWEATING STAGE)
- FATIGUE
- HEADACHE
- DIZZINESS
- MYALGIA
DINGIN DEMAM
- ARTHRALGIA
APIREKSI KERINGAT
- BACKACHE
- DRY COUGH
DI-DE-RI-TA
CLINICAL FINDNGS (2)

SYMPTOMS (2)
- GASTROINTESTINAL SYMPTOMS:
~ ANOREXIA
~ NAUSEA
~ VOMITING
~ DIARRHEA
~ ABDOMINAL CRAMPS
CLINICAL FINDINGS (3)

SYMPTOMS (3)

-THE ATTACKS PERIODICITY:

~ EVERY-DAY  FALCIPARUM
~ EVERY-OTHER-DAY  TERTIAN  PL. VIVAX & OVALE
~ EVERY-THIRD-DAY  QUARTIAN  PL. MALARIAE
~ TIRED BETWEEN ATTACKS, BUT FEELS WELL
~ AFTER THIS PRIMARY EPISODE, RECURRENCE ARE
COMMON, EACH SEPERATED BY A LATENT PERIOD
CLINICAL FINDINGS (4)

SIGNS

- SPLENOMEGALY:
 APPEAR  ACUTE SYMPTOMS 
CONTINUED ≥4 DAYS
- MILDY HEPATOMEGALY
- ANEMIA
COMPLICATIONS (1):
1. CEREBRAL MALARIA:
- HEADACHE
- MENTAL DISTURBANCES
- NEUROLOGIC SIGNS
- RETINAL HEMORRHAGES
- CONVULSIONS
- DELIRIUM
- COMA
COMLICATIONS (2):
2. HYPERPYREXIA
3. HEMOLYTIC ANEMIA
4. NONCARDIOGENIC PULMONARY EDEMA
5. ACUTE TUBULAR NECROSIS & RENAL
FAILURE  BLACKWATER FEVER DUE TO
>QUININE TREATMENT
COMPLICATIONS (3)
6. ACUTE HEPATOPATHY  MARKED
JAUNDICE, BUT NO LIVER FAILURE
7. HYPOGLYCEMIA
8. ADRENAL INSUFFICIENCY-LIKE SYNDROME
9. CARDIAC DYSRHYTHMIAS
10, GASTROINTESTINAL SYNDROMES
11. LACTIC ACIDOSIS & HYPOGLYCEMIA
12. PNEUMONIA
13. WATER & ELECTROLYTE IMBALANCE
MANAGEMENT:
A. TREATMENT OF ACUTE ATTACKS (1)
1. ELIMINATION OF ASEXUAL ERYTHROCYTIC PARASITES
- CHLOROQUINE PHOSPHATE (SALT) 1G AT 0, 24, AND
THEN 0.5 G AT 48 HOURS

HOURS 0 24 48
CHLOROQ/ GR 1 1 0.5
- MEFLOQUINE,
~ 1 x 250 MG FOR 3 DAYS, OR 750-1250 MG,
THEN 500 MG AFTER 6-8 HOURS
Day 1 2 3
↓ ↓ ↓ ↓

250 mg + + + OR
I: 1000 MG  7 HOUR  500 MG
TREATMENT OF ACUTE ATTACKS (2)

- QUININE SULFATE (PLUS DOXYCYCLINE, CLINDAMYCIN,

OR FANSIDAR
- ATOVAQUONE 250 MG (PLUS DOXYCYCLINE 100 MG OR
PROGUANIL 100 MG)
- HALOFANTRINE,
- ARTEMISININ (QINGHAOSU), FISRT DAY 2X2 TABS,
THEN 2X1 TABLET FOR 5 DAYS
Day 1 2 3 4 5 6
↓ ↓ ↓ ↓ ↓ ↓ ↓
Tablet 2x2 2x1 2x1 2x1 2x1 2x1

↑
TREATMENT OF ACUTE ATTACKS (3)
IN SEVERE PATIENTS 
- START ORAL THERAPY WITH CHLOROQUINE
AS SOON AS POSSIBLE
- IV QUININE DIHYDROCHLORIDE
- QUINIDINE GLUCONATE
- PARENTERAL CHLOROQUINE
TREATMENT OF ACUTE ATTACKS (4)

2. ERADICATION OF P. VIVAX OR P. OVALE

CHLOROQUINE AS ABOVE FOLLOWED BY 0.5 G ON DAYS 10
AND 17 PLUS PRIMAQUINE PHOSPHATE, 26,3 MG (SALT)
DAILY FOR 14 DAYS STARTING ABOUT DAY 4

DAY 1 2 3 4 10 17

↓ ↓ ↓ ↓ ↓ ↓ ↓

CHLOROQ/G 1.0 1.0 0.5 ↓ 0.5 0.5

PRIMAQUINE 25/ 26.3 FOR 14 DAYS

TREATMENT OF ACUTE ATTACKS (5)

3. ELIMINATION OF PERSISTENT GAMETOCYTEMIA

- CHLOROQUINE FOR P.VIVAX, P. OVALE,
P. MALARIAE
- PRIMAQUINE SALT, SINGLE DOSE, 26.3 MG
FOR P. FALCIPARUM
TREATMENT OF ACUTE ATTACKS (6)

* TREATMENT OF FALCIPARUM MALARIA ACQUIRED

IN AREAS WHERE P. FALCIPARUM IS RESISTANT TO
CHLOROQUINE (1)
- START WITH ORAL QUININE SULFATE, 10 MG/KG 3X
DAILY FOR 3-7 DAYS, PLUS :
~ DOXYCYCLINE, 2X100 MG FOR 7 DAYS
~ CLINDAMYCIN. 3X900 MG DAILY FOR 5 DAYS
~ PYRIMETHAMINE, 2X25 MG DAILY FOR 3 DAYS
~ SULFADIAZINE, 4X500 MG DAILY FOR 7 DAYS
~ 3 TABLETS OF FANSIDAR (PYRIMETHAMIN+
SULFADOXINE)
TREATMENT OF ACUTE ATTACKS (7)
P. FALCIPARUM IS RESISTANT TO CHLOROQUINE (2).
- ALTERNATIVE DRUGS ARE:
~ MEFLOQUINE
~ HALOPHANTRINE
~ ARTESUNATE
~ ATOVAQUONE
- SEVERELY ILL:
~ IV QUININE OR QUINIDINE
~ DOCYCYCLINE OR CLINDAMYCIN 
PARENTRALLY
- ORAL TREATMENT WITH QUININE PLUS THE
ANTIBIOTIC SHOULD BE AS SOON AS POSSIBLE
TREATMENT OF ACUTE ATTACKS (8)
* SPECIAL TREATMENT FOR TREATMENT OF SEVERE
P. FALCIPARUM MALARIA (1)
- MEDICAL EMERGENCY THAT REQUIRES:
~ HOSPITALIZATION
~ INTENSIVE CARE
~ IV CHEMOTHERAPY AS RAPID AS POSSIBLE
~ REQUIRING >48 HOUR OF PARENTRAL THERAPY
~ REDUCE THE QUININE OR QUINIDINE DOSE BY
ONE-THIRD TO ONE-HALF
~ REHYDRATION SHOULD BE DONE WITH CAUTION
~ FLUID, ELECTROLYTE & ACID- BASE BALANCE
MUST BE MONITORED
TREATMENT OF ACUTE ATTACKS (9)
* SPECIAL TREATMENT FOR TREATMENT OF
SEVERE P. FALCIPARUM MALARIA (2):
~ EARLY DIALYSIS MAY BE NECESSARY FOR RENAL
FAILURE
~ BLOOD GLUCOSE LEVELS SHOULD BE MONITORED
EVERY 6 HOURS  IF HYPOGLYCEMIA +,
~ 50% DEXTROSE, 1-2 ML/KG 
~ MAINTENANCE 5-10% DEXTROSE
TREATMENT OF ACUTE ATTACKS (10)
* SPECIAL TREATMENT FOR TREATMENT OF SEVERE
P. FALCIPARUM MALARIA (3)
- DIC  FRESH WHOLE BLOOD
- HCT < 20%  TRANSFUSION
- EXCHANGE TRANSFUSION  WHEN >15% RBC
ARE PARASITIZED
- SEIZURES  ANTICONVULSANTS
- TEMPERATURE IS MAINTAINED <38.5 ºC
- BLOOD FILM SHOULD BE CHECKED DAILY UNTIL
PARASITEMIA CLEARS; WEEKLY THEREAFTER
FOR 4 WEEKS  RECRUDESCENCE?
B. CHEMOPROPHYLAXIX (1)
a. IN REGIONS WHERE P. FALCIPARUM AND P. VIVAX
ARE SENSITIVE TO CHLOROQUINE
~ DRUG OF CHOICE
1. CHLOROQUINE PHOSPHATE, 500 MG WEEKLY, ONE
WEEK BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEK AFTER LEAVING

Week  1 ▓ 1 2 3 4
500 mg + +/wks + + + +
CHEMOPROPHYLAXIX (2)

~ ALTERNATIVE DRUGS
1. HALOFANTRINE.
2. FANSIDAR
3. AMODIAQUINE.
4. PYRIMETHAMINE
5. ARTEMISININ
6. PROGUANIL
7. QUININE
CHEMOPROPHYLAXIX (3)
b. IN REGIONS WHERE P. FALCIPARUM IS RESISTANT
TO CHLOROQUININE
~ DRUGS OF CHOICE
1. MEFLOQUINE SALT, 250 MG (228 MG BASE) WEEKLY,
3 WEEKS BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING

Week  1 2 3 ▓ 1 2 3 4
↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
250 mg + + + +/wks + + + +
CHEMOPROPHYLAXIX (4)
~ ALTERNATIVE:
- FIRST ALTERNATIVE: DOXYCYCLINE, 100 MG DAILY,
2 DAYS BEFORE ENTERING THE ENDEMIC AREA,
WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING
Day  1 2 ▓ week 1 2 3 4
↓ ↓ ↓ ↓ ↓ ↓ ↓

100 mg + + +/day + + + +
CHEMOPROPHYLAXIX (4)
~ ALTERNATIVE:
- SECOND ALTERNATIVE: MALARONE (ATOVAQUONE
250 MG + PROGUANIL 100 MG), ONE TABLET DAILY,
ONE TABLET THE DAY BEFORE ENTERING THE
ENDEMIC AREA, WHILE THERE, AND FOR 1 WEEK
AFTER LEAVING

Day  1 ▓ Day 1  7

↓ ↓ ↓ ↓
250 Malarone + +/day + +
100 Proguanil
CHEMOPROPHYLAXIX (5)
- OTHER ALTERNATIVES: DAILY PROGUANIL 200 MG +
WEEKLY CHLOROQUINE 0.5 G, MORE PROTECTION THAN
CHLOROQUINE ALONE:

Week  1 ▓ 1 2 3 4
↓ ↓ ↓ ↓ ↓ ↓ ↓
500 /Klrqn + +/wks + + + +

PLUS

Day  1  7 ▓ 1  7
↓ ↓ ↓ ↓
200/ Prognl + + +/day + +
CHEMOPROPHYLAXIX (6)
c. PROPHYLAXIS FOR PREGNANT WOMEN
- THE BEST COURSE IS WEEKLY CHLOROQUINE +/–
PROGUANIL
- IN AREAS OF CHLOROQUINE-RESISTANT MALARIA 
MEFLOQUININE, EXCEPT IN THE FIRST TRIMESTER
- DRUGS CONTRAINDICATED ARE DOXYCYCLINE &
PRIMAQUINE
PROGNOSIS
- UNCOMPLICATED & UNTREATED PRIMARY ATTACK OF
P. VIVAX, P. OVALE, OR P. FALCIPARUM MALARIA USUALLY
LASTS 2-4 WEEKS; P. MALARIAE ABOUT TWICE AS LONG.
- WITH PROMPT ANTIMALARIAL THERAPY, THE PROGNOSIS
IS GENERALLY GOOD, BUT IN P. FALCIPARUM INFECTIONS,
WHEN SEVERE COMPLICATIONS DEVELOP, THE PROGNOSIS
IS POOR EVEN WITH TREATMENT