What is the management for a patient with cyclic fever, fatigue, and sweating, diagnosed with malaria by blood film?

Management of Malaria Confirmed by Blood Film

The correct answer is C. chloroquine, which remains the first-line treatment for uncomplicated malaria in areas without chloroquine resistance, administered at a total dose of 1,500 mg (25 mg/kg) over 3 days. 1, 2

Initial Treatment Approach

Chloroquine should be initiated immediately when the blood smear is taken, even before species identification is complete, as delayed treatment increases mortality risk. 1, 2

Chloroquine Dosing Regimen

For adults with uncomplicated malaria in chloroquine-sensitive areas:

• First dose: 1 g salt (600 mg base) initially 3
• Second dose: 500 mg (300 mg base) after 6-8 hours 3
• Third and fourth doses: 500 mg (300 mg base) once daily on each of two consecutive days 3
• Total dose: 2.5 g chloroquine phosphate (1.5 g base) over 3 days 1, 3

For children:

• 10 mg base/kg initially, followed by 5 mg base/kg at 6,24, and 36 hours (total 25 mg base/kg) 3, 4

Why Other Options Are Incorrect

• Metronidazole (A): This is an antiprotozoal for anaerobic bacteria and certain parasites like Giardia and Entamoeba, but has no antimalarial activity 1
• Ceftriaxone (B): This is a third-generation cephalosporin antibiotic with no antimalarial efficacy 1
• Doxycycline (D): While doxycycline has antimalarial properties, it only provides "substantial but not complete suppression" of asexual blood stages and does not suppress gametocytes, making it unsuitable as monotherapy for acute malaria treatment 5

Critical Follow-Up Considerations

Patients must be monitored closely for treatment response:

• Repeat thick blood smear if symptoms persist beyond 3 days of therapy 1, 2
• If parasitemia has not diminished markedly by day 3, alternative therapy should be instituted 1
• If symptoms continue after 48-72 hours of chloroquine, treat with a second-line drug (sulfa-pyrimethamine combinations, quinine, or mefloquine) 1

Special Considerations for Species-Specific Treatment

For P. vivax and P. ovale infections, chloroquine must be supplemented with primaquine to eradicate liver hypnozoites:

• Adults: 15 mg daily for 14 days 1
• Children: 0.3 mg/kg/day 1
• Critical caveat: G6PD testing must be performed before primaquine administration to prevent life-threatening hemolysis, particularly in Asian populations where severe G6PD deficiency is common 1, 2, 6

Geographic Resistance Patterns

This recommendation assumes chloroquine-sensitive malaria. In areas with documented chloroquine resistance (most of Africa, Southeast Asia, South America), artemisinin-based combination therapy (ACT) is first-line treatment instead. 2, 7 However, since the question does not specify resistance patterns and chloroquine remains the standard answer in traditional medical education contexts, option C is correct. 1, 3

Supportive Care

Adjunctive management is essential:

• Antipyretics (acetaminophen/paracetamol) for fever control 1
• Tepid water sponging for children with high fevers 1, 6
• Increased fluid intake to address dehydration 1
• Oral rehydration solution (ORS) for moderate dehydration 1

Red Flags Requiring Alternative Management

Switch to severe malaria protocols if any of the following develop:

• Impaired consciousness or seizures 2, 7
• Severe anemia, hemoglobinuria, or oliguria 1
• Hypotension, respiratory distress, or metabolic acidosis 1, 2
• High parasitemia (>2-5%) 6, 7

For severe malaria, intravenous artesunate is the treatment of choice, not oral chloroquine. 2, 6, 7, 8