Given the cardiotoxicity of quinidine, artesunate has been approved for parenteral treatment of malaria. Artesunate has several benefits over quinidine, and it is the mainstay of treatment of malaria outside the United States. Artesunate does not require cardiac monitoring, and the drug is easily dosed every 12 hours.⁸ It is available from the CDC Malaria Branch hotline (770-488-7100) at no charge, and is stored at 20 quarantined sites across the continental United States.

Summary

Fever in a traveler presenting to the emergency department should prompt an evaluation for malaria. History should focus on use of chemoprophylaxis, travel to endemic regions, and onset and type of symptoms. Diagnosis is confirmed by peripheral blood smear, and therapy is initiated in the emergency department based on risk stratification into uncomplicated or severe malaria.

Emergency physicians should be aware of possible pitfalls in the diagnosis, as well as signs of severe malaria. In cases where oral medications are not tolerated or quinidine is contraindicated, IV artesunate is readily available from the CDC.

References

1. Greenwood BM, K Bojang, CJ Whitty, and GA Targett. Malaria. Lancet. 2005 April 23-29; 365(9469):1487-98.
2. Centers for Disease Control and Prevention. The Impact of Malaria, a Leading Cause of Death Worldwide. (www.cdc.gov/malaria/impact/index.htm).
3. Stanley J. Malaria. Emergency Medicine Clinics of North America. 1997 February; 15(1):113-55.
4. World Health Organization. Guidelines for the Treatment of Malaria. 2006.
5. Centers for Disease Control and Prevention. Treatment of Malaria: Guidelines for Clinicians. (Last updated May 18, 2009).
6. Bailey JW, Williams J, Bain BJ, Parker-Williams J, Chiodini P. General Haematology Task Force. Guideline for laboratory diagnosis of malaria. London (UK): British Committee for Standards in Haematology. 2007;19.
7. Griffith KS, Lewis LS, Mali S, Parise ME. Treatment of malaria in the United States: a systematic review. JAMA. May 23 2007;297(20):2264-77.
8. Rosenthal PJ. Artesunate for the treatment of severe malaria. New England Journal of Medicine. 2008 April 24; 358(17):1829-36.
9. Centers for Disease Control and Prevention. Malaria. Topic Home. Last updated May 21, 2009. Available at www.cdc.gov/malaria/index.htm.
10. “Intracellular ringed forms, malaria.” Charles E. Hess, M.D. and Lindsey Krstic, B.A.

Contributors

Dr. Malya is a second-year emergency medicine resident at the University of Chicago. Dr. Pillow is an assistant professor at Baylor College of Medicine and assistant director of medical education at the Ben Taub Emergency Center in Houston, Texas. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.