1
Q
Is malaria preventable and treatable?
A
Yes – prevention via mosquito control, treatment via antimalarial drugs.
2
Q
How is malaria linked to poverty?
A
Strongly – poverty increases exposure, and malaria worsens poverty by reducing productivity and increasing healthcare costs.
3
Q
What is the vector for malaria?
A
The female Anopheles mosquito.
4
Q
What happens when an infected mosquito bites a human?
A
It injects sporozoites into the bloodstream.
5
Q
Where do sporozoites go first?
A
To the liver, where they infect hepatocytes
6
Q
What happens in the liver stage?
A
Sporozoites multiply and form schizonts → release merozoites into the blood.
7
Q
What happens in the blood stage?
A
Merozoites infect RBCs, multiply asexually → rupture RBCs → cause fever and symptoms.
8
Q
What forms sexual stages of the parasite?
A
Some parasites develop into gametocytes in RBCs.
9
Q
How are gametocytes transmitted?
A
When another mosquito bites, it ingests gametocytes → sexual reproduction in mosquito midgut → sporozoites form in salivary glands → transmission cycle continues.
10
Q
When should malaria be suspected?
A
In anyone with fever (or history of fever) who has lived in or travelled to a malaria area.
11
Q
What are the classic symptoms of malaria?
A
Fever, chills/rigors, sweats, headache, malaise, muscle aches.
12
Q
What are GI symptoms that may occur?
A
Nausea, vomiting, abdominal pain, diarrhoea.
13
Q
What are the respiratory symptoms that may occur?
A
Cough, shortness of breath (esp. in severe malaria).
14
Q
What are neurological symptoms in severe malaria?
A
Confusion, seizures, altered consciousness (cerebral malaria).
15
Q
What are haematological manifestations?
A
Anaemia, jaundice, splenomegaly.
16
Q
What are the warning signs for severe malaria?
A
Persistent vomiting, impaired consciousness, respiratory distress, severe anaemia, hypoglycaemia, shock, renal failure.
17
Q
When should you always test for malaria?
A
Any sick patient with a history of travel to or residence in a malaria area.
18
Q
What is the role of rapid diagnostic tests (RDTs) in malaria?
A
Detect malaria antigens, are sensitive and specific when used by experienced staff.
19
Q
What is the role of blood smears in malaria diagnosis?
A
Multiple smears are done until diagnosis is confirmed or the patient is asymptomatic.
20
Q
Why might a blood culture be considered in suspected malaria?
A
To rule out bacterial sepsis or typhoid, which can mimic malaria.
21
Q
What full blood count finding is commonly seen in malaria?
A
Thrombocytopenia (low platelet count).
22
Q
After a positive malaria test, what is the first step in assessment?
A
Determine whether it is uncomplicated or severe malaria.
23
Q
What key risk factors should you always check in a malaria-positive patient?
A
What key risk factors should you always check in a malaria-positive patient?
24
Q
Why is checking for risk factors important in malaria management?
A
They increase the risk of progression to severe disease and influence choice of treatment.
25
26
Case report 1
• 65-year-old man, 4 day h/o fever, 14/7 in Mozambique 19 days ago, took chloroquine prophylaxis.
• Vitals: Temp 38.4C, P 104, O/E: NAD
• Bloods: P falciparum 2.9%, Hb 12.2g/dL, Platelets 20 x 109
Admitted
• Rx oral quinine
• 2hr later drowsy, confused, dysphasic
o Despite adequate treatment – can still deteriorate – monitor!!
• Glucose 3.8 mmol/L
• Rx IV quinine
• Respiratory distress
• Haemolysis (Hb 7.4g/dL),
• Thrombocytopenia (9x 109/L
• Hyperparasitaemia (5.2%)
27
Case report 2
• 17 year old woman, returned from 3/52 in Nigeria 2/7 ago, fever and vomiting x 2/7
• Vitals: T 38.2C, P 110bpm, O/E: Mildly jaundiced, NAD
• Bloods: P falciparum 1.2%, Platelets 60 x 109
, Bilirubin 84 mol/L
• Admitted
• Rx oral quinine
• +24 h:
o Parasitaemia 30%, GCS 11/15, Hb 10.9 g/dL, Bilirubin 136 mol/L, Creatinine 279 mol/L,
Platelets 35 x 109/L
• Rx IV quinine
• +48h:
o Parasitaemia 0.2%, Metabolic acidosis, GCS 8/15, Fixed gaze palsy, Acute renal failure
(Creatinine 445 mol/L)
28
Malaria case management problems in Cape Town
• Delay in presentation (mean duration of symptoms 6 days)
• Delay in diagnosis - 17%
• Underassessment of disease severity
• Choice of antimalarial, route of administration, dose
29
Features of severe malaria needing IV treatment
• Impaired consciousness
• Hypoglycaemia
• Convulsions
• Jaundice
• Abnormal bleeding
• Macroscopic haematuria
• Weakness
• Vomiting
• Anaemia
• Hyperthermia (temp >40 degrees)
30
What are the neurological features of severe malaria?
Impaired consciousness, convulsions.
31
What are the metabolic features of severe malaria?
Hypoglycaemia, hyperthermia >40°C.
32
What are the haematological features of severe malaria?
Anaemia, abnormal bleeding, macroscopic haematuria.
33
What are the hepatic features of severe malaria?
Jaundice
34
What are the general features of severe malaria?
Weakness, persistent vomiting
35
How is impaired consciousness defined in adults vs children with malaria?
Adults: Glasgow Coma Score <11.
Children: Blantyre score <3
36
How is severe weakness defined in adults vs children?
Adults: Unable to sit, stand, or walk without assistance.
Children: Unable to breastfeed, sit, stand, or walk without assistance (age appropriate)
37
How are convulsions defined as severe malaria?
Two or more seizures within 24 hours.
38
How is shock defined in malaria?
• Compensated shock: capillary refill ≥3s or temp gradient on leg, no hypotension.
• Decompensated shock: SBP <70 mmHg in children, <80 mmHg in adults plus poor perfusion.
39
What are the respiratory signs of severe malaria?
RR >30/min, Kussmaul breathing, O₂ sat <92% RA, chest indrawing/crepitations, or pulmonary oedema on CXR.
40
How is jaundice defined in severe malaria?
Yellow sclera (visible jaundice).
41
What is the definition of renal involvement in severe malaria?
Adults: Serum creatinine >265 µmol/L or urea >20 mmol/L.
Children: No urine for 12h or macroscopic haematuria.
42
What are the haematological criteria for severe malaria?
Severe anaemia: Adults Hb <7 g/dL (Hct <20%). Children Hb <5 g/dL (Hct <15%).
Abnormal bleeding: recurrent/prolonged from nose, gums, venepuncture, or GI bleeding/retinal haemorrhage.
43
What are the metabolic features of severe malaria?
• Hypoglycaemia: <2.2 mmol/L
• Acidosis: Base deficit >8 OR HCO₃ <15 mmol/L
• Hyperlactataemia: venous lactate >5 mmol/L
44
What is the parasite threshold for hyperparasitaemia?
>4% parasitaemia
45
What is the bilirubin cutoff for severe malaria?
Bilirubin >50 µmol/L.
46
What is the first step in managing severe malaria?
Rapid assessment of organ function (CNS, jaundice, renal, cardiac, respiratory, bleeding, anaemia).
47
What urgent baseline investigations should be done in severe malaria?
Hb, U&E, blood glucose, lactate.
48
How should you manage reduced level of consciousness in malaria?
Always check glucose and give empiric glucose if unsure.
49
What is the preferred urgent parenteral antimalarial treatment?
IV artesunate (strongly preferred).
50
What is the alternative to IV artesunate if unavailable?
IV quinine – use a loading dose and give as a slow, rate-controlled infusion.
51
Where should a patient with severe malaria be admitted?
To the highest level of care available (e.g., ICU/HDU if possible).
52
What monitoring is required in severe malaria?
Vital signs and glucose every 4 hours, daily electrolytes, daily blood smears, monitor fluid balance carefully.
53
What supportive measures should be included in management?
Control convulsions, manage fever, and provide organ support as needed (respiratory, renal, cardiac).
54
Which drug is superior for severe malaria: artesunate or quinine?
Artesunate is superior.
55
What is the effect of artesunate on mortality in severe malaria?
39% reduction in in-hospital mortality in adults, 24% reduction in children, compared to quinine.
56
Why is artesunate preferred over quinine?
• Greater survival benefit
• Faster parasite clearance
• Better safety profile (less hypoglycaemia, fewer cardiac side effects).
57
When is quinine still used?
If artesunate is unavailable.
58
What is the main evidence base for parenteral artesunate in severe malaria?
The SEAQUAMAT and AQUAMAT multicentre RCTs
59
Who were the study populations in SEAQUAMAT and AQUAMAT?
SEAQUAMAT: ~1500 Southeast Asian adults.
AQUAMAT: >5000 African children.
60
What did these trials demonstrate about artesunate vs quinine?
Both showed a significant reduction in risk of death with artesunate.
61
What is the number needed to treat (NNT) with artesunate vs quinine?
About 15 adults or 40 children must be treated with artesunate to prevent one death.
62
Why is parenteral artesunate emphasized for severe malaria?
Because it saves lives and is cost-effective.
63
What is the main mortality benefit of artesunate compared to quinine?
Reduction in mortality in both adults and children
64
How does artesunate compare to quinine in parasite clearance?
More rapid parasite clearance.
65
How does artesunate score on ease of administration?
Simple to administer with a simple dosing regimen.
66
How does artesunate compare to quinine in safety?
Better safety profile, including safe in all pregnancy trimesters.
67
Does artesunate require dose adjustment in renal or hepatic impairment?
No dose adjustments are required.
68
Advantages of IV (IM) artesunate vs quinine
• Reduction in mortality
• More rapid parasite clearance
• Simple to administer
• Simple dose regimen
• Better safety profile, including in all pregnancy trimesters
• No dose adjustments required in renal and hepatic impairment
69
What is the IV artesunate dose for adults and children?
2.4 mg/kg IV at 0, 12, and 24 hours; for <20 kg, 3 mg/kg IV.
70
How is IV artesunate reconstituted?
• Dissolve 60 mg artesunate powder in 1 ml 5% sodium bicarbonate.
• Add 5 ml 5% dextrose or 0.9% NaCl → final concentration 10 mg/ml.
• Administer as a bolus via IV cannula.
71
How long is reconstituted IV artesunate stable?
Must be administered within 30 minutes; discard if longer.
72
How many IV doses are required before switching to oral therapy?
At least three doses (0, 12, 24 hours)
73
What oral therapy should follow IV artesunate?
Complete a full course (six doses) of artemether-lumefantrine.
74
How is IM artesunate used for pre-transfer treatment?
Same mg/kg doses, mixed to a concentration of 20 mg/ml.
75
How is the overall safety and tolerability of IV artesunate?
Excellent – well tolerated in most patients
76
What are the common adverse events?
Gastrointestinal disturbance (nausea, vomiting, anorexia) and dizziness; some symptoms are also due to malaria itself.
77
What is a notable delayed complication of artesunate?
Delayed haemolysis >1 week after treatment in hyperparasitaemic patients
78
How should delayed haemolysis be managed?
Careful follow-up of hyperparasitaemic patients to identify and treat late-onset anaemia.
79
How does artesunate compare to quinine regarding hypoglycaemia and cardiac monitoring?
Few patients develop hypoglycaemia, and cardiac monitoring is not required.
80
What are rare adverse events of artesunate?
Haematological disorders (neutropenia, reduced reticulocytes, anaemia, eosinophilia), elevated AST, transient ECG abnormalities, and very rare hypersensitivity reactions.
81
Is there evidence of neurotoxicity or teratogenicity in humans?
No – these were documented in animal studies but not observed in humans.
82
What is the IV artesunate dose for adults and children?
2.4 mg/kg IV at 0, 12, and 24 hours; for <20 kg, 3 mg/kg IV.
83
How is IV artesunate reconstituted?
• Dissolve 60 mg artesunate powder in 1 ml 5% sodium bicarbonate.
• Add 5 ml 5% dextrose or 0.9% NaCl → final concentration 10 mg/ml.
• Administer as a bolus via IV cannula.
84
How long is reconstituted IV artesunate stable?
Must be administered within 30 minutes; discard if longer.
85
How many IV doses are required before switching to oral therapy?
At least three doses (0, 12, 24 hours).
86
What oral therapy should follow IV artesunate?
Complete a full course (six doses) of artemether-lumefantrine.
87
How is IM artesunate used for pre-transfer treatment?
Same mg/kg doses, mixed to a concentration of 20 mg/ml.
88
How is the overall safety and tolerability of IV artesunate?
Excellent – well tolerated in most patients.
89
What are the common adverse events?
Gastrointestinal disturbance (nausea, vomiting, anorexia) and dizziness; some symptoms are also due to malaria itself.
90
What is a notable delayed complication of artesunate?
Delayed haemolysis >1 week after treatment in hyperparasitaemic patients.
91
How should delayed haemolysis be managed?
Careful follow-up of hyperparasitaemic patients to identify and treat late-onset anaemia.
92
How does artesunate compare to quinine regarding hypoglycaemia and cardiac monitoring?
Few patients develop hypoglycaemia, and cardiac monitoring is not required.
93
What are rare adverse events of artesunate?
Haematological disorders (neutropenia, reduced reticulocytes, anaemia, eosinophilia), elevated AST, transient ECG abnormalities, and very rare hypersensitivity reactions.
94
Is there evidence of neurotoxicity or teratogenicity in humans?
No – these were documented in animal studies but not observed in humans.
95
When should quinine be used for severe malaria?
Only if IV artesunate is not promptly available or if the patient has an allergy to artesunate.
96
What is the quinine loading dose and how should it be given?
20 mg/kg quinine dihydrochloride salt by slow IV infusion over 4 hours.
97
What is the maintenance dose after loading?
10 mg/kg by slow IV infusion over 4 hours, given every 8 hours.
98
What must be monitored during quinine infusion?
Blood glucose, vitals, and if possible cardiac monitoring (ECG).
99
How should treatment be completed after IV quinine?
With a full oral course of artemether-lumefantrine.
100
What are common problems with quinine administration?
• Loading dose not given
• Loading dose repeated (toxic risk)
• Infusion rate not controlled
• Hypoglycaemia
101
What are the supportive (ancillary) treatments you should do in severe malaria?
• Oxygen
• Antipyretics (e.g. paracetamol)
• Anticonvulsants
• Consider antibiotics (if sepsis suspected)
• Blood transfusion (for severe anaemia)
• Mechanical ventilation (if respiratory failure)
• Haemofiltration/dialysis (if renal failure)
• Exchange transfusion (rare, selected cases)
102
What treatments should be avoided in severe malaria?
• Aspirin / NSAIDs
• Heparin
• Corticosteroids
• Mannitol
• Desferrioxamine
• Anti-TNF antibody
• High dose phenobarbitone
103
What are the features of uncomplicated malaria?
• Patient ambulant
• No excessive vomiting
• No jaundice
• Normal mental state
• Normal respiratory rate
• No organ dysfunction
104
What is the preferred treatment for uncomplicated malaria?
Artemether-lumefantrine (artemisinin-based combination therapy, ACT).
105
What is the recommended treatment for uncomplicated malaria?
Fixed-dose artemisinin-based combination: Artemether + Lumefantrine (AL).
106
In which patients is artemether–lumefantrine NOT recommended?
• Allergy to artemisinins or lumefantrine
• Weight < 5 kg
• Severe malaria (needs IV treatment instead)
107
What should be emphasized for outpatients if malaria cannot be admitted?
• Full compliance with Coartem course
• Take with fat-containing food/drink (improves absorption)
• Fluids & fever control: use paracetamol (not aspirin/NSAIDs)
• Expected response: fever improves in 24–48 hrs; return if fever persists beyond day 3 or if unwell
• Urgent return if vomiting, deterioration, or drowsiness
108
Which outpatient groups are high risk and need close (ideally daily) review?
• Young children, especially malnourished
• Elderly
• Comorbidities e.g. HIV (particularly if on efavirenz or rifampicin, as these reduce AL concentrations)
109
Case 1: severe malaria
• NM, a 34-year-old female is brought in to your hospital’s emergency room in a semi-conscious state,
with high fever, sweating and rigors. Her husband provides the following history:
o NM lives in a rural village in KwaZulu Natal on the Mozambican border.
o She visited a private general practitioner four days ago with a four-day history of headache,
fever, joint pains, nausea and vomiting.
o She was given four artemether-lumefantrine (AL) tablets and sent home with 20 AL tablets
and paracetamol.
o She vomited soon after leaving the doctor and continued to deteriorate over the next three
days until she became confused and very sleepy.
o Her husband took her to the traditional healer who gave a special tea that he said would
help, but she did not improve.
• Past Medical History:
o Asthma controlled on an inhaler
• Medication:
o Unknown inhaler PRN, unknown traditional medicine for 2 days
• Physical examination (significant findings only)
o General: Underweight, acutely ill woman in significant distress with sweating and rigors.
Palms mildly jaundiced. Sclerae jaundiced.
o Vital Signs: BP 117/67, P 100, RR 14, T 39.3C; Wt 47 kg, Ht 159cm
o Abdomen: Soft and tender in epigastrium and right and left upper quadrants. Liver not
palpable; normal bowel sounds present.
o CNS: Semi-conscious, Glasgow Coma Scale 12/15 (Eyes = 4, Verbal = 3, Motor = 5). No
meningism or focal neurological signs.
• Laboratory tests on admission:
o HRP2 Antigen Rapid diagnostic test: P. falciparum malaria Positive
o Malaria smear: Plasmodium falciparum parasite density 5%
o Full Blood Count: Haemoglobin 6.9 g/dl, HCT 21.5%, Platelets 253,
o White Blood Count – 2.9 x106 cells/mm3 (no differential)
• Assess the severity of this patient’s malaria
o Severe
o Jaundiced, decreased LOC, hyper-parasitaemia (>5%), anaemia (<7%), shock (systolic < 70)
110
Case 1: severe malaria
• NM, a 34-year-old female is brought in to your hospital’s emergency room in a semi-conscious state,
with high fever, sweating and rigors. Her husband provides the following history:
o NM lives in a rural village in KwaZulu Natal on the Mozambican border.
o She visited a private general practitioner four days ago with a four-day history of headache,
fever, joint pains, nausea and vomiting.
o She was given four artemether-lumefantrine (AL) tablets and sent home with 20 AL tablets
and paracetamol.
o She vomited soon after leaving the doctor and continued to deteriorate over the next three
days until she became confused and very sleepy.
o Her husband took her to the traditional healer who gave a special tea that he said would
help, but she did not improve.
• Past Medical History:
o Asthma controlled on an inhaler
• Medication:
o Unknown inhaler PRN, unknown traditional medicine for 2 days
• Physical examination (significant findings only)
o General: Underweight, acutely ill woman in significant distress with sweating and rigors.
Palms mildly jaundiced. Sclerae jaundiced.
o Vital Signs: BP 117/67, P 100, RR 14, T 39.3C; Wt 47 kg, Ht 159cm
o Abdomen: Soft and tender in epigastrium and right and left upper quadrants. Liver not
palpable; normal bowel sounds present.
o CNS: Semi-conscious, Glasgow Coma Scale 12/15 (Eyes = 4, Verbal = 3, Motor = 5). No
meningism or focal neurological signs.
• Laboratory tests on admission:
o HRP2 Antigen Rapid diagnostic test: P. falciparum malaria Positive
o Malaria smear: Plasmodium falciparum parasite density 5%
o Full Blood Count: Haemoglobin 6.9 g/dl, HCT 21.5%, Platelets 253,
o White Blood Count – 2.9 x106 cells/mm3 (no differential)
• Assess the severity of this patient’s malaria
o Severe
o Jaundiced, decreased LOC, hyper-parasitaemia (>5%), anaemia (<7%), shock (systolic < 70)
What are the goals of treating NM?
o Treat for severe malaria, prevent long term organ damage, preventing death
111
Case 1: severe malaria
• NM, a 34-year-old female is brought in to your hospital’s emergency room in a semi-conscious state,
with high fever, sweating and rigors. Her husband provides the following history:
o NM lives in a rural village in KwaZulu Natal on the Mozambican border.
o She visited a private general practitioner four days ago with a four-day history of headache,
fever, joint pains, nausea and vomiting.
o She was given four artemether-lumefantrine (AL) tablets and sent home with 20 AL tablets
and paracetamol.
o She vomited soon after leaving the doctor and continued to deteriorate over the next three
days until she became confused and very sleepy.
o Her husband took her to the traditional healer who gave a special tea that he said would
help, but she did not improve.
• Past Medical History:
o Asthma controlled on an inhaler
• Medication:
o Unknown inhaler PRN, unknown traditional medicine for 2 days
• Physical examination (significant findings only)
o General: Underweight, acutely ill woman in significant distress with sweating and rigors.
Palms mildly jaundiced. Sclerae jaundiced.
o Vital Signs: BP 117/67, P 100, RR 14, T 39.3C; Wt 47 kg, Ht 159cm
o Abdomen: Soft and tender in epigastrium and right and left upper quadrants. Liver not
palpable; normal bowel sounds present.
o CNS: Semi-conscious, Glasgow Coma Scale 12/15 (Eyes = 4, Verbal = 3, Motor = 5). No
meningism or focal neurological signs.
• Laboratory tests on admission:
o HRP2 Antigen Rapid diagnostic test: P. falciparum malaria Positive
o Malaria smear: Plasmodium falciparum parasite density 5%
o Full Blood Count: Haemoglobin 6.9 g/dl, HCT 21.5%, Platelets 253,
o White Blood Count – 2.9 x106 cells/mm3 (no differential)
• Assess the severity of this patient’s malaria
o Severe
o Jaundiced, decreased LOC, hyper-parasitaemia (>5%), anaemia (<7%), shock (systolic < 70)
What are the goals of treating NM?
o Treat for severe malaria, prevent long term organ damage, preventing death
• How could NM’s disease progression have been avoided?
o Came in vomiting, gave her tablets which she vomited up
o Dose them and keep them there for at least an hour, if they vomit, then they need to be
retreated or given IV medication
o The GP may have underassessed disease severity
112
Case 1: severe malaria
• NM, a 34-year-old female is brought in to your hospital’s emergency room in a semi-conscious state,
with high fever, sweating and rigors. Her husband provides the following history:
o NM lives in a rural village in KwaZulu Natal on the Mozambican border.
o She visited a private general practitioner four days ago with a four-day history of headache,
fever, joint pains, nausea and vomiting.
o She was given four artemether-lumefantrine (AL) tablets and sent home with 20 AL tablets
and paracetamol.
o She vomited soon after leaving the doctor and continued to deteriorate over the next three
days until she became confused and very sleepy.
o Her husband took her to the traditional healer who gave a special tea that he said would
help, but she did not improve.
• Past Medical History:
o Asthma controlled on an inhaler
• Medication:
o Unknown inhaler PRN, unknown traditional medicine for 2 days
• Physical examination (significant findings only)
o General: Underweight, acutely ill woman in significant distress with sweating and rigors.
Palms mildly jaundiced. Sclerae jaundiced.
o Vital Signs: BP 117/67, P 100, RR 14, T 39.3C; Wt 47 kg, Ht 159cm
o Abdomen: Soft and tender in epigastrium and right and left upper quadrants. Liver not
palpable; normal bowel sounds present.
o CNS: Semi-conscious, Glasgow Coma Scale 12/15 (Eyes = 4, Verbal = 3, Motor = 5). No
meningism or focal neurological signs.
• Laboratory tests on admission:
o HRP2 Antigen Rapid diagnostic test: P. falciparum malaria Positive
o Malaria smear: Plasmodium falciparum parasite density 5%
o Full Blood Count: Haemoglobin 6.9 g/dl, HCT 21.5%, Platelets 253,
o White Blood Count – 2.9 x106 cells/mm3 (no differential)
• Assess the severity of this patient’s malaria
o Severe
o Jaundiced, decreased LOC, hyper-parasitaemia (>5%), anaemia (<7%), shock (systolic < 70)
What are the goals of treating NM?
o Treat for severe malaria, prevent long term organ damage, preventing death
• How could NM’s disease progression have been avoided?
o Came in vomiting, gave her tablets which she vomited up
o Dose them and keep them there for at least an hour, if they vomit, then they need to be
retreated or given IV medication
o The GP may have underassessed disease severity
• Was NM’s assessment at admission adequate?
Blood glucose (decreased LOC), pregnancy test, blood gas, U&E for renal failure in severe
malaria
113
Case 1: severe malaria
• NM, a 34-year-old female is brought in to your hospital’s emergency room in a semi-conscious state,
with high fever, sweating and rigors. Her husband provides the following history:
o NM lives in a rural village in KwaZulu Natal on the Mozambican border.
o She visited a private general practitioner four days ago with a four-day history of headache,
fever, joint pains, nausea and vomiting.
o She was given four artemether-lumefantrine (AL) tablets and sent home with 20 AL tablets
and paracetamol.
o She vomited soon after leaving the doctor and continued to deteriorate over the next three
days until she became confused and very sleepy.
o Her husband took her to the traditional healer who gave a special tea that he said would
help, but she did not improve.
• Past Medical History:
o Asthma controlled on an inhaler
• Medication:
o Unknown inhaler PRN, unknown traditional medicine for 2 days
• Physical examination (significant findings only)
o General: Underweight, acutely ill woman in significant distress with sweating and rigors.
Palms mildly jaundiced. Sclerae jaundiced.
o Vital Signs: BP 117/67, P 100, RR 14, T 39.3C; Wt 47 kg, Ht 159cm
o Abdomen: Soft and tender in epigastrium and right and left upper quadrants. Liver not
palpable; normal bowel sounds present.
o CNS: Semi-conscious, Glasgow Coma Scale 12/15 (Eyes = 4, Verbal = 3, Motor = 5). No
meningism or focal neurological signs.
• Laboratory tests on admission:
o HRP2 Antigen Rapid diagnostic test: P. falciparum malaria Positive
o Malaria smear: Plasmodium falciparum parasite density 5%
o Full Blood Count: Haemoglobin 6.9 g/dl, HCT 21.5%, Platelets 253,
o White Blood Count – 2.9 x106 cells/mm3 (no differential)
• Assess the severity of this patient’s malaria
o Severe
o Jaundiced, decreased LOC, hyper-parasitaemia (>5%), anaemia (<7%), shock (systolic < 70)
What are the goals of treating NM?
o Treat for severe malaria, prevent long term organ damage, preventing death
• How could NM’s disease progression have been avoided?
o Came in vomiting, gave her tablets which she vomited up
o Dose them and keep them there for at least an hour, if they vomit, then they need to be
retreated or given IV medication
o The GP may have underassessed disease severity
• Was NM’s assessment at admission adequate?
o Blood glucose (decreased LOC), pregnancy test, blood gas, U&E for renal failure in severe
malaria
• What is the treatment of choice for managing NM now?
IV artesunate, can give IM if shocked and venous access is not possible
114
Case 1: severe malaria
• NM, a 34-year-old female is brought in to your hospital’s emergency room in a semi-conscious state,
with high fever, sweating and rigors. Her husband provides the following history:
o NM lives in a rural village in KwaZulu Natal on the Mozambican border.
o She visited a private general practitioner four days ago with a four-day history of headache,
fever, joint pains, nausea and vomiting.
o She was given four artemether-lumefantrine (AL) tablets and sent home with 20 AL tablets
and paracetamol.
o She vomited soon after leaving the doctor and continued to deteriorate over the next three
days until she became confused and very sleepy.
o Her husband took her to the traditional healer who gave a special tea that he said would
help, but she did not improve.
• Past Medical History:
o Asthma controlled on an inhaler
• Medication:
o Unknown inhaler PRN, unknown traditional medicine for 2 days
• Physical examination (significant findings only)
o General: Underweight, acutely ill woman in significant distress with sweating and rigors.
Palms mildly jaundiced. Sclerae jaundiced.
o Vital Signs: BP 117/67, P 100, RR 14, T 39.3C; Wt 47 kg, Ht 159cm
o Abdomen: Soft and tender in epigastrium and right and left upper quadrants. Liver not
palpable; normal bowel sounds present.
o CNS: Semi-conscious, Glasgow Coma Scale 12/15 (Eyes = 4, Verbal = 3, Motor = 5). No
meningism or focal neurological signs.
• Laboratory tests on admission:
o HRP2 Antigen Rapid diagnostic test: P. falciparum malaria Positive
o Malaria smear: Plasmodium falciparum parasite density 5%
o Full Blood Count: Haemoglobin 6.9 g/dl, HCT 21.5%, Platelets 253,
o White Blood Count – 2.9 x106 cells/mm3 (no differential)
• Assess the severity of this patient’s malaria
o Severe
o Jaundiced, decreased LOC, hyper-parasitaemia (>5%), anaemia (<7%), shock (systolic < 70)
What are the goals of treating NM?
o Treat for severe malaria, prevent long term organ damage, preventing death
• How could NM’s disease progression have been avoided?
o Came in vomiting, gave her tablets which she vomited up
o Dose them and keep them there for at least an hour, if they vomit, then they need to be
retreated or given IV medication
o The GP may have underassessed disease severity
Was NM’s assessment at admission adequate?
o Blood glucose (decreased LOC), pregnancy test, blood gas, U&E for renal failure in severe
malaria
• What is the treatment of choice for managing NM now?
o IV artesunate, can give IM if shocked and venous access is not possible
• What drugs should be avoided?
o NSAIDs would increase risk of renal failure and DIC
o Steroids since they can cause water retention (especially in renal failure) and develop ARDS
o Heparin due to risk of GIT bleeds
115
Case 1: severe malaria
• NM, a 34-year-old female is brought in to your hospital’s emergency room in a semi-conscious state,
with high fever, sweating and rigors. Her husband provides the following history:
o NM lives in a rural village in KwaZulu Natal on the Mozambican border.
o She visited a private general practitioner four days ago with a four-day history of headache,
fever, joint pains, nausea and vomiting.
o She was given four artemether-lumefantrine (AL) tablets and sent home with 20 AL tablets
and paracetamol.
o She vomited soon after leaving the doctor and continued to deteriorate over the next three
days until she became confused and very sleepy.
o Her husband took her to the traditional healer who gave a special tea that he said would
help, but she did not improve.
• Past Medical History:
o Asthma controlled on an inhaler
• Medication:
o Unknown inhaler PRN, unknown traditional medicine for 2 days
• Physical examination (significant findings only)
o General: Underweight, acutely ill woman in significant distress with sweating and rigors.
Palms mildly jaundiced. Sclerae jaundiced.
o Vital Signs: BP 117/67, P 100, RR 14, T 39.3C; Wt 47 kg, Ht 159cm
o Abdomen: Soft and tender in epigastrium and right and left upper quadrants. Liver not
palpable; normal bowel sounds present.
o CNS: Semi-conscious, Glasgow Coma Scale 12/15 (Eyes = 4, Verbal = 3, Motor = 5). No
meningism or focal neurological signs.
• Laboratory tests on admission:
o HRP2 Antigen Rapid diagnostic test: P. falciparum malaria Positive
o Malaria smear: Plasmodium falciparum parasite density 5%
o Full Blood Count: Haemoglobin 6.9 g/dl, HCT 21.5%, Platelets 253,
o White Blood Count – 2.9 x106 cells/mm3 (no differential)
• Assess the severity of this patient’s malaria
o Severe
o Jaundiced, decreased LOC, hyper-parasitaemia (>5%), anaemia (<7%), shock (systolic < 70)
What are the goals of treating NM?
o Treat for severe malaria, prevent long term organ damage, preventing death
• How could NM’s disease progression have been avoided?
o Came in vomiting, gave her tablets which she vomited up
o Dose them and keep them there for at least an hour, if they vomit, then they need to be
retreated or given IV medication
o The GP may have underassessed disease severity
Was NM’s assessment at admission adequate?
o Blood glucose (decreased LOC), pregnancy test, blood gas, U&E for renal failure in severe
malaria
• What is the treatment of choice for managing NM now?
o IV artesunate, can give IM if shocked and venous access is not possible
• What drugs should be avoided?
o NSAIDs would increase risk of renal failure and DIC
o Steroids since they can cause water retention (especially in renal failure) and develop ARDS
o Heparin due to risk of GIT bleeds
• What clinical and laboratory parameters should be monitored during NM’s admission?
o See the patient twice a day
o Glucose 4 hrly until LOC is normal
o U&E every day
o Hb (will decrease until 3 days after treatment then increase), may need a transfusion
o Liver function tests once or twice a week
o Monitor all complications
116
Case 2:
• A 60-year-old man who developed flu-like symptoms shortly after he returned from a public health
consultancy in Nigeria.
• One week later he collapsed at work, was found to be P. falciparum malaria positive on a rapid
diagnostic test and was admitted to a private hospital and treated with artemether-lumefantrine for
3 days.
o Right treatment, right duration
• During this period, he deteriorated with increasing weakness and a decreased level of
consciousness, and was finally started on IV quinine on day 4.
• It took months after discharge before he was able to walk normally again.
What would you have done differently for this patient?
o Started immediately on IV artesunate as he had severe malaria (collapse at work)
o More constant checkups, started earlier on more treatment
117
Case 2:
• A 60-year-old man who developed flu-like symptoms shortly after he returned from a public health
consultancy in Nigeria.
• One week later he collapsed at work, was found to be P. falciparum malaria positive on a rapid
diagnostic test and was admitted to a private hospital and treated with artemether-lumefantrine for
3 days.
o Right treatment, right duration
• During this period, he deteriorated with increasing weakness and a decreased level of
consciousness, and was finally started on IV quinine on day 4.
• It took months after discharge before he was able to walk normally again.
What would you have done differently for this patient?
o Started immediately on IV artesunate as he had severe malaria (collapse at work)
o More constant checkups, started earlier on more treatment
Which of the following are features of severe malaria
• Impaired consciousness (sleepy / confused)
• Hypoglycaemia (low blood sugar)
• Weakness
o Has to be worse than baseline
• Convulsions (seizures / fits)
o Must be more than 2 convulsions
• Jaundice
• Oliguria
• Macroscopic haematuria (coca-cola colour)
• Hyperthermia (temp >40 degrees)
o Not a feature, as you have a higher risk of dying if you cannot mount a fever
• Abnormal bleeding
• Vomiting
o Repeated vomiting or within an hour of dosing is concerning
• Anaemia
o Average woman does have anaemia, so it must be lower than their baseline or severely low
118
Case 3:
• Mr SX, 26-year-old opera singer from Khayelitsha, Cape Town
• 1-3 Jun 2018: travelled via Nairobi to Dar es Salaam
• 23 Jun 2018: Fever, rigors, nausea and vomiting. Malaria confirmed and treated with artemether-
lumefantrine.
• Recovered. No further travel.
• 22 July 2018: Flu-like illness, Confusion. Malaria confirmed.
• Immediate treatment?
o Artesunate
▪ IV, 1mg/kg dose twice a day, then daily until no features of severe malaria
o Artemether-lumefantrine
▪ Once no features of severe malaria
▪ Full course, 4 tablets twice a day for 3 days
o Full adherence
o Monitor more closely
119
Causes of treatment failure
• Adherence??
• Drug quality?
• Concomitant meds?
• Comorbidities?
• Sub-optimal dose, PK (or vomiting)?
• Antimalarial Resistance?
o MDR malaria is prevalent in Southeast Asia
o It has not been reported in Africa
• Malarial subtypes can lie dormant
o Vivax and ovale form hypnozoites
120
Case 3:
• Mr SX, 26-year-old opera singer from Khayelitsha, Cape Town
• 1-3 Jun 2018: travelled via Nairobi to Dar es Salaam
• 23 Jun 2018: Fever, rigors, nausea and vomiting. Malaria confirmed and treated with artemether-
lumefantrine.
• Recovered. No further travel.
• 22 July 2018: Flu-like illness, Confusion. Malaria confirmed.
• Treatment plan
Treatment plan
• IV artesunate
• Artemether-lumefantrine
• Primaquine?
o Does not help malaria symptoms get better
o Prevents the gametocytes from forming and prevents the mosquitos from gaining infection
o Also kills hypnozoites in vivax and ovale species if given for 7 days
• Treat all as if falciparum, give primaquine as a single dose to prevent transmission and as an
extended dose if vivax/ovale
121
Core antimalarial medicines
Artemether-lumefantrine
• Parenteral Artesunate
• Primaquine
• [Quinine (IV/IM/oral)]
• [Doxycycline and Clindamycin]
Therapeutics
flashcards
Decks in class (28)
# Cards
-
Asthma/ COPD143
-
Infectious disease emergency103
-
Depression and Anxiety249
-
Rational Drug Use: Malaria67
-
Poisoning102
-
Hypertension78
-
Prescription Writing51
-
Ischemic Heart Disease81
-
Diabetes Mellitus114
-
Rational Drug Use54
-
Critical Appraisal of medical literature111
-
Therapeutic Drug Monitoring91
-
Antibiotic cases194
-
Diabetes Mellitus- Treatment142
-
Hypertension Drugs22
-
Malaria121
-
Prescribing In Special Populations165
-
Non- Communicable Diseases88
-
Anti- TB Drugs130
-
Upper Respiratory Tract Infections0
-
Anticonvulsants216
-
Immunosuppressants300
-
Opportunistic Infections105
-
Antiretroviral Therapy92
-
Pain Management136
-
Drug Hypersensitivity136
-
Anticoagulants136
-
Substance Use Disorder251
