Symptomatic Malaria Case

Uncomplicated  malaria  is  defined  as  symptomatic  malaria  without  signs  of  severity  or  evidence (clinical or laboratory) of vital organ dysfunction. 

Clinical presentation  

• Fever 
• Headache 
• Joint pains 
• Malaise 
• Vomiting 
• Diarrhoea 
• Body ache, body weakness
• Poor appetite 
• Pallor, enlarged spleen 

Investigations 

The recommended investigations are: 

• Quality malaria microscopy or quality malaria Rapid Diagnostic Tests (mRDTs)  

Note 

• It is compulsory to test and confirm all suspected malaria patients. Give antimalarial only to those who test positive. 
• In  cases  where  non-response  to  malaria  treatment  (treatment  failure)  is  suspected  in patients who initially tested positive, microscopy is the recommended laboratory procedure  as mRDTs are not recommended because parasite antigens persist up to 4 weeks after  parasitaemia has cleared. 

Non-Pharmacological Treatment

• Continue with feeding and fluid intake
• Followed up immediately if the condition worsens or on the fourth day if symptoms persist. 

Pharmacological Treatment

Drug of choice for treatment of uncomplicated malaria is: 

A: Artemether + Lumefantrine (FDC) (PO) 20mg+120mg   

Common formulations:  

• Fixed formulation Artemether 20mg, Lumefantrine 120mg; 6, 12, 18 and 24 tablets blister 
• Fixed formulation Artemether 80mg, Lumefantrine 480mg; 6 tablets blister 

Dispersible tablets: Fixed formulation for children 

A: Artemether 20mg + Lumefantrine 120mg; 6 tablets blister (5–14kg): 1 tablet; 15–24 kg: 2 tablets   

Table 5.1: Dosage regimen for ALu (artemether 20mg/lumefantrine 120mg) 

Table 5.2: The recommended dosing schedule for ALu strength 80/480 mg

For practical purposes, a simpler dosage regimen is recommended in order to improve  compliance:  the  first  dose  should  be  given  as  DOT;  the  second  dose should strictly be given after 8 hours; subsequent doses could be given 12hourly in the second and third day of treatment until completion of 6 doses 

The alternative medicines for the treatment of uncomplicated malaria, where there is no response to Artemether-Lumefantrine or it is contraindicated, is Dihydroartemisinin-Piperaquine.  

C: dihydroartemisinin+piperaquine (FDC) (PO). 

Adult formulation containing 40 mg Dihydroartemisinin + 320 mg Piperaquine.  Paediatrics  formulation contains  a  fixed  combination  of  20  mg  of  Dihydroartemisinin +160 mg Piperaquine.

Table 5.3: Dose Schedule for Dihydroartemisinin + Piperaquine 

Management of fever 

Patients with high fever (38.5^oC and above) should be given an anti-pyretic medicine like  paracetamol or acetylsalicylic acid every 4 to 6 hours  (maximum 4 doses in 24 hours) until symptoms resolve, usually after two days.  

Note: Children below 12 years should not be given acetylsalicylic acid because of the risk of developing  Reye's syndrome. 

Table 5.4: Treatment Schedule for Paracetamol (500mg) Tablets Children  10mg/kg body weight 

In a patient with P. falciparum asexual parasitaemia and no other obvious cause of symptoms the presence of one or more of features listed below classify the patient as suffering from severe malaria.

Clinical presentation

• Prostration/extreme weakness
• Impaired consciousness
• Change of behaviour
• Convulsions
• Respiratory distress (due to lactic acidosis and/or pulmonary oedema)
• Jaundice
• Circulatory collapse/shock
• Vomiting everything
• Inability to drink or breast feed
• Bleeding tendency/DIC

Investigations

In severe malaria, blood slide (BS) is a recommended malaria test as it quantifies parasitemia. In severe ill patients receiving injectable antimalarial, serial BS investigations monitors level of parasitemia to verify malaria recovery, or if clinical condition is not improving to rule out another serious condition.

• Blood film for malaria parasites
• Blood glucose estimation in patients with altered consciousness
• Haematocrit and/or haemoglobin estimation
• Lumbar puncture to exclude meningitis (if facilities for LP assessment are available)
• Serum creatinine or urea– to assess Kidney function 112
• Electrolytes– for early detection of acute renal failure
• Full blood cell count and differential white cell count for additional diagnosis of other infectious diseases
• Blood gases, pH and anion gap– to diagnose acidosis
• Radiological investigation: Chest X–ray; look for pulmonary oedema or lobar consolidation
• Blood culture and sensitivity where feasible

Non-Pharmacological Treatment

A rapid assessment must be conducted including airway, breathing, circulation, coma, convulsion, and dehydration status.

Referral: If effective management of severe malaria and supportive care for complications is not possible, patients should be given pre-referral treatment and referred immediately to an appropriate facility for continued treatment.

Pharmacological Treatment

A: Parenteral artesunate

Dosage:

• 2.4 mg/kg in body weight. (IV) or (IM) given on admission (time = 0 hour), then at 12 hours and 24 hours for a minimum of 3 injections in 24 hours regardless of patient’s recovery.
• Children weighing less than 20 kg Dosage: 3 mg/kg/dose (or higher). Same schedule as indicated above (0, 12, 24 hours)
• Complete artesunate injection treatment by giving a complete course (3days) of
  artemether-lumefantrine (ALu) or other ACT.

Consider broad spectrum antibiotic as treatment of septicemia.

Administration and dosage (30 mg, 60mg and 120mg strength): Injectable artesunate has 2-steps dilutions.

• Step 1: The powder for injection should be diluted with 1ml of 5% sodium bicarbonate solution (provided in each box) and shaken vigorously 2–3 minutes for better dissolving until the solution becomes clear.
• Step 2: For slow intravenous infusion (3–4 minutes), add 5 ml of 5% dextrose or normal saline, to obtain artesunate concentration of 10 mg/ml. For deep intra–muscular injection, add 2 ml of 5% dextrose or normal saline to obtain artesunate concentration of 20 mg/ml.

Table 5.5: Dilution of Artesunate for Injection

Table 5.6: Dosage Schedule for Artesunate Injection 

*Half the dose is rounded up to 1ml; **Full vial (s) might not be required for a given weight band. The  left–over solution must be discarded within 1hr of preparation and must not be reused

If the patient can tolerate oral medication after 24 hours provide a full treatment course of AL. Initiate  the first dose of AL 8 hours after the last injection.   

Alternative 

C: Injectable Artemether 

Injectable Artemether is to be used when Artesunate is contraindicated (in case of allergy, medicine  interaction or non- response) and when not available. Artemether should be administered in a dose  of 3.2mg/kg loading dose IM stat (0hour) then 1.6mg/kg (24hours and 48hours). 

Table 5.7: Artemether Injectable Dosage by Weight 

If the patient can tolerate oral medication after 24 hours provide a full treatment course of ALu.  Initiate the first dose of ALu 8hours after the last injection. 

Management of complications 

To reduce the unacceptably high mortality of severe malaria, patients require intensive care. Clinical  observations should be made as frequently as possible. Airway maintenance, nurse on side, fanning  if hyperpyrexia is present, fluid balance review: 

Coma (cerebral malaria): maintain airway, nurse on side, and exclude other causes of coma (e.g.  hypoglycemia, bacterial meningitis); avoid giving corticosteroids. 

Dehydration: Correct dehydration 

Hyperpyrexia: fanning, paracetamol if patient can swallow 

Convulsions: maintain airways; treat with 

Adult 

A: diazepam (IV) 0.15 mg/ kg (maximum 10 mg) slow bolus IV injection. 

Children 

A: diazepam (rectal) 0.5–1.0 mg/ kg¹ 

If  convulsions  persist  after  10  minutes  repeat  rectal  diazepam  treatment  as  above.  Should convulsions continue despite a second dose, give a further dose of rectal diazepam  

OR  

A: phenobarbitone (IM/IV) 20 mg/ kg after another 10 minutes. 

Hypoglycemia: remains a major problem in the management of severe malaria especially in young  children and pregnant women. It should be deliberately looked for and treated accordingly. Urgent  and repeated blood glucose screening. 

In children:  

B: dextrose 10% (IV) 5 ml/kg 

OR 

C: dextrose 25% (IV) 2.5ml/kg as bolus;  

If 50% dextrose solution is available, it should be diluted to make 25% by adding an equal volume of  water for injection or normal saline.  

In adults:  

B: dextrose 10% (IV) 125ml 

OR 

C: dextrose 25% (IV) 50ml as bolus. 

Where dextrose is not available, sugar water should be prepared by mixing 20g of sugar (4–level  teaspoons) with 200ml of clean water. 50ml of this solution is given ORALLY or by nasogastric tube if unconscious. 

Severe anaemia: Refer to haematology chapter 

Acute pulmonary oedema: Refer to respiratory conditions chapter 

Acute renal failure: Refer to cardiovascular disease condition chapter 

Shock: Refer to emergency and critical care chapter

¹Draw the IV preparation into a small syringe and remove the needle. Insert 5 cm of a nasogastric tube into the rectum. Inject the diazepam into the nasogastric tube and flush it with 5 ml of water. If a nasogastric tube is not available, use a syringe without a needle. Hold buttocks together for few minutes to ensure retention and absorption of the medicine.