Case Report

Department of Child Health, Faculty of Medicine, Sriwijaya University –

dr. Moh. Hoesin Hospital, Palembang

MALARIA VIVAX
by : Diah Anggraini

Advisor :
Dr. dr. Yulia Iriani, Sp.A (K)

Resource Speaker :
Prof. dr. Chairil Anwar, Ph.D.,DAP&E.,Sp.ParK

Moderator :
dr. Msy. Rita Dewi, Sp.A (K)

Assessor : 1
dr. M. Nazir, Sp.A (K)
dr. Silvia Triratna, Sp. A (K)
 Introduction
• Malaria  burden
• Case of Malaria vivax is about 70-80 million every year in
worldwide
• Based on WHO  40% caused by Plasmodium vivax
• Plasmodium vivax  dominant caused of malaria in Southern Asia ,
Eastern Europe, North Asia, South and Central America
• Malaria vivax :
- Affected morbidity
- Affected economic status

2
 Introduction
• South Sumatera  6 district is endemic and 8 per 1000 people
was in high risk to be infected
• Number of malaria case (2015)  36.201 cases
• Highest positif case :
• Lahat : API 2,57 per 1000 people
• Lubuk Linggau : API 2,28 per 1000 people

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 Introduction

4
Malaria map of endemic area at Sout Sumatera
 Introduction
Objective of this case report

• To discuss how to diagnose

• To discuss the management

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Identity
• 5 yo 6 mo, male
• Wt : 14.5kg
• Ht : 102 cm
• Address : Tanjung Sakti Pumi, Lahat
• Admitted in Infection and Tropical disease ward at RSMH, on
October 6th, 2017

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History of Present Illness
• Chief Complaint
fever

• Additional complaints
white spot on the right eye

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History of Present Illness

• Patient got fever

• Followed by shivering
• Almost every day
• Peak (?)
• Cough (+), runny nose (+)
• Sore throat (-), ear pain (-), red eye (-), vomit (-),
urination and defecation was normal
1 month PTA • Midwife  got paracetamol and antibiotic 
cough and cold getting better
• Fever still exist

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History of Present Illness
• Patient come to opthalmologist for the white spot
on the right eye
• Patient got fever
• Followed by shivering and sweating
• Fever can reach the normal temperature
• Fever repeated about 24-48 hours
• Peak (?)
4 days PTA • Cough (-), cold (-), Sore throat (-), ear pain (-), red
eye (-), vomit (-), urination and defecation was
normal
• Pale (+)
• Patient was living at endemic malaria area
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History of Present Illness

• Admitted in Infection and Tropical disease ward at

RSMH
on
6th Oct 17

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Past Medical History
• History of malaria infection (-)
• History of malaria treatment (-)
• History of pale (-)
• History of allergy (-)
• History of eye trauma(-)
• History of eye disorder since birth (-)

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Family Medical History
• Uncle had been infected by malaria
• No allergic history
• No cataract history in the family

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Birth History
• Born term from 30 yo mother, G3P2A0 spontaneous assisted
by midwife at home, crying (+)
• Birth weight 2800 g, birth length 47 cm
• ANC regular at public health

• Summary : there is no problem in pregnancy and birt

history

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Immunization History
• BCG : (+) scar (+)
• DPT I, II, Ill : (+)
• Hepatitis B I, II, Ill : (+)
• Polio, I, II, Ill, IV : (+)
• Measles : (+)
• Booster : (-)

• Summary : Basic Immunization

14
Completed
Nutritional History
• Breast feeding: on demand until 9 yo
• Formula since 2 mo
• Milk porridge : 6 mo – 1 yr
• Rice : 1 yo – now
• Since 3 y.o child doesn’t finish his meal,
prefer snacking and rarely consume milk

• Summary: Quality and quantity of food 15

intake is inadequate
Developmental History
• Roll over : 3-4 month
• Sit : 6 month
• Standing : 10 month
• Walking : 12 month
• 3 years old : patient able to eat by his
own, step up and down stairs, playing and
communication with family
Summary: Normal Development 16
Social History
• Father 36 yo, elementary graduate, as farmer
• Mother 36 yo, elementary graduate, as
farmer
• Income: IDR 1000-1500K / month
• Patient using Jamsoskes

• Summary: Low social and economy

status 17
Physical Examination
• General appearance : pale (+), cyanotic (-), icteric (-), dyspnea (-)
• Sensorium : alert
• Blood pressure : 90/60 mmHg
• Heart rate : 108 x/ min (regular, full and, equal pulses)
• Temperature : 37.2 oC
• Respiratory rate : 24 x/ min

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Physical Examination
• Wt : 13 kg
• Ht : 89 cm
• WFA : < P.5
• HFA : < P.5
• WFH : 14.5/17 = 85,2%

• Summary : undernourished with

short stature
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Physical Examination
Head:
• Nasal flare (-), nasal secretion (-)
• Eye: anemic conjungtiva (+), conjunctival injection (-), icteric
sclerae (-),
• Ear : no redness, tympany membran intact

Neck:
• No Lymph Node enlargement
• Normal Jugular vein pressure

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Physical Examination
Thorax:
• Normal shape, symmetric (+) in static and
dynamic, retraction (-), no widening inter-
costal space
• Lung: symmetric in static and dynamic,,
vesicular breath sounds, crackles (-),
wheezing (-)
• Heart: non visualized and non palpable ictus
cordis, normal 1st and 2nd, no additional heart
sound 21
Physical Examination
Abdomen:
• Globular, normal bowel sound, soft, non tender, liver and
spleen unpalpable

External Genital:
• Male sex, no abnormalities seen, no phimosis

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Physical Examination
Extremities:
• Warm extremities, pale

Puberty:
• P1G1

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 Physical Examination
Neurologic Status
Motor
RUE LUE RLE LLE
Function
Motion Wide Wide Wide Wide
Strength 5 5 5 5
Tone Normal Normal Normal Normal
Clonus - -
Physiologic Normal Normal Normal Normal
Reflex
Pathologic - - - -
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Reflex
Physical Examination
• Sensory Function : normal
• Autonomic Function : normal
• Meningeal signs : (-)
• Cranial nerves : normal

25
Pictures were taken with parents’ permission

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Lab examination at October 2, 2017
examination result
Hemoglobin 9.4 g/dl
Erythrocyte 3.70 106/mm3
Leucocyte 5.4 103/mm3
Hematocryte 28 %
Trhombocyte 153 10 /mm3
3

MCV 76.8 fL
MCH 25 pg
MCHC 33 g/dL
ESR 63 mm/jam
DC 0/0/74/18/8 %
Malaria Tropozoit plasmodium vivax (+)
skizon plasmodium vivax (+)

SGOT 20 U/L
SGPT 8 U/L
Random Blood Glucose 107 mg/dL
ureum 31 mg/dL
kreatinin 0.5 mg/dL
Ca 9.1 mg/dL
Na 141 mEq/L
K 4.3 mEq/L
Cl 109 mmol/L
Toxo IgG <0.130 (non reactive) IU/mL
Toxo IgM 0,276 (non reactive) IU/mL
Rubella IgG <0.170 (non reactive) IU/mL 27
Rubella IgM 0.03 (non reactive) IU/mL
CMV IgG 31.03 (reactive) IU/mL
CMV IgM 0.29 (non reactive) COI
Thin blood smear examination

28

Trophozoit and skizon stage

Problem
• Malaria vivak
• Anemia
• Catharract
• undernourished

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Working diagnosis
• Severe malaria vivax + Juvenile Catharract OD +
Undernourished

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Initial Plan
• Artesunat inj 2,4 mg/kgBW IV at 0,12,24 next every
24 h
• Laboratory work-up
• CBC, retikulocyte
• Urinalysis
• Iron status
• Opthalmology consult
• Diet
• Treatment evaluation every 3 day
• Then could be continue in the ward at day 7, 14, 21
31
and 28 with physical examination and microscopic
axamination
COURSE IN THE WARDS 32
 Day I (6th Oct 17) Day III (8th Oct 17)

S Fever (+), shivering (+),pale(+), Fever (-), shivering (-), pale (+),

O Vital sign : TD : 90/50 mmHg Vital sign was normal

n: 118 x/mnt (strong pulse) t : 38.4 oC rr : Conjungtiva anemis (+), cloudy patches in the
24x/mnt lens of the right eye (+)
Conjungtiva anemis (+), cloudy patches in the lens
of the right eye (+)
Lab Hb 8.9g/dl, erythrocyte 3.450.000/mm3, leucocyte Hb 8.3 g/dl, erythrocyte 3.240.000/mm3,
5.700/mm3, Ht 27%, plt 110.000/µL, DC leucocyte 4.400/mm3, Ht 25%, Plt 133.000/µL,
0/1/65/26/8, CRP 38 MCV 77.5, MCH 26, MCHC 33, ESR 43,
Urinalysis: yellow clear BJ 1.025, pH 6.0, protein (- DC 0/0/56/33/11, reticulocyte 5.6 %
), glucosa (-), keton (-), blood(-), bilirubin (-), nitrit
(-), leucocyte esterase (-), epitel (-), leucocyte 0-5
/fields , erythrocyte 0-2/fields, cast (-), bacteria (-),
mucuos(+), fungi (-)

A Severe malaria+ Juvenile catharract OD + anemia + trombhocytopenia +

undernourished

P Artesunat inj 2,4 mg/kgBW IV every 0,12,24 h Artesunat inj 2,4 mg/kgBW IV every 0,12,24 h
followed by giving every 24 h followed by giving every 24 h
Paracetamol Syrup 7.5 ml bila t>38.5 Paracetamol Syrup 7.5 ml bila t>38.5 33
Diet plan Diet plan
 Day IV (9th Oct 17) Day VII (12th Oct 17)

S Fever (-), shivering (-), pale (+), Fever (-), shivering (-), pale (+),

O Vital sign was normal Vital sign was normal

Conjungtiva anemis (+) , cloudy patches in the Conjungtiva anemis (+), cloudy patches in the
lens of the right eye (+) lens of the right eye (+)

Lab Hb 9.9 g/dl, erythrocyte 3.950.000/mm3, leucocyte The result of Evaluation of microscopic and
10.600/mm3, Ht 31%, trombocyte 278.000/µL, parasite count :
MCV 77.2, MCH 25, MCHC 33, LED 56, DC There is no malaria in ane stage found in the
0/2/38/54/6, reticulocyte 3.4 % thin or thick blood smear
Iron 74 µg/dL TIBC 261 µg/dL, transferrin
saturation 28.3%, ferritin 339 ng/mL
Peripheral blood film:
Erythrocyte : microcytic, hipocromic, anisositosis
Leucocyte : normal count and morphology
Thrombocyte : normal count and morphology
summary : anemia m hipokrom e.c suspek
defisiensi Fe
A Severe malaria vivak+ Juvenile catharract OD + anemia + undernourished

P DHP 1x1 tablet (3 days) DHP 1x1 tablet (3 days)

Primakuin 1 x ¼ tablet (14 days) Primakuin 1 x ¼ tablet (14 days)
Paracetamol Syrup 7.5 ml bila t>38.5 Diet plan
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Consult to opthalmologist
Evaluation of microscopic and parasite count
Diet plan
LITERATURE REVIEW 35
Malaria Vivax
• Malaria caused by Plasmodium Vivax
• Plasmodium vivax is a protozoal parasite and a human
pathogen.
• The most frequent and widely distributed cause of recurring
(Benign tertian) malaria

36
 37

Illustration from : scientistsagainstmalaria.net

Life cycle
• The incubation period for the infection usually ranges from 12
to 17 days with the median is about 16 days.
• The parasite can go dormant in the liver for days to years,
causing no symptoms and remaining undetectable in blood
tests (hypnozoites)
• Persistent liver stages allow relapse up to five years after
elimination of red blood cell stages and clinical cure.

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 Stages of P. vivax in thin
smears
Fig. 1:Normal red cell;Figs. 2-6:Young
trophozoites (ring stage
parasites);Figs. 7-
18:Trophozoites;Figs. 19-
27:Schizonts;Figs.
28and29:Macrogametocytes
(female);Fig. 30:Microgametocyte
(male).

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llustrations from: Coatney GR, Collins WE, Warren M, Contacos PG. The Primate Malarias.
Bethesda: U.S. Department of Health, Education and Welfare; 1971.
SYMPTOM
• fever and chills
• Trias malaria (paroxysm malaria) : shivering chills, rise of
temperature and then sweating
• accompanied by headache, myalgias, arthralgias, weakness,
vomiting, and diarrhea
• Other clinical features include splenomegaly, anemia,
thrombocytopenia, hypoglycemia, pulmonary or renal
dysfunction, and neurologic changes.

40
SYMPTOM
Malaria without complication
• Fever
• Pale
• splenomegali
• Hepatomegali

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SYMPTOM
Malaria with complication :
P. Falciparum aseksual stadium with minimal one of these
clinical manifestation or laboratorium result :
1. Altered of conciusness
2. Muscle weakness
3. Unable to drink or eat
4. Repeated seizure more than 2 episodes in 24 hour
5. Respiratory distress
6. Shock
7. Ikterus followed by organ dysfuntion
8. Hemoglobinuria
9. Spontaneus bleeding
10. Lung edema (radiologic) 42
Cont..
Malaria with complication :
Laboratorium result :
1. Hypoglycemia (blood glucose < 40 mg%)
2. Metabolic acidosis (plasma bicarbonate <15mm/L)
3. Severe anemia (Hb <5g% atau hematocryte <15%)
4. Hyperparasitemia (parasite >2 % per 100.000/μL in the low
endemic area atau > 5% per 100.0000/in the high endemic
area)
5. Hyperlactatemia (lactate acid >5 mmol/L)
6. Hemoglobinuria
7. Renal impairment (creatinine >3 mg%) 43
DIAGNOSIS
• diagnosis of Plasmodium vivax infection can be broadly
categorized into three purposes:
• identification of clinical cases (passive case detection [PCD])
• surveillance (active case detection [ACD])
• clinical trials.

44
(passive case detection [PCD])
• microscopy examination of a Giemsa-stained blood smear
(microscopy)
• Examination of at least 200 fields of a thick blood film under oil
immersion magnification (×1,000)
• The limit of detection for expert microscopists is considered to be
about 10–20 parasites/μL
• immunochromatographic cassette containing monoclonal
antibodies to a P. vivax antigen (rapid diagnostic test [RDT]).

45
(active case detection [ACD])
• The majority of mass blood surveys (historically and today) are
performed using microscopy.
• loop-mediated isothermal amplification (LAMP)
• polymerase chain reaction (PCR).

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TREATMENT

47
 Malaria without complications

TREATMENT

48

Algorithm taken from : Kemenkes RI,2013

Severe vivax malaria
• Artesunate: 2.4 mg/kg body weight, intravenously or
intramuscularly given on admission (time = 0), then at 12 and 24
hours, and then once a day. This is the treatment of choice.
• Artemether: 3.2 mg/kg body weight, intramuscularly given on
admission, then 1.6 mg/kg body weight per day.
• Quinine: 20 mg quinine salt/kg body weight on admission
(intravenous infusion in 5% dextrose/dextrose saline over a
period of 4 hours) followed by maintenance dose of 10 mg/kg
body weight 8 hourly (maximum infusion rate 5 mg
salt/kg/hour).

• Parenteral antimalarials should be administered for at least 24

hours. Once the patient can accept oral therapy, full course of
49
oral ACT should be given to the patients
CASE ANALYSIS 50
Case analysis

Final diagnosis:
Malaria vivak +
Catharract Juvenile
OD + Undernourished
51
Case analysis
Patient Literature
• fever • fever and chills,
• Followed by shivering and • which can be accompanied
sweating by headache, myalgias,
• Fever can reach the normal arthralgias, weakness,
temperature
vomiting, and diarrhea.
• Fever repeated about 24-48
hours • Other clinical features
• Peak (?) include splenomegaly,
• Cough (-), cold (-), Sore throat (-), anemia,
ear pain (-), red eye (-), vomit (-), thrombocytopenia,
urination and defecation was hypoglycemia, pulmonary
normal
or renal dysfunction, and
• Pale (+)
neurologic changes.
52
Case Analysis
Patient Literature
• Live in endemic area : • Lahat : API 2,57 per 1000
Lahat people (high positive case)
firmed by histopathology :
Langerhans cell &
immunohistochemistry :
(+) CD1a, CD207 (langerin)

53
Case analysis
Patient Literature
• Tropozoit plasmodium The accurate diagnosis of
vivax malaria in an acutely ill
vivax (+) skizon patient seeking routine care
plasmodium vivax (+) at requires microscopy
examination of a Giemsa-
thin blood smear
stained blood smear
(microscopy), or use of an
immunochromatographic
cassette containing
monoclonal antibodies to a P.
vivax antigen (rapid
diagnostic test [RDT])
54
Case analysis
Patient
• Artesunat inj 2,4 mg/kgBW
IV at 0,12,24 h followed by
giving every 24 h
• DHP 1x1 tablet (3 days)
• Primakuin 1 x ¼ tablet (14
days)
Literature
• Therapy for severe malaria
Artesunate: 2.4 mg/kg body
weight, intravenously or
intramuscularly given on
admission (time = 0), then at
12 and 24 hours, and then
once a day. This is the
treatment of choice
Once the patient can accept
oral therapy, full course of
oral ACT should be given to
the patients 55
Case analysis
Patient
• cloudy patches in the
lens of the right eye (+)
• Since 5 month ago
• History of eye trauma(-)
• History of eye disorder
since birth (-)
• No history of catharract
in the family
Literature
• Cloudy patches in the lens that appears in older
babies or children
• causes of congenital or juvenile cataracts can be
divided into:
• —intrauterine: infection (toxoplasmosis, rubella,
cytomegalovirus, herpes, varicella, syphilis), drug
exposure (corticosteroids, vitamin A), ionizing
radiation (X-rays), metabolic disorder (maternal
diabetes);
• —hereditary: (i) isolated—without associated eye
or systemic disorder (autosomal dominant
inheritance); (ii) complex—associated ocular or
multi-system syndrome (anterior segment
dysgenesis, aniridia, Stickler syndrome, myotonic
dystrophy, Norrie disease, Lowe syndrome, Alport
syndrome, Nance–Horan, incontinentia pigmenti,
congenital icthyosis);
• —chromosomal (Down syndrome: trisomy 21,
Turner syndrome);
• —extrinsic: malnutrition, acute dehydrating
diseases;
• —metabolic disease (galactosaemia,
hypocalcaemia); 56
• —trauma.
Case analysis
Patient Literature
• Evaluation of therapy  It is less virulent than
there is no stage of P. Vivax Plasmodium falciparum
found in thin or thick
smears

Good Prognosis
Depend on :
- Compliance to therapy
- Evaluation routinely
- Nutrition 57
THANK YOU

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