The Management of Patients with Severe Malaria

Nicholas Day Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand, and the Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom

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Arjen M. Dondorp Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand, and the Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom

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Severe malaria is a global problem, claiming at least 1 million lives annually. Few adequately powered clinical studies have been directed at improving the management of severe malaria over the years, but this situation is slowly changing. The antimalarial treatment of severe disease is being transformed by the development and deployment of the water-soluble artemisinin derivative artesunate. Parenteral artesunate is now the treatment of choice in low-transmission areas and in the 2nd and 3rd trimesters of pregnancy, and research is underway into whether it should replace quinine as the treatment of choice in African children. Development of good manufacturing practice (GMP) formulations should make parenteral artesunate more widely available in the near future. The development of artesunate suppositories offers another exciting prospect, the ability to treat patients with severe disease in remote rural settings, delaying the evolution of disease and buying them time to reach a health care facility. No adjunctive therapy has been shown to improve the outcome of severe malaria, but most studies have been underpowered. Future trials of interventions shown to be promising in pilot studies should be large and adequately powered. This will require multi-center designs and necessitate close collaboration between groups, as well as agreement on the research agenda. We suggest a list of candidate interventions for debate.

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  • 1

    Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI, 2005. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature 434 :214–217.

  • 2

    World Health Organization Communicable Diseases Cluster, 2000. Severe falciparum malaria. Trans R Soc Trop Med Hyg 94 (Suppl 1):S1–90.

  • 3

    World Health Organization Division of Control of Tropical Diseases, 1990. Severe and complicated malaria. Trans R Soc Trop Med Hyg 84 (Suppl 2):1–65.

  • 4

    World Health Organization, 2006. Guidelines for the Treatment of Malaria. Geneva: WHO.

    • PubMed
    • Export Citation
  • 5

    Berkley JA, Mwangi I, Mellington F, Mwarumba S, Marsh K, 1999. Cerebral malaria versus bacterial meningitis in children with impaired consciousness. Q J Med 92 :151–157.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Berkley J, Mwarumba S, Bramham K, Lowe B, Marsh K, 1999. Bacteraemia complicating severe malaria in children. Trans R Soc Trop Med Hyg 93 :283–286.

  • 7

    Evans JA, Adusei A, Timmann C, May J, Mack D, Agbenyega T, Horstmann RD, Frimpong E, 2004. High mortality of infant bacteraemia clinically indistinguishable from severe malaria. Q J Med 97 :591–597.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Yen LM, Dao LM, Day NP, Waller DJ, Bethell DB, Son LH, Hien TT, White NJ, 1994. Role of quinine in the high mortality of intramuscular injection tetanus. Lancet 344 :786–787.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    White NJ, Warrell DA, Chanthavanich P, Looareesuwan S, Warrell MJ, Krishna S, Williamson DH, Turner RC, 1983. Severe hypoglycemia and hyperinsulinemia in falciparum malaria. N Engl J Med 309 :61–66.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    White NJ, Miller KD, Marsh K, Berry CD, Turner RC, Williamson DH, Brown J, 1987. Hypoglycaemia in African children with severe malaria. Lancet 1 :708–711.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    White NJ, Looareesuwan S, Warrell DA, Warrell MJ, Chanthavanich P, Bunnag D, Harinasuta T, 1983. Quinine loading dose in cerebral malaria. Am J Trop Med Hyg 32 :1–5.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Krishna S, White NJ, 1996. Pharmacokinetics of quinine, chloroquine and amodiaquine. Clinical implications. Clin Pharmacokinet 30 :263–299.

  • 13

    Dondorp A, Nosten F, Stepniewska K, Day N, White N, 2005. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet 366 :717–725.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Artemether–Quinine Meta-analysis Study Group, 2001. A meta-analysis using individual patient data of trials comparing artemether with quinine in the treatment of severe falciparum malaria. Trans R Soc Trop Med Hyg 95 :637–650.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Murphy SA, Mberu E, Muhia D, English M, Crawley J, Waruiru C, Lowe B, Newton CR, Winstanley P, Marsh K, Watkins WM, 1997. The disposition of intramuscular artemether in children with cerebral malaria; a preliminary study. Trans R Soc Trop Med Hyg 91 :331–334.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Hien TT, Davis TM, Chuong LV, Ilett KF, Sinh DX, Phu NH, Agus C, Chiswell GM, White NJ, Farrar J, 2004. Comparative pharmacokinetics of intramuscular artesunate and artemether in patients with severe falciparum malaria. Antimicrob Agents Chemother 48 :4234–4239.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Magill A, Panosian C, 2005. Making antimalarial agents available in the United States. N Engl J Med 353 :335–337.

  • 18

    Brewer TG, Peggins JO, Grate SJ, Petras JM, Levine BS, Weina PJ, Swearengen J, Heiffer MH, Schuster BG, 1994. Neurotoxicity in animals due to arteether and artemether. Trans R Soc Trop Med Hyg 88 (Suppl 1):S33–S36.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Hien TT, Turner GD, Mai NT, Phu NH, Bethell D, Blakemore WF, Cavanagh JB, Dayan A, Medana I, Weller RO, Day NP, White NJ, 2003. Neuropathological assessment of artemether-treated severe malaria. Lancet 362 :295–296.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Nontprasert A, Pukrittayakamee S, Dondorp AM, Clemens R, Looareesuwan S, White NJ, 2002. Neuropathologic toxicity of artemisinin derivatives in a mouse model. Am J Trop Med Hyg 67 :423–429.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Clark RL, White TE, A Clode S, Gaunt I, Winstanley P, Ward SA, 2004. Developmental toxicity of artesunate and an arte-sunate combination in the rat and rabbit. Birth Defects Res B Dev Reprod Toxicol 71 :380–394.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    White TE, Bushdid PB, Ritter S, Laffan SB, Clark RL, 2006. Artesunate-induced depletion of embryonic erythroblasts precedes embryolethality and teratogenicity in vivo. Birth Defects Res B Dev Reprod Toxicol 77 :413–429.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Hien TT, Arnold K, Vinh H, Cuong BM, Phu NH, Chau TT, Hoa NT, Chuong LV, Mai NT, Vinh NN, et al., 1992. Comparison of artemisinin suppositories with intravenous artesunate and intravenous quinine in the treatment of cerebral malaria. Trans R Soc Trop Med Hyg 86 :582–583.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Cao XT, Bethell DB, Pham TP, Ta TT, Tran TN, Nguyen TT, Pham TT, Nguyen TT, Day NP, White NJ, 1997. Comparison of artemisinin suppositories, intramuscular artesunate and intravenous quinine for the treatment of severe childhood malaria. Trans R Soc Trop Med Hyg 91 :335–342.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Sabchareon A, Attanath P, Chanthavanich P, Phanuaksook P, Prarinyanupharb V, Poonpanich Y, Mookmanee D, Teja-Isavadharm P, Heppner DG, Brewer TG, Chongsuphajaisiddhi T, 1998. Comparative clinical trial of artesunate suppositories and oral artesunate in combination with mefloquine in the treatment of children with acute falciparum malaria. Am J Trop Med Hyg 58 :11–16.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Barnes KI, Mwenechanya J, Tembo M, McIlleron H, Folb PI, Ribeiro I, Little F, Gomes M, Molyneux ME, 2004. Efficacy of rectal artesunate compared with parenteral quinine in initial treatment of moderately severe malaria in African children and adults: a randomised study. Lancet 363 :1598–1605.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Karunajeewa HA, Reeder J, Lorry K, Dabod E, Hamzah J, Page-Sharp M, Chiswell GM, Ilett KF, Davis TM, 2006. Artesunate suppositories versus intramuscular artemether for treatment of severe malaria in children in Papua New Guinea. Antimicrob Agents Chemother 50 :968–974.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Simpson JA, Agbenyega T, Barnes KI, Di Perri G, Folb P, Gomes M, Krishna S, Krudsood S, Looareesuwan S, Mansor S, McIlleron H, Miller R, Molyneux M, Mwenechanya J, Navaratnam V, Nosten F, Olliaro P, Pang L, Ribeiro I, Tembo M, van Vugt M, Ward S, Weerasuriya K, Win K, White NJ, 2006. Population pharmacokinetics of artesunate and dihydroartemisinin following intra-rectal dosing of artesunate in malaria patients. PLoS Med 3 :e444.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Gerardin P, Rogier C, Ka AS, Jouvencel P, Diatta B, Imbert P, 2007. Outcome of life-threatening malaria in African children requiring endotracheal intubation. Malar J 6 :51.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Newton CR, Crawley J, Sowumni A, Waruiru C, Mwangi I, English M, Murphy S, Winstanley PA, Marsh K, Kirkham FJ, 1997. Intracranial hypertension in Africans with cerebral malaria. Arch Dis Child 76 :219–226.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Maitland K, Nadel S, Pollard AJ, Williams TN, Newton CR, Levin M, 2005. Management of severe malaria in children: proposed guidelines for the United Kingdom. BMJ 331 :337–343.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Crawley J, Waruiru C, Mithwani S, Mwangi I, Watkins W, Ouma D, Winstanley P, Peto T, Marsh K, 2000. Effect of phenobarbital on seizure frequency and mortality in childhood cerebral malaria: a randomised, controlled intervention study. Lancet 355 :701–706.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    White NJ, Looareesuwan S, Phillips RE, Chanthavanich P, Warrell DA, 1988. Single dose phenobarbitone prevents convulsions in cerebral malaria. Lancet 2 :64–66.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Trang TT, Phu NH, Vinh H, Hien TT, Cuong BM, Chau TT, Mai NT, Waller DJ, White NJ, 1992. Acute renal failure in patients with severe falciparum malaria. Clin Infect Dis 15 :874–880.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Phu NH, Hien TT, Mai NT, Chau TT, Chuong LV, Loc PP, Winearls C, Farrar J, White N, Day N, 2002. Hemofiltration and peritoneal dialysis in infection-associated acute renal failure in Vietnam. N Engl J Med 347 :895–902.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Tran TH, Day NP, Nguyen HP, Nguyen TH, Tran TH, Pham PL, Dinh XS, Ly VC, Ha V, Waller D, Peto TE, White NJ, 1996. A controlled trial of artemether or quinine in Vietnamese adults with severe falciparum malaria. N Engl J Med 335 :76–83.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Bruneel F, Gachot B, Timsit JF, Wolff M, Bedos JP, Regnier B, Vachon F, 1997. Shock complicating severe falciparum malaria in European adults. Intensive Care Med 23 :698–701.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Day NP, Phu NH, Bethell DP, Mai NT, Chau TT, Hien TT, White NJ, 1996. The effects of dopamine and adrenaline infusions on acid–base balance and systemic haemodynamics in severe infection. Lancet 348 :219–223.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Planche T, Onanga M, Schwenk A, Dzeing A, Borrmann S, Faucher JF, Wright A, Bluck L, Ward L, Kombila M, Kremsner PG, Krishna S, 2004. Assessment of volume depletion in children with malaria. PLoS Med 1 :e18.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Planche T, 2005. Malaria and fluids—balancing acts. Trends Parasitol 21 :562–567.

  • 41

    Maitland K, 2006. Severe malaria: lessons learned from the management of critical illness in children. Trends Parasitol 22 :457–462.

  • 42

    Day N, 2006. Fluid resuscitation in malaria: the need for new randomised clinical trials. PLoS Clin Trials 1 :e24.

  • 43

    Krishna S, Waller DW, ter Kuile F, Kwiatkowski D, Crawley J, Craddock CF, Nosten F, Chapman D, Brewster D, Holloway PA, et al., 1994. Lactic acidosis and hypoglycaemia in children with severe malaria: pathophysiological and prognostic significance. Trans R Soc Trop Med Hyg 88 :67–73.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Day NP, Phu NH, Mai NT, Chau TT, Loc PP, Chuong LV, Sinh DX, Holloway P, Hien TT, White NJ, 2000. The pathophysiologic and prognostic significance of acidosis in severe adult malaria. Crit Care Med 28 :1833–1840.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Dondorp AM, Chau TT, Phu NH, Mai NT, Loc PP, Chuong LV, Sinh DX, Taylor A, Hien TT, White NJ, Day NP, 2004. Unidentified acids of strong prognostic significance in severe malaria. Crit Care Med 32 :1683–1688.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Krishna S, Supanaranond W, Pukrittayakamee S, Karter D, Supputamongkol Y, Davis TM, Holloway PA, White NJ, 1994. Dichloroacetate for lactic acidosis in severe malaria: a pharmacokinetic and pharmacodynamic assessment. Metabolism 43 :974–981.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Agbenyega T, Planche T, Bedu-Addo G, Ansong D, Owusu-Ofori A, Bhattaram VA, Nagaraja NV, Shroads AL, Henderson GN, Hutson AD, Derendorf H, Krishna S, Stacpoole PW, 2003. Population kinetics, efficacy, and safety of dichloroacetate for lactic acidosis due to severe malaria in children. J Clin Pharmacol 43 :386–396.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    World Health Organization, 2001. The Prevention and Management of Severe Anaemia in Children in Malaria-Endemic Regions of Africa: A Review of Research. Geneva: WHO.

    • PubMed
    • Export Citation
  • 49

    Enwere G, 2005. A review of the quality of randomized clinical trials of adjunctive therapy for the treatment of cerebral malaria. Trop Med Int Health 10 :1171–1175.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    van Hensbroek MB, Palmer A, Onyiorah E, Schneider G, Jaffar S, Dolan G, Memming H, Frenkel J, Enwere G, Bennett S, Kwiatkowski D, Greenwood B, 1996. The effect of a monoclonal antibody to tumor necrosis factor on survival from childhood cerebral malaria. J Infect Dis 174 :1091–1097.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Warrell DA, Looareesuwan S, Warrell MJ, Kasemsarn P, Intara-prasert R, Bunnag D, Harinasuta T, 1982. Dexamethasone proves deleterious in cerebral malaria. A double-blind trial in 100 comatose patients. N Engl J Med 306 :313–319.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Hoffman SL, Rustama D, Punjabi NH, Surampaet B, Sanjaya B, Dimpudus AJ, McKee KT Jr, Paleologo FP, Campbell JR, Marwoto H, et al., 1988. High-dose dexamethasone in quinine-treated patients with cerebral malaria: a double-blind, placebo-controlled trial. J Infect Dis 158 :325–331.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53

    Prasad K, Garner P, 2000. Steroids for treating cerebral malaria. Cochrane Database Syst Rev CD000972.

  • 54

    Smith HJ, Meremikwu M, 2003. Iron chelating agents for treating malaria. Cochrane Database Syst Rev CD001474.

  • 55

    Powell VI, Grima K, 2002. Exchange transfusion for malaria and Babesia infection. Transfus Med Rev 16 :239–250.

  • 56

    Riddle MS, Jackson JL, Sanders JW, Blazes DL, 2002. Exchange transfusion as an adjunct therapy in severe Plasmodium falciparum malaria: a meta-analysis. Clin Infect Dis 34 :1192–1198.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    Watt G, Jongsakul K, Ruangvirayuth R, 2002. A pilot study of N-acetylcysteine as adjunctive therapy for severe malaria. Q J Med 95 :285–290.

  • 58

    Dondorp AM, Silamut K, Charunwatthana P, Chuasuwanchai S, Ruangveerayut R, Krintratun S, White NJ, Ho M, Day NPJ, 2007. Levamisole inhibits sequestration of infected red blood cells in patients with falciparum malaria. J Int Dis 196 :460–466.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59

    Yipp BG, Robbins SM, Resek ME, Baruch DI, Looareesuwan S, Ho M, 2003. Src-family kinase signaling modulates the adhesion of Plasmodium falciparum on human microvascular endothelium under flow. Blood 101 :2850–2857.

    • PubMed
    • Search Google Scholar
    • Export Citation
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