DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MALARIA| Tutorial E-2 TM

DIAGNOSISHistory TakingChief complaint in malaria is fever, chills, sweating, headache, nausea, vomiting, diarrhea and muscle pain. In history taking, it should be ask about:a) Travelling history to endemic placeb) Residential history in endemic placec) Past medical history for malaria/feverd) Medication history for malaria drugs for last 1 monthe) blood transfusion

Physical Examination Intermittent fever (>37,5oC axilla) Conjunctiva or palms anemic Splenomegaly Hepatomegaly Clinical manifestation for severe malaria can be unconsciousness, high fever, anemic conjunctiva, and icteric, oliguria, black brown colored urine (Black Water Fever), convulsion and very weak (prostration) In severe anemia condition: GCS40o C, blood pressure and pulse rate decreasing, weak, neurologic symptoms positive

Lab Examination1) Microscopic examinationMicroscopic examination is a gold standard for malaria. Microscopic examination is done by do thick and thin blood smear examination.Thick and thin blood smear examination in hospital/puskesmas for deciding: If there is any parasitic malaria (positive or negative) Species and stadium Plasmodium Parasitic quantity

THICK BLOOD SMEAR for screening and examine parasite quantitya) Semi quantitative(-): negative (no parasitic in 100 HPF)(+): positive 1 (found 1-10 parasitic in 100 HPF)(++): positive 2 (found 11-100 parasitic in 100 HPF)(+++): positive 3 (found in 1-10 parasitic in 1 HPF)(++++): positive 4 (found >10 parasitic in 1 HPF)

In correlation between parasitic quantity with mortility: Parasitic quantity 1% Parasitic quantity >500.000/ul, so mortality >50%

b) Quantitative Parasitic count can be count /ul for thick blood smear (leukocyte) or thin blood smear (erythrocyte)Example:If we found 1500 parasite in 200 leukocyte, while leukocyte count is 8000/ul, so we count parasite = 8000/200 x 1500 parasite = 60.000 parasite/ulIf we found 50 parasite in 1000 erythrocyte = 5%. If erythrocyte count is 4.500.000, so we count erythrocyte = 4.500.000/1000 x 50 = 225.000 parasite/ul

THIN BLOOD SMEAR to identify the type of plasmodium with giemsa staining

2) Rapid Diagnostic Test (RDT)Mechanism for this test is based on detection for malaria parasite antigen by using immunochromatography methods. This test is used in emergency room, in outbreak cases, and in area without microscopic laboratory facility.The most important thing which have to be concerned is before RDT can be used, we must read the manual book first to ensure the accuracy from the result that we get. In this moment, the RDT using by Program Pengendalian Malaria is which can identify P. falciparum and P. non falciparum

3) Polymerase Chain Reaction (PCR) and DNA SequencingThis examination can be done in available facility. This examination is important to distinguish between re-infection and recrudescence in P. falciparum. Besides that, it can be used to identify Plasmodium species which have low parasitic count or below microscopic borderline. Examination that using CPR also very important in eliminating malaria because it can be used to distinguish between import and indigenous parasite.

4) Besides those examination above, in severe malaria supportive examination that should done are:a) Hemoglobin and hematocrit countb) Leukocyte and thrombocyte countc) Other blood chemistry (blood glucose, bilirubin serum, SGOT and SGPT, alkaline phosphatase, albumin/globulin, ureum, creatinine, sodium and potassium, blood gas analysis)d) Urinalysis

DIFFERENTIAL DIAGNOSISClinical manifestation for malaria is varied from mild to severe symptoms, especially with diseases below:1) Malaria without complication must be differ with other infectious disease such as:a. Typhoid feverFever more than 7 days with headache, abdominal pain (diarrhea and constipation), relative bradycardia, rose spot, leukopenia, relative lymphocytosis, serologic test and cultureb. Dengue feverContinuous fever for 2-7 days with headache, prostration, bone pain, vomiting, tourniquet test positive, thrombocyte count decrease and hemoglobin and hematocrit increasing in dengue hemorrhagic fever, serologic test (antigen and antibody)c. LeptospirosisHigh fever, headache, myalgia, abdominal pain, nausea, vomiting, and conjunctival injection, serologic examination Microscopic Agglutination Test (MAT) or serologic test positive2) Severe malaria differentiate with other infectious disease such as:a. Brain infectionFever patient with progressive headache, unconsciousness, nuchal rigidity, convulsion, and other neurologic symptoms. In patients can be done CSF exam and brain imaging b. Stroke (cerebrovascular disturbance)Unconsciousness, lateralization neurologic symptoms (hemiparesis or hemiplegia), without fever and there is underlying condition (hypertension, diabetes mellitus, and others)c. Typhoid encephalopathyTyphoid fever symptoms begin with unconsciousness and other signs (special characteristic is there are abdominal sign like abdominal pain and diarrhea), supported by supporting examinationd. Hepatitis AHepatitis prodromal (fever, nausea, vomiting, cant eat followed by icteric without fever), eyes or skin jaundice, and tea-colored urine. ALT and AST increasing >5-fold without clinical manifestation or increasing >3-fold with clinical manifestatione. Severe leptospirosis (Weils Disease)Fever with Icteric, pain in calf and bone, occupational history that supported leptospirosis transmission, leukocytosis, and kidney failure. Incidence for this disease commonly arising after flood f. Acute glomerulonephritisAcute kidney failure symptoms with negative blood examination result to malariag. SepsisFever with clearly local infection, unconsciousness, circulation disturbance, leukocytosis with toxic granule that supported by microbiology culture h. Dengue Hemorrhagic Fever or Dengue Shock SyndromeHigh fever continuously for 2-7 days, accompanied by shock or without shock with headache, bone pain, bleeding manifestation (epistaxis, petechiae, purpura, hematoma, hematemesis, and melena), vomiting, thrombocyte count decreasing, hemoglobin and hematocrit count increasing, and serologic test positive (antigen and antibody)

130110110177|Gabriella Chafrina| 05/09/14