MALARIA – II

Complicated Malaria
Dr. Kumbakumba Elias
Department of Paediatrics and
Child Health
 Definition:

• Malaria is a clinical disease (collection of

symptoms and signs) due to infection by
asexual forms of the parasites Plasmodium
falciparum, P. vivax, P. ovale, P. malariae.
 Complicated malaria
• Malaria is regarded as severe or complicated if
there are asexual forms of P. falciparum in
blood plus one or more of the following
complications:

- Severe normocytic anaemia

- Cerebral malaria
- Pulmonary edema/Respiratory distress
- Shock/Circulatory collapse
- Bleeding tendency/DIC
- Thrombocytopenia
- Acidosis
- Hypoglycaemia
- Hyperparasitaemia
- Hyperpyrexia
- Jaundice
- Haemoglobinuria
- Severe vomiting
- Generalised convulsions
- Fluid and electrolyte disturbances
 Pathophysiology
• Sequestration
• Cytoadherence
• Rosetting and Agglutination
• Red Cell deformability
 Specific treatment:
• Intravenous Quinine 10mg/Kg body weight in 10ml/kg
of 5% dextrose infusion every 8 hours till the patient
can take orally (usually 1 – 3 days), then oral quinine
10mg/kg 8 hourly to complete 7 days of treatment.
IV artesunate is being studied.

• Always assess children for all complications and

manage them at the same time

• Take the child’s weight before administering any

treatment.
COMPLICATIONS - Cerebral Malaria:
Definition: (WHO)
unconsciousness/ unrousable coma (unable
to localize pain or a Blantyre Coma Score of
< 2) in the presence of asexual P. falciparum
parasitaemia of any density and no other
obvious cause of the clinical syndrome (e.g.
meningitis, hypoglycaemia).
• In practice, all children with a depressed level
of consciousness and P. falciparum on the
blood smear are treated as CM.
 Pathophysiology:

• Seizures and coma:

Intracranial sequestration of metabolically
active parasites, cerebral hypoxia, increased
intracranial pressure, cerebral edema,
hypoglycaemia, hyponatremia.
 Clinical features:
• Coma/ altered consciousness
• Convulsions (60 – 80%)
• Hypertonic posturing (decorticate or
decerebrate rigidity, opisthotonos)
• Pupillary changes
• Absent corneal reflexes
• Abnormal respiratory pattern (Kussmaul’s,
Cheyne-Stokes, periodic apnoea)
• Gaze abnormalities (eyes wide open, conjugate
gaze deviation, nystagmus)
 Blantyre Coma Scale:
Best Response Score
Best Motor Response:
• Localises painful stimuli 2
• Withdraws from a painful stimulus 1
• Extends/No response 0

Best Verbal Response:

• Normal cry 2
• Abnormal cry/ moan 1
• No response 0

Eye movements:
• Follows mother’s face/ moving object 1
• Unfocused gaze/ Does not follow mother’s face 0
 BCS

• Total score = sum of individual scores from the

three categories; (Max = 5, Min = 0)

• Unrousable Coma = BCS score of 2 or less

• Standard painful stimulus is firm pressure on a

nailbed, sternum, supraorbital rigde
 Management:
• CM is an emergency
• Manage Airway, Breathing and Circulation
• Place child in lateral position and turn 2 hourly
• Nasogastric tube to empty stomach in first 2
hours to avoid aspiration, then for feeding
• Intravenous access for drugs and maintenance
fluids; avoid fluid overload
• Check blood sugar and treat hypoglycaemia
• Intravenous quinine started immediately
• Lumbar puncture for CSF analysis, blood
cultures,
• Monitor and record vital signs at least every 4
hours (BP, Pulse, RR, Temp, Level of
consciousness)

Outcome:
• Mortality rate 15 – 30%
• 9–12% are discharged with neurological
sequelae, half of these recover fully within 4-6
weeks
 COMPLICATIONS - Severe anaemia

Definition
• Packed Cell Volume =/< 15%

• Haemoglobin =/< 5 g/dl

• If MCV is normal Hb = 1/3 PCV. This is

altered by micro/macrocytosis
 Pathophysiology:
• Haemolysis/ destruction of parasitised RBCs at
merogony or by erythrophagocytosis in the
spleen

• Unparasitised RBCs also have a shorter

lifespan during malaria infection

• Preexisting Iron deficiency or

hemoglobinopathies

• Dyserythropoiesis
 Features:

• Severe pallor of mucous membranes, palms

and soles
• Respiratory distress (deep, laboured breathing)
• Hyperdynamic circulation (gallop rhythm,
tachycardia, hepatomegaly, pulmonary edema)
• Confusion, restlessnes, coma, retinal
hemorrhages
 Management:
• Do PCV or Hb estimation, Thick and thin film

• If Hb =/< 5g/dl, give a blood transfusion.

• If Hb >5 but <6g/dl, with features of cardiac

failure, hyperparasitaemia, respiratory distress,
impaired consciousness; tranfuse.
• Transfuse with packed cells 10 – 15ml/Kg or
whole blood 20ml/Kg over 2 -3 hours
• A diuretic is not often required but IV
furosemide (1-2mg/Kg) may be given if there
fluid overload
• Folic acid and/or iron at discharge

Outcome:
• Mortality rate is 4.7 – 16% but is higher if
severe anemia occurs with other complications
like cerebral malaria and respiratory distress
3) Hypoglycaemia:
• Very common in children who have been
undernourished, those below 3 years, those
with convulsions and in 10 – 20% of those
with cerebral malaria

• Blood sugar =/< 2.5 mmol/l

Pathophysiology:
a) Pretreatment:
• Impaired gluconeogenesis
• Accelerated metabolism
• Reduced food intake
• Parasite glucose consumption

b) During treatment:
• Quinine stimulates insulin secretion. Rapid
infusions of quinine (>10mg/kg in 1 hour) can
precipitate hypoglycaemia
 Features:

• Blood glucose =/< 2.5 mmol/l

• Convulsions/ altered consciousness

• Sweating

• Extreme weakness
Management:
• Check random blood sugar before and even
after correcting hypoglycaemia
• Intravenous infusion or bolus push of 5ml/kg
dextrose 10% solution
• Feed the patient
• Prepare a solution of sugar which may be given
by NGTube
Outcome:
• Mortality of pretreatment hypoglycemia in
children with cerebral malaria is 22 – 37%
• Recurrent hypoglycaemia - 71% mortality
4) Respiratory distress:
Features:
• Tachypnoea
• Alae nasi flaring
• Chest/ subcostal recessions
• Use of accessory muscles of respiration
• Deep acidotic breathing
• Grunting

Pathophysiology:
• Metabolic acidosis (PH < 7.3) from anaerobic
glycolysis
• Pulmonary edema
• Anaemia, Hypogylcamia
Management:
• Correct reversible causes of acidosis; Anaemia,
dehydration, hypoglycaemia, treat convulsions

• Prop the child up in bed

• +/- oxygen

Outcome:
• Mortality is up to 19%
5) Shock:
• A systolic BP of 50mmhg or less signifies
shock.
• Children may have cold clammy cyanotic skin;
constricted peripheral veins and a rapid feeble
pulse.
• Circulatory collapse may result from a
complicating gram negative septicaemia,
hypovolaemia from dehydration, pulmonary
edema or metabolic acidosis.
• Possible foci of infection should be sought e.g.
lungs, urinary tract, meninges, intravenous
lines and sites.
Management:
• Correct hypovolaemia with normal saline or
appropriate plasma expander
• Take blood for culture and sensitivity, and
start broad spectrum antibiotics which can be
modified when results are available.
6) Hyperpyrexia:
• Axillary temperature of 39o C and above
Pathophysiolgy:
• Release of metabolites and cytokines from red
blood cell breakdown leading to elevation of
the hypothalamic set point
• Rapid rise in temp may lead to febrile
convulsions.
Management:
• Antipyretics – Paracetamol 10mg/kg rectally
or orally
• Tepid sponging, fanning
7) DIC/Bleeding tendency:
• Bleeding from gums, epistaxis, petechiae,
subconjunctival haemorrhages, and
sometimes GI bleeding may occur.
• Thrombocytopenia is common in falciparum
malaria, often without other coagulation
abnormalities and resolves soon after
treatment

Management:
• Transfusion with blood, platelets, clotting
factors
• Vitamin K
 MANAGEMENT OF CONVULSIONS
• These are either febrile convulsions or due to
cerebral malaria.
• Management includes:
- Airway: Lie child in left lateral position, clear
the airway of secretions, put nothing in the
mouth
- Breathing: Ensure child is breathing, +/- ambu
bag
- Circulation: IV access,
- Dextrose: Quick random blood sugar, then
give a slow push of dextrose 10% 5ml/kg
- Give diazepam per rectal 0.25 - 0.5mg/kg
- If convulsions recur, repeat another dose of
diazepam and then start intravenous
Phenobarbitone 15mg/kg loading dose given as
a slow push over 5-10min,and continue with
oral/NGT phenobarbitone 5mg/kg once a day
for up to 5 days.
- Monitor random blood sugar and feed the
child by NGT
- When the convulsion is controlled, do an LP
for CSF analysis to rule out Meningitis
 QUININE

• Intravenous Quinine is the drug of choice for

the treatment of complicated malaria

• Presentation: IV/IM Quinine dihydrochloride

300mg/ml, 2ml ampoule

• Dosage: 10mg/kg 8 hourly in 10ml/kg of 5%

dextrose infusion
 Administration:
- Intravenously: slow infusion of 10mg/kg in
10ml/kg of 5% dextrose solution ran over 4
hours 8hourly till the patient can take orally,
then give oral quinine 10mg/kg to complete 7
days

- Intramuscular quinine - dilutions of 100mg per

ml into the anterior thigh, if the total dose to be
given exceeds 3ml or 300mg, then divide the
dose into two and give each half in either thigh.
• Bioavailability of iv, im and oral quinine is
comparable.
 Side effects:
• Cinchonism: Tinnitus, headache, nausea, visual
disturbances

• Others: Vertigo, reduced hearing, blurred

vision, diplopia

• Cardiac: Prolongation of QT interval, AV block,

sinus arrest, vetricular tachycardia
• Hypoglycaemia.
Reference:
• WHO, 2000: Management of severe malaria
• Toto ward protocals MRRH

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