5-45
per day for 14 days.
- Unknown Malaria Species: Treat as P. falciparum.
- For children, the dose of chloroquine is 10 mg base/kg followed by 5 mg base/kg at 12, 24 and 36 hours.
Mefloquine is dosed at 15 mg base/kg in a single dose. Quinine is dosed at 10 mg salt/kg every 8 hours
for 7 days and clindamycin at 10 mg/kg twice daily for 3-7 days. - Medication Contraindications: Primaquine should not be given to pregnant women or newborn babies
because of the risk of hemolysis. Doxycycline and tetracycline should not be given to pregnant women or
children less than eight years old. Chloroquine, quinine, and quinidine are considered safe in all
trimesters of pregnancy, and there is evidence that mefloquine is safe in the second and third trimesters.
Alternative: Alternative treatments include quinine plus clindamycin 900 mg po tid x 5 days, mefloquine
1250 mg as a single dose or Malarone 4 tablets po q d x 3 days.
Patient Education
General: Malaria is transmitted by mosquitoes that are active from dusk to dawn, so avoid outdoor activities
during that time.
Activity: As tolerated
Diet: As tolerated
Medications: Doxycycline can cause photosensitivity, so avoid the sun or use sunscreen. Primaquine
can cause hemolytic anemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, and is
contraindicated in severe deficiency.
Prevention and Hygiene: Prophylaxis:
- For travel to areas without chloroquine-resistant P. falciparum (see above), give chloroquine 300 mg
base weekly beginning 1-2 weeks before travel and continuing 4 weeks after returning. - For travel to areas with chloroquine-resistant P. falciparum, give mefloquine 250 mg weekly 1-2 weeks
before travel and continuing 4 weeks after returning. Doxycycline 100 mg po q d beginning 1-2 days
before travel and continuing 4 weeks after returning is an alternative regimen (watch for photosensitivity). - For patients with prolonged exposure to P. vivax and P. ovale, give primaquine phosphate 26.3 mg (15
mg base) po per day the last 2 weeks of the 4 week period of prophylaxis on return (may not be well
tolerated by persons with G6PD deficiency).
No Improvement/Deterioration: Return for reevaluation promptly.
Follow-up Actions
Return evaluation: Repeat smears to assess effectiveness of treatment. Consider co-infections.
Evacuation/Consultation Criteria: The presence of severe malaria should prompt consultation with an
expert in malaria. For complicated malaria (cerebral dysfunction, renal failure, very high parasitemia, ARDS)
rapid evacuation to a higher echelon care facility is needed.
ID: Paragonimiasis
LTC Glenn Wortmann, MC, USAIntroduction: The only lung fluke that infects man, Paragonimus is found throughout the Far East (particularly
China), in West Africa and in several parts of Central and South America. It is acquired from eating raw, salted,
dried, pickled or incompletely cooked freshwater crabs, crayfish and shrimp.
Subjective: Symptoms
Most infections are asymptomatic. Heavier infections result in chronic productive cough, chest pain (pleuritic),
hemoptysis and night sweats. Extrapulmonary disease can be found in subcutaneous tissues, liver, lymph
nodes, others.
Focused History Questions: Have you had a cough? If so, has your cough been bloody? (typical symptoms)
How long have you had a cough? (can have chronic bronchitis)