Severe Malaria : Quick revision

Criteria for Severe and Complicated Malaria

Positive peripheral blood smear for P.falciparum + ≥1 of the CHAPLINS (Mnemonic)

  1. Convulsions: >2 in 24 hour
  2. Cerebral edema (Consciousness impaired)
  3. Hypoglycemia (glucose <40 mg/dl)
  4. Hemorrhage (DIC)
  5. Hemoglobinuria (Black water fever)
  6. Anemia (hemoglobin <5 gm/dl or PCV <15% in children; hemoglobin <7 gm/dl or PCV <20% in adults)
  7. Pulmonary edema or ARDS
  8. Lactic acidosis (pH <7.25, lactate >5 mmol/l, bicarbonate <15 mmol/l)
  9. Infection (>5% erythrocytes infested)
  10. Icterus (Bilirubin >3 gm/dl)
  11. Necrosis i.e. ATN (Serum creatinine >3 mg/dl, oliguria)
  12. Shock (SBP <80 mmHg in adults; SBP <50 mmHg in children)

severe malaria

Where microscopy is unavailable or not feasible, Rapid Diagnostic Test (RDT) using HRP-2 must be used. Frequent monitoring of parasitemia (e.g. every 12 hour) is important during the first 2-3 days of treatment in order to monitor the parasite response during the treatment. RDTs for detecting HRP-2 cannot be used for this purpose because it can remain positive for upto 4 weeks after clearance of parasitemia.

Antimalaria Drugs for Severe Malaria

Antimalaria drugs should be given:

  1. Parenterally for minimum 24 hours (intramuscular injections must not be given in buttocks due to risk of sciatic nerve injury)
  2. Then, replaced by oral medications as soon as it is tolerable

severe malaria treatment

Drug of choice: Artesunate IV or IM

Alternatives: Arthemeter IM, Quinine IV or IM

Besides, antimalarial drugs – patient must be treated side by side for seizure, hypoglycemia, hyperpyrexia, DIC, renal failure, acute pulmonary edema, etc.

Start broad-spectrum antibiotics along with antimalarials in following conditions:

  1. Meningitis cannot be ruled out in case of altered sensorium.
  2. Suspected bacterial co-infection: hypotension, pneumonia.

Reference: Management of Severe Malaria – A practical Handbook 3rd edition byWHO

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