Cerebral malaria in a child — DTM&H MCQ

Correct answer: A — Parenteral artesunate, dextrose and management of severe anaemia

The correct answer is A, parenteral artesunate, dextrose and management of severe anaemia. This child meets multiple WHO/UK criteria for severe falciparum malaria: repeated seizures (cerebral malaria), hypoglycaemia (1.8 mmol/L) and severe anaemia (Hb 5.8 g/dL), each of which independently mandates emergency parenteral treatment. Intravenous artesunate is the treatment of choice for severe or complicated malaria in both adults and children, and treatment must not be delayed once severe disease is suspected. Hypoglycaemia is common in severe paediatric malaria (worsened by both the disease and quinine, though not artesunate) and requires immediate correction with dextrose alongside careful transfusion assessment for the severe anaemia. Delaying definitive therapy for any reason in this setting increases mortality. Why the other options are wrong: E. Oral ACT after the next seizure settles: oral therapy is unsafe and inadequate here because the child has severe malaria with reduced consciousness/seizures and cannot reliably absorb or tolerate oral drugs; parenteral treatment must not be delayed until seizures settle. B. Phenobarbital without antimalarial therapy: seizure control alone ignores the underlying life-threatening cause; anticonvulsants are adjunctive, not a substitute for antimalarial treatment, and phenobarbital alone in this context has been associated with increased mortality. C. Primaquine with iron supplementation: primaquine targets P. vivax/ovale hypnozoites and gametocytes, not acute falciparum infection, and iron alone does nothing for the acute severe anaemia or the malaria itself. D. Lumbar puncture before antimalarial treatment: investigations to exclude bacterial meningitis are reasonable once stable, but they must never delay urgent antimalarial and supportive treatment in a child with proven severe falciparum malaria. Key point: seizures, hypoglycaemia and severe anaemia in a child with falciparum malaria define severe malaria, which is a medical emergency requiring immediate intravenous artesunate plus correction of glucose and anaemia without delay for other investigations or treatments.

Reference: UK Malaria Treatment Guidelines 2016 (Journal of Infection / PHE, Lalloo et al.), Recommendation 12: intravenous artesunate is the treatment of choice for severe or complicated malaria in adults and children; hypoglycaemia and severe anaemia require concurrent correction. https://pmc.ncbi.nlm.nih.gov/articles/PMC7132403/