(548) Time to Artesunate: Severe Malaria Treated With Intravenous Artesunate

Introduction: Malaria is a preventable mosquito-borne illness that can present with non-specific symptoms. Identifying patients at risk of severe malaria and initiation of intravenous anti-malarial medication is imperative at reducing mortality. We describe a case of a patient who presented to a community hospital with severe malaria and required prompt initiation of intravenous anti-malarial therapy.

Description: A 45-year-old male presented to the hospital with four days of nausea, vomiting, and myalgias. The patient had no past medical history but did return from a trip to Sierra Leone 2 days prior to symptom onset. Before the trip, a provider evaluated the patient and prescribed malaria prophylaxis with doxycycline, but the patient only started taking the medication two days after symptom onset. ED workup was notable for severe thrombocytopenia and lactic acidosis. Due to the recent travel, a malaria smear was performed which was positive and the patient was started on PO anti-malarial medication. The hospital course was complicated by encephalopathy requiring intubation, worsening acidosis found on blood gas evaluation attributed to acute renal failure, and cardiac arrest requiring ACLS. ROSC was obtained, and the patient had decreased pupillary response prompting a CT of the head which revealed evidence of cerebral edema. Repeat malaria smear revealed 12% parasitemia and patient was transitioned to IV artesunate. Despite IV anti-malarial treatment initiation within 12 hours of hospital presentation, the patient’s clinical status continued to decline, and the patient developed multi-system organ failure resulting in death.

Discussion: Malaria, a mosquito-borne illness caused by the Plasmodium spp., is the most common traveler disease considered preventable with prophylaxis. After diagnosis of malaria with a positive blood smear, the World Health Organization defined and revised criteria for diagnosing severe malaria as multi-organ failure with evidence of parasitemia of >5% on peripheral smear. If criteria for severe malaria is met, initiation of IV anti-malarial therapy is recommended to prevent further organ dysfunction. Literature previously suggested the use of IV quinine for severe malaria; however, there is evidence to suggest the use of IV artesunate for a more rapid parasite clearance.