Severe imported malaria — DTM&H MCQ

Correct answer: C — Treat presumptively for severe malaria while urgent microscopy is processed

The correct answer is C, treat presumptively for severe malaria while urgent microscopy is processed. This man has classic features of severe falciparum malaria: recent travel to a high-transmission area (Lagos), fever, confusion (cerebral malaria) and respiratory distress (acidosis or ARDS), plus thrombocytopenia and an elevated creatinine indicating acute kidney injury, another WHO severity criterion. Current UK malaria treatment guidance is explicit that once severe malaria is clinically suspected, treatment (intravenous artesunate) should start immediately and must never be delayed while awaiting laboratory confirmation, because falciparum malaria in a non-immune traveller can progress to multi-organ failure and death within hours. Microscopy and parasitaemia quantification still proceed in parallel to confirm the diagnosis and guide ongoing management, but they do not gate the decision to treat. Why the other options are wrong: A. Wait for the first film before giving therapy: delaying treatment for a result that is only pending risks fatal deterioration in a patient who already meets multiple severity criteria; guidance mandates immediate treatment on clinical suspicion. D. Discharge with safety-net advice after an RDT: a patient with confusion, thrombocytopenia and renal impairment has severe disease and requires emergency admission and IV therapy, not discharge, regardless of a single RDT result. E. Start oral chloroquine and review tomorrow: chloroquine is not used for falciparum malaria in most imported cases due to resistance, and oral therapy is inappropriate in a patient with reduced consciousness and severe disease needing parenteral treatment. B. Give oseltamivir pending respiratory viral PCR: this targets influenza, not the life-threatening diagnosis suggested by the travel history and severity markers, and would leave severe malaria untreated. Key point: any returning traveller with fever and one or more WHO severe malaria criteria (impaired consciousness, AKI, thrombocytopenia, respiratory distress) must start IV artesunate immediately, without waiting for blood film confirmation.

Reference: UK Malaria Treatment Guidelines 2016 (Journal of Infection; PHE/UKHSA-endorsed), Lalloo DG et al., 'UK malaria treatment guidelines 2016', Journal of Infection 2016;72(6):635-649 (https://pmc.ncbi.nlm.nih.gov/articles/PMC7132403/)