Fever and severe pallor

A 7-year-old Kenyan boy was brought to the outpatient department by his mother with a 5-day history of high fever, chills, sweating, and progressive pallor. The child appeared lethargic and had reduced food intake. He lives in a malaria-endemic area. No prior antimalarial treatment had been given. Vaccination history incomplete.

Temperature: 39.8°C, HR: 142 bpm, RR: 32/min, SpO2: 94% on room air. Pallor: severe (conjunctival, palmar). Jaundice: mild. Spleen: splenomegaly (4cm below costal margin). Liver: hepatomegaly (3cm). No neck stiffness. GCS: 14/15.

FBC: Hb 4.2g/dL, WBC 8.4×10⁹/L, Platelets 68×10⁹/L. Malaria RDT: positive (P. falciparum). Thick and thin blood film: P. falciparum +++, ring forms predominant. Reticulocyte count: 8.2%. Bilirubin: 45μmol/L (unconjugated). Blood glucose: 2.8mmol/L (borderline low). Blood cultures: pending.

Severe Malaria (Plasmodium falciparum) with Severe Anaemia

IV artesunate 3mg/kg (as per WHO guidelines for severe malaria). Blood transfusion: packed RBCs 10ml/kg over 4 hours (Hb <5g/dL with respiratory distress). IV dextrose for hypoglycaemia. Antipyretics for fever management. Careful fluid balance (avoid fluid overload). Oxygen supplementation. Completion of oral artemether-lumefantrine after IV treatment.

• 1. Severe malaria criteria include: Hb <5g/dL, cerebral malaria, renal impairment, respiratory distress.
• 2. IV artesunate is superior to IV quinine for severe malaria.
• 3. Hypoglycaemia is common in severe malaria - always check blood glucose.
• 4. Blood transfusion indicated when Hb <5g/dL with signs of decompensation.
• 5. P. falciparum is responsible for most severe and fatal malaria in sub-Saharan Africa.