🦟 Chapter 108: Severe Malaria

Plasmodium falciparum · Cerebral malaria · Severe anemia · Acidosis · Hypoglycemia · Artesunate · Artemether · Quinine · Exchange transfusion · Supportive care

🔍 Core Concepts: Severe Malaria

📌 Case definition (WHO)
Cerebral malaria (unrousable coma, GCS <11, P. falciparum), severe anemia (Hb <5 g/dL), respiratory distress (acidosis), hypoglycemia (<40 mg/dL), renal failure, shock, hyperparasitemia (>5%).
🧠 Cerebral malaria
Seizures, posturing, raised ICP, neurological sequelae (5-30% in children). Coma may develop in 1-2 days. Treat with IV artesunate.
💊 First-line antimalarial
IV artesunate: 2.4 mg/kg at 0, 12h, 24h, then daily until oral tolerated (total 6 days). Superior to quinine (lower mortality).
🩸 Supportive care
Treat hypoglycemia (dextrose), seizures (benzodiazepines), severe anemia (transfusion if Hb <4-5 g/dL), acidosis (fluids, bicarbonate controversial).
⚠️ Complications in children
Hypoglycemia, acidosis, seizures, severe anemia (more common than adults). Respiratory distress = poor prognostic sign. Co-infection with sepsis (algid malaria).
🔄 Exchange transfusion?
Role not well established; consider if hyperparasitemia >10-20% with organ failure; evidence limited.
💡 Prevention
Insecticide-treated nets, chemoprophylaxis for travelers. G6PD testing before primaquine.

🩺 Stepwise Management of Severe Malaria (P. falciparum)

1
Rapid assessment & stabilization (ABCs)
Secure airway if coma or seizures, give oxygen, IV access. Check blood glucose (hypoglycemia common), correct with dextrose.
2
Confirm diagnosis & assess severity
Thick/thin smear, rapid diagnostic test (RDT). Parasitemia level, hemoglobin, lactate, glucose, renal/liver function. GCS.
3
Start parenteral artesunate immediately
Dose: 2.4 mg/kg IV/IM at 0, 12h, 24h, then daily. Do not delay for oral intake. If artesunate unavailable, use artemether or quinine (20 mg salt/kg loading).
4
Manage complications
Seizures: benzodiazepines; status epilepticus: phenobarbital/phenytoin. Severe anemia (Hb<5 g/dL): transfuse. Acidosis: fluid resuscitation, avoid overhydration. Renal failure: dialysis if indicated.
5
Treat bacterial co-infection (algid malaria)
If shock persists after artesunate/fluids, consider broad-spectrum antibiotics (sepsis common in severe malaria).
6
Transition to oral therapy after 24h
Once able to swallow, complete 6 days total with oral artemisinin combination therapy (ACT): artesunate-mefloquine, artemether-lumefantrine, or atovaquone-proguanil.