Management of Severe Malaria

Clinical Presentation and Diagnosis

Cerebral manifestations in malaria may include drowsiness, mental confusion, coma, and seizures, which are signs of abnormal central nervous system function in cerebral malaria, as recommended by the Centers for Disease Control and Prevention 1
Headache may be a symptom of increased intracranial pressure in severe cases, according to the World Health Organization 2

The American College of Physicians recommends intravenous artesunate as the treatment of choice for severe malaria, with intravenous quinine as an alternative if artesunate is unavailable, as stated by the Centers for Disease Control and Prevention 1
The World Health Organization recommends antipyretics such as paracetamol (acetaminophen) or aspirin for fever control and to help alleviate headache, with a strength of evidence rated as high 3, 4
The Centers for Disease Control and Prevention suggest tepid water sponging to reduce fever, especially in children with high fevers, with a moderate level of evidence 3, 5

For convulsions, the World Health Organization recommends administering 0.2 mL/kg paraldehyde by IM injection, with a repeat dose if convulsions recur, based on strong evidence 1
If convulsions persist, the American Academy of Neurology suggests giving phenobarbitone 10 mg/kg IM injection, with a moderate level of evidence 1
In patients with altered consciousness, the Centers for Disease Control and Prevention recommend performing lumbar puncture if possible to rule out meningitis, with a high strength of evidence 1

The World Health Organization advises careful fluid administration to prevent fluid overload, which can precipitate pulmonary edema or adult respiratory distress syndrome and worsen cerebral edema, with a high level of evidence 1
The American College of Physicians recommends using 5% dextrose with 1/2 normal saline as the IV fluid of choice, providing dextrose to prevent hypoglycemia and less salt to leak into pulmonary and cerebral tissues, based on moderate evidence 1