MALARIA KOMPILASI.ppt

7/25/2019 MALARIA KOMPILASI.ppt

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NameName : KURNIA F: KURNIA FITRIITRIJAMILJAMIL

Place/Place/BBirthirth : Medan, 8 Februar !: Medan, 8 Februar !"#$"#$

%ducati&n :%ducati&n :' Medical (&ct&r )raduate' Medical (&ct&r )raduate : FK'UI *: FK'UI *Ja+arta,Ja+arta, !""-!""-

' Interni.t )raduate' Interni.t )raduate : FK'UNPA( *: FK'UNPA( *Bandun,Bandun, 001-001-

' 2ealth Mai.ter )raduate' 2ealth Mai.ter )raduate : FK'UNPA( *: FK'UNPA( *Bandun,Bandun, 003-003-

' 4&n.ultant &5 Tr&6ical In5ecti&n:' 4&n.ultant &5 Tr&6ical In5ecti&n: 4&leium &5 Internal4&leium &5 Internal

Medicine Ind&ne.iaMedicine Ind&ne.ia **K&leium Ilmu Pena+it (alam di Ja+arta,K&leium Ilmu Pena+it (alam di Ja+arta, 008-008-

' Pa.ca 7arana Ph9( Pr&ram : FK'U)M, &a+arta *.tart 008'999-' Pa.ca 7arana Ph9( Pr&ram : FK'U)M, &a+arta *.tart 008'999- ' Fell&; &5 Ind&ne.ian 7&ciet &5 Internal Medicine *PB9PAP(I, 00"-' Fell&; &5 Ind&ne.ian 7&ciet &5 Internal Medicine *PB9PAP(I, 00"-

' 4&ur.e &5 Internal Medicine *)erman, 003, Netherland, 00#-' 4&ur.e &5 Internal Medicine *)erman, 003, Netherland, 00#-

' Internati&nal )enetic. *Au.tralia, 008-' 4&ur.e Tr&6ical (i.ea.e. > )enetic. *Au.tralia, 008-

' 4&ur.e &5 Bi&l& M&lecular &5 Tr&6ical Medicine *)erman, 00"-' 4&ur.e &5 Bi&l& M&lecular &5 Tr&6ical Medicine *)erman, 00"-

' Internati&nal &5 Tr&6ical Medicine > In5ecti&u. (i.ea.e. *U)M, 0!0-' Internati&nal &5 Tr&6ical Medicine > In5ecti&u. (i.ea.e. *U)M, 0!0-

?ccu6ati&n:?ccu

6ati&n:

'' 7ta55 &5 Internal Medicine, Medical Facult &5 7iah Kual7ta55 &5 Internal Medicine, Medical Facult &5 7iah Kual aa [email protected]/[email protected]/R7UA '' 2ead &5 In5ecti&u. (i.ea.e. and Tr&6ical Medicine ([email protected]&n,2ead &5 In5ecti&u. (i.ea.e. and Tr&6ical Medicine ([email protected]&n,

Internal Medicine (e6t' ain&el Abidin )eneral 2&.6italInternal Medicine (e6t' ain&el Abidin )eneral 2&.6ital

' 4&&rdinat&r &5 7+ill. Medical Lab&rat&r &5 Facult &5 Medicine Un.iah' 4&&rdinat&r &5 7+ill. Medical Lab&rat&r &5 Facult &5 Medicine Un.iah

' 4&n.ultant' 4&n.ultant&5 2I/AI(7 )r&u6 ain&el Abidin )eneral 2&5 2I/AI(7 )r&u6 ain&el Abidin )eneral 2&&.6ital.6ital' 2ead &5 P%TRI Aceh Branch' 2ead &5 P%TRI Aceh Branch

4urriculum itae4urriculum itae


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MANIFESTASI KLINIK

MALARIABERAT

KURNIA FITRI JAMIL

Divisi Penyakit Tropik & InfeksiBagian/MF! I"#$ Penyakit Da"a#

FK%UNIA'/RU(A

BANDA A)*' % +,--


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MALARIA

RINGAN

MALARIA DAPAT

MENYEBABKANKEMATIAN


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400 Gigitan

Nyamuk

200

Meng-infeksi

Manusia

00 Ma!a"ia

K!inis

2 # $ %

Ma!a"ia Be"at


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Plasmodium Falciparum, Vivax, Knowlesi

dapat menyebabkan Malaria Berat

Ke#atian0 # &0 %

2-- 6%


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MALARIA BERAT

MALARIA *R*BRALMALARIA *R*BRAL AN*MIA B*RAT 'B . gr0 / 't . -0 1 parasit 2AN*MIA B*RAT 'B . gr0 / 't . -0 1 parasit 2

-,,,,-,,,,

3A3AL 3INJAL AKUT . 4,, #"/+4 5a# & Kreat 2 6 #g03A3AL 3INJAL AKUT . 4,, #"/+4 5a# & Kreat 2 6 #g0

*D*MA PARU / ARD*D*MA PARU / ARD

'IP73LIK*MI . 4, #g0'IP73LIK*MI . 4, #g0

7K IT7LIK . 8, ##'g / Anak . , ##'g7K IT7LIK . 8, ##'g / Anak . , ##'g

P*RDARA'AN P7NTAN / DI)P*RDARA'AN P7NTAN / DI)

K*JAN3 B*RULAN3 2 + 9/ +4 5a#K*JAN3 B*RULAN3 2 + 9/ +4 5a#

AID7I P: .8!+ ; P"as#a Bi


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SEVERE MALARIA

DEFINITION : Patient, Plasmosium Asexual parasitemia,with oneor more !INIA! or !A"O#ATO#$ FEAT#E& :

P#O&T#ATION

I'PAI#ED ON&IO&NE&&

#E&PI#ATO#$ DI&T#E&&

'!TIP!E ON(!&ION&

I#!ATO#$ O!!AP&E

P!'ONA#$ EDE'A

A"NO#'A! "!EEDIN)*ANDIE

+AE'O)!O"IN#IA

&E(E#E ANAE'IA

+$PO)!$AE'IA

AIDO&I&

#ENA! I'PAI#'ENT

+$PE#!ATATAE'IA

+$PE#PA#A&ITE'IA

WHO: Guidelines for the Treatment of Malaria 2010


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BEDA ALARIA BERAT PADA DEWASA &

ANAK

A N A K DEWASA

Batuk Sering Jarang

Kejang Sangat sering Sering

Ikterik Jarang Sering

Lama sakit Pendek (1-2 hr Panjang (!-" hr

Lama k#ma Pendek (1-2 hr Panjang (2-$ hr%i&er&arasitemia Sering Jarang

%ig'ikemia Sering see'um )* Sering sesudah )*+%m'

,aga' ginja' Jarang Sering

ek.I.K naik Sering+naik Jarang+ n#rma'Edema &aru Jarang Sering

Perdarahan Jarang ---1/ 0

,gn rain stem Leih sering Jarang

Seue'ae Neur#. 1/ 0 3 ! 0


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Syndromes of severe malariaSyndromes of severe malaria

!" #$ildren!" #$ildren

1. Severe anemia1. Severe anemia

2. Metabolic acidosis2. Metabolic acidosis

3. Cerebral malaria3. Cerebral malaria

Exacerbated by:Exacerbated by:

hypovolemiahypovolemia

hypoglycemiahypoglycemia

salicylate toxicitysalicylate toxicity

Renal failre rareRenal failre rare

!ng in"ry#$R%S rare!ng in"ry#$R%S rare


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Syndromes of severe malariaSyndromes of severe malaria

%" nonimm'ne ad'l(s%" nonimm'ne ad'l(sMltiorgan failre:Mltiorgan failre: &yperparasitemia&yperparasitemia

$cte renal failre$cte renal failre 'andice'andice

Metabolic acidosisMetabolic acidosis

&ypoglycemia&ypoglycemia

$cte respiratory$cte respiratorydistress syndromedistress syndrome

$nemia#thrombocytop$nemia#thrombocytopeniaenia

Cerebral malariaCerebral malaria


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Pro)nos(i* val'e & fre+'en*y of SM in

ad'l(s , *$ildren

Children ChildrenAdults AdultsClinical manifestations orLaboratory finding

Prostration

Impaired counciousness

Respiratory distress ( acidotic breathing )Multiple convulsions

Circulatory collapse

Pulmonary Edema (radiological)

Abnormal bleeding

aundice

!aemoglobinuria

"evere Anemia

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#lassifi*a(ions Severe Malaria

in #$ildren

(rop 1: )re*ire parenteral Rx + Spport.,x -1. rostration ) inability to sit pright-/ 3 sbsgrop :

rostrate bt flly concios

rostrate 0ith impaired conciosness not coma

C o m a2. Respiratory distress ) acidotic breathing

Mild nasal aring +# or mild intercostal indra0ing

Severe mar intercoctal indra0ing or deep

acidotic (rop 2 )able to tae oral Rx/ re*ire spervised- :

1. &aemoglobin 4 5 gr6 or haematocrit 4 156

2. 7 8 2 convlsions in 29 hors

(rop 3 : re*ire parenteral ,x becase of persistentvomitin not in ro 1 or 2.


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DIA-N.SIS .F !!/ #ASES SEVERE MALARIA

RS0D" Dr" 1ainoel A2idin Banda A*e$

"epsis # $"epsis # $ %ephrolithiasis #$%ephrolithiasis #$

"yncope #$"yncope #$

Epilepsy #$Epilepsy #$

"evere Malaria &' (&$)"evere Malaria &'(&$)

Clinical Malaria * (#$)Clinical Malaria * (#$)

"tro+e , (-$)"tro+e , (-$)

!epatitis * (&$)!epatitis * (&$)

.yphoid fever & (/*$).yphoid fever & (/*$) 0astritis (/-$)0astritis (/-$)

Liver absces ($)Liver absces ($)

Pneumonia ($)Pneumonia ($)

1ehydration #$1ehydration #$ Pharyngitis #$Pharyngitis #$

Chronic Renal 2ailure #$Chronic Renal 2ailure #$

3rinary .ract Infection #$3rinary .ract Infection #$

Malaria cerebral * (*$)

Malaria4 5aundice (&-$)Malaria 4 AR2 # ($)

Malaria 4 5aundice #- (&-6)

Malaria 4 AR2 7 (-$)

Malaria cerebral - (#,$)!yperparasitemia (##$)


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RELATI.NS3IP BETWEEN .R-AN

INV.LVE ENT AND .RTALIT4

in Severe alaria


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Severe Malaria in

Indonesia

ot ;!< in Endemic Malaria $rea)East =ndonesia -

Spreading to 'a0a + >ali ) %enpasar/Malang/ Srabaya/ andng + 'aarta -

$lso reported in Smatra )adang/

Ria/ >atam/ !ampng/ alembang/$ceh-


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PAT.-ENESIS

MALARIA #EREBRAL

ME?$=SME ;>S,R@?S= ?$=!ER : Rosetting ) penggerombolan eritrosit -

Sitoadherensi ) perleatan eritrosit e endothel -

ME?$=SME =M@;!;(=?: pembentansitoin/ nitrit oxide

ME?$=SME E=(?$,$ ,E?$$ =,R$ACR$=$!: hanya ass ana

ME?$=SME E%;,;?S=


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MEKANISME PAT.-ENESIS

R.SSETTIN-

PRB*


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MEKANISME SIT.AD3EREN

END+TEL

PRB*

Kn#

EP


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ME?$=SME $,;(EES=SME?$=SME $,;(EES=S

END+TEL

I4A5-1ELA5 64A5 SP4D-78

P-E'P-

PRB*


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Pa($o5$ysiolo)y !" Red *ell

des(r'*(ion,im5aired 5rod'*(ion


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Pa($o5$ysiolo)y %

*y(oad$eren*e


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#y(oad$eren*e *ere2ral

malaria 2rain $is(olo)y


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Pa($o5$ysiolo)y 6 dysre)'la(ed

*y(o7ine res5onse

, LT

GPI


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Is N. 5ro(e*(ive in malaria8

NO: antiparasitic effects: inhibits parasite growth in vitro

NO: antitoxic effects:

inhibits TNF production downregulates expression of endothelial adhesionmolecules (ICAM-1 etc..)

inhibits host cell apoptosis in tissues

NO: rodent models: either no effect or disease-protective


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Indonesian s'29e*(sIndonesian s'29e*(s

Severe malaria (SM)-cerebral malaria

-non-cerebral malaria

Uncomplicated malaria

(UM)

Healthy controls (HC)

Rural (RHC)

Urban (UHC)


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L-a"ginine N+L-,it"u!!ine 'NO synthase

Ni(ri* o:ide syn($esis from

ar)inine


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IN6ASI E)I)9SI

)IN,

)9P9:9I

SI:9N

PE4A%

5E)9:9IANE5IA

,PI

N;

DE5A5%IP9,LIKE5I

9BS) )ENAL> PA) oculovestibular refleF normal response

symetri 3M%> increased tone G 5er+> clonus> eFtensor plantar response 4 > bris+ aH 5er+

pout refleF 4 > abdominal refleF > cremasteric refleF 4 /

cerebellar sign present


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Malaria

Re(ino5a($y

A. )am/aran retina pa0apen0erita malaria sere/ral )&

1, 0enan anemia +/ 3.2 r

%. Tampa4 am/aran

per0arahan 0an papile0ema.

". )am/aran retina pa0a

pen0erita malaria sere/ral )&

3, e0emaparu 0an 0emam

4en5in hitam. Tampa4am/aran pemutihan retina.( Maude RJ, Beare NR, et all, Trans! R!

"o#! Tro$!Med % H&', 200, 10):**+*-1.


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DIFFERENTIAL DIA-N.SIS #MDIFFERENTIAL DIA-N.SIS #M

I%2EC.I9% 8I%2EC.I9% 8

ME%I%0I.I">ME%I%0I.I">

E%CEP!ALI.I">E%CEP!ALI.I">.@P!9I1 2E:ER>.@P!9I1 2E:ER>"EP.IC "!9C"EP.IC "!9C

".R9E G !EA1 I%3R@".R9E G !EA1 I%3R@

ME.A I%.9;ICA.I9%


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' hours after

admission

& hours

after admission


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I7(eri7 ere2ral


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Ma!a"ia ,e"e"a! . /auni,e. in D"1ain3e! Aiin 3s5ita!

-AN--0AN FAAL 3ATI PADA


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-AN--0AN FAAL 3ATI PADA

MALARIA BERAT

IKT*RIK *RIN3 DIJUMPAI > RIN3AN %B*RAT ?

IKT*RIK T*R3ANTUN3 JUMLA' PARAIT

IKT*RIK > '*M7LII / DIFUN3I 'ATI ? E BILI7U R*MIT*NT F**R E

> IKT*RIK; 'IP*RPARAIT*MIA; *R*BRAL& 3A3AL 3INJAL E A"gi Ma"ariaG ?

AKIBAT % 'ipoa"=$#ine#ia

% 3angg$an koag$"asi

% Pen$r$nan k"irens


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alaria $e5a(i(is < Deller

!=>? @

3aga" :ati 5arang

'epato#ega"i sering; nyeri

ringan; sp"eno#ega"i'iper=i"ir$=ine#ia > irek &inirek ?

Transa#inase #eningkat ringan% seang; 5arang 2 +,, i!$

Hakt$ protro#=in #e#an5ang


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3IP.-LIKEMIA

>ila gla darah 4 9B mg6 Sering di"mpai pada ib hamil

) primiA gravida- ada anaAana sering sebelmpengobatan

ada orang de0asa sering ter"adisesdah pengobatan ina ) 3 "ampost terapi ina -


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Pa(o)enesa 3i5o)li7emiaPa(o)enesa 3i5o)li7emia

arasit memerlan arboAhidrat ntmetabolismenya

ada malaria dengan hiperbilirbinaemia/ ter"adi egagalangloneogenesis

?ina menstimli prodsi inslin

) hiperinslinemia - eningatan ,mor ecrosis factor

) ,Aalfa -


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A#0TE KIDNE4 IN0R4


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ator nt mempermdah M$?= : ?ehamilan

arasitemia tinggi =teri yang tinggi

%ehydrasi

S$=%

ator yang penting prognosa M$?= &ipovolemia# hipervolemia

&iperparasitemia

&emoconcentrasi

&iperbilirbinemia

&iperpiresia


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2 ,ypes of lm.;edema :2 ,ypes of lm.;edema :

D ;verload plm.oedemaD ;verload plm.oedema

D $R%SD $R%S

P'lmonary .edema in

sev"malaria


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ARDS

RDS

A synro#e of severeA synro#e of severe

respiratory fai"$re $e to anyrespiratory fai"$re $e to any.8, torr? $ring

inter#ittent positive press$reinter#ittent positive press$re=reat:ing >IPPB? it: Fi7+=reat:ing >IPPB? it: Fi7+

,0!,0!


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P0LM.NAR4P0LM.NAR4

MANIFESTATI.N IN MALARIAMANIFESTATI.N IN MALARIA

&istorically :&istorically : >ronchitic>ronchitic

nemonicnemonic >ronchopnemonic>ronchopnemonic

$cte !ng =n"ry )$!=-$cte !ng =n"ry )$!=-

$cte Respiratory %istress$cte Respiratory %istressSyndrome )$R%S-Syndrome )$R%S-


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A"R"D"SA"R"D"S

;ccrs in . alciparm/ . ivax/ . ;vale + F .;ccrs in . alciparm/ . ivax/ . ;vale + F .?no0lesi?no0lesi

Common in adlt than children/ pregnancy andCommon in adlt than children/ pregnancy and

nonAimmnenonAimmne

Mechanism : =ncreased alveolar cappilaryMechanism : =ncreased alveolar cappilary

permeabilitypermeability intravasclar id loss into theintravasclar id loss into the

lngslngs

resentation : initial presentation or afterresentation : initial presentation or after

initiation treatmentinitiation treatment

Clinical : acte onset dyspneaClinical : acte onset dyspnea respiratoryrespiratory

failrefailre


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#LINI#AL FINDIN-#LINI#AL FINDIN-

Manifest abrpt onset dyspnoea/ cogh/ tightness inManifest abrpt onset dyspnoea/ cogh/ tightness in

the chest that progresses rapidly over a fe0 horsthe chest that progresses rapidly over a fe0 hors

%isorientation and agitation is fre*ently present.%isorientation and agitation is fre*ently present.

hysical examinationhysical examination : signs of respiratory distress: signs of respiratory distress) air hnger/ se of accessory mscles of) air hnger/ se of accessory mscles of

respiration/ sprasternal and intercostal indra0ing -/respiration/ sprasternal and intercostal indra0ing -/

central and peripheral cyanosis )arterialcentral and peripheral cyanosis )arterial

hypoxaemia-/ basal crepitations and expiratoryhypoxaemia-/ basal crepitations and expiratory

0heeGing.0heeGing.

=n these patients/ high parasitaemia/acte renal=n these patients/ high parasitaemia/acte renal

failre/ hypoglycemia/ metabolic acidosis/failre/ hypoglycemia/ metabolic acidosis/

disseminated intravasclar coaglation )%=C-/ anddisseminated intravasclar coaglation )%=C-/ and

bacterial sepsis sally coAexist.bacterial sepsis sally coAexist.


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#$es( radio)ra5$y #$es( radio)ra5$y

>ilateral frontal opacities )alveolar>ilateral frontal opacities )alveolar

pattern-/ increased interstitial maringspattern-/ increased interstitial marings

,he cardiac siGe is sally normal,he cardiac siGe is sally normal Rarely/ thicening of lng Hssres/Rarely/ thicening of lng Hssres/

interloblar septal linesinterloblar septal lines

leral eIsionleral eIsion

=n assisted ventilator :=n assisted ventilator : complications pnemothorax/complications pnemothorax/

pnemomediastinm / pnemonia maypnemomediastinm / pnemonia may

occroccr


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Malaria den)aMalaria den)annedema 5ar'edema 5ar'

?ompliasi berat/ sering fatal.?ompliasi berat/ sering fatal.

Sering pada de0asa.Sering pada de0asa.

,i,immbl cepat ) 1A2 hari ,x-bl cepat ) 1A2 hari ,x- $da 2 tipe :$da 2 tipe :

1.?elebihan cairan: teanan vena1.?elebihan cairan: teanan vena

sentral / $J /balance cairan K.sentral / $J /balance cairan K.2. $R%S : teana2. $R%S : teanannvena sentral # L/vena sentral # L/

balance cairan #K.balance cairan #K.


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Cerebral Malaria with infiltrate both lung''-

*6est

7-"ay

8 63u"s

Afte"

amissi3n


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Definisi ARDS Definisi ARDS

-a)al res5irasi 2era(-a)al res5irasi 2era(

Pa .%


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CM-ARDS, RSUP 2000


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P'lmonary .edema in

sev"malaria

Deh?drati#n 9@erh?drati#n

Lo 5$g$"ar veno$spress$re

kin tentingPost$ra" iinessPost$ra" ="oo press$rerop

of - ##'gTa


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Edema 5ar'Edema 5ar'

isiisi roni basah e2 lap parroni basah e2 lap par RadiologiRadiologiinHltrat intrathoraal# alveolsinHltrat intrathoraal# alveols

difs bilateral.difs bilateral.

&iposemia&iposemia

&iperapnia&iperapnia esadaran Lesadaran Le"ange"ang

ren"atanren"atan

%% : nemonia aspirasi%% : nemonia aspirasi $sidosis Metaboli$sidosis Metaboli


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ANEMIA BERATANEMIA BERAT

&b. 4 5 gr6 ata &t 4 15 6&b. 4 5 gr6 ata &t 4 15 6

arasit 7 1B.BBB par# !arasit 7 1B.BBB par# !

>an thallasemia/ iron>an thallasemia/ irondeIeciency ata eadaandeIeciency ata eadaan

lain yang dapatlain yang dapat

menyebaban anemia.menyebaban anemia.


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Malaria den)anMalaria den)an

5erdara$an5erdara$an (e"ala: perdaraha gsi/petiie/(e"ala: perdaraha gsi/petiie/hematom/ epitasi/ perdarahanhematom/ epitasi/ perdarahan

sb con"ngtiva.sb con"ngtiva.,anda: anemia/ trombositosis/,anda: anemia/ trombositosis/

oaglopati/ ?=% 71B6.oaglopati/ ?=% 71B6.

>erhbngan dengan : edema>erhbngan dengan : edemapar/ iteri/ hiperparasitemiapar/ iteri/ hiperparasitemia

''1-


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A ,6i!. & m3nt6s. ma!a"ia fa!,i5a"um ''''. 1 1$ g"%

In R9MM-Timika 3s5ita!. Pa5ua


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Perdarahan pada malaria berat : ematom di pipi


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Purpura ! perdarahan dibawah kulit, pada malaria

dengan trombosit "###/ mm$


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Asidosis me(a2oli7Asidosis me(a2oli7

afasafas ??ssssmmaallll// $$sltasi parsltasi par

normalnormal

?adar asam lat?adar asam lataatt

p& serm 4 N/2p& serm 4 N/2

>iarbonat rendah )415 ml#l->iarbonat rendah )415 ml#l-

>eraitan dengan : edema par/>eraitan dengan : edema par/

hiperparasitemia/ syo/ gagal gin"al/hiperparasitemia/ syo/ gagal gin"al/

hipogliemia.hipogliemia.


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34P.TENSI.N34P.TENSI.N


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34P.TENSI.N34P.TENSI.N


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Malaria Al)id Malaria Al)id

Malaria Kren"atan : ,% sistole 4 OB mm&g.Malaria Kren"atan : ,% sistole 4 OB mm&g. ,andaA,anda sirlasi periferL:,andaA,anda sirlasi periferL:

)lit dingin/ lembab/ nadi cepat/ nyeri)lit dingin/ lembab/ nadi cepat/ nyeriepigastrim/ mal/ mntah/ diare mirip olera/epigastrim/ mal/ mntah/ diare mirip olera/

iteri/ parasitemia beratiteri/ parasitemia beratschiGon dalamschiGon dalamdarah/ dll-.darah/ dll-.

%apat disebaban . no0lesi ) simian Malaria-%apat disebaban . no0lesi ) simian Malaria-

Berkaitan enganBerkaitan engan:edema par/ asidosis/:edema par/ asidosis/sepsis bateri gram A/ perdarahan salransepsis bateri gram A/ perdarahan salran

cerna.cerna.

%% : A%ehidrasi berat ren"atan septi.%% : A%ehidrasi berat ren"atan septi.

Setiap pasien malaria algidSetiap pasien malaria algid perl ltr darah.perl ltr darah.


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Infe7si se7'nder 2a7(eriInfe7si se7'nder 2a7(eri

Pne#onia aspirasi > sering? I!!K ok kateter

U"k$s ik$=it$s terinfeksi

Infeksi paa te#pat inf$s

epsis

3ra# 22

ering pse$o#onas; *!)o"i;sa"#one"a; streptokok$s ""!

)$riga =ris =ekepan5angan parasit%;syok #enetap; "e$kositosis/ne$tropenia!


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Dia)nosis Bandin)Dia)nosis Bandin)

Malaria Cerebral: encepalitis#Malaria Cerebral: encepalitis#meninggitis )bateri/ virs/ "amr-/meninggitis )bateri/ virs/ "amr-/ggn metaboli/ stroe/ intosiasiggn metaboli/ stroe/ intosiasi

alohol#obat/ trama epala.alohol#obat/ trama epala. Malaria dengan iters :leptospirosis/Malaria dengan iters :leptospirosis/hepatitis tifosa/ olelitiasis dll.hepatitis tifosa/ olelitiasis dll.

Malaria algid : Sepsis baterial berat/Malaria algid : Sepsis baterial berat/

=M$/ dehidrasi berat / perdarahan=M$/ dehidrasi berat / perdarahantersembnyi dll.tersembnyi dll. Edema par :pnemonia aspirasi/Edema par :pnemonia aspirasi/

elebihan cairan/ intosiasi obat/ dll.elebihan cairan/ intosiasi obat/ dll.


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Pro)nosis Pro)nosis

'mlah + beratnya disfngsi organ

?ecepatan diagnosis + mlai pengobatanyang adeat.

=ndiator linis:A %era"at esadaran Lprog "ele

A (($ Kedema prog "ele

A asidosis berat prog "ele

A gagal nafasprog "eleA perdarahanmortalitas 77

A =mn L)splenetomi/ steroid/ dll-prog"ele


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Indi7asi la2ora(ori'mIndi7asi la2ora(ori'm

&iperparasitemia KShiGont perifer

!eositosis

?adar asam latat CSS7/ serm 7P mmoll#l

?adar gla CSS44 ?adar anti trombin === 44

?reatinin73 mg#dl/ >@ 7PB mg#dl

&b 4 N/1 g#dl.

(%S 4 9B gr6 >iarbonat serm

,ransaminase 7 3Q .


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KE4 S0##EED F.R MANA-IN-

SEVERE MALARIA

$ccracy diagnosis ) microscopic biochemical -

Malaria drg ) to combat resistency - $bility to treat organ failre ) =C@ +

Medical e*ipment -

(ood man po0er) nrses AAA doctor - (ood referral system


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4urriculum itae4urriculum itae


78/133

NameName : KURNIA F: KURNIA FITRIITRIJAMILJAMIL

Place/Place/BBirthirth : Medan, 8 Februar !"#8: Medan, 8 Februar !"#8

%ducati&n :%ducati&n :

' Medical (&ct&r )raduate' Medical (&ct&r )raduate : FK'UI *: FK'UI *Ja+arta,Ja+arta, !""-!""-

' Interni.t )raduate' Interni.t )raduate : FK'UNPA( *: FK'UNPA( *Bandun,Bandun, 001-001-

' 2ealth Mai.ter )raduate' 2ealth Mai.ter )raduate : FK'UNPA( *: FK'UNPA( *Bandun,Bandun, 003-003-

' 4&n.ultant &5 Tr&6ical In5ecti&n:' 4&n.ultant &5 Tr&6ical In5ecti&n: 4&leium &5 Internal4&leium &5 Internal

Medicine Ind&ne.iaMedicine Ind&ne.ia **K&leium Ilmu Pena+it (alam di Ja+arta,K&leium Ilmu Pena+it (alam di Ja+arta, 008-008-

' Pa.ca 7arana Ph9( Pr&ram : FK'U)M, &a+arta *.tart 00"'999-' Pa.ca 7arana Ph9( Pr&ram : FK'U)M, &a+arta *.tart 00"'999-

' Fell&; &5 Ind&ne.ian 7&ciet &5 Internal Medicine *PB9PAP(I, 00"-' Fell&; &5 Ind&ne.ian 7&ciet &5 Internal Medicine *PB9PAP(I, 00"-

' 4&ur.e &5 Internal Medicine *)erman, 003, Netherland, 00#-' 4&ur.e &5 Internal Medicine *)erman, 003, Netherland, 00#-

' Internati&nal )enetic. *Au.tralia, 008-' 4&ur.e Tr&6ical (i.ea.e. > )enetic. *Au.tralia, 008-

' 4&ur.e &5 Bi&l& M&lecular &5 Tr&6ical Medicine *)erman, 00"-' 4&ur.e &5 Bi&l& M&lecular &5 Tr&6ical Medicine *)erman, 00"-

' Internati&nal &5 Tr&6ical Medicine > In5ecti&u. (i.ea.e. *U)M, 0!0-' Internati&nal &5 Tr&6ical Medicine > In5ecti&u. (i.ea.e. *U)M, 0!0-

?ccu6ati&n:?ccu6ati&n:'' 7ta55 &5 Internal Medicine, Medical Facult &5 7iah Kual7ta55 &5 Internal Medicine, Medical Facult &5 7iah Kual aa [email protected]/[email protected]/R7UA

'' 2ead &5 In5ecti&u. (i.ea.e. and Tr&6ical Medicine ([email protected]&n,2ead &5 In5ecti&u. (i.ea.e. and Tr&6ical Medicine ([email protected]&n,

Internal Medicine (e6t' ain&el Abidin )eneral 2&.6italInternal Medicine (e6t' ain&el Abidin )eneral 2&.6ital

' 4&&rdinat&r &5 7+ill. Medical Lab&rat&r &5 Facult &5 Medicine Un.iah' 4&&rdinat&r &5 7+ill. Medical Lab&rat&r &5 Facult &5 Medicine Un.iah

' 4&n.ultant' 4&n.ultant&5 2I/AI(7 )r&u6 ain&el Abidin )eneral 2&5 2I/AI(7 )r&u6 ain&el Abidin )eneral 2&&.6ital.6ital

' 2ead &5 P%TRI Aceh Branch' 2ead &5 P%TRI Aceh Branch


79/133

M$!$R=$:RECE, M$$(EME,

?@R=$ =,R= '$M=!%ivisi enyait ,ropi + =nfesi

>agian#SM. =lm enyait %alam

?A@S$%$ $CE& A 2B19


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;tline

)ase i""$stration

evere #a"aria

Fa


81/133

7+O. 7orl0 'alaria #eport 288

Estimate :00-&00 mi!!i3n

,!ini,a! ,ases ea,6 yea"

'ortalit9 per ,888; /9 5ountr9, 288'ortalit9 per ,888; /9 5ountr9, 288


82/133

9 p , ; 9 9,9 p , ; 9 9,

A55"3;imate!y 21& mi!!i3n ie

ea,6 yea"

7+O. 7orl0 'alaria #eport 288

P! fa"


83/133

H'7!

p ;p ;

)o$ntries at risk of trans#ission +,,)o$ntries at risk of trans#ission +,,


84/133

)o$ntries at risk of trans#ission; +,,)o$ntries at risk of trans#ission; +,,

7+O. 288

=nsidence )per 1/BBB- =ndonesia 2BBO


85/133

$CE& 2/B3

S@MA@, O/15

S@MA>$R 2/5O

R=$@ 3/BP

'$M>= 1O/BO

S@MASE! 5/9P

>E(?@!@ 22/P

!$M@( 2/N>$(?$ >E!=,@( 9B/5O

R=$@ 13/32

%?= '$?$R,$ B

'$J$ >$R$, B/5O

'$J$ ,E($& B/BN% =


86/133

=ncidence rate tends to decrease/ since GebrakMalaria or Roll >ac Malaria )R>M- initiative in 2BBB.

In 2008 95e,ies *ase


88/133

uman Malaria is %aused b& one of ' proto(oan parasites:

Plasmodium fal%iparum

Plasmodium )i)a*

Plasmodium o)ale

Plasmodium malariae

Plasmodium knowlesi+

! sighh et al, "##-

http://www.tulane.edu/wiser/malaria/%mb.html


89/133

,odays challenges


90/133

,odays challenges

Malaria is still a big concern in =ndonesiahealth problem

Challenge of resistance in antimalarial

drg ,reatment policy to overcome the

problem by sing artemisininederivatives

Clinical malaria diagnosis no longer sed

Malarial elimination program in =ndonesia


91/133

M $ ! $ R = $

Many cases 0orld0ide

&igh mortalityof severe malaria

Resistanceto drgs Serios eIects in pregnancy

?6at

,an

>e3)

TREAT

MENT

AND

PRE@

ENT

I+N

, t t f l i


92/133

,reatment of malaria

=deally all patients shold be treated inhospital

=ndications for hospital admission:

$ll children T 1 year )and consider admittingchildren p to 5 years 0here possible-

$ll pregnant patients

$ll patients U P5 years

=mmnoAcompromised patients 0here

possible

Severe malaria or danger signs

(@=%E!=ES ;R ,&E ,RE$,ME, ; M$!$R=$ = S;@,& $R=C$/ 2BB

@ncomplicated malaria


93/133


Symptomatic malaria 0ithot signs ofseverity or evidence of vital organdysfnction.

,reatment ob"ectives: eradicate the infection

prevent the emergence and spread of drgresistance

combinationof t0o or more antimalarials 0ithdiIerent mechanismsof action

$l0ays give a fll corse of eIective treatment

)ui0elines or the treatment o malaria, 7+O 288



94/133

,reatment coverage: ,reatment of .vivax or .ovale infection

,reatment of mild#moderate .falciparm

infection/ . falciparm and .vivaxmixed infection

$ntimalarial drgs:


"ines for t:e treat#ent of #a"aria in Inonesia; Ministry of 'ea"t: RI;

$C, )1stline- # nonA$C, )2ndline- K rima*ine

$rtemisinin derivatives


95/133

$rtemisinin derivatives

ery short ,Vshold be given in a longer

period to avoid relaps

reventresistance of

antimalarial drg

Da=is T'E, >aruna?eewa +A, Ilett >F. Artemisinin-/ase0 5om/ination therapies or un5ompli5ate0 malaria. '*A 288@ 32 1;:3-@.

$eun &, Ponta=ornpin9o 7, +astins I', 'ills A*, 7hite N* Am. *. Trop. 'e0. +9. 2881 B&uppl 2;: B


96/133

Arte#isinin erivatives

S&;@!% ;, be sed asmonotherapies for the

treatment of ncomplicatedmalaria as this 0ill promote

resistance to this criticallyimportant class of

antimalarials

Avai"a="e A)T in +,-,; H'7


97/133

D"ugs *3m53siti3n 3"m

Artemether lumeantrine

28 m 28 m /ied dose talets

Artesunate amo0ia4uin

2@ m 6B,@ m

/ied dose talets@8 m @ m

88 m 2B8 m

@8 m @8 m ase; olistered talets

Artesunate melo4uin

288 m 2@8 m olistered talets

Dihi0roartemisinin pipera4uin 18 m 28 m Fixe0 0ose ta/lets

Artesunate sula0o4sin p9rimethamine

@8 m @882@ m olistered talets

Hor" 'ea"t: 7rganiation! Anti#a"aria" #eiArthemisinin-based Combination Therapy)

H'7 re


98/133

H'7 reJ#day-K amodia*ine)1Bmg#>J#day-

)$rtesdia*ineW/ $rtesamoonW- once daily in3days

$rtesnate)9mg#>J#day once daily in 3 days-K

Meo*ine)25 mg#>J split over 2 or 3 days- $rtesnate)9mg#>J#day once daily in 3 days-K

SlfadoxineApyrimethamine)25mg#1.25mg base#>J on1stday-

)ui0elines or the treatment o malaria, 7+O 288



99/133

(idelines for the treatment of malaria Ministry of &ealth R=/ 2BB/ J&; 2


FIRT LIN* A)T 1 PRIMAUIN*

T"eatment 3f P1ia; 3" P13a!e infe,ti3n C

$rtesnate )2BBmg#day/ in 3 days-K amodia*ine )PBBmg#day/ in 3

days-$rtemether 2B mg Klmefantrine 12B mgX2x9 tablets for 3 days

%ihydroartemisinin 9B mg Kpipera*ine 32B mg2 tablets initial dose/2 tablets in the next O/ 29/ and 32

hors

B.25mg#>J#dayin 19 days



100/133

*)7ND LIN*

UININ* ULFA 1 PRIMAUIN*

T"eatment 3f P1ia; 3" P13a!e infe,ti3n C2

3 Q 9BBAPBBmg#dayin N days

B.25mg#>J#dayin 19 days

e"ines for t:e treat#ent of #a"aria; Ministry of 'ea"t: RI; +,,; H'7 +

Un


101/133

Un


102/133

FIRT LIN*$C,

K

R=M$Y@=E

pT"eatment 3f mi!(m3e"ate P1fa!,i5a"um infe,ti3n.

P1 fa!,i5a"um an P1ia; mi;e infe,ti3n C

P fa"Jsingle dose

Mi9e infeJ

e"ines for t:e treat#ent of #a"aria; Ministry of 'ea"t: RI; +,,; H'7 +

Un


103/133

*)7ND LIN*

UININ* 1 D7O/T*TRA 1 PRIMAUIN* Yinine: 3x9BBAPBB mg in N days

%oxycycline: 2 x 2 mg#>J in N days

,etracycline:9 x 9A5 mg#>J in N days rima*ine: B.25mg#>J in 19 daysvivax #mixed

B.N5mg#>J single dose. inf.

pT"eatment 3f mi!(m3e"ate P1fa!,i5a"um infe,ti3n.

P1 fa!,i5a"um an P1ia; mi;e infe,ti3n C2

Key too"s of prevention


104/133

>e A0are: ris factor/ incbation period/symptom

$void being Bitten by mos*itoes

)hemoprophylaxis

=mmediately see Diagnosis + treatment: iffever occr 1 0ee 3 months after arrival inendemic areas

Key too"s of prevention

Malaria Ris revention,=E = ,ransmission ris very >ite avoidance


105/133

,=E = ,ransmission ris verylo0

>ite avoidance

,=E == Ris of malaria vivax orfalciparm 0hichsensitive to chloro*ine

>ite avoidance KChemoprophylaxis )chloro*ine-

,=E ===

Ris of malaria vivax#falciparm/ Kprobability ofchloro*ine resistance

>ite avoidance KChemoprophylaxis )according drgsensitivity in the

area-,=E =

&igh ris of malariafalciparm K drg

resistance

Moderate ris ofmalaria falciparm Khigh resistance

7+O. International Tra=el +ealth 2883

$void being >itten by mos*itos


106/133

$void being >itten by mos*itos

=nsecticide treated net )=,-: )conventional=, or !ongAlasting insecticidal nets )!!=s-prevent infectios mos*ito bites.

=ndoor Residal Spraying )=RS-:indoorapplication of longAlasting chemicalinsecticides )%%,-

;ther vector )mos*ito- controls: larvicidingand environmental management/ repellent/clothes/ fogging/ domestic insectiside

J&;/ ,he Roll >ac Malaria artnership 2BBO: (lobal Malaria $ction

lan.

):e#oprop:y"a9is


107/133

*ausa!

P"356y!a;is

9u55"essie

P"356y!a;is

)ui0elines or 'alaria Pre=ention in Tra=ellers rom the nite0 >in0om. 288B

):e#oprop:y"a9is


108/133

Recommended drgs: Chloro*ine

roganil

Chloro*ine K proganil Meo*ine

Do9i


109/133

Recommended by Ministry of &ealth R=/ 2BB Sppresive prophylaxis )eIectivity Z

meo*ine-

$dlt dose: 1BBmg#day/ start on 1stA2nddaybefore arrival/ ntil 9 0ees after leaving otthe area

ot recommended for 7 3 month of sing/

children/ and pregnant 0oman. )Ministry of&ealth R=/ 2BB-

[[ redisposition of Candidosis vagina

):e#oprop:y"a9isDo9i


110/133

Save: chloro*ine and proganil )K folicacid 5mg#day-less protection to resistantstrain

Meo*ine: e0 reported side eIects

Careflly se for 2nd+ 3rdtrimester pregnancy inarea 0ith chloro*ine resistance

%oxicycline C;,R$ =%=C$,E%

):e#oprop:y"a9isIn pregnant trave""er

)ui0elines or 'alaria Pre=ention in Tra=ellers rom the nite0 >in0om. 288B

):e#oprop:y"a9is


111/133

=ntermittent reventive ,reatment )=,/ J&;2BBN-: RecommendedSlfadoxineApyrimethamine

Single doseX minimm se is t0ice/ sincetrimester == ntil parts

revalence of &= in pregnancy 7 1B6 the 3rddose shold be given on the last antenatal care

F

):e#oprop:y"a9isIn pregnant trave""er in ene#i

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MALARIA KOMPILASI.ppt