Post-malaria neurological syndromes
Editor – O’Brien and Jagathesan gave a succinct review of neurological sequelae following treated malaria infection, illustrated by a case of acute encephalomyelitis in a commercial airline pilot who contracted Plasmodium falciparum malaria in West Africa.1
The reported case also illustrates the continuing practice in some UK centres of using quinine to treat severe malaria because of a lack of awareness of the evidence that the treatment of choice is parenteral artesunate. Use of artesunate has been associated with a 34% mortality reduction compared with parenteral quinine in adults with severe malaria and a corresponding 22% mortality reduction in African children.2,3 The patient presented in this report was treated with intravenous quinine and an exchange transfusion for the initial management of his severe malaria. Prompt administration of artesunate results in a rapid fall in peripheral parasitaemia and would have obviated the need for exchange transfusion, a procedure of unproven benefit in the management of severe malaria.4 Of note for this case report, despite conferring a survival advantage, artesunate treatment of severe malaria has not been associated with a reduction in neurological sequelae compared with quinine.
Most practitioners would agree it is important to ensure treatment guidelines are based on the best available evidence, including for conditions that are seldom encountered. The World Health Organization has recommended artesunate for the treatment of all patients with severe malaria since 2006.5 The same recommendation was included in the UK malaria treatment guidelines in 2016, although larger centres that encounter malaria more frequently have been using it for some time.6 Earlier difficulties with the procurement of parenteral artesunate have been overcome, meaning that all UK trusts can now update their formularies to ensure artesunate is available as a life-saving treatment for all patients presenting with severe malaria.
Conflicts of interest
The author has no conflicts of interest to declare.
- © Royal College of Physicians 2017. All rights reserved.
References
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- O’Brien MD
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- Tan KR
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- World Health Organization
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