Severe malaria is a life-threatening medical emergency. Caused by Plasmodium falciparum parasites, it can rapidly progress, affecting multiple organ systems and leading to complications. Unlike uncomplicated malaria, which is often managed with oral medications, severe malaria requires urgent hospitalization. Early recognition of symptoms is important for improving patient outcomes.
Recognizing Severe Symptoms
Severe malaria presents with specific signs. These include impaired consciousness, ranging from drowsiness to coma, often associated with cerebral malaria affecting the brain. Severe anemia, characterized by a low red blood cell count, is another sign. Respiratory distress, including deep, labored breathing, can also occur.
Acute kidney injury, evidenced by reduced urine output, can develop. Repeated generalized convulsions or seizures are a serious symptom, common in children, indicating neurological involvement. Jaundice, a yellowing of the skin and eyes, may suggest liver dysfunction or severe hemolysis. These manifestations collectively signal a medical emergency.
Primary Drug Treatments
Primary drug treatment for severe malaria involves potent antimalarial medications, with intravenous (IV) administration for rapid action. IV artesunate is the recommended first-line treatment for severe P. falciparum malaria in adults and children. This artemisinin derivative quickly reduces parasite load and has shown better efficacy than quinine, reducing mortality. It is administered as an injection.
Once a patient stabilizes and can tolerate oral medications, treatment transitions from IV artesunate to an oral artemisinin-based combination therapy (ACT). This transition occurs after at least 24 hours of IV treatment, provided there is improvement in consciousness and other severe symptoms. The oral ACT course is completed over several days to ensure parasite clearance and prevent relapse.
Essential Supportive Care
Beyond specific drug treatments, supportive care is important for managing severe malaria, often requiring an intensive care unit (ICU) setting. Managing fluid balance is important, as both dehydration and fluid overload can worsen outcomes, especially in patients with acute kidney injury or pulmonary edema. Electrolyte imbalances, such as low blood glucose (hypoglycemia) or abnormal potassium levels, must be corrected promptly.
Severe anemia often requires blood transfusions to restore oxygen capacity and prevent organ damage. For acute kidney injury, dialysis may be needed to support kidney function and remove toxins. Respiratory distress might involve oxygen therapy or, in severe cases, mechanical ventilation. Seizures are managed with anticonvulsant medications to prevent brain damage and complications.
After Treatment and Recovery
Following the acute phase of severe malaria treatment, recovery varies among individuals. Patients often require convalescence to regain strength and recover from the infection’s effects. Long-term complications can occur, particularly in children who experienced cerebral malaria, with neurological issues like cognitive impairments, behavioral changes, or epilepsy. Regular follow-up care is important to monitor for these effects and provide rehabilitation.
Preventing recurrence is an important part of post-treatment care, especially in areas with ongoing malaria transmission. This involves educating patients on mosquito bite prevention strategies, such as using insecticide-treated bed nets and repellents. While post-treatment prophylaxis is not routinely recommended, awareness of re-infection risk and prompt medical attention for new fever episodes are encouraged.
References
1. World Health Organization. Guidelines for the treatment of malaria. Third edition. 2015.
2. World Health Organization. Management of severe malaria: a practical handbook. Third edition. 2012.
3. World Health Organization. A guide to the treatment of malaria. 2021.