What is the recommended treatment for cerebral malaria?

Cerebral Malaria Treatment

First-Line Treatment: Intravenous Artesunate

Intravenous artesunate is the definitive first-line treatment for cerebral malaria, administered at 2.4 mg/kg IV at 0,12,24, and 48 hours, providing faster parasite clearance and superior outcomes compared to quinine. 1, 2

• Artesunate achieves 90% parasite clearance in approximately 16 hours compared to 34.5 hours with quinine 3
• Continue treatment until the patient improves clinically and parasitemia drops below 1% 2
• This regimen has replaced quinine as the WHO-recommended standard of care 1

Alternative Treatment: Intravenous Quinine (When Artesunate Unavailable)

If artesunate is not available, use intravenous quinine with the following protocol 1, 4:

• Loading dose: 20 mg salt/kg body weight in 10 mL/kg 5% dextrose infused over 3-4 hours 5, 4
• Maintenance dose: 10 mg/kg every 8-12 hours 5, 1
• Critical caveat: Omit the loading dose if the patient received quinine or mefloquine in the previous 24 hours 1, 4
• Switch to oral medications as soon as the patient can swallow 5, 4

Immediate Supportive Care Measures

Hypoglycemia Management

• Monitor blood glucose regularly, as hypoglycemia is a common complication and independent risk factor for death 5, 1
• Treat confirmed or suspected hypoglycemia with 50 mL of 50% IV dextrose 5, 1
• Suspect hypoglycemia with any clinical deterioration, especially new neurologic findings 5

Fluid Management

• Use restrictive fluid therapy to avoid pulmonary edema or ARDS, which can worsen cerebral edema 5, 1
• Preferred IV fluid: 5% dextrose with 1/2 normal saline to prevent hypoglycemia while minimizing salt leakage into cerebral tissues 5, 4
• Administer fluids only to maintain cardiac output and renal perfusion in volume-depleted patients 5

Seizure Management Protocol

Use a stepwise approach for active seizures 1:

1. First-line: Lorazepam 0.1 mg/kg IV/IO; repeat once if seizure persists 1
2. Second-line: If seizures continue, administer paraldehyde 0.2 mL/kg IM 5, 2
3. Third-line: For persistent convulsions, give phenobarbital 10 mg/kg IM 5, 2

Critical warning: Do NOT use prophylactic anticonvulsants, as prophylactic phenobarbital increased mortality in children with cerebral malaria, particularly when combined with benzodiazepines due to respiratory depression 1

Management of Raised Intracranial Pressure

• Treat as a medical emergency with rapid intubation and mechanical ventilation 1
• Maintain PaCO2 in the normal range 1
• Consider mannitol 0.5 mg/kg IV over 5-10 minutes 1
• Never use steroids—they worsen outcomes in cerebral malaria 5, 1, 2

Blood Transfusion Indications

Transfuse when 5, 1, 2:

• Hemoglobin <4 g/dL, OR
• Hemoglobin <6 g/dL with signs of heart failure (dyspnea, enlarging liver, gallop rhythm)

Monitoring Requirements

Parasitemia Surveillance

• Check parasitemia every 12 hours until decline to <1%, then every 24 hours until negative 1, 2
• Note: Parasitemia may increase in the first 24 hours with quinine—this does NOT indicate treatment failure 1

Post-Artesunate Delayed Hemolysis (PADH)

• Monitor hemoglobin, haptoglobin, and lactate dehydrogenase at days 7,14,21, and 28 post-treatment 1, 2

Initial Diagnostic Workup

Perform immediately upon presentation 2, 4:

• Thick blood film for parasite identification
• Hemoglobin measurement
• Blood glucose level
• Lumbar puncture to rule out bacterial meningitis/encephalitis (cerebral malaria can present with CSF pleocytosis) 4
• Blood grouping and cross-matching if hemoglobin <4 g/dL 5

Antibiotic Considerations

• Start empiric antibiotics only if bacterial co-infection is suspected 1, 2
• Continue antibiotics only if blood cultures are positive 1, 2

Treatment Initiation in Outpatient Settings

If cerebral malaria is diagnosed outside a hospital 5, 2:

• Begin treatment immediately—do not delay for transfer
• If patient can swallow: Give oral sulfadoxine-pyrimethamine based on age-appropriate dosing 5
• If patient cannot swallow or is vomiting: Give quinine dihydrochloride 10 mg/kg IM, repeatable every 4 hours for two additional doses 5
• Arrange urgent hospitalization while continuing treatment 5, 2

Treatments to Avoid

• Steroids: Adverse effect on outcomes 5, 1, 2
• Prophylactic anticonvulsants: Increased mortality 1
• Exchange transfusion: No longer indicated with artesunate availability 1, 2
• Excessive fluid administration: Risk of pulmonary edema and worsening cerebral edema 5, 1