A 28-year-old man from rural Jharkhand presents with fever, rigors, and jaundice on day 7 of illness. Blood smear shows P. falciparum with 8% parasitaemia. He is conscious, has a respiratory rate of 32/min, and blood glucose is 35 mg/dL. Which is the most appropriate immediate next step?

Explanation

## Severity Assessment **Key Point:** This patient has severe malaria (WHO criteria): parasitaemia ≥4%, respiratory distress (RR 32), severe anaemia (implied by jaundice), and hypoglycaemia (35 mg/dL). ## Why IV Artesunate Is the Gold Standard **High-Yield:** Intravenous artesunate is the WHO-recommended first-line treatment for severe malaria globally and in India. It reduces mortality by ~35% compared to quinine. | Feature | IV Artesunate | IM Quinine | Oral Artemether | |---------|---------------|-----------|------------------| | **Onset** | Rapid (minutes) | Slower | Unreliable in severe disease | | **Mortality reduction** | 35% vs quinine | Baseline | Not established in severe | | **Bioavailability** | 100% | Variable | Poor in severe illness | | **WHO recommendation** | First-line | Second-line | Not for severe | | **Hypoglycaemia risk** | Lower | Higher (quinine-induced) | N/A | ## Management of Complications **Clinical Pearl:** Hypoglycaemia is a medical emergency in severe malaria and must be corrected immediately with 50% dextrose IV (10 mL bolus), not oral glucose. Quinine paradoxically worsens hypoglycaemia via insulin release. ## Dosing Regimen - **IV artesunate:** 2.4 mg/kg IV at 0, 12, 24 hours, then once daily - **Hypoglycaemia:** 50% dextrose IV 10 mL stat, then 5–10% dextrose infusion - **Monitoring:** Blood glucose, parasitaemia, renal function, haemoglobin **Mnemonic:** **SEVERE MALARIA = ARTESUNATE IV** (not oral, not IM quinine) [cite:Harrison 21e Ch 219; WHO Severe Malaria Guidelines 2022]