Manifestasi Klinik Severe Malaria-new

8/19/2019 Manifestasi Klinik Severe Malaria-new

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P.N. HarijantoP.N. HarijantoSMF PENYAKIT DALAM, RSU BETHESDASMF PENYAKIT DALAM, RSU BETHESDA

TOMOHONTOMOHON

Div. Penyakit Tropik & Infeksi, Bag. Penyakit DalamDiv. Penyakit Tropik & Infeksi, Bag. Penyakit Dalam

F.K. UNSRT, !ana"oF.K. UNSRT, !ana"o

S#la$esi Utara, In"onesiaS#la$esi Utara, In"onesia

MANIFESTASI KLINIKMANIFESTASI KLINIK

MALARIAMALARIA BERATBERAT


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MALARIA

SERINGHIDUP

MALARIA DAPAT

MENYEBABKANKEMATIAN


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400 Giitan

N!a"#$

%00

M&n'in(&$)i

Man#)ia

*00 Ma+aria

K+ini)

% -

Ma+aria B&rat


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Plasmodium Falciparum, Vivax, Knowlesi dapat menyebabkan Malaria Berat

Kematian*0 /0

%'' -


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!%RI BRT!%RI BRT

MALARIA SEREBRALMALARIA SEREBRAL ANEMIA BERAT HB / r 1 Ht */ 2 3ara)it *0000ANEMIA BERAT HB / r 1 Ht */ 2 3ara)it *0000 GAGAL GIN5AL AKUT 400 "+1%4 ja" 6 Kr&at 7 "GAGAL GIN5AL AKUT 400 "+1%4 ja" 6 Kr&at 7 " EDEMA PARU 1 ARDSEDEMA PARU 1 ARDS

HIPOGLIKEMI 40 "HIPOGLIKEMI 40 " SYOK SISTOLIK 80 ""H 1 Ana$ /0 ""HSYOK SISTOLIK 80 ""H 1 Ana$ /0 ""H PERDARAHAN SPONTAN 1 DI9PERDARAHAN SPONTAN 1 DI9 KE5ANG BERULANG % :1 %4 ja"KE5ANG BERULANG % :1 %4 ja"

ASIDOSIS P; 8.%/ , P+a)"a Bi


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S'R !%RI ()*+*S'R !%RI ()*+*

DFINITIN - Patient, Plasmosi#m se#al parasitemia,$it/ oneor more 0%INI0% or %BRTR1 FTURS -

PRSTRTIN

Fail#re" to Fee"

I!PIRD 0NS0IUSNSS

RSPIRTR1 DISTRSS

!U%TIP% 0N'U%SINS, 2)3 )4 /rs

0IR0U%TR1 0%%PS

5Systoli6 7 8*, 6/li"ren 7 9* :

PU%!NR1 D! 5 ra"iology :

BNR!% B%DIN; 5 spontane#s :


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PN1BB 3 TI%;IPN1BB 3 TI%;I

Plasmo"i#m fal6ipar#mPlasmo"i#m fal6ipar#m

!ie" plasmo"i#m 5 Fal6ipar#m= viva:!ie" plasmo"i#m 5 Fal6ipar#m= viva:

Plasmo"i#m vivaPlasmo"i#m vivaPlasmodium knowlesi Plasmodium knowlesi


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P%S!DIU! KNA%SIP%S!DIU! KNA%SI

Simian malaria 5 !a66a6a m#llata:Simian malaria 5 !a66a6a m#llata: Un#s#al presentation P. !alariaeUn#s#al presentation P. !alariae Diagnosis y P0RDiagnosis y P0R 6#te "iare, a"ominal pain, Ca#n"i6e 6#te "iare, a"ominal pain, Ca#n"i6e

lgi" malaria, /ypotension lgi" malaria, /ypotension

Renal fail#re, respiratory fail#reRenal fail#re, respiratory fail#re


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BEDA MALARIA BERAT PADA DE@ASA 6 ANAKBEDA MALARIA BERAT PADA DE@ASA 6 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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Syn"romes of severe malaria-Syn"romes of severe malaria-

+. 0/il"ren+. 0/il"ren

+. Severe anemia+. Severe anemia

). !etaoli6 a6i"osis). !etaoli6 a6i"osis

@. 0ereral malaria@. 0ereral malaria

a6erate" y-a6erate" y- /ypovolemia/ypovolemia

/ypogly6emia/ypogly6emia sali6ylate toi6itysali6ylate toi6ity

Renal fail#re rareRenal fail#re rare

%#ng inC#ry3RDS rare%#ng inC#ry3RDS rare


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Syn"romes of severe malaria-Syn"romes of severe malaria-

). non(imm#ne a"#lts). non(imm#ne a"#lts

!#ltiorgan fail#re-!#ltiorgan fail#re- >yperparasitemia>yperparasitemia

6#te renal fail#re 6#te renal fail#re ypogly6emia>ypogly6emia

6#te respiratory "istress 6#te respiratory "istresssyn"romesyn"rome

nemia3t/romo6ytopenia nemia3t/romo6ytopenia

0ereral malaria0ereral malaria


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Prognosti6 val#e & fre#en6y of S! in a"#lts 3 6/il"renPrognosti6 val#e & fre#en6y of S! in a"#lts 3 6/il"ren

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

2

2

222

2 2

22

2

2 222

2

2

2

2

2

2 1 '

2 1 '

2 1 '

222

222

222

222

222

222

222

222

222

222222

222

222

222

2222

22

2222


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0lassifi6ations S! in 0/il"ren0lassifi6ations S! in 0/il"ren ;ro#p +- 5re#ire parenteral R & S#pport.T :;ro#p +- 5re#ire parenteral R & S#pport.T :

+.+. Prostration 5 inaility to sit #prig/t:, @ s#sgro#p -Prostration 5 inaility to sit #prig/t:, @ s#sgro#p - Prostrate #t f#lly 6on6io#sProstrate #t f#lly 6on6io#s

Prostrate $it/ impaire" 6on6io#sness not 6omaProstrate $it/ impaire" 6on6io#sness not 6oma

0 o m a0 o m a

).). Respiratory "istress 5 a6i"oti6 reat/ingRespiratory "istress 5 a6i"oti6 reat/ing !il" E nasal flaring &3 or mil" inter6ostal in"ra$ing!il" E nasal flaring &3 or mil" inter6ostal in"ra$ing

Severe E mark inter6o6tal in"ra$ing or "eep a6i"oti6Severe E mark inter6o6tal in"ra$ing or "eep a6i"oti6

;ro#p ) 5ale to take oral R, re#ire s#pervise": -;ro#p ) 5ale to take oral R, re#ire s#pervise": -

+.+. >aemogloin 7 9 gr? or /aemato6rit 7 +9?>aemogloin 7 9 gr? or /aemato6rit 7 +9?).). 2 ) 6onv#lsions in )4 /o#rs2 ) 6onv#lsions in )4 /o#rs

;ro#p @ - re#ire parenteral T e6a#se of persistent;ro#p @ - re#ire parenteral T e6a#se of persistent

vomiting, not in gro#p + or ).vomiting, not in gro#p + or ).


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DIAGNOSIS OF **4 9ASES SEERE MALARIA

in E"&r&n

B&t;&)Ca Ho)3ita+ To"o;on

DIAGNOSIS OF **4 9ASES SEERE MALARIA

in E"&r&n

B&t;&)Ca Ho)3ita+ To"o;on

"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 * (*$)

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

Malaria 4 5aundice #- (&-6)

Malaria 4 AR2 7 (-$)

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


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RELATIONSHIP BET@EEN ORGANRELATIONSHIP BET@EEN ORGAN

INOLEMENT AND MORTALITY in S&&r&INOLEMENT AND MORTALITY in S&&r&

Ma+ariaMa+aria

RELATIONSHIP BET@EEN ORGANRELATIONSHIP BET@EEN ORGAN

INOLEMENT AND MORTALITY in S&&r&INOLEMENT AND MORTALITY in S&&r&

Ma+ariaMa+aria


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Severe !alaria in In"onesiaSevere !alaria in In"onesia

Not N%1 in n"emi6 !alaria rea 5ast

In"onesia :

Sprea"ing to


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PATOGENESISPATOGENESISA!A"IA #E"E$"A!A!A"IA #E"E$"A!

!KNIS! BSTRUKSI KPI%R -!KNIS! BSTRUKSI KPI%R - Rosetting 5 penggeromolan eritrosit :Rosetting 5 penggeromolan eritrosit :

Sitoa"/erensi 5 perlekatan eritrosit ke en"ot/el :Sitoa"/erensi 5 perlekatan eritrosit ke en"ot/el : !KNIS! I!UN%;IK - pement#kan!KNIS! I!UN%;IK - pement#kan

sitokin, nitrit oi"esitokin, nitrit oi"e

!KNIS! PNIN;KTN TKNN!KNIS! PNIN;KTN TKNN

INTR(0RNI% - /anya kas#s anakINTR(0RNI% - /anya kas#s anak

!KNIS! NDTKSIN!KNIS! NDTKSIN


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!KNIS! PT;NSIS- RSSTTIN;!KNIS! PT;NSIS- RSSTTIN;

PRB9


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PRB9

Kn#

!KNIS! SITD>RN!KNIS! SITD>RN

ENDOTEL

EP


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!KNIS! PT;NSIS!KNIS! PT;NSIS

ENDOTELI4A5-1

ELA5 64A5 SP4D-78

Pf(!P(+

PRB9


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Pat/op/ysiology +. Re" 6ellPat/op/ysiology +. Re" 6ell

"estr#6tion3impaire" pro"#6tion"estr#6tion3impaire" pro"#6tion


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Pat/op/ysiology )- 6ytoa"/eren6ePat/op/ysiology )- 6ytoa"/eren6e


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0ytoa"/eren6e- 6ereral malaria-0ytoa"/eren6e- 6ereral malaria-

rain /istologyrain /istology


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Pat/op/ysiology @- "ysreg#late" 6ytokinePat/op/ysiology @- "ysreg#late" 6ytokine

responseresponse

, LTα

GPI


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Is NO protective in malaria?Is NO protective in malaria?

NO: antiparasitic effects:NO: antiparasitic effects:inhibits parasite growth in vitroinhibits parasite growth in vitro

NO: “antitoxic” effects:NO: “antitoxic” effects:

inhibits TNF productioninhibits TNF productiondownregulates expression of endothelial adhesiondownregulates expression of endothelial adhesion

molecules (ICAM-1 etc..)molecules (ICAM-1 etc..)

inhibits host cell apoptosis in tissuesinhibits host cell apoptosis in tissues

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


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Indonesian subjectsIndonesian subjects

Severe malaria (SM)Severe malaria (SM)-- cerebral malariacerebral malaria

--non-cerebral malarianon-cerebral malaria

Uncomplicated malariaUncomplicated malaria

(UM)(UM)

Healthy controls (HC)Healthy controls (HC)

Rural (RHC)Rural (RHC)

Urban (UHC)Urban (UHC)

N3PB!0 NS i I " iN3PB!0 NS i I " i


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N3PB!0 NS in In"onesianN3PB!0 NS in In"onesian

a"#lts- lo$est in severe malariaa"#lts- lo$est in severe malaria

0.000

0.0/0

0.*00

0.*/0

RH9 UH9 UM SM0

*000

%000

7000

4000

/000

RH9 UH9 UM SM

0

/

*0

*/

%0

%/

RH9 UH9 UM SM0.0

0./

*.0

*./

%.0

%./

UH9 UM SM


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L'arinin&L'arinin& NONOL'


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rginine 6on6entrations an" risk rginine 6on6entrations an" risk

of "eat/ in 6ereral malariaof "eat/ in 6ereral malaria @G 0! 5+H "eat/s:@G 0! 5+H "eat/s: %ogisti6 regression%ogisti6 regression rg elo$ me"ian levels in 0! rg elo$ me"ian levels in 0!

asso6iate" $it/ in6rease" risk ofasso6iate" $it/ in6rease" risk of"eat/ from 0!"eat/ from 0!

Crude OR = 4Crude OR = 4

[95% CI 1.1 to 15.2][95% CI 1.1 to 15.2](p=0.04)(p=0.04)

"C#ste" R ).) "C#ste" R ).)

JG9? 0I +.) to 9HJG9? 0I +.) to 9H5p*.*4:5p*.*4:D#ration of fasting,D#ration of fasting,

Blantyre 6oma s6ore,Blantyre 6oma s6ore,/emogloin, $/ite loo"/emogloin, $/ite loo"6ell 6o#nt, parasitemia6ell 6o#nt, parasitemia

Pl i i l l iPl i i l l i


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Plasma arginine also lo$ inPlasma arginine also lo$ in

In"onesian a"#lts $it/ severe malariaIn"onesian a"#lts $it/ severe malaria


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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)<

LAIN K95PLIKASI

E;EK ;ISIK

PADA E)I

5AN SI9ADE)

DE;9)5 %ILAN,

PE5AKAIAN ,L<%IP9,LIKE5I

LAKIK ASID9SIS


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*0 o( (a+


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DFINITINDFINITINDFINITINDFINITIN

PRAC.ICAL 8PRAC.ICAL 8

IMPAIRME%. 92 C9%"CI93"%E"" 9R C9%:3L"I9% I%IMPAIRME%. 92 C9%"CI93"%E"" 9R C9%:3L"I9% I%

PA.IE%. E;P9"E1 .9 MALARIAPA.IE%. E;P9"E1 .9 MALARIA

RE"EARC!RE"EARC!

A% 3%R93"A


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0lini6al !anifestations0lini6al !anifestations

G+ 9 S +G+ 9 S +


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G+a)o 9o"a S


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E%tensi &ada mala'ia (e'e)'al


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0%INI0% !NIFSTTIN0%INI0% !NIFSTTIN

%E3R9L90ICAL "@%1R9ME 8 1I223"E> P9.E%.IALL@%E3R9L90ICAL "@%1R9ME 8 1I223"E> P9.E%.IALL@RAPI1L@ RE:ER"I


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!alaria Retinopat/y!alaria Retinopat/y

. ;amaran retina pa"a

pen"erita malaria sereral ;0S

+4, "engan anemia > H.) gr?.

Tampak gamaran per"ara/an

"an papile"ema.

B. ;amaran retina pa"a

pen"erita malaria sereral ;0S H,

e"emapar# "an "emam ken6ing

/itam. Tampak gamaran

pem#ti/an retina.

( Maude !" #eare $%" et all"Trans& & 'oc& Tro&Med ) H*+"

200," 10:../-.1


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DIFFERENTIAL DIAGNOSIS CMDIFFERENTIAL DIAGNOSIS CM

&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 "!9CD"EP.IC "!9CD

&".R9DE !EA1 I%3R@".R9DE !EA1 I%3R@

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


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Diagnosis & management important startDiagnosis & management important start

from emergen6y #nitfrom emergen6y #nit


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' hours after

admission

& hoursafter admission

Ma+aria


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Ma+aria TI


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;N;;UN F% >TI;N;;UN F% >TI

PD !%RI BRTPD !%RI BRT IKTRIK SRIN; DITI :IKTRIK 5 >!%ISIS 3 DISFUN;SI >TI :LL BI%IUS R!ITNT F'R LBI%IUS R!ITNT F'R L

5 IKTRIK, >IPRPRSIT!I, SRBR%5 IKTRIK, >IPRPRSIT!I, SRBR%

& ;;% ;INipoal#minemia

( ;angg#an koag#lasi( ;angg#an koag#lasi

( Pen#r#nan klirens( Pen#r#nan klirens


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!alaria /epatitis 5 Deller +G8 :!alaria /epatitis 5 Deller +G8 :

;agal /ati Carang;agal /ati Carang

>epatomegali sering, nyeri ringan,>epatomegali sering, nyeri ringan,

splenomegalisplenomegali

>iperilir#inemia 5 "irek & in"irek :>iperilir#inemia 5 "irek & in"irek :

Transaminase meningkat ringan ( se"ang,Transaminase meningkat ringan ( se"ang,

Carang 2 )** i.# Carang 2 )** i.#

Aakt# protromin memanCangAakt# protromin memanCang


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>IP;%IK!I>IP;%IK!I

Bila g#la "ara/ 7 4* mg?Bila g#la "ara/ 7 4* mg?Sering "iC#mpai pa"a i# /amil 5 primi(Sering "iC#mpai pa"a i# /amil 5 primi(

gravi"a:gravi"a:Pa"a anak(anak sering seel#mPa"a anak(anak sering seel#m

pengoatanpengoatanPa"a orang "e$asa sering terCa"iPa"a orang "e$asa sering terCa"i

ses#"a/ pengoatan kina 5 @ Cam postses#"a/ pengoatan kina 5 @ Cam postterapi kina :terapi kina :


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Patogenesa >ipoglikemiaPatogenesa >ipoglikemia

Parasit memerl#kan karo(/i"rat #nt#kParasit memerl#kan karo(/i"rat #nt#kmetaolismenyametaolismenya

Pa"a malaria "engan /iperilir#in aemia,Pa"a malaria "engan /iperilir#in aemia,terCa"i kegagalan gl#koneogenesisterCa"i kegagalan gl#koneogenesis

Kina menstim#li pro"#ksi ins#linKina menstim#li pro"#ksi ins#lin

5 /iperins#linemia :5 /iperins#linemia :Peningkatan T#mor Ne6rosis fa6torPeningkatan T#mor Ne6rosis fa6tor

5 TNF(alfa :5 TNF(alfa :

0UT KIDN1 IN


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0UT KIDN1 IN


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0UT RN% FI%UR IN S'R !%RI 0UT RN% FI%UR IN S'R !%RI

P)E-)ENAL )ENAL


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Faktor #nt#k memperm#"a/ !KI -Faktor #nt#k memperm#"a/ !KI -Ke/amilanKe/amilan

Parasitemia tinggiParasitemia tinggi Ikterik yang tinggiIkterik yang tinggi

De/y"rasiDe/y"rasi

NSIDNSIDFaktor yang penting prognosa !KIFaktor yang penting prognosa !KI>ipovolemia3 /ipervolemia>ipovolemia3 /ipervolemia

>iperparasitemia>iperparasitemia>emo6on6entrasi>emo6on6entrasi

>iperilir#inemia>iperilir#inemia

>iperpireksia>iperpireksia

PU%!NR1 !NIFSTTIN IN !%RI


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PU%!NR1 !NIFSTTIN IN !%RIPU%!NR1 !NIFSTTIN IN !%RI

>istori6ally ->istori6ally -Bron6/iti6Bron6/iti6

Pne#moni6Pne#moni6

Bron6/opne#moni6Bron6/opne#moni6

6#te %#ng InC#ry 5%I: 6#te %#ng InC#ry 5%I:

6#te Respiratory Distress Syn"rome 6#te Respiratory Distress Syn"rome

5RDS:5RDS:


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ARDSARDS

A )!nCro"& o( )&&r& r&)3irator!A )!nCro"& o( )&&r& r&)3irator!

(ai+#r& C#& to an! 80

torr? C#rin int&r"itt&nt 3o)iti&torr? C#rin int&r"itt&nt 3o)iti&

3r&))#r& =r&at;in >IPPB? it;3r&))#r& =r&at;in >IPPB? it;

FiO% /0.FiO% /0.


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.R.D.S .R.D.S

66#rs in P. Fal6ipar#m, P. 'iva, P. vale & P.66#rs in P. Fal6ipar#m, P. 'iva, P. vale & P.Kno$lesiKno$lesi

0ommon in a"#lt t/an 6/il"ren, pregnan6y an" non(0ommon in a"#lt t/an 6/il"ren, pregnan6y an" non(

imm#neimm#ne

!e6/anism - In6rease" alveolar 6appilary!e6/anism - In6rease" alveolar 6appilary

permeailitypermeaility intravas6#lar fl#i" loss into t/e l#ngsintravas6#lar fl#i" loss into t/e l#ngs

Presentation - initial presentation or after initiationPresentation - initial presentation or after initiation

treatmenttreatment 0lini6al - a6#te onset "yspnea0lini6al - a6#te onset "yspnea respiratory fail#rerespiratory fail#re

0%INI0% FINDIN;0%INI0% FINDIN;


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0%INI0% FINDIN;0%INI0% FINDIN; !anifest ar#pt onset "yspnoea, 6o#g/, tig/tness in t/e 6/est!anifest ar#pt onset "yspnoea, 6o#g/, tig/tness in t/e 6/est

t/at progresses rapi"ly over a fe$ /o#rst/at progresses rapi"ly over a fe$ /o#rs Disorientation an" agitation is fre#ently present.Disorientation an" agitation is fre#ently present.

P/ysi6al eaminationP/ysi6al eamination - signs of respiratory "istress 5 air /#nger,- signs of respiratory "istress 5 air /#nger,

#se of a66essory m#s6les of respiration, s#prasternal an"#se of a66essory m#s6les of respiration, s#prasternal an"

inter6ostal in"ra$ing :, 6entral an" perip/eral 6yanosis 5arterialinter6ostal in"ra$ing :, 6entral an" perip/eral 6yanosis 5arterial/ypoaemia:, asal 6repitations an" epiratory $/eeOing./ypoaemia:, asal 6repitations an" epiratory $/eeOing.

In t/ese patients, /ig/ parasitaemia,a6#te renal fail#re,In t/ese patients, /ig/ parasitaemia,a6#te renal fail#re,

/ypogly6emia, metaoli6 a6i"osis, "isseminate" intravas6#lar/ypogly6emia, metaoli6 a6i"osis, "isseminate" intravas6#lar

6oag#lation 5DI0:, an" a6terial sepsis #s#ally 6o(eist.6oag#lation 5DI0:, an" a6terial sepsis #s#ally 6o(eist.

0/ t "i /0/ t "i /


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0/est ra"iograp/y -0/est ra"iograp/y -Bilateral frontal opa6ities 5alveolar pattern:,Bilateral frontal opa6ities 5alveolar pattern:,

in6rease" interstitial markingsin6rease" interstitial markings

T/e 6ar"ia6 siOe is #s#ally normalT/e 6ar"ia6 siOe is #s#ally normal

Rarely, t/i6kening of l#ng fiss#res, interlo#larRarely, t/i6kening of l#ng fiss#res, interlo#lar

septal linesseptal lines

Ple#ral eff#sionPle#ral eff#sion

In assiste" ventilator -In assiste" ventilator -6ompli6ations pne#mot/ora,6ompli6ations pne#mot/ora,

pne#mome"iastin#m , pne#monia may o66#r pne#mome"iastin#m , pne#monia may o66#r


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N!I BRT N!I BRT

>. 7 9 gr? ata# >t 7 +9 ?>. 7 9 gr? ata# >t 7 +9 ?

Parasit 2 +*.*** par3 #%Parasit 2 +*.*** par3 #%

B#kan t/allasemia, iron "effe6ien6y ata#B#kan t/allasemia, iron "effe6ien6y ata#

kea"aan lain yang "apat menyeakankea"aan lain yang "apat menyeakan

anemia.anemia.


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A


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!alaria "engan per"ara/an-!alaria "engan per"ara/an-

;eCala- per"ara/a g#si,petikie, /ematom,;eCala- per"ara/a g#si,petikie, /ematom,

epiktaksi, per"ara/an s# 6onC#ngtiva.epiktaksi, per"ara/an s# 6onC#ngtiva.

Tan"a- anemia, tromositosis,Tan"a- anemia, tromositosis,

koag#lopati, KID 2+*?.koag#lopati, KID 2+*?.

Ber/##ngan "engan - e"ema par#, ikterik,Ber/##ngan "engan - e"ema par#, ikterik,

/iperparasitemia/iperparasitemia


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Pe'da'ahan &ada mala'ia )e'at : *ematom di &i&i


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Pu'&u'a + &e'da'ahan di)aah kulit, &ada mala'iadengan t'om)osit -.../ mm

i" i t liksi"osis metaolik-


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si"osis metaolik- si"osis metaolik-

Nafas k#smo#l, a#sk#ltasi par# NNafas k#smo#l, a#sk#ltasi par# N

Ka"ar asam laktetKa"ar asam laktet

p> ser#m 7 8,)p> ser#m 7 8,)

Bikaronat ren"a/ 57+9 ml3l:Bikaronat ren"a/ 57+9 ml3l:

Berkaitan "engan - e"ema par#,Berkaitan "engan - e"ema par#,

/iperparasitemia, syok, gagal ginCal,/iperparasitemia, syok, gagal ginCal,/ipoglikemia./ipoglikemia.


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>1PTNSIN 5algi" malaria:>1PTNSIN 5algi" malaria:

9a#)&) ra" ' & =a


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!alaria lgi" -!alaria lgi" -

!alaria =renCatan - TD sistole 7 H* mm>g.!alaria =renCatan - TD sistole 7 H* mm>g. Tan"a(Tan"a sirk#lasi perifer-Tan"a(Tan"a sirk#lasi perifer-

5k#lit "ingin, lema, na"i 6epat, nyeri5k#lit "ingin, lema, na"i 6epat, nyeriepigastri#m, m#al, m#nta/, "iare mirip kolera,epigastri#m, m#al, m#nta/, "iare mirip kolera,ikterik, parasitemia eratikterik, parasitemia erat s6/iOon "alams6/iOon "alam"ara/, "ll:."ara/, "ll:.

Dapat "iseakan P. kno$lesi 5 simian !alaria:Dapat "iseakan P. kno$lesi 5 simian !alaria:

B&r$aitan C&nanB&r$aitan C&nan -e"ema par#, asi"osis, sepsis-e"ema par#, asi"osis, sepsis

akteri gram (, per"ara/an sal#ran 6erna.akteri gram (, per"ara/an sal#ran 6erna.DD - (De/i"rasi erat E renCatan septik.DD - (De/i"rasi erat E renCatan septik.

Setiap pasien malaria algi"Setiap pasien malaria algi" perl# k#lt#r "ara/.perl# k#lt#r "ara/.

Infeksi sek#n"er akteri-Infeksi sek#n"er akteri-


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Infeksi sek#n"er akteri-Infeksi sek#n"er akteri- Pnemonia aspirasi 5 sering:Pnemonia aspirasi 5 sering:

I.S.K ok kateter I.S.K ok kateter

Ulk#s "ik#it#s terinfeksiUlk#s "ik#it#s terinfeksi

Infeksi pa"a tempat inf#sInfeksi pa"a tempat inf#s

Sepsis -Sepsis - ;ram E 22;ram E 22

Sering - pse#"omonas, .0oli, salmonela,Sering - pse#"omonas, .0oli, salmonela,

streptokok#s "ll.streptokok#s "ll. 0#riga - firis ekepanCangan parasit(, syok0#riga - firis ekepanCangan parasit(, syok

menetap, le#kositosis3ne#tropenia.menetap, le#kositosis3ne#tropenia.


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Diagnosis Ban"ing-Diagnosis Ban"ing-

!alaria 0ereral- en6epalitis3 meninggitis!alaria 0ereral- en6epalitis3 meninggitis5akteri, vir#s, Cam#r:, ggn metaolik, stroke,5akteri, vir#s, Cam#r:, ggn metaolik, stroke,intoksikasi alko/ol3oat, tra#ma kepala.intoksikasi alko/ol3oat, tra#ma kepala.

!alaria "engan ikter#s -leptospirosis, /epatitis!alaria "engan ikter#s -leptospirosis, /epatitis

tifosa, kolelitiasis "ll.tifosa, kolelitiasis "ll. !alaria algi" - Sepsis akterial erat, I!,!alaria algi" - Sepsis akterial erat, I!,

"e/i"rasi erat , per"ara/an tersem#nyi "ll."e/i"rasi erat , per"ara/an tersem#nyi "ll. "ema par# -pnemonia aspirasi, kelei/an"ema par# -pnemonia aspirasi, kelei/an

6airan, intoksikasi oat, "ll.6airan, intoksikasi oat, "ll.


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Prognosis -Prognosis -


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In"ikasi laoratori#m-In"ikasi laoratori#m-

>iperparasitemia =S/iOont perifer >iperparasitemia =S/iOont perifer %ekositosis%ekositosis Ka"ar asam laktat 0SS2, ser#m 2 mmoll3lKa"ar asam laktat 0SS2, ser#m 2 mmoll3l Ka"ar g#la 0SS77Ka"ar g#la 0SS77 Ka"ar anti tromin III 77Ka"ar anti tromin III 77 Kreatinin2@ mg3"l, BUN 2* mg3"lKreatinin2@ mg3"l, BUN 2* mg3"l > 7 8,+ g3"l.> 7 8,+ g3"l. ;DS 7 4* gr?;DS 7 4* gr? Bikaronat ser#mBikaronat ser#m Transaminase 2 @Q N.Transaminase 2 @Q N.


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!an0ut &enanganan mala'ia )e'at

PAKATUAN WO PAKALAWIREN


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PAKATUAN WO PAKALAWIREN

'r. (aul )arijanto, *p.(''iv. (enyakit +ropik ! Infeksi

*- ag. (enyakit 'alam

/ UN*01+- 0*U( anado

0*U et2esda %+omo2on

+elp.3 4567%857987 :0*U( anado;

4567%6974

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Manifestasi Klinik Severe Malaria-new