Abstract

Management of severe malaria

Author(s): Limangeni Mankhambo, Ajib Phiri, MacPherson Mallewa and Malcolm Molyneux

Plasmodium falciparum and other human malaria parasites can cause a variety of life-threatening syndromes. Diagnosis is difficult because none of these syndromes is unique to malaria, and parasitemia may be incidental rather than responsible for the illness. Malaria must be considered in the differential diagnosis of each of the severe syndromes it can cause – severe anemia, coma and convulsions, acidosis, hypoglycemia, shock, acute renal failure, intravascular hemolysis, acute respiratory distress syndrome and disseminated intravascular coagulation. The possibility of an alternative or additional infection must be considered and, in many circumstances, covered by initial emergency treatment. In the comatose patient the presence of a distinctive retinopathy is suggestive that malaria is the cause of the disease. Management must begin with emergency measures to ensure vital functions, followed by prompt provision of supportive measures (airway protection, glucose, fluids, oxygen, blood, antipyresis and anticonvulsants), and supervised referral to an appropriate available facility offering optimal clinical management. In a remote site, specific antimalarial therapy may be started with artesunate by suppository to cover the journey to hospital, where treatment can continue with intravenous or intramuscular quinine or with intravenous artesunate, followed by full artemisinin combination therapy as soon as oral treatment is possible. Identifying and managing severe disease events remains crucially important as malaria control measures successfully reduce the burden of the infection, with the possibility of waning of both immunity of hosts to the infection and familiarity of clinicians with the disease.