Patients with severe malaria should be treated aggressively with intravenous therapy (IV) anti-malarials. But first, let’s take a closer look at what severe malaria looks like, and how we manage patients with severe malaria.
What is severe malaria?
We classify Plasmodium falciparum infection as severe malaria when a positive diagnostic test for malaria is accompanied by the presence of at least one of a number of clinical criteria:
- Impaired consciousness or coma
- Severe anemia (hemoglobin < 7g / dL)
- Acute kidney injury
- Acute respiratory distress syndrome (ARDS)
- Disseminated intravascular coagulation (DIC)
- Spontaneous bleeding
- More than 5% of red blood cells (RBCs) on a blood film are infected
What anti-malaria drugs should I use to treat severe malaria?
When treating severe malaria, obviously we first want to get rid of the cause—the parasite—using anti-malaria drugs.
Historically, for severe malaria, we used quinidine, an anti-arrhythmic related to quinine. However, recent studies have shown that the anti-malarial drug, artesunate, results in much lower mortality than quinidine when used to treat severe malaria, so it has become the standard treatment over quinidine.
Artesunate, given intravenously, works by disrupting the mitochondrial membrane and the energy production of the mitochondrion, causing the parasite to die.
Artesunate can also be used in patients with less severe malaria who cannot take quinine-based medications.
How should I address the other symptoms that are associated with severe malaria?
So, we’ve addressed treatment to eliminate the parasite. But remember that a patient may already be quite sick, so we’ll likely also need to treat their symptoms.
A patient may need mechanical ventilation, benzodiazepines for controlling seizures, or fluids for the accompanying DIC.
In very severe cases, exchange transfusions may help to get rid of the blood containing the high-grade parasitemia by replacing it with some uninfected blood. This technique has been life-saving in a few individuals.
Although coinfection is uncommon, keep in mind that patients with severe malaria can have two infections going on simultaneously. So, it’s prudent to draw blood cultures to check for other infections.
Finally, if the patient has severe malaria and the neurological presentation is the least bit atypical, consider a lumbar puncture to test the cerebrospinal fluid for infection. For instance, cerebral malaria is generally associated with increased intracranial pressure, but not with neck stiffness. So a patient complaining of neck stiffness suggests meningitis and warrants a lumbar puncture to rule out other causes of central nervous system (CNS) infections.
That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.
- Ashley, EA, Phyo, AP, and Woodrow, CJ. 2018. Malaria. Lancet. 391: 1608–1621. PMID: 29631781
- Fairhurst, RM and Wellems, TE. 2014. “Malaria (Plasmodium Species)”. In: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, edited by Bennett, JE, Dolin, R, Blaser, MJ. 8th edition. Philadelphia: Elsevier Saunders. (Fairhurst and Wellems 2014, 3070–3090)
- Phillips, MA, Burrows, JN, Manyando, C, et al. 2017. Malaria. Nat Rev Dis Primers. 3: 17050. PMID: 28770814
- World Health Organization. 2015. Guidelines for treatment of malaria third edition. World Health Organization. World Health Organization
- World Health Organization. 2019. World malaria report 2019. World Health Organization. https://www.who.int