Clinical Scenario:
An 8-year-old boy is admitted with a 4-day history of high-grade fever and vomiting. During admission, he becomes increasingly drowsy and develops two episodes of generalized tonic-clonic seizures. On examination, his Glasgow Coma Scale is 8/15. Fundoscopy is normal. Blood glucose is 92 mg/dL, serum sodium is 138 mmol/L, and cerebrospinal fluid examination is normal. Peripheral blood smear demonstrates Plasmodium falciparum.
What is the most appropriate initial treatment?
A. Intravenous artesunate
B. Intravenous quinine
C. Oral artemether-lumefantrine
D. Intravenous ceftriaxone
E. Exchange transfusion
Correct answer & Explanation:
Correct answer : A. Intravenous artesunate
Explanation: Malaria/ cerebral malaria/ treatment
This child has cerebral malaria, a manifestation of severe falciparum malaria, characterized by:
- Impaired consciousness (GCS <11)
- Recurrent seizures
- No alternative explanation for coma (normal CSF and glucose)
- Confirmation of P. falciparum infection
According to WHO guidelines, intravenous artesunate is the treatment of choice for severe malaria because it rapidly reduces parasite burden and has been shown to reduce mortality compared with quinine.
Why the other options are incorrect
B. Intravenous quinine
Effective but no longer first-line where intravenous artesunate is available because artesunate has superior survival outcomes and fewer adverse effects.
C. Oral artemether-lumefantrine
Recommended only after the patient can tolerate oral medication and has completed at least 24 hours of parenteral therapy.
D. Intravenous ceftriaxone
May be used if bacterial meningitis cannot initially be excluded, but it is not the definitive treatment for severe malaria.
E. Exchange transfusion
Not recommended routinely and has not shown consistent clinical benefit in severe malaria.
Learning Point
Features of severe malaria include:
- Impaired consciousness or coma
- Repeated seizures
- Severe anemia
- Acute kidney injury
- Respiratory distress
- Shock
- Hypoglycemia
- Acidosis
- Hemoglobinuria (blackwater fever)
Intravenous artesunate is the first-line treatment for all forms of severe falciparum malaria.
