Dr. Arpit Varshney
General Medicine
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I belong to a western country but lived in a non-western country for about 16 years. I had malaria a couple of times while living there. My illness started with fever or flu-like symptoms, severe muscle aches and pains through the neck and shoulders, head pain, chills, and fatigue. I have not been the same since this all began 16 years ago.
About five weeks after returning home, I got very sick, and my symptoms are still present today. I am wondering if I may have a missed malaria diagnosis. I did not have health insurance at that time, and I also did not know that malaria could show up weeks and months after returning home. The muscle pain spread to different areas of my body in the next month until it all settled over. I also developed digestive issues (severe constipation) and my lungs (new allergies and sensitivity with cleaning products). I saw an infectious disease doctor within that first year in the foreign country 16 years ago, and he tested me for many things except for malaria. I recently asked my current doctor to test me for malaria, but the test results were negative. I have heard that testing in my country is not as accurate for malaria, and I also do not know if it would even show up in a test this many years later. I asked my doctor for a re-test, but she said it was not needed. I had taken Malarone (the dose was not considering malaria), Metronidazole, Cefuroxime, and Minocycline. But I stopped them despite improvements as I could not tolerate those drugs.
I also realized that some of the medications and herbs that helped lessen my symptoms over the years also treat malaria. Do you think I could be dealing with malaria? I am not sure what to do at this point. Kindly help.
Hello,
Welcome to icliniq.com.
When I read about the symptoms you had, I could only think of malaria. I would strongly suggest getting tested for malaria. Malaria has two tests peripheral blood smear and rapid diagnostic test. It would help if you underwent both of them. There is another possibility, kala-azar, but it comes low on the chart as compared to malaria. The treatment for malaria is very simple. Seven days of injections and the next seven days of the tablet, and you will be completely fine. So I would suggest getting malaria tests immediately and starting with the treatment.
I hope this helps.
Kindly revert in case of further queries.
Patient's Query
Hi doctor,
Thank you so much for your reply, and your input is very helpful.
I did try to do a couple of malaria tests here, but they came back negative. I feel it would be wise to try to treat it, as I am not sure if it would even show up on our tests at this point. Will I be able to make an actual doctor’s appointment on here and get a prescription as well?
Hello,
Welcome back to icliniq.com.
Now, you have two options: start injectable antimalarial drug for one week and then shift to tablet for one or two weeks. The dose for the injection will be Artesunate 180 mg twice daily for three days and then 120 mg once a day for one week, followed by tablet artesunate 50 mg once a day. It would be wise enough to start treatment for malaria. If not, I would suggest tablet Falcigo (Artesunate) 50 mg, two tablets (100mg once a day) for one week. Later, one tablet once a day. I prefer the first option with my patients, but for that, you will need hospital admission. You should get your malaria rapid diagnostic test and peripheral blood smear test (thick and thin) for malaria. For a prescription, you should consult a physician nearby.
I want to assure you that you will be fine with the proper diagnosis, and treatment is all we need.
Kindly revert in case of further queries.
I hope this helps.
Regards.
Patient's Query
Hi doctor,
You have been so helpful to me. Thank you very much for your time and input!
Also, from what I have read online, I do not know if we have Artesunate readily available here in my country for prescriptions? Are there any additional treatment options if the drug is not available? Or maybe it is available only by being admitted to the hospital, as you mentioned. Since I have been dealing with this for 16 years, do you think I would need to treat for longer than the usual treatment, or the two weeks should be fine?
Hello,
Welcome back to icliniq.com.
As you mentioned earlier, I am not sure whether you will get this medicine easily in your country. So, I would suggest you visit a doctor, ask for a malaria test, take treatment. If you do not get the solution, then visit a nearby pharmacy and ask them if they have these medicines over-the-counter.
There are other treatment options available. But they are inferior to Artesunate, and make sure you are not pregnant as Artesunate is contraindicated in the first trimester of pregnancy.
Whether you need treatment for a longer duration depends on your current clinical condition and reports and the number of organs involved, which can only be assessed by physical examination. So the doctor examining you personally can come to a better conclusion than me in this regard. Generally, treatment for two weeks is more than enough in 90% of the patients.
I hope this helps.
Kindly revert in case of further queries.
Patient's Query
Hello doctor,
I have taken your advice and contacted pharmacies here. Unfortunately, Artesunate is only available for intravenous use from the pharmacies, which would require being in the hospital. If the insurance company does not pay, the cost is also high. The pharmacy can fill prescriptions for Malarone (Atovaquone 250 mg and Proguanil 100 mg) or Coartem (Artemether 20 mg and Lumefantrine 120 mg). How effective do you think these medications are if I am unable to get Artesunate?
I will see if I can find another infectious disease doctor here, but I do not feel very hopeful with them because they are not as familiar with malaria. I have seen many of them over the years, and none considered malaria a possibility for me. After being sick for so many years, and because my country is not as familiar with it, do you think my malaria tests would be accurate here? I am awaiting my test results, but I am wondering how reliable the tests will be. Even if the tests are negative, I know I have responded to antimalarials before, so it makes me think I should still try the treatment.
Would you please tell me if neck stiffness, pain, and lung problems are common with a malaria infection? The doctors here cannot seem to answer that for me. You mentioned that treatment time might depend on the organs affected. I guess that my lungs have been affected, I have also had some pain through my abdomen, and I occasionally have had heart palpitations since my illness began.
Finally, you also mentioned a lower possibility of another disease called kala-azar. Just in case I speak with a doctor here about it, can you mention what the treatment is for that and if it is hard to treat it?
Thank you again for all of your help.
Hello,
Welcome back to icliniq.com.
Atovaquone and Proguanil is not as effective as Artesunate. Artemether and Lumefantrine are equally good, as Artemether and Artesunate both belong to the same class of drugs. There is a different trend in different countries, and the doctors treat accordingly. The reports will be accurate if the laboratory is good. Do not worry about it.
Neck stiffness and neck rigidity can be seen in malaria. Especially in a complicated long-standing, incompletely treated malaria, when malaria enters the meninges, but that is quite rare. This can only be diagnosed after physical examination.
Kala-azar is very easily diagnosable and treatable. I will tell you the treatment in detail if it is diagnosed, but I dont want to bug you with unnecessary medical terms and knowledge as that will only stress you out.
Again, my goodwill suggestion will be to talk to your treating doctor patiently and tell them you want to make sure it is not malaria and that you are not getting better. I am sure your doctor will consider your request.
Lastly, we should not forget malaria is only one possibility. There can also be a possibility that this is not malaria, and we are overthinking all of this. If all malaria tests are negative, then it is not malaria. It will show up in one test or the other.
I hope this helps
Kindly revert in case of further queries.
Patient's Query
Hi doctor,
Thanks for your answers. I will take all of these things into account and see what the doctors here say also. Would you please tell me how to know if untreated malaria has entered the meninges? Is there something specific a doctor can check for in a physical exam? I am just curious in case the doctor here is unaware. Any input is greatly appreciated.
Hello,
Welcome back to icliniq.com.
The only way to determine whether the malarial parasites have entered meninges is to do a lumbar puncture and MRI (magnetic resonance imaging) brain. Neck rigidity, Kernig's sign (inability to straighten the leg when the hip is flexed) Brudzinski's sign are few clinical tests to detect meningitis (inflammation of meninges).
But again, I will emphasize that clinical physical examination is more important than tests. I hope this helps.
Kindly revert in case of further queries.
Patient's Query
Hi doctor,
Thank you for your reply. I appreciate you sharing what to look for with malaria entering the meninges. I am trying to get a doctor’s appointment here and get as much information as possible since the doctors have not been as knowledgeable about malaria. I will share all of this with a doctor here if possible. You also mentioned an eye test for malaria. Is there anything about that I can mention to a doctor here as well? Are there any signs to look for?
And previously, you also mentioned that the Artemether and Lumefantrine combination works well too. If that is my best available treatment here, what is the recommended treatment dose and duration? I guess it is slightly different from what you shared about Artesunate.
Hello,
Welcome back to icliniq.com.
Artemether and Lumefantrine is a fixed-dose combination, so, all over the world, the dose is the same. Do not worry regarding the dose. The doctor giving you this medicine has no option apart from the fixed-dose.
I wish you all the best and a speedy recovery. Kindly do let me know about your progress and health.
Patient's Query
Hi doctor,
Thank you for your reply. It seems the CDC here only recommends a few days of treatment for malaria versus what you have mentioned as two weeks.
Hello,
Welcome back to icliniq.com.
Kindly revert in case of further queries.
Regards.
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