Malaria severe anaemia — DTM&H MCQ

Correct answer: C — Artesunate with urgent blood transfusion

Artesunate with urgent blood transfusion (option B) is correct because this child has severe malaria defined by profound anaemia (Hb 4.2 g/dL, below the WHO severe malarial anaemia threshold of 5 g/dL) with tachycardia indicating cardiovascular compromise. UK and WHO guidance mandate intravenous artesunate as first line therapy for any case meeting severe malaria criteria, regardless of consciousness level, because it rapidly clears parasitaemia and reduces mortality compared with quinine. The haemoglobin value alone qualifies this as severe disease requiring parenteral treatment, and the profound anaemia with haemodynamic stress (tachycardia) mandates urgent transfusion alongside antimalarial therapy rather than antimalarial treatment alone. Correcting the anaemia and the parasitaemia simultaneously addresses both the immediate life threat and the underlying cause. Why the other options are wrong: D. Primaquine radical cure: this targets hypnozoites in Plasmodium vivax or ovale relapse prevention, not falciparum malaria, and does nothing for acute severe anaemia or active parasitaemia. E. Iron syrup with discharge: iron replacement is far too slow to correct an Hb of 4.2 g/dL and completely fails to treat the ongoing life threatening parasitaemia; discharging a child with severe malaria is unsafe. A. Ceftriaxone monotherapy: antibiotics may be added if bacterial co-infection is suspected but ceftriaxone has no antimalarial activity and would leave the causative falciparum infection and anaemia untreated. B. Oral artemether-lumefantrine alone: oral therapy is inappropriate in severe malaria because absorption is unreliable in unwell children, and it does not address the transfusion need for profound anaemia; parenteral artesunate is required once severity criteria are met. Key point: any WHO severe malaria criterion, including Hb below 5 g/dL, mandates parenteral artesunate plus supportive care such as transfusion, irrespective of the child's conscious level.

Reference: UK Malaria Treatment Guidelines Writing Group, Journal of Infection 2016 (PHE/UKHSA endorsed): intravenous artesunate is first line therapy for severe malaria, with blood transfusion indicated for symptomatic severe anaemia; https://www.journalofinfection.com/article/S0163-4453(16)00047-5/fulltext