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8. Treatment of severe P. falciparum malaria

8. treatment of severe P. falciParum malaria

8.1 definition

In a patient with P. falciparum asexual parasitaemia and no other obvious cause of
symptoms, the presence of one or more of the following clinical or laboratory features
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classifies the patient as suffering from severe malaria (see also Annex 8):

Clinical features:
– impaired consciousness or unrousable coma
– prostration, i.e. generalized weakness so that the patient is unable walk
or sit up without assistance
– failure to feed
– multiple convulsions – more than two episodes in 24 h
– deep breathing, respiratory distress (acidotic breathing)
– circulatory collapse or shock, systolic blood pressure < 70 mm Hg in adults
and < 50 mm Hg in children
– clinical jaundice plus evidence of other vital organ dysfunction
– haemoglobinuria
– abnormal spontaneous bleeding
– pulmonary oedema (radiological)

Laboratory findings:
– hypoglycaemia (blood glucose < 2.2 mmol/l or < 40 mg/dl)
– metabolic acidosis (plasma bicarbonate < 15 mmol/l)
– severe normocytic anaemia (Hb < 5 g/dl, packed cell volume < 15%)
– haemoglobinuria
– hyperparasitaemia (> 2%/100 000/μl in low intensity transmission areas or > 5%
or 250 000/μl in areas of high stable malaria transmission intensity)
– hyperlactataemia (lactate > 5 mmol/l)
– renal impairment (serum creatinine > 265 μmol/l).

13 Full details of the definition and prognostic factors are provided in: World Health Organization. Severe falciparum
malaria. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2000:94(Suppl. 1):1–90, and
Management of severe malaria: a practical handbook, 2nd ed. Geneva, World Health Organization, 2000.
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