CASE REPORT MALARIA

CASE REPORTMALARIAPresented by :Syed M. Kamal (110100415)

Supervised by :Dr. Tina Christina, Sp.A (K)

DEPARTMENT OF CHILD HEALTHMEDICAL FACULTY NORTH SUMATRA UNIVERSITYH. ADAM MALIK GENERAL HOSPITALMEDAN2015 IntroductionDefinitionEpedimiologyPlasmodium Life Cycle

PathogenesisClinical ManifestationDiagnosis

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

PrimaquineRelapses originating from liver hypnozoites are prevented by giving primaquineGiven for 14 days

Plasmodium falciparum and Plasmodium vivax malariaACT + PrimaquineDihydroartemisinin : 2-4 mg/kg BWPiperaquine : 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)ComplicationSevere malarial anemiaCerebral malariaRespiratory distressSeizuresHypoglycemia

CASE REPORTName: SSAge: 5 years 11 monthSex: FemaleDate of Admission: September 14th 2015 at 06.45 PM Chief of complaint: FeverHistory 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 headache, myalgia if she had fever . Cough and coryza was found in this 1 week. Her parents realized that patient was pallor since 1 week. History travel to endemic region was denied by her parents, but she lives in LangkatPrevious illness: Referred from RS Pirngadi and diagnosed with Plasmodium vivax malaria.History of medication: NovalginHistory of feeding: UnclearHistory of immunization: Complete immunization

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

Localized StatusHeadEye : Eye light reflect +/+, pale conjunctiva palpebral inferior +/+Ear/nose/mouth : Within normal range.NeckJugular Vein Pressure : R-2 cmH2OThoraxSymetrical fusiformis, Retractions (-)Respiratory Rate : 24 x/i, regular, ronchi -/-Heart rate : 140 x/i, regular, murmur (-) AbdomenSoepel, Peristaltic (+) normalHepar: palpable 2 cm BACLien: palpable S IIExtremitiesPulse: 140x/i, regular, adequate pressure and volume, warm, CRT < 3, Pale (+), Pretibial edema (-), Blood pressure: 100/50 mmHg.Laboratory FindingsTestResultUnitReferalHemoglobin5.60g%12.0-14.4Erythrocyte1.76106/mm34.75-4.85Leucocyte6.11103/mm34.5-11.0Thrombocyte164103/mm3150-450Lymphocyte27.00%20-40Monocyte8.30%2-8MCV64.70fL75-87MCH31.80Pg25-31MCHC37.60g%33-35HematologyElectrolyteTestResultUnitReferalNatrium138mEq/L135-155Kalium4.1mEq/L3.6-5.5Chloride105mEq/L96-106Differential Diagnosis: Thypoid feverViral infection : influenzaDiagnosis : Malaria

Therapy :IVFD D5% NaCl 0,45% 50 gtt/i microDiet MB 1200 kkal with 26 gram proteinParacetamol syr 3 x cth 11/2

Further Investigation Plan: Thick and thin blood smearsLFTRFTUrinalysis

Follow Up14th September 2015SFever (+)OSens: Alert, T: 38,3 oC, BW: 14 kg, BH: 104 cmHead: eye reflect +/+, isocor, pale conj. palpebral inferior +/+ear/nose/mouth: normalNeck: JVP R-2 cmH2OThorax: Symetris fusiformis, retraction (-)HR: 140x/i, regular, murmur (-)RR: 24 x/i, Ronchi -/-Abdomen: Soepel, Normal peristalticHepar : palpable 2 cm BAC, Lien : palpable S IIExtremities: Pulse: 140 x/i, regular, adequate pressure and volume, warm, CRT < 3, pale (+), pretibial edema (-)Others: NormalAMalaria+ anaemiaPIVFD D5% NaCl 0,45% 30 gtt/i,DHP tablet 1x1 for 3 days (Day 1)Diet MB 1200 kcal with 28 gram proteinPlanned to check RDT, thin blood smears, G6PD, LFT, RFT, Urinalysis, Urine culture, and PRC Transfusion (11-5,6) x 4 x 14 = 300Ability : 5 x 14 = 75 cc/12 hoursResult ( 07.00 pm)Clinical PathologyHematologiMalaria (+)MorfologyErythrocytes: Ring form (+), Trophozoite (+)15th September 2015SFever (-)OSens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cmHead: eye reflect +/+, isocor, pale conj. palpebral inferior +/+ear/nose/mouth: normalNeck: JVP R-2 cmH2OThorax: Symetris fusiformis, retraction (-)HR: 120x/i, regular, murmur (-)RR: 24 x/i, Ronchi -/-Abdomen: Soepel, Normal peristalticHepar : palpable 2 cm BAC, Lien : palpable S IIExtremities: Pulse: 140 x/i, regular, adequate pressure and volume, warm, CRT < 3, pale (+), pretibial edema (-)Others: NormalAMalaria+ anaemiaPIVFD D5% NaCl 0,45% 50 gtt/iDHP tablet 1x1 for 3 days (Day 2)Diet MB 1200 kcal with 28 gram protein PRC Tranfusion 75 cc (Bag 1)16th September 2015SFever (-)OSens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cmHead: eye reflect +/+, isocor, pale conj. palpebral inferior +/+ear/nose/mouth: normalNeck: JVP R-2 cmH2OThorax: Symetris fusiformis, retraction (-)HR: 110x/i, regular, murmur (-)RR: 24 x/i, Ronchi -/-Abdomen: Soepel, Normal peristalticHepar : palpable 2 cm BAC, Lien : palpable S IIExtremities: Pulse: 110 x/i, regular, adequate pressure and volume, warm, CRT < 3, pale (+), pretibial edema (-)Others: NormalAMalaria+ anaemiaPIVFD D5% NaCl 0,45% 50 gtt/iDHP 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)UrinalysisComplete Urine MorphologyColor : YellowGlocose : (-)Bilirubin : (-)Keton : (-)Berat Jenis : 1.015pH : 6Urobilinogen : (-)Nitrit : (-)Leucocyte : (+)Blood : (-)PUrine SedimentErythrocyte : 0-1Leucocyte : 1-2Epytel : 0-1Casts : (-)Crystal : (-)17th September 21015SFever (-)OSens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cmHead: eye reflect +/+, isocor, pale conj. palpebral inferior +/+ear/nose/mouth: normalNeck: JVP R-2 cmH2OThorax: Symetris fusiformis, retraction (-)HR: 94x/i, regular, murmur (-)RR: 24x/i, Ronchi -/-Abdomen: Soepel, Normal peristalticHepar : palpable 2 cm BAC, Lien : palpable S IIExtremities: Pulse: 110 x/i, regular, adequate pressure and volume, warm, CRT < 3, pale (+), pretibial edema (-)Others: NormalAMalaria+ anaemiaPIVFD D5% NaCl 0,45% 50 gtt/iDiet 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 2015SFever (-)OSens: Alert, T: 36,6 oC, BW: 14 kg, BH: 104 cmHead: eye reflect +/+, isocor, pale conj. palpebral inferior +/+ear/nose/mouth: normalNeck: JVP R-2 cmH2OThorax: Symetris fusiformis, retraction (-)HR: 100x/i, regular, murmur (-)RR: 22x/i, Ronchi -/-Abdomen: Soepel, Normal peristalticHepar : palpable 2 cm BAC, Lien : palpable S IIExtremities: Pulse: 110 x/i, regular, adequate pressure and volume, warm, CRT < 3, pale (+), pretibial edema (-)Others: NormalAMalaria+ anaemiaPIVFD D5% NaCl 0,45% 50 gtt/iDiet 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 transfusionTestResultHemoglobin10.40Erythrocyte2.70x103Leucocyte5.40x103Thrombocyte275x103Hematocryte23.20MCV85.90MCH38.50MCHC44.80Complete Blood Count 19th September 2015SFever (-)OSens: Alert, T: 36,8 oC, BW: 14 kg, BH: 104 cmHead: eye reflect +/+, isocor, pale conj. palpebral inferior +/+ear/nose/mouth: normalNeck: JVP R-2 cmH2OThorax: Symetris fusiformis, retraction (-)HR: 100x/i, regular, murmur (-)RR: 24 x/i, Ronchi -/-Abdomen: Soepel, Normal peristalticHepar : palpable 2 cm BAC, Lien : palpable S IIExtremities: Pulse: 140 x/i, regular, adequate pressure and volume, warm, CRT < 3, pale (+), pretibial edema (-)Others: NormalAMalariaPIVFD D5% NaCl 0,45% 50 gtt/iDiet MB 1200 kcal with 28 gram protein Primakuin tablet 1 x 1/4 for 14 days (Day 3)20th September 2015SFever (-)OSens: Alert, T: 36,6 oC, BW: 14 kg, BH: 104 cmHead: eye reflect +/+, isocor, pale conj. palpebral inferior +/+ear/nose/mouth: normalNeck: JVP R-2 cmH2OThorax: Symetris fusiformis, retraction (-)HR: 84x/i, regular, murmur (-)RR: 20 x/i, Ronchi -/-Abdomen: Soepel, Normal peristalticHepar : palpable 2 cm BAC, Lien : palpable S IIExtremities: Pulse: 140 x/i, regular, adequate pressure and volume, warm, CRT < 3, pale (+), pretibial edema (-)Others: NormalAMalariaPIVFD D5% NaCl 0,45% 50 gtt/iDiet MB 1200 kcal with 28 gram protein Primakuin tablet 1 x 1/4 for 14 days (Day 4)DiscussionIn this case, the patient is children, 5 years, 11 month and has Plasmodium vivax malariaMalaria 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 falciparum and Plasmodium vivax are the most species in Indonesia. Children are one of most vulnerable groups affected by malaria.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/dlWHO (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 PrimaquineSummarySS, 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.