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PENATALAKSANAANPENATALAKSANAAN
KASUS MALARIAKASUS MALARIA20112011
Dr. Paul Harijanto, SpPD-KPTIDr. Paul Harijanto, SpPD-KPTI
RSU Bethesda GMIM TomohonRSU Bethesda GMIM Tomohon
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Case 2Case 2
Laki-laki, 42 tahun dnLaki-laki, 42 tahun dn!ala"ia #asi$a"u! a!et%!ala"ia #asi$a"u! a!et%
Telah dikel&la dn Telah dikel&la dna"tesdia'uin dana"tesdia'uin dan$"i!a'uine 2 ta(%$"i!a'uine 2 ta(%
)a"i ke-* a!et !asih)a"i ke-* a!et !asih$enuh$enuh
+(at +(at
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IA.N+SA MALARIAIA.N+SA MALARIA
Clini/al s!$t&! Clini/alClini/al s!$t&! Clini/al
ian&sis ian&sis
Pa"asit&l&i/al ian&sis 3Pa"asit&l&i/al ian&sis 3Mik"&s/&$i/ .ie!sa s!ea" Mik"&s/&$i/ .ie!sa s!ea" entuk A-seksual 5entuk A-seksual 5
RT Ra$id ian&sti/ Test RT Ra$id ian&sti/ Test
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KLASI6IKASI IA.N+SAKLASI6IKASI IA.N+SA
MALARIA AS7MPT+MATIK MALARIA AS7MPT+MATIK
MALARIA KLINISMALARIA KLINIS
MALARIA ERATMALARIA ERATMALARIA ENTUK K)USUS 3MALARIA ENTUK K)USUS 3Mala"ia keha!ilanMala"ia keha!ilan
Mala"ia 8 )I9Mala"ia 8 )I9
Mala"ia Malnut"isiMala"ia Malnut"isi
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ALGORITME PENANGANAN KASUS MALARIAALGORITME PENANGANAN KASUS MALARIA
Tak ada Rpd Tes/
Tak ada Mikrosc
Pem.Mikroskopik
ukan 3
ISPA TI6+I
ISK EN.UE
Le$t&s$i"&sisIn#eksi lain
FalciparumMixed/F+V
Vivax
ERATRinan:Sedan
Parasit ++++/>5%
ata/+ko!p"ikasi #
G$ Kesadara
Ikterik& 'i" > (!$%
Sisto"ik )* !!,$Sesak a-as
O"i$ria/Kreat
Ada Rapid Test/ Tak
ada Mikroskopik
Lii I. 0(+P01
Terapi MalariaBerat
Tes Rapid + Tes Rapid -
ukan 3ISPA
TI6+IISK
EN.UELe$t&s$i"&sis
In#eksi lain
Korfirmasi Mikroskopik
Lii I. 0(+P01
Lii I. 0(+P01
Lii I. 0(+P012
Lii II. 0N*+P01
Lii II. SP1+P01
Lii III. 0N*+P01
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Kasus 2Kasus 2
Ana!nesa3Ana!nesa3 Laki-laki, ;4 tahun tinal di T&!&h&n,Laki-laki, ;4 tahun tinal di T&!&h&n,
datan ke RS denan de!a! sudah ;datan ke RS denan de!a! sudah ;
ha"i% Pende"ita (a"u ti(a da"i Pa$ua 2ha"i% Pende"ita (a"u ti(a da"i Pa$ua 2ha"i lalu dan sudah !e"asa tidak sehatha"i lalu dan sudah !e"asa tidak sehat
P% 6isik 3P% 6isik 3 tensi
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La(&"at&"iu!La(&"at&"iu!
>:10:2011>:10:2011•)(3 ,;00
•)t3 2*?)t3 2*?•Se!en @0?Se!en @0?•Li!#&sit 10?Li!#&sit 10?•R3 6al%"in 5,R3 6al%"in 5,
6al%a!et 56al%a!et 5200 l$3 42 $a"asit200 l$3 42 $a"asit
1000 l$3 2 $a"asit1000 l$3 2 $a"asit
=:10:2011=:10:2011•R3 -R3 -•il%di"e/t3 1,2il%di"e/t3 1,2
•il%indi"e/t3 2,4il%indi"e/t3 2,4•il%t&tal3 ;,=il%t&tal3 ;,=•S.+T3 >1S.+T3 >1•S.PT3 1=S.PT3 1=•U"eu!3 2
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Pen&(atanPen&(atan
A$a Pilihan A$a Pilihan
ACT A$a ACT A$a
Mala"ia (e"at Mala"ia (e"at
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High Levels of DrugResistace i Papua
!liical "tudies #pril $ %ul& '(()
P% #al/i$a"u! C' 5 S$ N10;a 42 C&""e/ted 4
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ACT Clinical Trials in Papua ACT Clinical Trials in Papua
Stud 2
)P Ds AAF
Hasugian et al !ID, :1067-7,2007
Githin 4< h"s3@*? =@0:*12 a$a"asitae!i/@
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"*D, - M-#H#"# R*H"*D, - M-#H#"# R*H
"L#01"-"L#01"-'(()$'((23 "*D, #" + #MD-#4-1'(()$'((23 "*D, #" + #MD-#4-1
4> /ases Hith "st line R3 N& ET6 and > /ases11,11? LT6
1< $asien se/&nd line the"a$ 3 n& ET6 and ; /ases 1=,=*? LT6
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!omparative "tud& of #rteki vs!oartemether
Inte"i! Analsis a 2< Cu"e Rates
>th Jan 2004 N;*>P."al#iparumC&a"te! @0? @;:10; @>? CI3 ?A"tekin @
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*R1#*M1**R1#*M1* PL-!-1"PL-!-1"
II%II% TREATMENT TREATMENT A"te!isininA"te!isinin-(ased-(ased C&!(inati&n The"a$C&!(inati&n The"a$
ACTACT
"*PM*H1R#P,
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Pen&(atan Mala"iaPen&(atan Mala"ia
Tan$a K&!$likasi 6ALSIPARUM:9I9A Tan$a K&!$likasi 6ALSIPARUM:9I9A
Mala"ia RIN.AN: Tan$a K&!$likasi 3Mala"ia RIN.AN: Tan$a K&!$likasi 3A"tesunate 5 A!&dia'uine AS 5 A!&A"tesunate 5 A!&dia'uine AS 5 A!&
ihid"&a"te!isinin Pi$e"akuinihid"&a"te!isinin Pi$e"akuin
A"te!ethe"-Lu!e#ant"ine ALA"te!ethe"-Lu!e#ant"ine AL
Lini Pe"ta!a A%C%T 5 P"i!akuin
• PILI)AN ACT TER.ANTUN. ACT 8 P&la Resistensi• Keaalan $ada AS 5A!& di La!$un, Pa$ua dan SulaHesi Uta• 6C 6ied d&se /&!(inati&n $ilihan• E#ek sa!$in se!ini!al !unkin
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Hari
Jenis obat Jumlah tablet menurut kelompok umur
Dosistunggal 0 – 1bulan 2 – 11bulan 1 - 4tahun 5 - 9tahun 10 - 14tahun > 15tahun
1 Artesunate ¼ ½ 1 2 3 4
Amodiakuin ¼ ½ 1 2 3 4
Primakuin -- -- 1 ½ 2 2 - 3
2 Artesunate ¼ ½ 1 2 3 4
Amodiakuin ¼ ½ 1 2 3 4
3 Artesunate ¼ ½ 1 2 3 4
Amodiakuin ¼ ½ 1 2 3 4
Pen&(atan Lini I, P% 6alsi$a"u! !enu"ut u!u"
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Pen&(atan denan ihd"&a"te!isinin-Pi$e"akuinPen&(atan denan ihd"&a"te!isinin-Pi$e"akuin
)-P)-PHariHari %eis %eis
o5ato5at
%umlah ta5let meurut kelompok umur %umlah ta5let meurut kelompok umur
6dosis tuggal76dosis tuggal7
( $ 8( $ 8
5ula5ula'' – –
8888 5ul5ul
aa
88 – – ))
tatahuhu
22 – – 99
tahtahuu
8(8( – – 8)8)
tahutahu
:: 8282
tahutahu
88 DHPDHP ¼¼ ½½ 88 832832 '' ; $ ); $ )
F3 H8F3 H8 PrimakuiPrimakui
$$$$ $$$$ 88 ½½ '' ' $ ;' $ ;
'$;'$; DHPDHP ¼¼ ½½ 88 832832 '' ; $ ); $ )Dihydroartemisinin(DH) : 2-4 mg ( 2,2mg)/kgBB (1tablet = 40 mg)i!erak"in !hos!hate(): 1#-$2mg (1%mg/kgBB (1tablet = $20 mg)
rimak"in : 0&' mg/kg BB
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ACT sekt&" sHastaACT sekt&" sHasta
A"te!ethe"-Lu!e#ant"ine C&-A"te!ethe"-Lu!e#ant"ine C&-
A"te! A"te! 6C6C
E#ekti# untuk #al/i$a"u!E#ekti# untuk #al/i$a"u!
Ku"an e#ekti# untuk DiDaksKu"an e#ekti# untuk DiDaks
&sis 2 seha"i&sis 2 seha"i
A(s&"$si !eninkat dn le!ak susuA(s&"$si !eninkat dn le!ak susu
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Jenis obat !mur " #tahun
> # - $tahun
> 9 – 14th
> 14 th
!ari "erat "adan#K$%
&am ' ( 14k$
1' ( 24 k$ 2' ( 34k$
) 34 k$
1 A - * + ,am 1 2 3 4
A - * ,am 1 2 3 4
Primakuin 12 ,am 1 ½ 2 2 - 3
2 A - * 24 ,am 1 2 3 4
A - * 3. ,am 1 2 3 4
3 A - * 4 ,am 1 2 3 4
A - * .+ ,am 1 2 3 4
Lini II ACT% &sis $enunaan a"te!ete"-lu!e#ant"ine A-L
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Hari
Jenis obat Jumlah tablet menurut kelompok umur
Dosis
tunggal
0 – 1
bulan
2 – 11
bulan
1 - 4
tahun
5 - 9
tahun
10 - 14
tahun
> 15
tahun
1 Artesunate ¼ ½ 1 2 3 4
Amodiakuin ¼ ½ 1 2 3 4
Primakuin -- -- 1/4 1/2 3/4 1
2 Artesunate ¼ ½ 1 2 3 4
Amodiakuin
Primakuin
¼ ½ 1
1/4
2
1/2
3
3/4
4
1
3
4-14
Artesunate ¼ ½ 1 2 3 4
Amodiakuin
Primakuin
Primakuin
¼ ½ 1
¼
1/4
2
½
1/2
3
3/4
4
1
1
Pen&(atan Lini I, 9iDaks !enu"ut u!u"
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Pen&(atan denan ihd"&a"te!isinin-Pi$e"akuinPen&(atan denan ihd"&a"te!isinin-Pi$e"akuin
)-P)-P
UNTUK 9I9AKSUNTUK 9I9AKSHariHari %eis %eiso5ato5at
%umlah ta5let meurut kelompok umur %umlah ta5let meurut kelompok umur6dosis tuggal76dosis tuggal7
( $ 8( $ 8
5ula5ula'' – –
8888 5ul5ul
aa
88 – – ))
tatahuhu
22 – – 99
tahtahuu
8(8( – – 8)8)
tahutahu
:: 8282
tahutahu
8$$;8$$; DHPDHP ¼¼ ½½ 88 832832 '' ; $ ); $ )
V3H8V3H8 – – 8)8)
PrimakuiPrimakui
$$ $$ ¼¼ ½½ 88
Dihydroartemisinin(DH) : 2-4 mg/kgBB (1tablet = 40 mg)i!erak"in !hos!hate(): 1#-$2 mg/kgBB ( 1tablet = $20 mg)
rimak"in : 0&2 mg/kg BB
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Case *Case *
Ada $asien sdh di&(ati ACT,Ada $asien sdh di&(ati ACT,
ha"i ke-4 $a"asit P 6 2: 200ha"i ke-4 $a"asit P 6 2: 200
leuk&, tidak $anas%leuk&, tidak $anas%
A$a ini aal &(at A$a ini aal &(at
Te"a$ina a$a Te"a$ina a$a
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Case =Case =
Pas/a te"a$i ACT ha"us di #&ll&H u$ ha"iPas/a te"a$i ACT ha"us di #&ll&H u$ ha"i*, 14 dan 2< %*, 14 dan 2< %
i Puskes!as te"$en/il tan$a !ik"&sk&$,i Puskes!as te"$en/il tan$a !ik"&sk&$,a$a RT tak (isa untuk #&ll&H u$ a$a RT tak (isa untuk #&ll&H u$
ila )* P# a!et ne% A$a (isa ) 14 atauila )* P# a!et ne% A$a (isa ) 14 atau) 2< !enadi $&siti#% A$a ini dise(ut L6T ) 2< !enadi $&siti#% A$a ini dise(ut L6T
aai!ana te"a$ina aai!ana te"a$ina
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ata$
RS/r
)-2 )0
,asi"
Ma" +
)-1
M"ai
O4at
)1
)2
);
)4
)> )= )*
)14 )21
)2<
K"iisMe!4rk
-K"iis !e!4rk-6 Parasit > 4a7ak
-K"iis !e!4rk-6 Parasit > 85 %-6 Parasit +& Te!p > (*95
MONITORING RESPONS DI RS/ PUSKESMAS RAWAT INAP
E9T9: ; G9O9ii L9T9: ; G9O9 La!4at
-K"iis !e!4rk-6 Parasit +& Te!p > (*95
- K"iis- !e!4rk-6 Parasit +
-K"iis !e!4rk-6 Parasit +&-Te!p > (*95
- K"iis- !e!4rk
-6 Parasit + - K"iis- !e!4rk-6 Parasit +
- K"iis- !e!4rk-6 Parasit +
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Panas0din$in
34C
alc0 rin$
34+ par/2++ *
!1 !2
0rin$
3+24/ 2++*
C 4/4/2 P3
!3
0rin$
115 par/2++*
Kina t6
3 7 3 t6/ 5 8ari
E.T.F
!5
Kasus Malaria Gagal Obat Dini
E.T.F
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*7 Fal$ip ring
/2leuk%
0( *27 Fal$ip ring2/2leuk%
*7 Fal$ip ring0/2leuk%
*1/ ,7 Fal$ip ring
9/2leuk%, SP1
*0/ ,17 Fal$ip ring19/2leuk%
*9/ ,87 Fal$ip ring
1 /2leuk%
*/ ,( 7 Fal$ip ring
2 /2leuk%
Temp 8C
:ina ; 2 tab
KASUS MALARIA
TANPA KOMPLIKASI
MULTI-DRUGS
RESISTANCE
,4. 159< $/d"
Leko . =
Tro!4o.259
'i".89*
reat . 1912
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Manae!ent T"eat!entManae!ent T"eat!ent
6ailu"es6ailu"es T"eat!ent #ailu"e Hithin 14 das De" T"eat!ent #ailu"e Hithin 14 das De"
unusual 3unusual 3;2 t"ials 4@1* $atients, n& #ailu"e &n 14;2 t"ials 4@1* $atients, n& #ailu"e &n 14* t"ials #ailu"e at 14 1 * ?* t"ials #ailu"e at 14 1 * ?6ailu"e a#te" 14 das 3 "e/"udes/ense &" "e-6ailu"e a#te" 14 das 3 "e/"udes/ense &" "e-
in#e/ti&nin#e/ti&nRes/ue t"eat!ent 3Res/ue t"eat!ent 3
Alte"natiDe ACT kn&Hn ee/tiDe in this "ei&nAlte"natiDe ACT kn&Hn ee/tiDe in this "ei&nA"tesunate 5 tet"a//lin: d&//line:A"tesunate 5 tet"a//lin: d&//line:
/linda!/in/linda!/inFuinine 5 tet"a//lin: d&//line: /linda!/inFuinine 5 tet"a//lin: d&//line: /linda!/in
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Lini keduaLini kedua
Kina 5 &ksisiklin: Tet"asiklin 5 P"i!akuinKina 5 &ksisiklin: Tet"asiklin 5 P"i!akuin
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!ari &enis o6at ¨a8 ta6let menurut kelompok umur 9osis tun$$al +-11
6ulan1 - 4ta8un
' - :ta8un
1+ - 14ta8un
) 1'ta8un
1 Kina ;% 3 7 ½ 3 7 1 3 7 1 ½ 3 7 #2-3%
9oksisiklin -- -- -- 2 7 '+ m$ 2 7 1++ m$
Primakuin - 1 ½ 2 2 ( 3
2 - 5 Kina ;% 3 7 ½ 3 7 1 3 7 1 ½ 3 7 2
9oksisiklin -- -- -- 2 7 '+ m$ 2 7 1++ m$
9osis T?K*?@ -- -- -- 474 m$/k$""
4 7 2'+ m$
9osisC*?@9AMC?@
-- -- -- 271+ m$/k$""
271+ m$/k$""
Pen&(atan lini II alte"nati# k&!(inasi Kina 5 &ksisiklin: Tet"asiklin: Clinda!/in (ila aal $en&(atan lini I
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!ari &enis o6at ¨a8 ta6let menurut kelompok umur
9osistun$$al
+ - 116ulan
1 - 4ta8un
' - :ta8un
1+ - 14ta8un
) 1'ta8un
1-5 Kina ;% 3 7 ½ 3 7 1 3 7 1 ½ 3 7 #2-3%
9oksisiklin -- -- -- 2 7 '+ m$ 2 7 1++ m$
1 - 14 Primakuin - ¼ ½ 1
9osisT?K*?@
-- -- -- 474 m$/k$""
4 7 2'+ m$
9osisC*?@9AMC?@
-- -- -- 271+m$/k$ ""
271+ m$/k$""
Pe$o4ata !"tiresiste ?i?a@/ o?a"e de$a ko!4iasi Kia +
oksisik"i/Tetrasik"i/"ida!7ci 4i"a $a$a" pe$o4ata "ii IB
P ( t M l i 9i k RELAPS
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Hari
Jenis obat Jumlah tablet menurut kelompok umur
Dosis
tunggal
0 – 1
bulan
2 – 11
bulan
1 - 4
tahun
5 - 9
tahun
10 - 14
tahun
> 15
tahun
1 Artesunate ¼ ½ 1 2 3 4
Amodiakuin ¼ ½ 1 2 3 4
Primakuin -- -- 1/2 1 11/2 2
2 Artesunate ¼ ½ 1 2 3 4
Amodiakuin
Primakuin
¼
--
½
--
1
1/2
2
1
3
11/2
4
2
3
4-14
Artesunate ¼ ½ 1 2 3 4
Amodiakuin
Primakuin
Primakuin
¼
--
½
--
1
1/2
1/2
2
1
1
3
1 1/2
1 1/2
4
2
2
Pen&(atan Mala"ia 9iDaks RELAPS
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Pen&(atan Mala"iaPen&(atan Mala"ia
Ca!$u"an Mied in#e/ti&n ,Ca!$u"an Mied in#e/ti&n ,
hal 20hal 20P% DiDaks dan P% #alsi$a"u!P% DiDaks dan P% #alsi$a"u!Lini $e"ta!a 3Lini $e"ta!a 3
A"tesunate 5 A!&diakuin 5 P"i!akuinA"tesunate 5 A!&diakuin 5 P"i!akuin
&sis P"i!akuin ha"i I 3 0%*> !:k :&sis P"i!akuin ha"i I 3 0%*> !:k :
sinle d&sesinle d&se
&sis PF ha"i 2 14 3 0,2> !:k &sis PF ha"i 2 14 3 0,2> !:k
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Hari
Jenis obat Jumlah tablet menurut kelompok umur
Dosis
tunggal
0 – 1
bulan
2 – 11
bulan
1 - 4
tahun
5 - 9
tahun
10 - 14
tahun
> 15
tahun
1 Artesunate ¼ ½ 1 2 3 4
Amodiakuin ¼ ½ 1 2 3 4
Primakuin -- -- 3/4 11/2 2 2-3
2 Artesunate ¼ ½ 1 2 3 4
Amodiakuin
Primakuin
¼ ½ 1
1/4
2
1/2
3
3/4
4
1
3
4-14
Artesunate ¼ ½ 1 2 3 4
Amodiakuin
Primakuin
Primakuin
¼ ½ 1
¼
1/4
2
½
1/2
3
3/4
4
1
1
Pen&(atan Mala"ia Ca!$u"an 9iDaks 5 6alsi$a"u! , hal
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Pen&(atan denan ihd"&a"te!isinin-Pi$e"akuinPen&(atan denan ihd"&a"te!isinin-Pi$e"akuin
)-P)-PHariHari %eis %eis
o5ato5at %umlah ta5let meurut kelompok umur %umlah ta5let meurut kelompok umur
6dosis tuggal76dosis tuggal7
( $ 8( $ 8
5ula5ula'' – –
8888 5ul5ul
aa
88 – – ))
tatahuhu
22 – – 99
tahtahuu
8(8( – – 8)8)
tahutahu
:: 8282
tahutahu
8$$;8$$; DHPDHP ¼¼ ½½ 88 832832 '' ; $ ); $ )
H8H8 PrimakuiPrimakui
$$$$ $$$$ 88 ½½ '' ' $ ;' $ ;
H'H' – – 8)8) PrimakuiPrimakui
$$ $$ ¼¼ ½½ 88Dihydroartemisinin(DH) : 2-4 mg/kgBB (1tablet = 40 mg)i!erak"in !hos!hate(): 1#-$2 mg/kgBB ( 1tablet = $20 mg)
rimak"in : 0&2 mg 0&' mg/kg BB
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Case 1 ulCase 1 ul
20102010
G&!an, >* ea"s &ld, heada/he >G&!an, >* ea"s &ld, heada/he >
das, #eDe" and /&ld, a/hin Hh&ledas, #eDe" and /&ld, a/hin Hh&le
li!(s, e$iast"i/ $ain, nauseated%li!(s, e$iast"i/ $ain, nauseated%
7ell&H skin 1 Heek, da"k u"ine > das 7ell&H skin 1 Heek, da"k u"ine > das
LiDed in T&!(atu a"eaLiDed in T&!(atu a"ea
P% E 3 /&un/i&us, aundi/e, %P%P% E 3 /&un/i&us, aundi/e, %P%
1;0:
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La(&"at&" 3 )(% 12%; "?, )t ;=?, ESR 4>La(&"at&" 3 )(% 12%; "?, )t ;=?, ESR 4>
!!:1 h", leu/& %000% Mala"ia #al/i$% Rin 5555,O>000 $a": 200 GC, 21 $a": 1000 RC%O>000 $a": 200 GC, 21 $a": 1000 RC%
U"inalsis 3 ell&H, lu -, (il ;5, ket ne, S.U"inalsis 3 ell&H, lu -, (il ;5, ket ne, S.
1%01>, $) >%>, $"& ;5, u"& 0%2, nit -, leu 1%01>, $) >%>, $"& ;5, u"& 0%2, nit -, leu
ALT 10@, AST 144, P"&tein *%;, al( ;%
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SE9ERE MALARIA -2010SE9ERE MALARIA -2010
9
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MALARIA ERATMALARIA ERAT%&'&()& *+(+,(&'
%&'&()& D. ,)')(!,). > # %/&&' ).J&' &! " 400 ml24 3am reat > # mg/
H)6')+%) " 40 mg/
*76 *)*6') " 80 mmHg &nak " 50 mmHg
&.+%)& ,+(& H, " 5 gr/ Ht " 15/+D+%& &(! &(D*
+(D&(&H&. *6.&. D)
+J&. ,+(!'&.
&*)D6*)* h "8:15 ; lasma ,i
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PEN7EA : ETI+L+.IPEN7EA : ETI+L+.I
Plas!&diu! #al/i$a"u!Plas!&diu! #al/i$a"u!
Mied $las!&diu! 6al/i$a"u!5Mied $las!&diu! 6al/i$a"u!5
DiDaDiDa
Plas!&diu! DiDaPlas!&diu! DiDa
!las"o#iu" $nowlesi!las"o#iu" $nowlesi
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PLASM+IUM KN+GLESIPLASM+IUM KN+GLESI
Si!ian !ala"ia Ma//a/a !ullataSi!ian !ala"ia Ma//a/a !ullata Unusual $"esentati&n P% Mala"iaeUnusual $"esentati&n P% Mala"iae ian&sis ( PCRian&sis ( PCR A/ute dia"e, a(d&!inal $ain, aundi/eA/ute dia"e, a(d&!inal $ain, aundi/e
Alid !ala"ia, h$&tensi&nAlid !ala"ia, h$&tensi&n
Renal #ailu"e, "es$i"at&" #ailu"eRenal #ailu"e, "es$i"at&" #ailu"e
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M##=1M1* "1V1R1M##=1M1* "1V1R1
M#L#R-#M#L#R-# SPECI6IC TREATMENTSPECI6IC TREATMENT
ANTI MALARIAL RU.SANTI MALARIAL RU.S
+R.AN 6AILURE TREATMENT+R.AN 6AILURE TREATMENT SUPP+RTI9E TREATMENTSUPP+RTI9E TREATMENT
ANCILLAR7 TREATMENTANCILLAR7 TREATMENT
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ANTI MALARIAL THERAPY FOR S.MANTI MALARIAL THERAPY FOR S.M
FUININEFUININE
FUINIINEFUINIINE
A"tesunate: ARTS i%D%: i%! : su$$ A"tesunate: ARTS i%D%: i%! : su$$ A"te!ethe" : ARTM i%!%A"te!ethe" : ARTM i%!%
A"te-ethe" i%! A"te-ethe" i%!
A"te!isinin su$$ A"te!isinin su$$ ihd"&-a"te!isinin su$$ ihd"&-a"te!isinin su$$
A"telinate i%DA"telinate i%D
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"1V1R1 M#L#R-#"1V1R1 M#L#R-#
Re'ui"ed $a"ente"al &" su$$&ssit&"ia t"eat!entRe'ui"ed $a"ente"al &" su$$&ssit&"ia t"eat!ent e/"eased $a"asite!ia "a$idle/"eased $a"asite!ia "a$idl
Less side ee/tLess side ee/t
Fuinine Ds A"te!isinin ARTM , ARTS Fuinine Ds A"te!isinin ARTM , ARTS
ARTM t"end t& haDe l&H !&"talit (ut /&!aARTM t"end t& haDe l&H !&"talit (ut /&!a"e/&De" $"&l&n, !&"e /&nDulsi&n"e/&De" $"&l&n, !&"e /&nDulsi&n
ARTS ette" than Fuinine SEFUAMAT ARTS ette" than Fuinine SEFUAMAT
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9osis
R1!MM1D1D D"1" F #*- M#L#R-#L DR=" FRR1!MM1D1D D"1" F #*- M#L#R-#L DR=" FR
*R1#*M1* F "1V1R1 M#L#R-#*R1#*M1* F "1V1R1 M#L#R-#
i%D% 2,4 !:k $ada a! 0, dani%D% 2,4 !:k $ada a! 0, dan a! 12, ke!udian dilanutkan a! 12, ke!udian dilanutkan a! 24, 4< dst sa!$ai * ha"i% a! 24, 4< dst sa!$ai * ha"i%&sis t&tal 1* 1< !: * ha"i&sis t&tal 1* 1< !: * ha"i 1 A!$ =0 ! 1 A!$ =0 !
;%2 !:k i! $ada ha"i I di(ai 2;%2 !:k i! $ada ha"i I di(ai 2d&sis, dilanutkan 1%= !:k:d&sis, dilanutkan 1%= !:k:ha"i% TIAK iD 1 a!$
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Dosis ARTEMISININ PADA MALARIADosis ARTEMISININ PADA MALARIABERAT BERAT
# ARTEMETER $ %an&a I.M $ 'osis ($) *g"+g BB
ARTESUNATE
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ARTESUNATE
I.V / I.M
1 6l =0 !
ARTEMETHER I.M1 A!$
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SEFUAMAT
9S
AFUAMAT
% 2005, &ancet, 'gst (
%2010, &ancet, )o* (
S&uth East-asia FUinine A"tesunateMala"ia T"ial
A#"i/a Funine A"tesunate
Mala"ia T"ial
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P#=F/ 'ag. Pen(akit Dalam
F: B>R!T/ R>BP =anad%
R>B 'et)esda -T%m%)%n
Telp.7
1-021/19 R>B 'et)esda&
82-1-289 *P& 1-08 Res&
E-mail 7 paul)ariant%gmail.$%m
Sa"+ai a$u a+a
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M+RTALIT7
0%1? /ase #atalit "ate $"&Dided$"&!$t and ee/tiDe t"eat!ent
Inee/tiDe, delaed seDe"e!ala"ia
SeDe"e !ala"ia, !&"talit 1> 20 ?
Unt"eated seDe"e !ala"ia, al!&stalHas #atal
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TREATMENT +JECTI9ES
Un/&!$li/ated !ala"ia 3 Cu"e in#e/ti&n P"eDent $"&"essi&n seDe"e disease P"eDent !&"(idit ass&/iated Hith t"eat!ent
#ailu"e Redu/ed t"ans!issi&n P"eDent the e!e"en/e 8 s$"ead "esistan/e
anti!ala"ial
SeDe"e Mala"ia 3 P"eDent death P"eDenti&n "e/"udes/en/e AD&iden/e !in&" adDe"se ee/ts
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>>>>
ase 1:
*aki-laki0 31 ta8un0 peker,a tam6an$ emas di !alma8era
#IosoDo% masuk =>0 31 Bkto6er 2++: den$an kelu8an PA@A>
9?@I?@0 4 8ari se6elum masuk => *ima 8ari se6elumnGa pasien ,u$a merasa sakit perut06a6 cair 170 =iDaGat PenGakit 9a8ulu L
>eptem6er 2++: Malaria FiJa7 di !alma8era dio6ati Klorouin 2-
2-1 dan Primakuin 172 ta6let selama 14 8ari
Pemeriksaan Fisik : >adar0 T9 13+/+mm!$0 nadi :.7/menit0su8u 4+NC0 tidak tampak anemia0 >clera tidak icteric &antun$
dan Paru dalam 6atas normal A6domen supel0nGeri tekan
epi$astrium#%0 8epar dan lien tidak tera6a mem6esar0 timpani0
6isin$ usus normal Hasil Laoratorium: !6 131 $r0 !t 3:L
*euko 41++/mm30 Trom6osit 41+++/mm30 Plasmodium JiJa7 rin$
!ia"nosa #er$a :OOOOOOO
ISKUSI
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>=>=
ISKUSI 31%.eala de!a! 8 dia"e 3 .eala n&n-klasik 2%Plas!&diu! 9iDa Rin 555 , satu (ulanse(elu!na DiDa $&s% Rela$s : Re-/"udensi : Re-in#eksi
;% )asil La(&"at&"iu! 3 T"&!(&sit&$enia 41%000: !!;% Se"in didian&se enue A$a na
4% Pen&(atan Mala"ia se(elu!na denan 3CF 5 PF 2 t(:14 ha"i% A$a $en&(atan
an (ena"
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Pene(a( T"&!(&sit&$eniaPene(a( T"&!(&sit&$enia
e#e/ts the !a""&He#e/ts the !a""&H
Se'uest"ati&n due t& s$len&!ealSe'uest"ati&n due t& s$len&!eal
A//ele"ated dest"u/ti&n 3A//ele"ated dest"u/ti&n 3In#e/ti&ns denue, !ala"ia, t$h&id,In#e/ti&ns denue, !ala"ia, t$h&id,
"a! ne "a! ne
"us"usAut&i!!uneAut&i!!une
>*>*
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ian&saian&sa
andin 3andin 3
!6 131 $r0 !t 3:L *euko 41++/mm30!6 131 $r0 !t 3:L *euko 41++/mm30
Trom6osit 41+++/mm3 9en$ue infection Trom6osit 41+++/mm3 9en$ue infection
><
'andingkan kasus ini 7
*ari ?. *b 9 gr6, *t 006, Leuk% 1, Tr%mb% .*ari ?? 7 *b, 0.0 gr6, *t 06, Tr%mb% .
*ari ???7 *b 1.0 gr6, *t 16, Tr%mb% 2.
*ari ?7 *b 1.0 gr6, *t 196, Tr%mb% 2.
* t l Ai di i t t ti li t d*emat%l%g Aindings in a$ te s mpt%mati$ n$%mpli$ated
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*emat%l%g( Aindings in a$ute s(mpt%mati$ un$%mpli$ated*emat%l%g( Aindings in a$ute s(mpt%mati$ un$%mpli$ated
P.falciparumP.falciparum malaria patients %n admissi%n "9&malaria patients %n admissi%n "9&
!nemia 6&!nemia 6& 7 7 9.&9.&*em%gl%bin7 means range&g/dl 7 2.*em%gl%bin7 means range&g/dl 7 2. 9. - 0.8&9. - 0.8&
Er(t)r%$(te7 means range&/ul in milli%nEr(t)r%$(te7 means range&/ul in milli%n 7 1.27 1.2 2.9 G0.&2.9 G0.&
Leuk%$(te7 means range&/ulLeuk%$(te7 means range&/ul 7 0,8 2,9 G ,2&7 0,8 2,9 G ,2&Platelet7 means range&/ul in t)%usandPlatelet7 means range&/ul in t)%usand 7 27 2 0 G 2&0 G 2&
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PEN.+ATAN 3PEN.+ATAN 3
CF; 5 PF 2 ta(;0!: ha"i , 14 ha"iCF; 5 PF 2 ta(;0!: ha"i , 14 ha"i
Pen&(atan an (ena" Pen&(atan an (ena"
=0=0
PLASM+IUM KN+GLESIPLASM+IUM KN+GLESI
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PLASM+IUM KN+GLESIPLASM+IUM KN+GLESI
The 6i#th Mala"ia The 6i#th Mala"iaulu hana !enin#eksi ke"a Ma/a/a Mullataulu hana !enin#eksi ke"a Ma/a/a Mullata Seak th 2004 dila$&"kan "et"&s$eksi# di Se"aHakSeak th 2004 dila$&"kan "et"&s$eksi# di Se"aHak9e/t&" An&$heles leu/&s$h"us "&u$ An% Laten,9e/t&" An&$heles leu/&s$h"us "&u$ An% Laten,
/"a/ens/"a/ensMisdian&sis se(aai !ala"ia !ala"iae,Misdian&sis se(aai !ala"ia !ala"iae,!ik"&sk&$ik !ene"u$ai P% !ala"iae!ik"&sk&$ik !ene"u$ai P% !ala"iae
Klinis TIAK se$e"ti !ala"iaeKlinis TIAK se$e"ti !ala"iae, de!a! tia$ 24 a!,, de!a! tia$ 24 a!,
dia"ea, ne"i a(d&!en dan dite!ukandia"ea, ne"i a(d&!en dan dite!ukanhi$e"$a"asite!ia O 2>0%000:uLhi$e"$a"asite!ia O 2>0%000:uLa$at !e!(e"ikan k&!$likasi ikte"ik, hi$&tensi,a$at !e!(e"ikan k&!$likasi ikte"ik, hi$&tensi,
aal inal, se"e("al dan aal $e"na#asanaal inal, se"e("al dan aal $e"na#asan
ian&sa $asti identikasi denan PCRian&sa $asti identikasi denan PCR
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Mala"ia Kn&Hlesi
IA.N+SISIA.N+SIS
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IA.N+SISIA.N+SISP"esentasi Klinis e"Da"iasiP"esentasi Klinis e"Da"iasi
.eala e!a! se"in dikeli"ukan denan.eala e!a! se"in dikeli"ukan denanin#eksi lain Ti#&id, enue,in#eksi lain Ti#&id, enue,
Le$t&s$i"&sis, Chinkukuna, ISPA Le$t&s$i"&sis, Chinkukuna, ISPA
K&!$likasi $enu"unan kesada"an, se"inK&!$likasi $enu"unan kesada"an, se"indikeli"ukan denan !eninitis,dikeli"ukan denan !eninitis,
ense#alitis, ense#al&$ati lainnaense#alitis, ense#al&$ati lainna
Jaundi/e:ikte"ik se"in didian&sis Jaundi/e:ikte"ik se"in didian&sisse(aai he$atitis atau k&lesistitisse(aai he$atitis atau k&lesistitis
ETEKSI PARASIT MIKR+SK+PIK atauETEKSI PARASIT MIKR+SK+PIK atau
RT RT
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Go"o$a ARTEMISININGo"o$a ARTEMISININ
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Go"o$a ARTEMISININGo"o$a ARTEMISININArte!isii& Artesate& Arte!etCer& ArteetCer& ,AArte!isii& Artesate& Arte!etCer& ArteetCer& ,A
H DD0i$Caos F Sesiterpee Lactoe0i$Caos F Sesiterpee Lactoe
H Lart da"a! air da dia4sor4si 4aikLart da"a! air da dia4sor4si 4aik
H E-ek 4C parasit 7a$ cepatE-ek 4C parasit 7a$ cepat
H epat diko?ersi ke 4aCa akti- ,ABepat diko?ersi ke 4aCa akti- ,AB
H tt1/81/8 i !a"aria. 8 Corsi !a"aria. 8 Cors
H Spektr! 7a$ "as tk se!a Heis parasit daSpektr! 7a$ "as tk se!a Heis parasit da
sta$i$sta$i$H 'i"a dipakai !ootCerap7& per" * Cari'i"a dipakai !ootCerap7& per" * Cari
H ireko!edasika pe$$aa ATireko!edasika pe$$aa AT
A t i i i ( C (i tiA"te!isinin (ase C&!(inati&n
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A"te!isinin-(ase C&!(inati&nA"te!isinin-(ase C&!(inati&n
The"a$ A%C%T The"a$ A%C%TRa$id /le"an/e $a"asitesRa$id /le"an/e $a"asites
Ra$id "es&luti&n s!$t&!sRa$id "es&luti&n s!$t&!s
Redu/e $a"asites ( 10%000://le $astRedu/e $a"asites ( 10%000://le $ast
anti!ala"ial &nl 100-1000 $a"asites:anti!ala"ial &nl 100-1000 $a"asites://le//le
Eli!inated "a$idl3Eli!inated "a$idl3 Hhen iDen t& "a$id d"u eli!inati&n, sh&uldHhen iDen t& "a$id d"u eli!inati&n, sh&uld
iDe &n * dasiDe &n * das
Ghen iDen /&!( Hith sl&H eli!inated, sh&"te"Ghen iDen /&!( Hith sl&H eli!inated, sh&"te"
/&u"se t"eat!ent ; das a"e ee/tiDe /&u"se t"eat!ent ; das a"e ee/tiDe
h =i l? & bi tih =i l? & bi ti
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he =ieal? & upplG o6at cukup
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URRENT APPROA, MALARIA TREATMENTURRENT APPROA, MALARIA TREATMENT
'ased o !icroscopic dia$osis'ased o !icroscopic dia$osis o!4iatio tCerap7o!4iatio tCerap7Mst radica" treat!etMst radica" treat!et Otco!e -ocs o c"iica" cre& parasito"o$ica"Otco!e -ocs o c"iica" cre& parasito"o$ica"
c"earace& ad 4"ocki$ tras!issioc"earace& ad 4"ocki$ tras!issioMoitori$ tCerapetic e--icac7 ati!a"aria" dr$s 4asedMoitori$ tCerapetic e--icac7 ati!a"aria" dr$s 4ased
o c"iica" ad parasito"o$ica" resposes o c"iica" ad parasito"o$ica" resposes in-vivoin-vivo 8
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Re/&!!endati&n G)+Re/&!!endati&n G)+
20102010in usin ACTs 3in usin ACTs 3
A"te!ethe"-lu!e#ant"ine AL A"te!ethe"-lu!e#ant"ine AL
A"tesunate 5 a!&dia'uine AS 5 AF A"tesunate 5 a!&dia'uine AS 5 AF A"tesunate 5 !eQ&'uine AS 5 MF A"tesunate 5 !eQ&'uine AS 5 MF
A"tesunate 5 sul#ad&ine-$"i!etha!ineA"tesunate 5 sul#ad&ine-$"i!etha!ine
AS 5 S-P AS 5 S-P ihd"&a"te!isinin Pi$e"a'uine )A-ihd"&a"te!isinin Pi$e"a'uine )A-
PPF PPF
Pen&(atan Mala"ia $adaPen&(atan Mala"ia $ada
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Pen&(atan Mala"ia $adaPen&(atan Mala"ia $ada
keha!ilankeha!ilan
Pakai &(at an e#ekti# Pakai &(at an e#ekti# Pe"ti!(ankan kea!anan &(at untukPe"ti!(ankan kea!anan &(at untuk
keha!ilankeha!ilan
PENTIN. 3PENTIN. 3e"atna $enakit Mala"iae"atna $enakit Mala"iaP&la "esitensi $en&(atanP&la "esitensi $en&(atan
A$a &(at an a!anA$a &(at an a!anACT untuk t"i!este" 2 8 ; A-L 8 A"s5MACT untuk t"i!este" 2 8 ; A-L 8 A"s5MKina )Cl denan: tan$a /linda!/inKina )Cl denan: tan$a /linda!/in
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i"th &ut/&!esi"th &ut/&!es
Pen&(atan u!il Tan$aPen&(atan u!il Tan$a
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Pen&(atan u!il Tan$aPen&(atan u!il Tan$a
k&!$likasi e$Kesk&!$likasi e$KesPlas!&diu! 6alsi$a"u! 3Plas!&diu! 6alsi$a"u! 3ACT A"s 5 A!&, tan$a P', T"i!este" 2ACT A"s 5 A!&, tan$a P', T"i!este" 2
-;-;
Kina ; 2-; t(, tan$a P', T"i!este" 1Kina ; 2-; t(, tan$a P', T"i!este" 1atau aal ACT Kina 5 Clinda!/in 2 atau aal ACT Kina 5 Clinda!/in 2
10 !:k : * ha"i10 !:k : * ha"i
Plas!&diu! 9iDaks 3Plas!&diu! 9iDaks 3Kl&"&'uin 4:4:2 t( , tan$a $"i!akuinKl&"&'uin 4:4:2 t( , tan$a $"i!akuin
Pen&(atan u!il Mala"iaPen&(atan u!il Mala"ia
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Pen&(atan u!il Mala"iaPen&(atan u!il Mala"ia
e"ate"at
T"i!este" 2 -; , du"ante: $&st $a"tu! 3 T"i!este" 2 -; , du"ante: $&st $a"tu! 3A"tesunate i%D 2,4 !:k a! 0, 12,A"tesunate i%D 2,4 !:k a! 0, 12,
24, 4< dst, (ila sada": (isa !inu!24, 4< dst, (ila sada": (isa !inu!
&(at anti &"al sa!$ai > * ha"i% ila&(at anti &"al sa!$ai > * ha"i% ila
&"al a"tesunate 2 !:k di(e"ikan&"al a"tesunate 2 !:k di(e"ikansa!$ai ha"i ke-* a"s 5 /linda!/insa!$ai ha"i ke-* a"s 5 /linda!/in
T"i!este" 1 3 Kina )Cl $e"in#us, 20 T"i!este" 1 3 Kina )Cl $e"in#us, 20
!:k d&sis aHal dan 10 !:k !:k d&sis aHal dan 10 !:k selanutnaselanutna
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hal% ;1
r$sr$s Ta4 siJeTa4 siJe Ad"tAd"t Ci"dCi"d Pre$Pre$ IitiateIitiate iscotiediscotied
9ru$ re$imens for prop8Gla7is a$ainst malaria
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r$sr$s Ta4 siJeTa4 siJe
mgmgAd"tAd"t
dosedoseCi"dCi"d Pre$Pre$ IitiateIitiate iscotiediscotied
Areas itC C"oroie F resistat :a"cipar!Areas itC C"oroie F resistat :a"cipar!
!t%@a#u%ne-!t%@a#u%ne-Pr%guanilPr%guanil
20-20-92.0-2092.0-20
11tb/dtb/d IesIes %% -2 d-2 d da(s da(s
=eAl%#uine *Cl=eAl%#uine *Cl 2020 11tb/Jtb/J IesIes IesIes Jks Jks 1 Jks1 Jks
o@7c7c"ieo@7c7c"ie 11 11t4/dt4/d NoNo NoNo 168 d168 d 2 ks2 ks
Areas itC C"oroie6 sesiti?e :a"cipar!Areas itC C"oroie6 sesiti?e :a"cipar!
C)l%r%#uineC)l%r%#uine 00 tb/Jtb/J IesIes IesIes Jk Jk 1 Jks1 Jks
Areas itC P9 ?i?a@& P o?a"e itC/ itCot P9 :acipar!Areas itC P9 ?i?a@& P o?a"e itC/ itCot P9 :acipar!
Prima#uinePrima#uine
primar(primar(
00 22
tb/dtb/d
IesIes %% Jk Jk 1 Jks1 Jks
Prima#uinePrima#uine
!nti-relaps!nti-relaps
00 22
tb/dtb/d
IesIes %% da( da( da(s da(s
engobatan ina Hli-hiroklori parenteralengobatan ina Hli-hiroklori parenteral
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00 44 $$ 1212 1@1@ 2020 2424
'oaing'oaing
20 mgkg,, )A inBus100-200 ml4 3am20 mgkg,, )A inBus100-200 ml4 3am
,erat baan C: g,erat baan C: g
ak pakai ina%eBlouin 24 3am sebelumnEaak pakai ina%eBlouin 24 3am sebelumnEa
iak lan3ut usia atau FF< int: pan3angiak lan3ut usia atau FF< int: pan3ang
10 mgkg,,10 mgkg,,
)A inBus 200 ml4 3am)A inBus 200 ml4 3am
iulang tiap $ 3amiulang tiap $ 3am)nBus kosong $ 3am)nBus kosong $ 3am
Gtanpa kinaGtanpa kina
)nBus kosong $ 3am)nBus kosong $ 3am
Gtanpa kinaGtanpa kina
I&! GJ&%I&! GJ&%
*tanar*tanar
10 mgkg,, )A10 mgkg,, )A
inBus200 ml4 3aminBus200 ml4 3am
SETELAH KESADARAN MEMBAIK/DAPAT MINUM :SETELAH KESADARAN MEMBAIK/DAPAT MINUM :
GANTI PER-ORAL 10 MG/KGBB/8 JAMGANTI PER-ORAL 10 MG/KGBB/8 JAM
SAMPAI HARI KE-7SAMPAI HARI KE-7
APABILA SETELAH 48 JAMAPABILA SETELAH 48 JAM
KEADAAN TIDAK MEMBAIK :KEADAAN TIDAK MEMBAIK :
GCS TETAP/MEMBURUK GCS TETAP/MEMBURUK
BILIRUBIN / KREATININ NAIK BILIRUBIN / KREATININ NAIK
URIN KURANG / TAK ADAURIN KURANG / TAK ADA
DOSIS DITURUNKAN 30-50%DOSIS DITURUNKAN 30-50%
10 mgkg,,10 mgkg,,
)A inBus 200 ml4 3am)A inBus 200 ml4 3am
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9e7trose '
Kina
Microdrips
1++-2++ cc
Pi$$G
"ackCairan
Maintenance
!#R# P1M>1R-#!#R# P1M>1R-#
1R#*
engobatan ina Hli-hiroklori parenteralengobatan ina Hli-hiroklori parenteral
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00 44 1212 1@1@ 2020 2424
I&! GJ&%I&! GJ&%
500 mg ina Hl G1 amp500 mg ina Hl G1 amp
alam 500
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Penesuaian d&sis $ada anuan 6unsi +"ane esua a d&s s $ada a ua u s + a
Ti'a+ ,-rlu ,-n&-suaian 'osis obat '-riat art-*isininTi'a+ ,-rlu ,-n&-suaian 'osis obat '-riat art-*isinin,a'a gangguan /ungsi %ati 'an atau gin0al,a'a gangguan /ungsi %ati 'an atau gin0al Dosis +ina ,ar-nt-ral 'iturun+an ("1 s-t-la% 23 0a*Dosis +ina ,ar-nt-ral 'iturun+an ("1 s-t-la% 23 0a*
,-*b-rian ,a'a 4,-*b-rian ,a'a 4 Gagal gin0al a+utGagal gin0al a+ut Gangguan /ungsi %atiGangguan /ungsi %ati Ti'a+ a'a ,-rbai+an +linis s-t-la% 23 0a*Ti'a+ a'a ,-rbai+an +linis s-t-la% 23 0a* Bila ,asi-n su'a% %-*o'ialisis ti'a+ ,-rluBila ,asi-n su'a% %-*o'ialisis ti'a+ ,-rlu
,-ngurangan 'osis +ina,-ngurangan 'osis +ina
( l P ( t l t
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Pen&(atan lanutanPen&(atan lanutan S-t-la% ,asi-n sa'ar"K *-*bai+$ t5. A6al ,ar-nt-ralS-t-la% ,asi-n sa'ar"K *-*bai+$ t5. A6al ,ar-nt-ral
'a,at 'iuba% 'gn. T5. Oral'a,at 'iuba% 'gn. T5. Oral Dit-rus+an '-ngan 4Dit-rus+an '-ngan 4 A7T 'osis l-ng+a, 8s-la*a 1 %ari94 AL $ AS : A;A7T 'osis l-ng+a, 8s-la*a 1 %ari94 AL $ AS : A; Art-sunat-"art-*-t%-r tab. 8total < %ari 9 : 'o+sisi+lin 1=Art-sunat-"art-*-t%-r tab. 8total < %ari 9 : 'o+sisi+lin 1=
> Kg BB ( +ali s-%ari s-la*a < %ari> Kg BB ( +ali s-%ari s-la*a < %ari Kina tab.8total < %ari9 : 'o+sisi+lin < %ariKina tab.8total < %ari9 : 'o+sisi+lin < %ari Bagi bu*il$ ana+=ana+ 4 'o+sisi+lin 'iganti '-nganBagi bu*il$ ana+=ana+ 4 'o+sisi+lin 'iganti '-ngan
+lin'a*isin (? *g"Kg BB @ +ali s-%ari+lin'a*isin (? *g"Kg BB @ +ali s-%ari
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Pen&(atan $"e-"e#e"alPen&(atan $"e-"e#e"al
ianu"kan se(elu! !e"uuk setidaknaianu"kan se(elu! !e"uuk setidaknad&sis $e"ta!a &(at anti!ala"ia $a"ente"ald&sis $e"ta!a &(at anti!ala"ia $a"ente"alsudah di(e"ikan%sudah di(e"ikan%
+(at an di$ilih 3+(at an di$ilih 3 A"te!ethe" i%!% atau A"tesunate i%!%A"te!ethe" i%!% atau A"tesunate i%!% A"tesunate atau a"te!isinin su$&sit&"iaA"tesunate atau a"te!isinin su$&sit&"ia
Kina i%!%Kina i%!% Kina i%D% dida!$ini $etuas !edis Kina i%D% dida!$ini $etuas !edis
Case Jul 200>Case Jul 200>
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J J
P"ia, >; th, de!a! > ha"i se(elu! MRS, !eniil, sakitP"ia, >; th, de!a! > ha"i se(elu! MRS, !eniil, sakitke$ala, (e"ke"inat, ne"i ulu hati, (adan kunin%ke$ala, (e"ke"inat, ne"i ulu hati, (adan kunin%
i"uuk da"i PKM dn dian&sa !ala"ia DiDa denani"uuk da"i PKM dn dian&sa !ala"ia DiDa denan!elena, Se(elu! (e"&(at di PKM di&(ati &leh (idan!elena, Se(elu! (e"&(at di PKM di&(ati &leh (idan%%Pende"ita ua !eneluh dia"ea ; h" se( ke RS, di&(atiPende"ita ua !eneluh dia"ea ; h" se( ke RS, di&(atidenan CF 4:4:2denan CF 4:4:2
P% 6isik 3 kesada"an (aik, tensi @0:=, nadi 100 : !enit,P% 6isik 3 kesada"an (aik, tensi @0:=, nadi 100 : !enit,"es$ 24:!enit, te!$ ;@C, ane!is 5, ikte"us 5% Jantun"es$ 24:!enit, te!$ ;@C, ane!is 5, ikte"us 5% Jantundan $a"u n&"!al% )e$at&!eali, lien tak te"a(a%dan $a"u n&"!al% )e$at&!eali, lien tak te"a(a%
ian&sa 3 Mala"ia e"atian&sa 3 Mala"ia e"at
La(&"at&"iu! 3 )( @,> "?, leuk& 4*00, t"&!(&La(&"at&"iu! 3 )( @,> "?, leuk& 4*00, t"&!(&1*%000, di% leuk& 3 -:-:2=:42:;0:2, LE 40, )t 2
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La(&"at&"iu!La(&"at&"iu!U"eu! 20> !:dl, /"eatinin ;,1= !:dl, (ili"u(inU"eu! 20> !:dl, /"eatinin ;,1= !:dl, (ili"u(in
t&tal >,@ !:dl di"ek ;,< !:dl, AST 2>;t&tal >,@ !:dl di"ek ;,< !:dl, AST 2>;
u:dl, ALT
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P#=F/ 'ag. Pen(akit Dalam
F: B>R!T/ R>BP =anad%
R>B 'et)esda -T%m%)%n
Telp.7
1-021/19 R>B 'et)esda&
82-1-289 *P& 1-08 Res&
E-mail 7 paul)ariant%gmail.$%m
Sa"+ai a$u a+a
TREATMENT +6 +R.AN 6AILURETREATMENT +6 +R.AN 6AILURE
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TREATMENT +6 +R.AN 6AILURE TREATMENT +6 +R.AN 6AILURE
1!1PH#LP#*H,/ !VL"-1!1PH#LP#*H,/ !VL"-R1#L F#-LR1R1#L F#-LR1
R1"P-R#*R, F#-LR1R1"P-R#*R, F#-LR1
#!-D"-"#!-D"-"H,P=L,!#1M-#H,P=L,!#1M-#
H,P1R>-L-R>-#1M-#H,P1R>-L-R>-#1M-#
H,P*1"-H,P*1"-
"1P"-""1P"-"
"1V1R1 ##1M-#"1V1R1 ##1M-#
A 2
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+n @ Se$te!(e" 2002 at 10%00 a%!%
Falcip ? +gamet
H5. 8'.;>l. "ugar ?8(2 mg@
>ill. Dir? A.B>ill.idir? 8."=* ?8B' u"=P* ? 8(9u
==* ? )C u/L#l.P)? ;A9!reat ? 8.2 pH ? B.)H!; ? ';.Cp' ? C(p!'? ;B>.1x.?$ (.9< ? ;.'!"F ?!ell E '((L&mph. ?9)
-
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7-r-bral Malaria 6it% in/iltrat- bot% lungMM1-;
!hest$ra&
8C hours#fteradmissio
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23 %ours a/t-r uinin- tr-at*-nt MM1-4
CLINICAL MANI6ESTATI+NCLINICAL MANI6ESTATI+N
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CMCMNEUROLOGIAL SNROME . I::USE& POTENTIALLNEUROLOGIAL SNROME . I::USE& POTENTIALL
RAPIL REERSI'LE ENEP,ALOPAT, ASSOIATERAPIL REERSI'LE ENEP,ALOPAT, ASSOIATE
IT, LOSS O: ONSIOUSNESS AN :ITTINGIT, LOSS O: ONSIOUSNESS AN :ITTING
mild meningism, n% ne$k rigidit(mild meningism, n% ne$k rigidit(
d(s$%nugate gaKed(s$%nugate gaKe
@erti$al n(stagmus@erti$al n(stagmus
.? pals(.? pals(
d%lls e(e, %$ul%@estibular reAle; n%rmal resp%nsed%lls e(e, %$ul%@estibular reAle; n%rmal resp%nse
s(metri B=, in$reased t%ne 4 erk, $l%nus, e;tens%rs(metri B=, in$reased t%ne 4 erk, $l%nus, e;tens%r plantar resp%nse + , brisk
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Respo mataRespo mata ? spota? spota ))dg suaradg suara ;;
dg &eridg &eri ''tak ada reaksitak ada reaksi 88
Respo >icaraRespo >icara ? ormal respo? ormal respo 225igug5igug ))
5erkata kacau5erkata kacau ;;suara meritihsuara meritih ''tak ada suaratak ada suara 88
Respo motorik? geraka ormalRespo motorik? geraka ormal AA
dapat melokalisir &eridapat melokalisir &eri 22eksi thdp &erieksi thdp &eri ))extesiextesi ;;decere5rate rigidit&decere5rate rigidit& ''tak ada reaksitak ada reaksi 88
TOTAL ( 66 15
'"at7re o!a Sca"e !odi-ikasiB'"at7re o!a Sca"e !odi-ikasiB
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7 B7 B
Respo mataRespo mata ??
megikuti GaIah i5umegikuti GaIah i5u 88tak ada reaksitak ada reaksi ((
Respo >icaraRespo >icara ??
meagis GaIarmeagis GaIar ''
meagis meritihmeagis meritih 88
tak ada suaratak ada suara((
Respo motorik Respo motorik ??
melokalisir &erimelokalisir &eri ''
mearik aggota o.k. &erimearik aggota o.k. &eri 88
tak ada reaksitak ada reaksi ((
TOTAL 66*
ACUTE KINE7 INJUR7 AKIACUTE KINE7 INJUR7 AKI
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Mala"ia "elated A/ute Kidne Inu" MAKIMala"ia "elated A/ute Kidne Inu" MAKI
Penu"unan #unsi inal dala! 4< a! 3Penu"unan #unsi inal dala! 4< a! 3Peninkatan se"u! k"eatinin 0%; !:dL, atauPeninkatan se"u! k"eatinin 0%; !:dL, atau
Peninkatan se"u! k"eatinn >0? dan nilaiPeninkatan se"u! k"eatinn >0? dan nilai
dasa", ataudasa", atauPenu"unan u"in &ut$ut 0%> !l:k:a! untuk =Penu"unan u"in &ut$ut 0%> !l:k:a! untuk =
a! a!
G)+ 3 se"u! k"eatinin O ; !:dLG)+ 3 se"u! k"eatinin O ; !:dL
Se"in $ada !ala"ia deHasa dan a"anSe"in $ada !ala"ia deHasa dan a"an
$ada anak$ada anak
ACUTE RENAL 6AILURE IN SE9ERE MALARIAACUTE RENAL 6AILURE IN SE9ERE MALARIA
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ACUTE RENAL 6AILURE IN SE9ERE MALARIAACUTE RENAL 6AILURE IN SE9ERE MALARIA
PRE-RENAL RENAL
U!"# S$G 1$0&0 '1$010
U!"# O()$ 500 '350
*)O()/+, H&O
U!"# N. *)#/L '10 &0P.(). BUN/C#.!"!"# 15:1 '10-15:1
U/P U#. &0:1 '10:1
U/P C#.!"!"# 40:1 '10:1
U/P O()2.! &:1 '1:1
R#". .!# I"6# '1 1
.9!2". #9#!2" 2
!##6 N. '1 1
PULM+NAR7 MANI6ESTATI+N IN MALARIAPULM+NAR7 MANI6ESTATI+N IN MALARIA
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)ist&"i/all 3)ist&"i/all 3"&n/hiti/"&n/hiti/
Pneu!&ni/Pneu!&ni/
"&n/h&$neu!&ni/"&n/h&$neu!&ni/A/ute Lun Inu" ALIA/ute Lun Inu" ALI
A/ute Res$i"at&" ist"essA/ute Res$i"at&" ist"ess
Snd"&!e ARSSnd"&!e ARS
A R SA%R%%S
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A%R%%SA%R%%S
+//u"s in P% 6al/i$a"u!, P% 9iDa, P% +Dale 8 P%+//u"s in P% 6al/i$a"u!, P% 9iDa, P% +Dale 8 P%Kn&HlesiKn&Hlesi
C&!!&n in adult than /hild"en, $"enan/ andC&!!&n in adult than /hild"en, $"enan/ and
n&n-i!!unen&n-i!!une
Me/hanis! 3 In/"eased alDe&la" /a$$ila"Me/hanis! 3 In/"eased alDe&la" /a$$ila"$e"!ea(ilit$e"!ea(ilit int"aDas/ula" Quid l&ss int& theint"aDas/ula" Quid l&ss int& the
lunsluns
P"esentati&n 3 initial $"esentati&n &" a#te" initiati&nP"esentati&n 3 initial $"esentati&n &" a#te" initiati&n
t"eat!entt"eat!entClini/al 3 a/ute &nset ds$neaClini/al 3 a/ute &nset ds$nea "es$i"at&" #ailu"e"es$i"at&" #ailu"e
CLINICAL 6ININ.CLINICAL 6ININ.
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CLINICAL 6ININ.CLINICAL 6ININ. Mani#est a("u$t &nset ds$n&ea, /&uh, tihtness inMani#est a("u$t &nset ds$n&ea, /&uh, tihtness in
the /hest that $"&"esses "a$idl &De" a #eH h&u"sthe /hest that $"&"esses "a$idl &De" a #eH h&u"s is&"ientati&n and aitati&n is #"e'uentl $"esent%is&"ientati&n and aitati&n is #"e'uentl $"esent%
Phsi/al ea!inati&nPhsi/al ea!inati&n 3 sins "es$i"at&" dist"ess ai"3 sins "es$i"at&" dist"ess ai"
hune", use a//ess&" !us/les "es$i"ati&n,hune", use a//ess&" !us/les "es$i"ati&n,
su$"aste"nal and inte"/&stal ind"aHin , /ent"al andsu$"aste"nal and inte"/&stal ind"aHin , /ent"al and$e"i$he"al /an&sis a"te"ial h$&ae!ia, (asal$e"i$he"al /an&sis a"te"ial h$&ae!ia, (asal
/"e$itati&ns and e$i"at&" Hheein%/"e$itati&ns and e$i"at&" Hheein%
In these $atients, hih $a"asitae!ia,a/ute "enal #ailu"e,In these $atients, hih $a"asitae!ia,a/ute "enal #ailu"e,
h$&l/e!ia, !eta(&li/ a/id&sis, disse!inatedh$&l/e!ia, !eta(&li/ a/id&sis, disse!inatedint"aDas/ula" /&aulati&n IC, and (a/te"ial se$sisint"aDas/ula" /&aulati&n IC, and (a/te"ial se$sis
usuall /&-eist%usuall /&-eist%
Chest "adi&"a$h 3Chest "adi&"a$h 3
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Chest "adi&"a$h 3 $ ilate"al #"&ntal &$a/ities alDe&la"ilate"al #"&ntal &$a/ities alDe&la"
$atte"n, in/"eased inte"stitial !a"kins$atte"n, in/"eased inte"stitial !a"kins The /a"dia/ sie is usuall n&"!al The /a"dia/ sie is usuall n&"!al
Ra"el, thi/kenin lun ssu"es,Ra"el, thi/kenin lun ssu"es,
inte"l&(ula" se$tal linesinte"l&(ula" se$tal lines
Pleu"al eusi&nPleu"al eusi&n
In assisted Dentilat&" 3In assisted Dentilat&" 3/&!$li/ati&ns $neu!&th&"a,/&!$li/ati&ns $neu!&th&"a,
$neu!&!ediastinu! , $neu!&nia !a &//u"$neu!&!ediastinu! , $neu!&nia !a &//u"
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=11R#L "PPR*-V1=11R#L "PPR*-V1M1#"R1"
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M1#"R1"M1#"R1" Patients sh&uld (e t"eated in an ICUPatients sh&uld (e t"eated in an ICU
In ende!i/ a"eas t"eat!ent sh&uld (eIn ende!i/ a"eas t"eat!ent sh&uld (e/&!!en/ed as ea"l as $&ssi(le, s&!eti!es/&!!en/ed as ea"l as $&ssi(le, s&!eti!es
(e#&"e $&sitiDe $a"asit&l&(e#&"e $&sitiDe $a"asit&l&
Patients sh&uld (e Heihed s& that d&se Patients sh&uld (e Heihed s& that d&se
anti !ala"ial /an (e /al/ulatedanti !ala"ial /an (e /al/ulated I9 Quids sh&uld (e iDen t& !aintain QuidI9 Quids sh&uld (e iDen t& !aintain Quid
(alan/e and /al&"i/ "e'ui"e!ents% A /ent"al(alan/e and /al&"i/ "e'ui"e!ents% A /ent"al
line and !&nit&"in /ent"al Den&usline and !&nit&"in /ent"al Den&us
$"essu"e !a (e ne/essa", es$e/iall in$"essu"e !a (e ne/essa", es$e/iall in
elde"l% All intake sh&uld (e "e/&"ded /a"e#ullelde"l% All intake sh&uld (e "e/&"ded /a"e#ull
Ai"Ha, +en "e'ui"e!entAi"Ha, +en "e'ui"e!ent
T"eat h$e"$"eia T"eat h$e"$"eia
=11R#L "PPR*-V1=11R#L "PPR*-V1
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M1#"R1"M1#"R1" U"ina" /athete"iati&n sh&uld (e used t& !&nit&"U"ina" /athete"iati&n sh&uld (e used t& !&nit&"
&ut$ut&ut$ut Patients sh&uld (e &(se"Ded #&" D&!itin% T&Patients sh&uld (e &(se"Ded #&" D&!itin% T&
ensu"e $atients sa#et, /&t-sides !a (e "e'ui"edensu"e $atients sa#et, /&t-sides !a (e "e'ui"ed
Reula" "e-$&siti&nin $atient is ne/essa" t&Reula" "e-$&siti&nin $atient is ne/essa" t&
$"eDent deDel&$!ent $"essu"e s&"es$"eDent deDel&$!ent $"essu"e s&"es Nas&ast"i/ tu(e sh&uld (e aD&ided (e/ause theNas&ast"i/ tu(e sh&uld (e aD&ided (e/ause the
"isk as$i"ati&n"isk as$i"ati&n M+NIT+RIN. .CS 8 9ITAL SI.NM+NIT+RIN. .CS 8 9ITAL SI.N
LA 3 6C, .LUC+SE, PAR%C+UNT, CREATININE, UREUM,LA 3 6C, .LUC+SE, PAR%C+UNT, CREATININE, UREUM,L++ .AS, URINE S%., S+IUM, P+TASSIUM%L++ .AS, URINE S%., S+IUM, P+TASSIUM%
PRE9ENT 3 S)+CK, SEPTICAEMIA, ACI+SIS, ARS,PRE9ENT 3 S)+CK, SEPTICAEMIA, ACI+SIS, ARS,
)7P+.L7CAEMIA, ASPIRATI+N, ES+RES%)7P+.L7CAEMIA, ASPIRATI+N, ES+RES%
T"eat!ent SeDe"e Mala"ia T"eat!ent SeDe"e Mala"ia
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-2010-2010
SeDe"e Mala"ia is a !edi/al e!e"en/SeDe"e Mala"ia is a !edi/al e!e"en/
Adult 3 A"tesunate iD : i!Adult 3 A"tesunate iD : i!
Child"en 3 A"tesunate iD:i!, FuinineChild"en 3 A"tesunate iD:i!, Fuinine
iD:i!, A"te!ete" i!iD:i!, A"te!ete" i!
.iDe Pa"ente"al at least 24 h&u"s.iDe Pa"ente"al at least 24 h&u"s
SHi/th t& &"al 3 ACT, a"tesunate 5SHi/th t& &"al 3 ACT, a"tesunate 5
/linda!/in:d&//lin, 'uinine 5 Cl:d/linda!/in:d&//lin, 'uinine 5 Cl:d
I# n&t $&si((le, iDe $"e-"e#e"al R, thenI# n&t $&si((le, iDe $"e-"e#e"al R, then
"e#e""ed i!!ediatel"e#e""ed i!!ediatel
KE7 SUCCEE 6+R MANA.IN.KE7 SUCCEE 6+R MANA.IN.
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SE9ERE MALARIASE9ERE MALARIA
A//u"a/ dian&sis !i/"&s/&$i/ (i&/he!i/al
Mala"ia d"u t& /&!(at "esisten/
A(ilit t& t"eat &"an #ailu"e ICU 8Medi/al e'ui$!ent
.&&d !an $&He" nu"ses --- d&/t&"
.&&d "e#e""al sste!
Ana!nesaAna!nesa
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Ana!nesaAna!nesa
• KU 3 EMAMKU 3 EMAM• RPS3 EMAM SEJAK V ; )ARI SMRS%EMAMRPS3 EMAM SEJAK V ; )ARI SMRS%EMAM
TIN..I,ISERTAI EN.AN ERKERIN.AT AN7AK AN TIN..I,ISERTAI EN.AN ERKERIN.AT AN7AK AN
MEN.I.IL%PENERITA JU.A MEN.ELU) SAKIT KEPALAMEN.I.IL%PENERITA JU.A MEN.ELU) SAKIT KEPALA
SEJAK V ; )ARI SMRS, SEPERTI ITUSUK TUSUKSEJAK V ; )ARI SMRS, SEPERTI ITUSUK TUSUK
ISELURU) A.IAN KEPALA%MUAL AN MUNTA) - , AISELURU) A.IAN KEPALA%MUAL AN MUNTA) - , ASEPERTI IASA AN AK SEIKIT SEIKIT AN PENERITASEPERTI IASA AN AK SEIKIT SEIKIT AN PENERITA
ME.ELU) TIAK PUAS SAAT AK, N7ERI SAAT AK 5 %ME.ELU) TIAK PUAS SAAT AK, N7ERI SAAT AK 5 %
• RP3RP3
• )IPERTENSI, JANTUN.,.INJAL, AN PARU ISAN.KAL)IPERTENSI, JANTUN.,.INJAL, AN PARU ISAN.KAL
PENERITA%PENERITA%• PENERITA SEELUMN7A PERNA) ERPER.IAN IPENERITA SEELUMN7A PERNA) ERPER.IAN I
AERA) EPINEMIK MALARIA T+MATU AERA) EPINEMIK MALARIA T+MATU
Pe!e"iksaan 6isikPe!e"iksaan 6isik
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Pe!e"iksaan 6isikPe!e"iksaan 6isik
• Ku 3 sedan, kesada"an 3 CMKu 3 sedan, kesada"an 3 CM• T 3 100:*0, N 3 100, R 3 20, S3 ; 5 0 /!)20• T)+RA 3 C 3 SI SII N+RMAL, ISIN. T)+RA 3 C 3 SI SII N+RMAL, ISIN.
P 3 S$%Desikule", Rh -:-, Gh-:-P 3 S$%Desikule", Rh -:-, Gh-:-
• A+MEN 3 ata", le!as, U 5 n&"!al,A+MEN 3 ata", le!as, U 5 n&"!al,
):L3tt(, NTE5, NK C9A 5 det"a):L3tt(, NTE5, NK C9A 5 det"a• Et"e!itas 3 )anat , +ede! -:-Et"e!itas 3 )anat , +ede! -:-
LA+RAT+RIUMLA+RAT+RIUM
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LA+RAT+RIUMLA+RAT+RIUM
1*:@:20111*:@:2011•R 3 6ALCIPARUM 5%R 3 6ALCIPARUM 5%
200 l$3 10 $a"asit200 l$3 10 $a"asit
1000 l$3 -1000 l$3 -
L 3L 3•)(3 14,>)(3 14,>•Leuk&3 4*00Leuk&3 4*00•E"it"&sit3 4,@0 tE"it"&sit3 4,@0 t•)t3 4;?)t3 4;?•
LE3 10 !!LE3 10 !!
•Neut"&l (atan
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Pen&(atanPen&(atan
1*:@:20111*:@:2011•C&a"te! 24 ta(C&a"te! 24 ta(
•P"i!a'uin 1; ta(P"i!a'uin 1; ta(
•Kina ;2 ta( a!Kina ;2 ta( a!2;%002;%00
1@:@:20111@:@:2011•P"i!akuin ta( 11P"i!akuin ta( 11
•Kina ;2 ta(Kina ;2 ta(
•A"tesunatA"tesunat•&ksisiklin 2200&ksisiklin 2200
!!
Pego5ata Malaria deJesiesi =$A$Pego5ata Malaria deJesiesi =$A$
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gg
PDPD
6 Vivaks !heso strai 76 Vivaks !heso strai 7Min$$u &enis o6at ¨a8 ta6let menurut kelompok umur/ min$$u
+ ( 16ulan
2 ( 11 6ulan
1 ( 4 ta8un
' ( : ta8un
1+ (14
ta8un
) 1'ta8un
1 s/d (12 Klorokuin ¼ ½ 1 2 3 3 - 4
1 s/d (12 Primakuin - - 1½ 2¼ 3
Pemantauan : Gagal rujuk
ACT
Pego5ata Malaria Vivax =#=#L #!* ? LiiPego5ata Malaria Vivax =#=#L #!* ? Lii
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----
HariHari %eis o5at %eis o5at %umlah ta5let meurut kelompok umur %umlah ta5let meurut kelompok umur
6dosis tuggal76dosis tuggal7
K 8K 8tahutahu
8 $ )8 $ )tahutahu
22 – – 99tahutahu
8( $ 8)8( $ 8)tahutahu
:: 8282tahutahu
8$ B8$ B
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%&'&()&' D(!* K6( (+&%+. 6K%&'&()&' D(!* K6( (+&%+. 6K
*+A+(++(+,(&' %&'&()&*+A+(++(+,(&' %&'&()&
)$&l/e!ia,)$&l/e!ia,
/hin/h&nis!,/hin/h&nis!,
tinnitus, hea"intinnitus, hea"ini!$ai"!ent,i!$ai"!ent,
nausea, ds$h&"ia,nausea, ds$h&"ia,
D&!itin, $"&l&nedD&!itin, $"&l&ned
FT inte"Dal,FT inte"Dal,
ds"hth!ias,ds"hth!ias,
h$&tensi&nh$&tensi&n
20 ! dihd"&/hl&"ide salt:k20 ! dihd"&/hl&"ide salt:k
( iD in#usi&n &De" 4 h", then( iD in#usi&n &De" 4 h", then
a#te" l&adin, #&ll&Hed ( 10a#te" l&adin, #&ll&Hed ( 10
!:k &De" 4 h" eDe" < h"%!:k &De" 4 h" eDe" < h"%Patients sh&uld n&t "e/eiDedPatients sh&uld n&t "e/eiDed
'uinine &" !eQ&'uine Hithin'uinine &" !eQ&'uine Hithin
last 24 h"last 24 h"
Alte"natiDel, * ! salt:kAlte"natiDel, * ! salt:k
/an (e in#used &De" a $e"i&d/an (e in#used &De" a $e"i&d
;0 !in, #&ll&Hed ( 10 ! ;0 !in, #&ll&Hed ( 10 !salt:k &De" a $e"i&d 4 h",salt:k &De" a $e"i&d 4 h",
&"&"
10 ! salt:k >00 ! #&"10 ! salt:k >00 ! #&"
adult ( i%D in#usi&n &De" < h"adult ( i%D in#usi&n &De" < h"
/&ntin&usl ; a da/&ntin&usl ; a da
uinineuinine
9=EI>9=EI> >?9?9
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"