Malaria
Test every fever in an endemic area. Severe malaria needs IV artesunate now. Uncomplicated falciparum gets an ACT, vivax gets chloroquine or an ACT plus primaquine after a G6PD test.
A 30-year-old labourer back from working in interior Sindh has had fever with shivering for 5 days. Today he is confused and yellow. Temperature 39.8 °C, BP 96/60. Rapid test positive for P. falciparum. Sugar 54 mg/dL (3 mmol/L), creatinine 2.6 mg/dL (230 µmol/L).
Is this severe malaria, and what do you give first?
- Test for malariaRapid diagnostic test (RDT) and/or thick and thin films in any fever in an endemic area.
- Look for severe featuresConfusion, fits, low sugar, acidosis, kidney injury, jaundice with organ dysfunction, breathlessness, bleeding, shock, severe anaemia.
- Severe: IV artesunate nowHDU or ICU. Do not wait for a parasite count.
- Check the sugarLow sugar is common in severe malaria, children and pregnancy, and with quinine.
- BloodsCBC, sugar, creatinine, electrolytes, LFTs, gas with lactate, blood culture.
- Uncomplicated: oral treatment by speciesFalciparum: ACT. Vivax: chloroquine (or ACT), then primaquine.
- G6PD test before primaquinePrimaquine can cause severe haemolysis if G6PD deficient.
- Look for co-infectionDengue and typhoid can coexist.
- Confusion, fits or coma
- Low sugar, acidosis or kidney failure
- Jaundice with organ dysfunction
- Breathlessness (pulmonary oedema)
- Severe anaemia, bleeding or shock
- Pregnant
- Severe falciparum malaria
- Low sugar
- Mixed infection
- Dengue or typhoid at the same time
- Vivax relapse without primaquine
| Severe malaria | IV artesunate 2.4 mg/kg at 0, 12 and 24 hours, then daily, then a full oral course |
| Uncomplicated falciparum | Artemether-lumefantrine twice daily for 3 days, with fatty food or milk |
| Uncomplicated vivax | Chloroquine over 3 days (total 25 mg/kg base), or an ACT |
| Vivax radical cure | Primaquine for 14 days after a normal G6PD test |
| Low sugar | Below 70 mg/dL (3.9 mmol/L): IV dextrose |
Check every dose against a current drug reference and your hospital protocol.
On this page
Malaria in Pakistan
- Spread by Anopheles mosquitoes, which bite from dusk to dawn.
- Plasmodium vivax causes most cases across Pakistan. P. falciparum is more common in Sindh and Balochistan and causes most severe disease and deaths.
- Peaks after the monsoon. Floods are followed by outbreaks.
- Vivax can hide in the liver (hypnozoites) and relapse weeks or months later, unless treated with primaquine.
- Vivax can also cause severe malaria. Do not assume it is always mild.
Recognising it
- Fever with chills and sweats, headache, body aches, vomiting. The classic "every other day" pattern is often absent.
- Large spleen, mild jaundice, anaemia, low platelets.
- In children: fever, vomiting, poor feeding, fits.
Testing
| Test | Use |
|---|---|
| Rapid diagnostic test (RDT) | Fast, detects falciparum and often vivax. Can stay positive for weeks after treatment |
| Thick film | Detects parasites (more sensitive) |
| Thin film | Species and parasite count (percentage of red cells infected) |
| Repeat test | If the first is negative but malaria is still suspected: repeat every 12–24 hours, up to 3 tests |
Severe malaria
- Confusion, drowsiness, coma or fits (cerebral malaria).
- Low sugar below 40 mg/dL (2.2 mmol/L).
- Acidosis or high lactate.
- Kidney injury (creatinine above 3 mg/dL or 265 µmol/L).
- Jaundice with parasite count above 2% or other organ dysfunction.
- Breathlessness, pulmonary oedema, low SpO₂.
- Severe anaemia (Hb below 7 g/dL in adults).
- Shock, significant bleeding.
- High parasite count (above 10% in non-immune patients).
In practice: any patient who looks very unwell with malaria should be treated as severe.
- If IV artesunate is not available: IM artesunate, or IV quinine (watch sugar closely), per local guidance. Do not delay treatment.
- Supportive care: HDU or ICU, careful fluids (pulmonary oedema develops easily), sugar checks, treat fits, transfuse for severe anaemia, dialysis for kidney failure, antibiotics if sepsis is possible.
Uncomplicated malaria
- Artemether-lumefantrine for 3 days
- Single low dose of primaquine may be added to reduce transmission, per national guidance
- Chloroquine for 3 days (or an ACT where chloroquine resistance is suspected)
- Then primaquine for 14 days after a normal G6PD test
G6PD before primaquine. In G6PD deficiency, primaquine can cause severe haemolysis (dark urine, anaemia, jaundice). Test first, or seek specialist advice on a modified regimen.
Special groups
- Pregnancy: malaria is more severe, with low sugar and harm to the baby. Severe: IV artesunate in any trimester. Uncomplicated falciparum: an ACT (artemether-lumefantrine) is used, including in the first trimester per current WHO guidance. No primaquine in pregnancy: give weekly chloroquine prophylaxis until after delivery for vivax.
- Children: weight-based doses, frequent sugar checks, fits are common.
Common mistakes
- Not testing for malaria because "it is probably typhoid or dengue".
- Assuming vivax is always mild.
- Giving oral treatment to a patient with severe features.
- Forgetting the sugar.
- Giving primaquine without a G6PD test.
- Stopping at chloroquine for vivax without primaquine: the patient relapses.
- Overloading severe malaria patients with fluid.
Frequently asked questions
What is the dose of IV artesunate in severe malaria?
2.4 mg/kg IV (3 mg/kg in children under 20 kg) at 0, 12 and 24 hours, then once daily until oral treatment is possible, followed by a full 3-day oral ACT.
What is the treatment of vivax malaria in Pakistan?
Chloroquine over 3 days (total 25 mg base/kg) or an ACT, followed by primaquine 0.25 mg/kg daily for 14 days after a normal G6PD test to prevent relapse.
Why is a G6PD test needed before primaquine?
Primaquine can cause severe haemolysis in people with G6PD deficiency.
What are the features of severe malaria?
Impaired consciousness or fits, low sugar, acidosis, kidney injury, jaundice with organ dysfunction, pulmonary oedema, severe anaemia, shock, bleeding, or a high parasite count.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A falciparum-positive patient is confused and jaundiced with glucose 3 mmol/L (54 mg/dL). What are the first steps?
Answer: IV dextrose and IV artesunate. Severe falciparum malaria: IV artesunate 2.4 mg/kg at 0, 12, 24 hours then daily, treat hypoglycaemia, careful fluids.
- Quinine tablets: Not first choice.
- Primaquine: Not for acute treatment.
- Oral artemether-lumefantrine: Severe malaria needs IV treatment.
- Chloroquine: Resistance; not for severe falciparum.
2. A patient has vivax malaria. The G6PD test result is not available yet. What is the best management?
Answer: Treat now, primaquine after G6PD. Primaquine eradicates liver hypnozoites but causes haemolysis in G6PD deficiency. Test first.
- No treatment until G6PD is known: The acute illness needs treatment.
- Doxycycline: Not standard.
- Primaquine now with chloroquine: Haemolysis risk if G6PD deficient.
- Primaquine alone: Doesn't treat blood stages.
3. A malaria rapid test is positive, but on day 5 the platelets are falling and the haematocrit is rising. What else should be considered?
Answer: Dengue co-infection. Dengue and malaria share seasons in Pakistan. Haemoconcentration with falling platelets suggests dengue plasma leakage.
- Typhoid: Doesn't cause haemoconcentration.
- Drug side effect: Not typical.
- Treatment failure only: Rising haematocrit suggests plasma leakage.
- Normal malaria course: Not with rising haematocrit.
4. A 30-year-old from Karachi has P. vivax malaria confirmed on film and recovers with chloroquine. G6PD activity is normal. What else is needed?
Answer: Primaquine for 14 days. P. vivax and P. ovale form hypnozoites in the liver that cause relapses weeks to months later. Chloroquine (or an ACT) treats the blood stage; primaquine (0.25–0.5 mg/kg/day for 14 days) or single-dose tafenoquine clears hypnozoites — after testing G6PD (risk of haemolysis). Avoid primaquine in pregnancy and infants; give weekly chloroquine prophylaxis in pregnancy until delivery.
- Repeat chloroquine monthly: Repeated chloroquine does not clear liver hypnozoites.
- Artesunate IV: Artesunate IV is for severe malaria.
- Nothing further: Without primaquine, relapses can occur.
5. A woman at 10 weeks’ gestation in Sindh has uncomplicated falciparum malaria confirmed on RDT. What is the WHO-recommended treatment?
Answer: Artemether–lumefantrine. Malaria in pregnancy: higher risk of severe malaria, hypoglycaemia, anaemia, miscarriage, stillbirth, low birth weight. WHO (2022 onward) recommends artemether–lumefantrine for uncomplicated falciparum malaria in the first trimester (previously quinine + clindamycin) and ACTs in 2nd/3rd trimesters. Severe malaria: IV artesunate in any trimester. Avoid primaquine, tetracyclines. Insecticide-treated nets; IPTp-SP in high-transmission areas.
- Primaquine: Primaquine is contraindicated in pregnancy.
- Doxycycline-based therapy: Doxycycline is contraindicated in pregnancy.
- No treatment until second trimester: Malaria must be treated in every trimester.
6. A woman on long-term chloroquine for lupus has blurred vision. Which eye problem is the drug known for?
Answer: Bull's eye maculopathy. Chloroquine and hydroxychloroquine accumulate in the retina and cornea, causing irreversible bull's eye maculopathy, so regular eye screening is needed. Corneal deposits are usually reversible. Ethambutol causes optic neuritis; steroids cause cataracts and glaucoma.
- Cataract: Steroids.
- Optic neuritis: Ethambutol.
- Acute angle-closure glaucoma: Anticholinergics.
- Conjunctivitis: Not typical.
7. Which Plasmodium species causes malignant tertian malaria?
Answer: Plasmodium falciparum. P. falciparum (malignant tertian) causes the severe disease: high parasitaemia, cerebral malaria, renal failure and death, because infected cells stick to vessel walls. P. vivax and ovale cause benign tertian malaria with liver hypnozoites (relapse). P. malariae causes quartan malaria and can cause nephrotic syndrome.
- Plasmodium vivax: Benign tertian; hypnozoites.
- Plasmodium ovale: Benign tertian; hypnozoites.
- Plasmodium malariae: Quartan (72 h).
- Plasmodium knowlesi: Daily fevers; Southeast Asia.
References and dose sources
- WHO guidelines for malaria
- CDC: Malaria
- Artesunate dosing: Drugs.com: Artesunate dosage (see also our artesunate dose page)
- Dextrose (glucose) dosing: Drugs.com: Dextrose dosage (see also our dextrose (glucose) dose page)
- Artemether-lumefantrine dosing: Drugs.com: Artemether-lumefantrine dosage (see also our artemether-lumefantrine dose page)
- Chloroquine dosing: Drugs.com: Chloroquine dosage (see also our chloroquine dose page)
- Primaquine dosing: Drugs.com: Primaquine dosage (see also our primaquine dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.