By the end of this article, one should be able to,
- Recognize severe malaria.
- Describe management of severe malaria.
Signs and symptoms of Severe Malaria
Severe malaria is a life threatening condition defined as Peripheral parasitaemia in the presence of the following clinical or laboratory features
- altered consciousness,
- respiratory distress,
- multiple generalized convulsions,
- severe anaemia (Hb<5g/dl),
- hypoglycaemia (<2.2mmol/l),
NB- features may occur singly or in combination
- Conjugate deviation of the eyes to the left
Role of laboratory diagnosis in severe malaria
- Parasitological confirmation is recommended.
- Presumptive treatment should be started immediately while waiting for parasitological confirmation.
- Antimalarial treatment should not be withheld if parasitological diagnosis is not possible or delayed.
- Other investigations to determine severity and prognosis should be undertaken where feasible;
(HB, Blood sugar, Urea and electrolyte).
- Positive slides do not rule out other causes of severe disease
Clinical Manifestations of Severe Malaria
- Severe Anaemia
- Cerebral Malaria
- All the clinical manifestations are primarily due to the involvement of red blood cells.
- P. Vivax predominantly invades young red cells and the number of parasites infected rarely exceeds 2%.
- P. Malariae develops mostly in mature red cells and parasitaemia is rarely greater than 1%.
- P. falciparum affects red cells of all ages and parasitaemia can be as high as 20-30% .
I. How to assess cerebral malaria clinically
- Assess level of consciousness using coma score.
- Determine the presence of severe anaemia.
- Examine for presence of respiratory distress.
- Determine hydration status
- Assess for renal insufficiency
- Look for evidence of Disseminated Intravascular Coagulopathy (DIC)
- Assess for stiff neck and do lumbar puncture
II. Laboratory Tests Assessment
- In children with altered consciousness, start treatment for both malaria, and meningitis until lumbar puncture results exclude meningitis.
- Do blood glucose to rule out hypoglycemia.
- Determine hemoglobin levels, blood group and cross match where applicable.
Inpatient management of severe malaria
Quinine administration in children
- Loading dose of 20mg/kg in 15ml/kg of 5% dextrose or normal saline to run over 4 hours
- Omit loading dose if any quinine has been given in the previous 24 hours 8 hours from commencement of initial dose, give 10mg/kg quinine in 10ml/kg of 5% dextrose or normal saline to run over 4 hours
- Repeat 10mg/kg infusion every 8 hours until the patient is able to sit up and take oral medication
Quinine administration in adults
- Loading dose of 20mg/kg (maximum of 1200mg)in 5% dextrose or normal saline to run over 4 hours
- Omit loading dose if any quinine has been given in the previous 24 hours
- Maintain with 10mg/kg (maximum of 600mg) infusion 8 hourly until the patient is able to take oral medication
Follow on treatment after IV quinine
- Once all patients are able to take oral medication: Give a full course of artemether-lumefantrine for 3 days
- Continue oral quinine at 10mg/kg (max 600mg) 8 hourly for a total of 7 days of treatment.
- Hypoglycaemia – IV or oral glucose (10% glucose 5 ml/kg)
diazepam 0.3mg/kg IV or 0.5 mg/kg rectally
Phenytoin or phenobarbitone
- Severe anaemia – transfuse
- Fluid and electrolyte balance
- Fever and nursing care
- Would you give Artesunate / IV Quinine to a child with severe malaria and Hb of 3g/dl?
- Would you give fluid to a child with Hb of 3g/dl before giving a blood transfusion?
- Yes, Artesunate or quinine must be given as soon as possible while waiting for blood transfusion.
- Yes, children with severe malaria and severe anaemia can be given fluids while waiting for blood transfusion