Grand Rounds

Malaria treatment

Medical Sciences Department, Pediatric Oncall, Mumbai

Clinical Problem :
A 10 years old boy born of non consanguineous marriage presented with fever with chills, pain in right hypochondriac region since 10 days and diarrhea since 3 days. There is no history of jaundice, bleeding or blood transfusion. On examination, vital parameters were normal. Child had pallor with hepatosplenomegaly. Other examination findings were normal.
Investigations showed:-
? Hemoglobin = 7.8 gm percent
? WBC count = 2,800, cumm {68 percent polymorphs, 29 percent lymphocytes}
? Platelet count = 56,000, cumm
? Total Bilirubin = 2.1 mg, dl {Direct bilirubin = 1.1 mg, dl}
? SGPT = 33 IU, L
? S. creatinine = 1.5 mg, dl
? Peripheral smear = Gametocytes of plasmodium falciparum
? OptiMAL test = Plasmodium falciparum positive
? Dengue, Leptospira = Negative

Child was treated with oral Quinine and IV Artesunate to which he responded.

Can artesunate and quinine be given together_?

Discussion :
Artemisinin compound has been used in China for treatment of malaria for over a thousand years. It has a broad spectrum activity against all stages of malarial parasite as well as all 4 plasmodium species. In falciparum malaria, it is also gametocidal. The elimination half-life is approximately 1 hour and thus they are potent short acting agents. The common side effects are gastrointestinal disturbances, dizziness, tinnitus and prolongation of QT interval.
Quinine is derived from bark of Cinchona tree. It acts on the mature trophozoite stage of parasite development. The elimination half life is about 11 hours in healthy individuals, 16 hours in uncomplicated malaria and 18 hours in severe malaria. Adverse effects are common and include tinnitus, impaired high pitch hearing, vomiting, urticaria, hemolytic-uremic syndrome, hypoglycemia and prolonged QT interval on ECG {seen in intravenous quinine}.
Since plasmodium falciparum has been found to be resistant to most of the currently used antimalarials, combination therapy with antimalarials is now recommended. The combination consists of two or more blood schizonticidal drugs and includes a combination of a short acting antimalarial with a long acting antimalarial. Both artemisinin compounds and Quinine are short acting and have common side effects. Hence they should not be used together.
Combinations that are recommended are:
• Artesunate {short acting}plus Mefloquine {long acting}
• Artesunate {short acting}plus Sulfadoxine-pyrimethamine {long acting}
• Artemether {short acting} plus Lumefantrine {long acting}
• Quinine plus Clindamycin
• Quinine plus Tetracycline, Doxycycline

E-published: March 2011 Vol 8 Issue 3 Art No. 21

Correct Answers :  yes 100%
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