What is the appropriate management for a patient presenting with irritability suspected to have malaria?

Management of Irritability in Suspected Malaria

Irritability in a patient with suspected malaria should be considered a potential sign of severe disease requiring immediate assessment for impaired consciousness and treated with intravenous artesunate if severe malaria is confirmed. 1

Initial Assessment

Irritability in malaria may indicate neurological involvement and requires prompt evaluation:

• Assess level of consciousness using Glasgow Coma Scale (score <11 indicates severe malaria) 1
• Check for other signs of severe malaria including:
  • Multiple convulsions (>2 seizures within 24h) 1
  • Prostration (inability to sit, stand, or walk without assistance) 1
  • Irregular breathing patterns or respiratory distress 1
  • Hypoxia (oxygen saturation <95%) 1
  • Signs of shock (tachycardia, hypotension, cold extremities) 1

Diagnostic Approach

• Obtain blood samples immediately for:
  • Thick and thin blood films for microscopic examination (gold standard) 2, 3
  • Rapid diagnostic tests for malaria 2
  • Complete blood count (may show normal WBC or mild leukocytosis in severe cases) 4
  • Blood glucose (hypoglycemia: <40 mg/dL indicates severe malaria) 1
  • Blood chemistry (assess for acidosis, renal impairment) 1

Management Algorithm

1. If Severe Malaria Confirmed or Strongly Suspected:

• Administer intravenous artesunate immediately (2.4 mg/kg at 0,12, and 24 hours, then daily) 5
• If artesunate unavailable, use intramuscular artemether 5
• Provide supportive care:
  • Maintain airway and provide oxygen if oxygen saturation <95% 1
  • Assess for and treat hypoglycemia 1
  • Use restrictive fluid management to avoid pulmonary or cerebral edema 5
  • Consider empiric antibiotics if bacterial co-infection suspected (especially with leukocytosis) 4, 5
  • Acetaminophen for fever and potential renoprotective effects 5

2. If Uncomplicated Malaria:

• For P. falciparum or unknown species:
  • Artemisinin-based combination therapy is first-line treatment 6, 7
  • If artemisinin unavailable, use atovaquone-proguanil or quinine plus clindamycin 6
• For confirmed chloroquine-sensitive species (P. vivax, P. ovale, P. malariae, P. knowlesi):
  • Chloroquine or artemisinin-based combination therapy 6
  • Add primaquine for P. vivax and P. ovale to eradicate liver stage 6

Monitoring During Treatment

• Monitor parasitemia every 12 hours until <1%, then every 24 hours until negative 5
• Continuous monitoring of vital signs and neurological status 5
• Serial blood glucose measurements 1, 5
• Monitor for post-artesunate delayed hemolysis at days 7,14,21, and 28 5

Special Considerations

• Irritability may be an early sign of cerebral malaria, especially in children 1
• Mefloquine should be avoided in patients with neuropsychiatric symptoms as it may worsen irritability 8
• P. falciparum is responsible for most cases requiring intensive care, but other species can also cause severe disease 1, 9
• Rapid progression from mild symptoms to severe complications can occur, requiring close observation 9

Pitfalls to Avoid

• Do not delay treatment while awaiting confirmation if clinical suspicion is high 1
• Do not miss hypoglycemia, which can mimic or worsen neurological symptoms 1
• Do not administer oral medications if patient has impaired consciousness or cannot tolerate oral intake 1
• Do not underestimate non-falciparum malaria, as P. vivax and P. knowlesi can also cause severe disease 9
• Do not rely solely on rapid diagnostic tests, as they may miss mixed infections or non-falciparum species 2