A 28-year-old woman from Kerala presents with progressive anaemia, jaundice, and dark urine for 3 weeks. Peripheral blood smear shows RBCs with intraerythrocytic parasites appearing as dots or stippling within the cytoplasm. Haemoglobin is 7.2 g/dL. What is the most appropriate immediate next step?

Explanation

## Clinical Scenario Analysis The patient presents with: - Progressive anaemia (Hb 7.2 g/dL) and jaundice → haemolysis - Dark urine → haemoglobinuria - RBC stippling/dots on smear → *Plasmodium vivax* or *P. ovale* - Geographic origin (Kerala) → *P. vivax* endemic area This is **severe vivax malaria with acute haemolytic anaemia**. ## Management Flowchart ```mermaid flowchart TD A[Vivax malaria + Hb 7.2 g/dL]:::outcome --> B{Severity assessment}:::decision B -->|Severe anaemia| C[Admit for supportive care]:::action C --> D[Blood transfusion if indicated]:::action D --> E[G6PD testing BEFORE primaquine]:::action E --> F[Start chloroquine + primaquine]:::action B -->|Mild-moderate| G[Outpatient chloroquine + primaquine]:::action style A fill:#fff3cd ``` ## Key Point: **Primaquine MUST NOT be given without G6PD testing.** Primaquine causes severe haemolysis in G6PD-deficient patients, especially in high-risk populations (Kerala, Dravidian ancestry). This patient is already haemolysing; primaquine without G6PD status confirmation could be fatal. ## High-Yield: - **Chloroquine** = blood schizonticidal (kills asexual forms); given for acute malaria - **Primaquine** = tissue schizonticidal + gametocidal; given for radical cure and relapse prevention in *P. vivax* and *P. ovale* - **G6PD deficiency prevalence in Kerala:** ~4–5% (higher than northern India); mandatory screening before primaquine - Severe anaemia (Hb < 7 g/dL) requires transfusion support and close monitoring ## Clinical Pearl: The stippling (Schüffner's dots) on RBC smear is pathognomonic for *P. vivax*. Unlike *P. falciparum*, vivax does not cause cerebral malaria but can cause severe anaemia and acute kidney injury. ## Mnemonic: **"CHOP" for vivax/ovale management:** - **C**hloroquine (acute) - **H**aemoglobin monitoring (transfuse if needed) - **O**btain G6PD status - **P**rimaquine (after G6PD clearance) ## Warning: ~~Starting primaquine immediately~~ — this is a common trap. Always check G6PD first in endemic populations.