A Man With Fever, Fatigue, and a Trip to Nigeria

The most appropriate action to take at this point is to admit the patient for IV therapy. Management of acute malaria starts with determining whether the patient has severe or uncomplicated malaria. The CDC criteria for severe malaria include:

Parasitemia ≥ 5%
Impaired consciousness
Seizures
Circulatory collapse/shock
Pulmonary edema or acute respiratory distress syndrome
Acidosis
Acute renal failure
Abnormal bleeding or disseminated intravascular coagulation
Jaundice, along with at least one other sign of severe malaria
Severe anemia (Hb < 7 g/dL)

Only one of these criteria is required to establish the diagnosis of severe malaria, but several are often present at the time of diagnosis. One commonly seen exception, as in this case, is hyperparasitemia (≥ 5%), which may occur in the absence of other severe clinical signs.

Severe malaria can rapidly progress to death, and requires hospital admission and treatment with IV artesunate, which the FDA approved for use in May 2020. Having intravenous artesunate readily available allows patients with severe malaria to be treated right away. Artesunate for Injection for treatment of severe malaria is commercially available in the United States.

It may take some time between the commercial launch of Artesunate for Injection and stocking of the drug in pharmacies and hospitals. During this time, CDC will continue to distribute artesunate under its investigational new drug (IND) protocol for patients in situations where FDA-approved Artesunate for Injection is not yet available within 24 hours of a clinician requesting the drug. When the distribution of Artesunate for Injection expands nationwide and is stocked in the states where the most cases of malaria are found, CDC will discontinue its distribution of intravenous artesunate.

IV artesunate is given as a series of three doses at 0, 12, and 24 hours.

Patients with P falciparum malaria, the species most likely to cause severe disease, should be admitted to monitor clinical response. If clinical presentation improves and the percent parasitemia by microscopy decreases, outpatient completion of treatment may be considered.

Uncomplicated malaria is defined as malaria infection in the absence of criteria for severe malaria and can usually be treated with oral medications. The appropriate regimen is determined by the infecting species and its likelihood of being resistant to specific drugs, based on the patient's travel history.

Clinical Course

After initiation of IV therapy, the final laboratory report of the patient's initial peripheral blood smear becomes available: "Positive for Plasmodium falciparum intracellular ring-stage parasites. No gametocytes seen. Parasitemia estimated at 7.1% (1000 RBCs examined)."

A repeat peripheral blood smear is negative for parasites after administration of the third dose of IV artesunate.