A 32-year-old woman from rural Odisha presents with fever, chills, and sweating for 3 days. She reports that fever spikes occur every 48 hours with a pattern of cold stage (15 min), hot stage (2 hours), and sweating stage (1 hour). On examination, she is febrile (39.5°C), with mild hepatosplenomegaly. Thick blood smear shows ring forms and Schüffner's stippling. Rapid diagnostic test (RDT) is positive for P. vivax. Which of the following is the most appropriate initial management according to NVBDCP guidelines?

Explanation

## Diagnosis and Classification **Key Point:** The clinical presentation (tertian fever pattern every 48 hours), microscopy findings (ring forms, Schüffner's stippling), and RDT positivity for P. vivax confirm uncomplicated P. vivax malaria. ## NVBDCP Treatment Protocol for P. vivax **High-Yield:** According to the National Vector Borne Disease Control Programme (NVBDCP), the first-line treatment for uncomplicated P. vivax malaria is: - **Chloroquine**: 600 mg base on day 1, 300 mg on day 2, and 300 mg on day 3 (total 1200 mg base over 3 days) - **Primaquine**: 0.75 mg/kg/day for 14 days (to eliminate hypnozoites and prevent relapse) **Clinical Pearl:** Primaquine is essential for P. vivax and P. ovale because these parasites form hypnozoites in the liver that cause relapses. Without primaquine, relapse occurs in 40–50% of cases. ## Why Chloroquine + Primaquine? | Aspect | Chloroquine | Artemisinin Derivatives | |--------|-------------|------------------------| | **Indication** | First-line for uncomplicated P. vivax | Reserved for severe malaria or artemisinin-resistant P. falciparum | | **Efficacy** | Excellent for P. vivax (no resistance in India) | Not needed for P. vivax in uncomplicated cases | | **Cost** | Low | High | | **Hypnozoite elimination** | Requires primaquine | Requires primaquine | **Mnemonic:** **CHAP** for P. vivax uncomplicated malaria: - **C**hloroquine (600–300–300 mg) - **H**ypnozoite elimination needed - **A**void artemisinin monotherapy - **P**rimaquine (14 days, 0.75 mg/kg/day) ## Contraindications to Primaquine Before prescribing primaquine, check for **G6PD deficiency** (risk of hemolysis). If G6PD-deficient, use primaquine 0.75 mg/kg once weekly for 8 weeks or defer until G6PD status is known. ## Why Artemisinin for Severe Malaria Only Artemisinin derivatives (artemether, artesunate) are reserved for: - Severe malaria (cerebral, renal, pulmonary edema, severe anemia, shock) - Artemisinin-resistant P. falciparum (Southeast Asia) - Pregnancy (artesunate is safer than quinine) This patient has uncomplicated malaria; artemisinin is unnecessary and wasteful.