CASE REPORT

“MALARIA VIVAX AND EARLY DETECTION BASED ON

CLINICAL MANIFESTATION AND PATOPHYSIOLOGY”

Supervisor: DR. dr. Soroy Lardo, Sp. PD, FINASIM

KEPANITERAAN KLINIK DEPARTEMEN ILMUPENYAKIT DALAM

FAKULTAS KEDOKTERAN –UNIVERSITAS YARSI JAKARTA
RUMAH SAKITPUSAT ANGKATAN DARAT GATOT SOEBROTO
PERIODE 07 AGUSTUS–14 OKTOBER2017
INTRODUCTION
 Malaria is a disease caused by protozoa infected through the bites of
Anopheles mosquito. This disease has been eradicated in most countries,
however it found its way back. Nowadays malaria is in 103 countries and
half of the human population is living in an area with risks of malaria. 3
million out of 300 million people infected with malaria dies from malaria,
meaning a couple of hundred every hour.
 On 2006 an extraordinary event of malaria occurred in some areas.
Prevention efforts like mass medication, fever survey, fogging, vector
disease inspections, and other actions have been carried out. Some factor
that caused this event is the change in environment that causes expansion
of potential breeding areas. One of the causes of the event is the malaria
vivax.
 Efforts are carried out to reduce the morbidity and mortality rate of malaria,
some of them are: early eradication of malaria such as early diagnosis, fast
and accurate medication, surveillances and vector control, all of them are
directed to break the chain of malaria infection (2). The objective of this case
report is to provide recommendation regarding malaria vivax.
CASE PRESENTATION
PATIENT’S IDENTITY
ANAMNESIS
HISTORY OF PRESENT ILLNESS

Patient came to Paviliun Kartika at emergency room RSPAD on 28 August 2017 with
main complaint of fever since 3 weeks before admitted to hospital, fever comes and
go. Fever is felt mainly at the afternoon and night, fever goes at the morning. Patient
claims to have fever for 3 days, and 1 day the fever is gone. Patient says this pattern
is experienced until now without any periods free of fever. Patient claimed to have
visited Asahan beach at North Sumatera on the 21st July 2017, 3 weeks later the
fever is experienced. Other complaints experienced are shivering and excessive cold
sweats. Complaints begin to worsen since patient started activities, and is better if
the patient rests and consume febrifuge. Other complaints such as: nausea (-),
vomiting (-), decreased appetite (+), nosebleed (-), bleeding gums (-), pain or
stiffness in muscles and joints (-), coughing (-), cold (-), throat pains (-), difficulties in
breathing (-). No complaints about urination and defecate are normal (1-2 times a
day, soft consistency, brown colored). Patient have difficulties in activities due to
limp. Patient have been hospitalized at RSUD Cengkareng and then referred to
RSPAD Gatot Soebroto because of no improvements.
HISTORY OF PAST ILLNESS

 Allergy (-)
 Hypertension (-)
 Diabetes (-)  Dengue fever (-)
 Asthma  Typhoid (-)
(-)  Malaria
 Cardiovascular disease (-) (-)
 Lungs diseases (-)
 Kidney diseases (-)
HISTORY OF FAMILY ILLNESS

 Allergy (-)
 Hypertension (-)
 Diabetes (-)  Dengue fever (-)
 Asthma  Typhoid (-)
(-)  Malaria
 Cardiovascular disease (-) (-)
 Lungs diseases (-)
 Kidney diseases (-)
HISTORY OF MEDICAL OPERATION & MEDICINE

Paracetamol 3 x 500 mg

Coronary stent installation (March 2017)

HISTORY OF OTHER SYSTEMIC ILLNESS

 Smoking (-)
 Alcohol consumption (-)
 Illegal drugs (-)
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

Pulmo Front Back

Inspection • Normal chest shape • Normal back chest shape
• Regular breathing, no chest walls left • Symmetrical scapua
• Abdominothoracal type of breathing • No scars or lumps
• Muscle assisting breathing (-)
Palpasi • No enlargement of Lymph found • Ratio of breathing movement
• Stem fritus are strong in both lungs and stem fremitus are strong in
• Breathing movements are strong in both both lungs
lungs
Percussion • Percussion sounded sonor in both lungs. • Sonor heard on right and left
• Lungs-hepar borders on ICS V linea part of the chest
midclavicularis dekstra • Diaphragm incline 4 cm on the
back (right side)
Auskultasi • Vesicular breathing voice • Vesicular breathing voice
• Ronkhi -/- • Ronkhi -/-
• Wheezing -/- • Wheezing -/-
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
SUPPORTING EXAMINATIONS

28-08-2017 29-08-2017 30-08-2017 Normal Value

Hematology
Hemoglobin 8.9 9.1 - 12.0-16.0
(g/dL)
Hematocrit (%) 25 27 - 37-47
Erythrocytes 3.1 3.2 - 4.3-6.0
(million/μL)
Leucocytes (/μL) 8270 5960 - 4,800 – 10,800
Thrombocytes(/μ 61000 47000 - 150,000 – 400 000
L)
SUPPORTING EXAMINATIONS

28-08- 29-08- 30-08- Normal Value

2017 2017 2017
Count type

Basophil (%) 0 0 - 0–1

Eosinophil (%) 2 2 - 1–3

Neutrophil (%) 88 75 - 50 – 70

Lymphocytes 6 12 - 20 - 40
(%)
Monocytes (%) 4 5 - 2–8

MCV (fL) 80 83 - 80 – 96

MCH (pg) 29 29 - 27 – 32

MCHC (g/dl) 36 34 - 32 – 36

RDW (%) 15.0 15.3 - 11.5 – 14.5

SUPPORTING EXAMINATIONS

28-08-2017 29-08-2017 30-08-2017 Normal Value

Coagulation
D-dimer (ng/mL) - 506 - 0 - 400
Chemical clinic
SGOT (AST) - 58 - < 35
(U/L)
SGPT (ALT) (U/L) - 337 - < 40
Urea (mg/dL) - 38 - 20 – 50
Creatinine - 0.7 - 0.5 – 1.5
(mg/dL)
Blood Glucose - 88 - 80 – 140
(mg/dL)
SUPPORTING EXAMINATIONS

28-08-2017 29-08-2017 30-08-2017 Normal Value

Chemical
clinic
Sodium(Na) - 144 - 135 – 147
(mmol/L)
Potassium(K) - 3.4 - 3.5 – 5.0
(mmol/L)
Chloride(Cl) - 105 - 95 – 105
(mmol/L)
Albumin (g/dL) - - 2.8 3.5 – 5.0
Imunoserolog
y
Tubex TF - Negative - ≤ 2 Negative
3 Borderline
4 Positive (weak)
6 – 10 Positive
Procalcitonin - 21.73 - 0.02 – 0.5
(ug/L)
SUPPORTING EXAMINATIONS
28-08- 29-08-2017 30-08-2017 Normal Value
2017
Urinalysis
Color - Yellow - Yellow
Clarity - Clear - Clear
Density - 1.005 - 1.000 – 1.030
pH - 6.0 - 5.0 – 8.0
Protein - +/Pos 1 - Negative
Glucose - -/Negatif - Negatif
Keton - -/Negatif - Negatif
Blood - -/Negatif - Negatif
Bilirubin - -/Negatif - Negatif
Urobilinogen(mg/dL) - -/Negatif - 0.1-1.0
Nitrite - -/Negatif - Negatif
Leucocyte Esterase - -/Negatif - Negatif
SUPPORTING EXAMINATIONS

28-08-2017 29-08-2017 30-08-2017 Normal Value

Malaria
I. Plasmodium - - Negative Negative
falciparum
• Tropozoit - - Negative Negative
• Schizont - - Negative Negative
• Gametosit - - Negative Negative
II. Plasmodium - - Found Negative
vivax
• Tropozoit - - 76/200 Negative
leucocyte
• Schizont - - Negative Negative
• Gametosit - - Negative Negative
SUPPORTING EXAMINATIONS

28-08-2017 29-08-2017 30-08-2017 Normal Value

III. Plasmodium
malariae
• Tropozoit - - Negative Negative
• Schizont - - Negative Negative
• Gametosit - - Negative Negative
IV. Plasmodium - - Negative Negative
ovale
• Tropozoit - - Negative Negative
• Schizont - - Negative Negative
• Gametosit - - Negative Negative
SUPPORTING EXAMINATIONS

Type of Examination Result

Hematology
Image of peripheral blood
• Erythrocytes Normositik normokrom, anulosit (+)
Parasit malaria: Vivax {all stadium (+)}
(Trofozoit, schizont, gamet)
• Leucocytes Normal amount, neutrophil (+)
• Thrombocytes Insufficient amount, no morphological
disorders
• Others -
• Impression Anemia normositik normokrom e.c. Malaria
vivax
• Suggestion Check: SI, TIBC, D-dimer, Liver functions.
 Impression: There are no irregularities on
RONTGEN OF THORAX heart and lungs
ELECTROCARDIOGRAPH
RESUME

Patient came to Paviliun Kartika at emergency room RSPAD on 28

August 2017 with main complaint og fever since 3 weeks before
admitted to hospital, fever comes and go. Fever is felt mainly at
the afternoon and night, fever goes at the morning. Patient claims
to have fever for 3 days, and 1 day the fever is gone. Patient says
this pattern is experienced until now without any periods free of
fever. Patient claimed to have visited Asahan beach at North
Sumatera on the 21st July 2017, 3 weeks later the fever is
experienced. Other complaints experienced are shivering and
excessive cold sweats. Complaints begin to worsen since patient
started activities, and is better if the patient rests and consume
febrifuge. Patient have difficulties in activities due to limp.
PHYSICAL EXAMINATION

 Bloof Pressure : 100/60 mmHg

 Heart Rate : 76 bpm
 Respiratory : 20 x/minute
 Temperature : 36.70C,
 Konjunctiva anemis +/+
SUPPORTING EXAMINATIONS

 Anemia normositik normokrom (Hb 9.1 g/dL)

 Trombositopenia 47000 /uL,
 Malaria vivax (+) found Plasmodium vivax (+) trofozoit 76/200 leucocyte in
blood and malaria vivax parasites found on all stages
 D-dimer increases 506 ng/mL
 SGOT/SGPT increases 58/337 U/L
 Hipokalemia 3.4 mmol/L
 Hipoalbumin 2.8 g/dL
 Procalcitonin increases 21.73 ug/L
 Proteinuria (+).
LIST OF PROBLEMS
PROBLEM REVIEWS
MALARIA VIVAX
 Anamnesis: Fever since 3 weeks before admitted to hospital, fever comes and goes, 3 days of fever. Complaint is
accompanied by shivering and cold sweats, history of visits to endemic area of malaria without prophylaxis.
 Physical examination: Conjunctiva anemic +/+
 Supporting examination: Anemia normocytic normochromic (Hb 9.1 g/dL), thrombocytopenia 47000 /uL, malaria vivax (+)
found Plasmodium vivax (+) trofozoit 76/200 leucocytes in blood and malaria vivax found on all stages., SGOT/SGPT
increases 58/337 U/L and procalcitonin increases 21.73 ug/L.
 Planning diagnostics: -
 Therapy:
 IVFD Aminofluid 500 cc / 8 hours
 IVFD Asering 500 cc / 8 hours
 Darplex (DHP) 1 x 3 tablets
 Primakuin 1 x 15 mg
 MDX Propoelix 3 x 2 tablets
 HP Pro 3 x 1 tablets

 Monitoring plans:
 General conditions
 Vital signs
 Hemodynamics
 After 7 days post-smear therapy check post-therapy anti-malarials

 Education:
 Know all the risk of malaria, the habitat of Anopheles, and the symptoms of malaria
 The importance of avoiding mosquito bites by using long sleeves clothing, bug sprays or anti-mosquito lotions, closing doors and windows or use a
mosquito net using insecticides.
 Avoid outdoor activities from dusk till dawn.
 Clean up potential areas of mosquito nests
 The importance of supervision of consuming medicines
ANEMIA NORMOCYTIC NORMOCHROMIC

 Anamnesis: Patient hardly does activities due to feeling weak.

 Physical examination: Conjunctiva anemic +/+
 Supporting examination: Hb 9.1 g/dL, MCV/MCH/MCHC 83/29/34, anemia
normocytic normochromic on the image of blood peripheral.
 Diagnostic plan: -
 Therapy plans:
 PRC 500 cc transfusion (Premed: Inj. Dexamethasone 1 ampule)
 Monitoring plans:
 General conditions
 Vital signs
 Hemodynamics
 Education:
 To the patient and family about the importance of transfusion
HIPOALBUMINEMIA

 Supporting examinations: Albumin 2.8 g/dL

 Therapy:
 Channa 3 x 2 tablets (Albumin 500 mg)
 Monitoring plans:
 Complete blood tests
 Education:
 To the patient and family about the importance of giving albumin
PROGNOSIS
DAILY FOLLOW UP
DAY 4 (31-08-2017)

Examination Results
S:
Fever (-), limp body (+)
O:
KS: CM, Ku: TSS TD: 100/60 mmHg, N: 67 x/min, RR: 20 x/min, T: 36.5⁰C
Lab results: Ca: 8.3 mg/dL
A:
• Malaria vivax
• Anemia normocytic normochromic
• Hipoalbumin
• Hipokalsemia
P: • MDX Propoelix 3 x 2 tablets
• Check G6PD • HP Pro 3 x 1 tablets
• Recheck microscopy malaria • Transfusion plan PRC 500cc (Premed: Inj.
• Plan Abdomen USG Dexamethasone 1 ampule)
• IVFD Aminofluid 500cc / 8 hours • Channa 3 x 2 tablets (Albumin 500 mg)
• IVFD Asering 500cc / 8 hours • Calcium sandoz 3 x 1 tablets
• Darplex (DHP) 1 x 3 tablets
• Primakuin 1 x 15 mg
DAY 5 (01-09-2017)

Examination Results
S:
Fever (-), limp body (+)
O:
Ks: CM, Ku: TSS TD: 130/80 mmHg, N:76x/min, RR: 20x/min, T: 36,6⁰C
Lab Results: Hb: 7.6 g/dL, Thrombocytes: 141000/uL, Leucocytes: 7360 /uL
A:
• Malaria vivax
• Anemia normocytic normochromic
• Hipoalbumin
• Hipokalsemia
P: • MDX Propoelix 3 x 2 tablets
• Check G6PD (waiting for result) • HP Pro 3 x 1 tablets
• Recheck microscopy malaria (waiting for • Transfusion plan PRC 500cc (Premed: Inj.
result) Dexamethasone 1 ampule)
• Plan Abdomen USG • Asam Folat 1 x 400mg (awaiting family
• IVFD Aminofluid 500cc / 8 hours approval for transfusion)
• IVFD Asering 500cc / 8 hours • Channa 3 x 2 tablets (Albumin 500 mg)
• Darplex (DHP) 1 x 3 tablets • Calcium sandoz 3 x 1 tablets
• Primakuin 1 x 15 mg
DAY 8 (04-09-2017)
Examination Results
S:
Fever (-)
O:
Ks: CM, Ku: TSS TD: 120/60mmHg, N:78x/mnt, RR:20x/mnt, T: 36.5 C
Lab Results: (03-09-17) Hb: 7.6 g/dL, Trombosit: 276000 /uL, Leukosit: 7690 /uL Albumin: 3.0
g/dL, Procalcitonin 1.58 ug/L. (04-09-17) SGOT: 80 U/L, SGPT: 140 U/L, Ca: 9.2 mg/dL, G6PD:
7.0 U/g Hb, Mikroskopi malaria: Negative on all plasmodium stages
A:
• Malaria vivax
• Anemia normocytic normochromic
• Hipoalbumin
P: • HP Pro 3 x 1 tablets
• Plan Abdomen USG • Transfusion plan PRC 500cc (Premed: Inj.
• IVFD Aminofluid 500cc / 8 hours Dexamethasone 1 ampule)
• Asam Folat 1 x 400mg (awaiting family
• IVFD Asering 500cc / 8 hours approval for transfusion)
• Darplex (DHP) 1 x 3 tablets • Channa 3 x 2 tablets (Albumin 500 mg)
• Primakuin 1 x 15 mg
• MDX Propoelix 3 x 2 tablets
DAY 9 (05-09-2017)
Examination Results
S:
Fever (-)
O:
Ks: CM, Ku: TSS TD: 120/60mmHg, N:67x/min, RR:20x/min, T: 36,5 C
Lab Result: Hb: 10.3 g/dL, Leucocyte: 15120 /uL, Thrombocytes: 303000 /uL
USG Abdomen results are normal
A:
• Malaria vivax
• Anemia normocytic normochromic
• Hipoalbumin
• Bacterial Infection
P: • HP Pro 3 x 1 tablet
• IVFD Aminofluid 500cc / 8 hours • Transfusion plan PRC 500cc (Premed: Inj.
• IVFD Asering 500cc / 8 hours Dexamethasone 1 ampule) = Patient rejected
• Asam Folat 1 x 400mg
• Darplex (DHP) 1 x 3 tablet • Channa 3 x 2 tablet (Albumin 500 mg
• Primakuin 1 x 15 mg
• MDX Propoelix 3 x 2 tablet
DAY 10 (06-09-2017)
Examination Results
S:
No complaints, the patient is allowed to leave
O:
Ks: CM, Ku: TSS, TD: 110/60 mmHg N:74 x/min, RR:18x/min, T: 36.5⁰C
A:
• Malaria vivax
• Anemia normocytic normochromic
• Hipoalbumin
• Bacterial Infection
P: • Control to the clinic in 1 week with the result
Home medicines: from the lab
• Primakuin 1 x 15 mg
• MDX Propoelix 3 x 1 tablet
• HP Pro 3 x 1 tablet
o Channa 3 x 2 tablet (Albumin 500 mg)
o Cravit 1 x 1 tablet (Levofloxacine 500
mg)
o Osfit DHA 3 x 1 tablet(Kalsium 500 mg
dan Vit. D3)
LITERATURE REFERENCES
DEFINITION

Malaria is an acute or chronic infectious disease

that is caused by the infection of Plasmodium that
attacks erythrocytes and is determined by the
asexual shapes in the blood, with symptoms such
as fever, shivering, anemia, and enlargement of
lymph (4).
EPIDEMIOLOGY

Sumber: Kemenkes RI, 2011

ETIOLOGY
LIFE CYCLE OF PLASMODIUM

Center for disease control and prevention, 2013

PATOGENESIS
CLINICAL MANIFESTATION
DIAGNOSIS

Sumber: Kemenkes RI, 2012

THERAPY

Sumber: Kemenkes RI, 2012

FIRST LINE THERAPY OF MALARIA VIVAX

Sumber: Kemenkes RI, 2012

OR

Sumber: Kemenkes RI, 2012

SECOND LINE THERAPY OF MALARIA VIVAX

Sumber: Kemenkes
RI, 2012
CHEMOPROFILACTIC

Sumber: Kemenkes RI, 2012

Dosis obat :
 P. falciparum = 2mg/kgBB (4-6 weeks)
 P. vivax = 5mg/kgBB (everyweek)
PROGNOSIS

 Prognosis of severe malaria depends on the speed and accuracy of the

diagnosis and the medication .
(3)

 On unattended severe malaria, reported mortality rate is 15% on children,

20% on adults, and up to 50% on pregnancy.
 Prognosis of severe malaria with one function of organ disorder is better
than 2 or more functions of organs (3) .
 Mortality with 3 organ function disorders are 50%.
 Mortality with 4 or more organ function disorders are 75%.
 The correlation between parasitic density with mortality is as follows:
 Parasitic density <100.000/µL, therefore mortality is <1%.
 Parasitic density >100.000/µL, therefore mortality is >1%.
 Parasitic density >500.000/µL, therefore mortality is >5%.
DISCUSSION
 Patient 28 August
arrives 2017

Complaint: Patient had fever since 3 weeks

before admitted to hospital

Fever is accompanied with shivering and

sweats (trias malaria), usually found on
parasites infection (malaria)

Malaria hypothesis is concluded

 Other complaints:
Nausea (-), vomiting (-), decreased appetite (+),
nosebleed (-), bleeding gums (-), pain or stiffness in
muscles and joints (-), coughing (-), cold (-), throat pains
(-), difficulties in breathing (-). No complaints about
urination and defecate are normal (1-2 times a day, soft
consistency, brown colored). Patient have difficulties in
activities due to limp.

 Not respiratory infections

 Not urinary or digestion disorders

Patient claims to visit Asahan Beach on 21

July 2017 (3 weeks before) in North
Sumatera

North Sumatera is one of the factor risks of

malaria

Malaria hypothesis is concluded

MANAGEMENT
1. Liquid: inFOR
this THE
case,PATIENT
asering liquids are given for
hemodynamic stability, to avoid hypovolemic shocks and
to maintain osmotic pressure. Amino fluid is also given for
nutrition.
2. Dihidroartemisinin and Piperakuin (DHP) and Primakuin: the
combination for the constant dose consists of
dihidroatremisinin and piperakuin (DHP) and primakuin.
DHP and primakuin are the first line of defence against
malaria vivax caused by plasmodium vivax.
3. MD Propoelix: stops anti-inflammation, anti-bacterial, anti-
virus, anti-fungi, immunomodulatory, reduces blood
pressure, anti-microbes, and contains high anti-oxidants.
4. HP Pro: used to stop hepar necro-inflammation, increases
detoxification abilities of hepar cells, prevent damages of
hepar cells due to free radical, increases super oxide
dismutase (SOD) one of the anti-oxidant enzymes,
MANAGEMENT FOR THE PATIENT

5. PRC 500 cc transfusion: if the Hb of the patient decreases

until < 8 g/dL.
6. Channa: corrects albumin on patient to reach normal value
(3.5 – 5.0 g/dL)
7. Calcium sandozs: corrects calcium content of the patient for
2 days
8. Cravit: contains antibiotics levofloxacine 500 mg given to
take care of bacterial infections
CONCLUSION

 Based on the anamnesis, physical examination and supporting examination carried out
on the patient the patient have some problems in the presence of Malaria Vivax along
with other medical conditions of Anemia Normocytic Normochrome and Hipoalbumenia.
Patient is given DHP for 3 days as ACT therapy with primakuin for 14 days with dose of
0.25 mg/kgBB, calculated according to the patient’s weight. Other therapy to repair the
main condition of the patient, in this case Anemia Normocytic Normochrome and
Hipoalbumenia with transfusion plan therapy of PRC 500 cc if the Hb keeps on
decreasing until < 8 g/dL and Albumin 500 mg 3 x 2 tablet per day is given. Other
symptomatic therapy are adjusted according to the symptoms on the patient.
 The decreased amount of thrombocytes are associated with some causes of lysis
mediated by immune, sequestration of the spleen, bone marrow disorders, and
phagocytosis by macrophages. Malaria infections cause abnormalities in the structure
and function of thrombocytes. The incidence of thrombocytopenia can be an important
indication of acute malaria. However, transfusion of thrombocytes on malaria patients is
not necessary because the thrombocytes can increase with the antimalarial therapy.
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