CASE REPORT

MALARIA
Presented by :
Syed M. Kamal (110100415)
Supervised by :
Dr. Tina Christina, Sp.A (K)
DEPARTMENT OF CHILD HEALTH
MEDICAL FACULTY NORTH SUMATRA UNIVERSITY
H. ADAM MALIK GENERAL HOSPITAL
MEDAN
2015

Introduction
Malaria is a common and life-threatening disease in
many tropical and subtropical areas. There are
currently over 100 countries and territories where
there is a risk of malaria transmission
Between 200 million and 500 million cases of clinical
malaria occur each year, leading to an estimated 1
million deaths. Most malarial deaths occur among
infants and young children
Indonesia is one of the countries that are endemic for
Malaria

Definition
Malaria is an acute and chronic illness caused by
intracellular Plasmodium protozoa transmitted to
humans by female Anopheles mosquitoes
Malaria is characterized by paroxysms of fever,
chills, sweats, fatigue, anemia, and splenomegaly
Plasmodium that cause malaria in humans: P.
falciparum, P. malariae, P. ovale, and P. vivax, P.
knowlesi

Epedimiology
World

Indonesia

North Sumatera

198 million cases

of malaria
occurred globally
in 2013 and the
disease led to 584
000 deaths
The principal
areas of
transmission are
Africa, Asia, and
South America

80% of districts in
Indonesia to be
endemic while
45% of
poppulation live
in places that are
high risk for
Malarial
transmission
Death rate due to
malaria was 11
per 100,000 for
male and 8 per
100,000 for
females
respectively

Endemic areas
incude Deli
Serdang, Labuhan
Batu, Serdang
Bedagai, Asahan,
Samosir, Tapanuli
Tengah, North
Tapanuli,
Mandailing Natal,
Nias, South Nias,
Langkat, Batu
Bara, Padang
Lawas, North
Padang Lawas
and Kabupaten
Labuhan Batu

Plasmodium Life Cycle

Pathogenesis
Fever
Anemia
Immunopathologic events
Tissue anoxia

Clinical Manifestation
Prodromal symptoms include
headache, fatigue, anorexia, myalgia,
slight fever, and pain in the chest,
abdomen, and joints
Febrile paroxysms are characterized by
high fever, sweats, and headache, as
well as myalgia, back pain, abdominal
pain, nausea, vomiting, diarrhea,
pallor, and jaundice

Diagnosis
Fever, Shivering,
Suspected
Sweating
Malaria
Palmar pallor
Parasitolo
gical
Diagnosis

Microscopic
evaluation
RDT

Treatment
Artemisinin base Combination treatment (ACT) is
a combination of a rapidly acting artemisinin
derivative with a longer-acting (more slowly
eliminated) partner drug
ACTs recommended for treatment of malaria are:
artemether + lumefantrine
artesunate + amodiaquine
artesunate + mefloquine
artesunate + SP
dihydroartemisinin + piperaquine.

Primaquine
Relapses originating from liver
hypnozoites are prevented by giving
primaquine
Given for 14 days

Plasmodium falciparum and

Plasmodium vivax malaria
ACT + Primaquine
Dihydroartemisinin : 2-4 mg/kg BW
Piperaquine : 16-32 mg/kg BW
Primaquine : 0.75 mg/kg BW for 1 day
(P. falciparum)
0.25 mg/kg BW for 14 days
(P.Vivax)

Complication

Severe malarial anemia

Cerebral malaria
Respiratory distress
Seizures
Hypoglycemia

CASE REPORT

Name
: SS
Age
: 5 years 11 month
Sex
: Female
Date of Admission : September 14th 2015
at 06.45 PM
Chief of complaint
: Fever
History of Present Illness :
Fever since +/- 2 weeks prior to admitted to the
hospital.
Body
temperature
is
unstable,
sometimes high grade fever and it is was
reduced with antipyretics. Patient experienced
shiverring while high fever. Convulsions was not
found. Patient reported vomiting since 2 weeks.
Vomiting happened after took medicine. It was
food and drink that she ate. Patient also reported

Previous

illness

: Referred from RS
Pirngadi and diagnosed
with Plasmodium vivax
malaria.
History of medication : Novalgin
History of feeding : Unclear
History
of
immunization :
Complete
immunization

Present Status:
Consciousness : Alert, Compos mentis.
Blood pressure : 100/40 mmHg
Respiratory rate : 24 x/i, regular
Body temperature : 38,3C,
Body weight : 14 kg
Body height : 104 cm.
Anemic (+), ikteric (-), dyspnea (-),
cyanotic (-), edema (-).

Localized Status
Head

Neck
Thorax

Abdomen

Eye : Eye light reflect +/+, pale

conjunctiva palpebral inferior +/
+
Ear/nose/mouth : Within normal
range.
Jugular Vein Pressure : R-2 cmH2O
Symetrical fusiformis, Retractions (-)
Respiratory Rate : 24 x/i, regular,
ronchi -/Heart rate : 140 x/i, regular, murmur
(-)
Soepel, Peristaltic (+) normal
Hepar: palpable 2 cm BAC
Lien: palpable S II

Laboratory Findings
Hematology

Test

Result

Unit

Referal

Hemoglobin

5.60

g%

12.0-14.4

Erythrocyte

1.76

106/mm3

4.75-4.85

Leucocyte

6.11

103/mm3

4.5-11.0

Thrombocyte

164

103/mm3

150-450

Lymphocyte

27.00

20-40

8.30

2-8

MCV

64.70

fL

75-87

MCH

31.80

Pg

25-31

MCHC

37.60

g%

33-35

Monocyte

Electrolyte
Test
Natrium
Kalium
Chloride

Result
138
4.1
105

Unit
mEq/L
mEq/L
mEq/L

Referal
135-155
3.6-5.5
96-106

Differential Diagnosis: Thypoid fever

Viral infection : influenza
Diagnosis : Malaria
Therapy :
IVFD D5% NaCl 0,45% 50 gtt/i micro
Diet MB 1200 kkal with 26 gram protein
Paracetamol syr 3 x cth 11/2
Further Investigation Plan:
Thick and thin blood smears
LFT
RFT
Urinalysis

Follow Up

14th September 2015

S
O

Fever (+)
Sens: Alert, T: 38,3 oC, BW: 14 kg, BH: 104 cm
Head: eye reflect +/+, isocor, pale conj. palpebral
inferior +/+
ear/nose/mouth: normal
Neck: JVP R-2 cmH2O
Thorax: Symetris fusiformis, retraction (-)
HR: 140x/i, regular, murmur (-)
RR: 24 x/i, Ronchi -/Abdomen: Soepel, Normal peristaltic
Hepar : palpable 2 cm BAC, Lien : palpable S II
Extremities: Pulse: 140 x/i, regular, adequate pressure
and volume, warm, CRT < 3, pale (+), pretibial edema (-)

Others: Normal
Malaria+ anaemia

IVFD D5% NaCl 0,45% 30 gtt/i,

DHP tablet 1x1 for 3 days (Day 1)
Diet MB 1200 kcal with 28 gram protein
Planned to check RDT, thin blood smears, G6PD, LFT,
RFT, Urinalysis, Urine culture, and PRC Transfusion (115,6) x 4 x 14 = 300
Ability : 5 x 14 = 75 cc/12 hours
Result ( 07.00 pm)
Clinical Pathology
Hematologi
Malaria (+)
Morfology
Erythrocytes: Ring form (+), Trophozoite (+)

15th September 2015

Fever (-)
Sens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cm
Head: eye reflect +/+, isocor, pale conj. palpebral inferior
+/+
ear/nose/mouth: normal
Neck: JVP R-2 cmH2O
Thorax: Symetris fusiformis, retraction (-)
HR: 120x/i, regular, murmur (-)
RR: 24 x/i, Ronchi -/Abdomen: Soepel, Normal peristaltic
Hepar : palpable 2 cm BAC, Lien : palpable S II
Extremities: Pulse: 140 x/i, regular, adequate pressure
and volume, warm, CRT < 3, pale (+), pretibial edema (-)
Others: Normal

Malaria+ anaemia

IVFD D5% NaCl 0,45% 50 gtt/i

DHP tablet 1x1 for 3 days (Day 2)
Diet MB 1200 kcal with 28 gram protein
PRC Tranfusion 75 cc (Bag 1)

S
O

16th September 2015

Fever (-)
Sens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cm
Head: eye reflect +/+, isocor, pale conj. palpebral inferior +/+
ear/nose/mouth: normal
Neck: JVP R-2 cmH2O
Thorax: Symetris fusiformis, retraction (-)
HR: 110x/i, regular, murmur (-)
RR: 24 x/i, Ronchi -/Abdomen: Soepel, Normal peristaltic
Hepar : palpable 2 cm BAC, Lien : palpable S II
Extremities: Pulse: 110 x/i, regular, adequate pressure and
volume, warm, CRT < 3, pale (+), pretibial edema (-)
Others: Normal

Malaria+ anaemia

IVFD D5% NaCl 0,45% 50 gtt/i

DHP tablet 1x1 for 3 days (Day 3)
Diet MB 1200 kcal with 28 gram protein
PRC Tranfusion 75 cc (Bag 2)

Clinical Pathology
(11.42 AM)
Urinalysis
Complete Urine Morphology
Color : Yellow
Glocose : (-)
Bilirubin : (-)
Keton : (-)
Berat Jenis : 1.015
pH : 6
Urobilinogen : (-)
Nitrit : (-)
Leucocyte : (+)
Blood : (-)

P Urine Sediment
Erythrocyte : 0-1
Leucocyte : 1-2
Epytel : 0-1
Casts : (-)
Crystal : (-)

17th September 21015

S
Fever (-)
O
Sens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cm

Head: eye reflect +/+, isocor, pale conj. palpebral inferior

+/+
ear/nose/mouth: normal
Neck: JVP R-2 cmH2O
Thorax: Symetris fusiformis, retraction (-)
HR: 94x/i, regular, murmur (-)
RR: 24x/i, Ronchi -/Abdomen: Soepel, Normal peristaltic
Hepar : palpable 2 cm BAC, Lien : palpable S II
Extremities: Pulse: 110 x/i, regular, adequate pressure and
volume, warm, CRT < 3, pale (+), pretibial edema (-)
Others: Normal
A

IVFD D5% NaCl 0,45% 50 gtt/i

Diet MB 1200 kcal with 28 gram protein
PRC Tranfusion 75 cc (Bag 3)
Primakuin tablet 1 x 1/4 for 14 days (Day
1)
G6PD Deficiency : (-)

18th September 2015

Fever (-)
Sens: Alert, T: 36,6 oC, BW: 14 kg, BH: 104 cm
Head: eye reflect +/+, isocor, pale conj. palpebral inferior
+/+
ear/nose/mouth: normal
Neck: JVP R-2 cmH2O
Thorax: Symetris fusiformis, retraction (-)
HR: 100x/i, regular, murmur (-)
RR: 22x/i, Ronchi -/Abdomen: Soepel, Normal peristaltic
Hepar : palpable 2 cm BAC, Lien : palpable S II
Extremities: Pulse: 110 x/i, regular, adequate pressure and
volume, warm, CRT < 3, pale (+), pretibial edema (-)
Others: Normal

IVFD D5% NaCl 0,45% 50 gtt/i

Diet MB 1200 kcal with 28 gram protein
Primakuin tablet 1 x 1/4 for 14 days (Day 2)
PRC Tranfusion 75 cc (Bag 4)

Check Complete Blood Count after transfusion

Complete Blood Count

Test

Result

Hemoglobin

10.40

Erythrocyte

2.70x103

Leucocyte

5.40x103

Thrombocyte

275x103

Hematocryte

23.20

MCV

85.90

MCH

38.50

MCHC

44.80

19th September 2015

S
O

Fever (-)
Sens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cm
Head: eye reflect +/+, isocor, pale conj. palpebral inferior
+/+
ear/nose/mouth: normal
Neck: JVP R-2 cmH2O
Thorax: Symetris fusiformis, retraction (-)
HR: 100x/i, regular, murmur (-)
RR: 24 x/i, Ronchi -/Abdomen: Soepel, Normal peristaltic
Hepar : palpable 2 cm BAC, Lien : palpable S II
Extremities: Pulse: 140 x/i, regular, adequate pressure
and volume, warm, CRT < 3, pale (+), pretibial edema (-)
Others: Normal

A
P

Malaria
IVFD D5% NaCl 0,45% 50 gtt/i
Diet MB 1200 kcal with 28 gram protein
Primakuin tablet 1 x 1/4 for 14 days (Day
3)

20th September 2015

S
O

Fever (-)
Sens: Alert, T: 36,6 oC, BW: 14 kg, BH: 104 cm
Head: eye reflect +/+, isocor, pale conj. palpebral inferior
+/+
ear/nose/mouth: normal
Neck: JVP R-2 cmH2O
Thorax: Symetris fusiformis, retraction (-)
HR: 84x/i, regular, murmur (-)
RR: 20 x/i, Ronchi -/Abdomen: Soepel, Normal peristaltic
Hepar : palpable 2 cm BAC, Lien : palpable S II
Extremities: Pulse: 140 x/i, regular, adequate pressure
and volume, warm, CRT < 3, pale (+), pretibial edema (-)
Others: Normal

A Malaria
P IVFD D5% NaCl 0,45% 50 gtt/i
Diet MB 1200 kcal with 28 gram
protein
Primakuin tablet 1 x 1/4 for 14 days
(Day 4)

Discussion
In this case, the patient is children, 5
years, 11 month and has Plasmodium
vivax malaria
Malaria is one of endemic disease in
tropical country or subtropic country.
Malaria is a health problem in Mexico,
Caribia, Central America, Africa, India,
South East, and Indo Cina. It is
estimated the prevalence of malaria
up to 160-400 million cases. In
Indonesia, malaria is still found in
some
provinces.
Plasmodium

North Sumatera there are some endemic regions of

malaria, such as: Kabupaten Langkat, Deli Serdang,
Labuhan Batu, Serdang Bedagai, Asahan, Samosir,
Tapanuli Tengah, Tapanuli Utara, Tapanuli Selatan,
Mandailing Natal, Nias, Batu Bara, Padang Lawas,
Padang Lawas Utara dan Kabupaten Labuhan Batu
Utara.
In this case, the patient is
from Langkat.

Anemia is one of important pathologic

processes have been identified in patients
with malaria. Anemia is caused by
hemolysis, sequestration of erythrocytes in
the spleen and other organs, and inhibition
of erythropoiesis by TNFa.
In this case, patient has an anemia with
Hemoglobin count is 5.60 gr/dl

WHO (2015)
Malaria should be treated with at least two
effective antimalarial medicines that is by
using Artemisinin base Combination treatment
(ACT) combined with Primaquine.
Patient treated with Dihydroartemisinin+Piperaquine combined with Primaquine

Summary
SS, 5 years and 11 months girl, with BW of 14 kg
and height of 104 cm, admitted from emergency
unit in H. Adam Malik General Hospital Medan on
September 14th 2015 at 06.45 PM developed fever
since a 2 weeks ago. Patient also experienced
shivering after high fever. Patient reported vomiting
since 2 weeks. Vomiting occurred after taking
medicine. Patient also reported headache, myalgia
if she had fever. She lives in Langkat. She is
diagnosed with Plasmodium vivax malaria. Patient
was treated with DHP for 3 days and Primaquine for
14 days.