Severe malaria with haemoglobinuria — DTM&H MCQ

Correct answer: E — Intravenous artesunate with renal and critical care support

A) Intravenous artesunate with renal and critical care support is correct because this patient meets criteria for severe falciparum malaria: acute kidney injury with oliguria, metabolic acidosis, and dark urine suggesting haemolysis, plus prior treatment failure on irregular quinine. UK national guidelines define severe malaria by organ dysfunction (renal impairment, acidosis, coma, pulmonary oedema, severe anaemia) and recommend IV artesunate as first line over IV quinine due to superior survival. Blackwater fever type haemolysis and AKI here reflect severe disease physiology, not a separate diagnosis, so organ support (fluid management, renal replacement if needed, critical care monitoring) must run alongside, not instead of, definitive antiparasitic therapy. Irregular subtherapeutic quinine explains ongoing parasitaemia and treatment failure, reinforcing the switch to IV artesunate rather than continuing quinine. Why the other options are wrong: C. Oral quinine and doxycycline at home: severe malaria with AKI and acidosis requires inpatient parenteral therapy and organ support; oral treatment at home cannot address ongoing organ failure and mirrors the failed irregular regimen already tried. D. High-dose corticosteroids for haemolysis: steroids do not treat parasitaemia and have been associated with worse outcomes in severe malaria; haemolysis here is a direct consequence of severe infection, not an autoimmune process. B. Chloroquine with urinary alkalinisation: chloroquine has no role in P. falciparum given widespread resistance, and alkalinisation does not replace antiparasitic treatment or renal support. A. Primaquine to clear mature gametocytes: primaquine targets gametocytes and hepatic hypnozoites relevant to P. vivax/ovale, not the acute life-threatening asexual parasitaemia causing organ failure, and requires G6PD testing before use. Key point: Any organ dysfunction (renal, acid-base, neurological, or haematological) with falciparum parasitaemia defines severe malaria and mandates IV artesunate plus critical care support, regardless of parasite percentage.

Reference: UK Malaria Treatment Guidelines 2016 (PHE/British Infection Association, updated), Journal of Infection: severe malaria criteria and recommendation for IV artesunate as first-line therapy over IV quinine. https://www.journalofinfection.com/article/S0163-4453(16)00047-5/fulltext