227.3 🩺 內科專科考前版

227.3.0.1 1⃣ Returning Traveler with Fever

  • Malaria #1 consideration if from endemic
  • Thick + thin smears × 3 negative not definitive (especially if early)
  • ID consultation + empirical Tx if very high suspicion + severe sx
  • Differential: typhoid, dengue, leptospirosis, Ebola, HIV seroconversion, etc.
  • Don’t delay treatment for severe malaria

227.3.0.2 2⃣ Cerebral Malaria

  • Retinal findings: retinal hemorrhages + retinal whitening (Beare-Lewallen) — distinct from other encephalopathies
  • ICP monitoring (selective)
  • No mannitol routine (mixed evidence; mostly avoided)
  • No steroid
  • Anticonvulsants for seizures
  • Supportive ICU + IV artesunate
  • Mortality 20-30%

227.3.0.3 3⃣ IV Artesunate Delayed Hemolysis

  • 7-14 days after IV artesunate
  • Rare (~ 10-15% in some series)
  • Most resolve spontaneously
  • Monitor CBC + reticulocyte + LDH
  • Transfuse if severe

227.3.0.4 4⃣ Pregnancy Malaria

  • ACT (artemether-lumefantrine) first-line all trimesters (2024 WHO update)
  • IV artesunate for severe
  • IPTp (sulfadoxine-pyrimethamine) in Africa endemic
  • No primaquine/tafenoquine (fetal G6PD unknown)
  • Counseling: avoid travel to endemic if possible

227.3.0.5 5⃣ Tafenoquine vs Primaquine

  • Tafenoquine: single dose 300 mg (easier adherence)
  • Primaquine: 14-day course (more established)
  • Both require G6PD activity testing (quantitative — > 70% female)
  • Tafenoquine causes methemoglobinemia (rare)
  • Tafenoquine cannot be used during breastfeeding (long half-life)

227.3.0.6 6⃣ Artemisinin Resistance Surveillance

  • WHO + global health partners
  • Genomic sequencing for kelch13 mutations
  • Therapeutic efficacy studies
  • 2024 reports of slow clearance in Rwanda + Eritrea (Africa)
  • Triple ACTs (artemisinin + 2 partner drugs) explored

227.3.0.7 7⃣ R21/Matrix-M Implementation 2024

  • Mass rollout in African countries
  • Cameroon, Kenya, etc.
  • Pediatric routine (5-36 months)
  • 3-dose primary + booster
  • Cost ~ $4 per dose (vs RTS,S $10+)
  • Expected major reduction in pediatric mortality

227.3.0.8 8⃣ 健保 / Taiwan

  • 通報 mandatory
  • 健保 antimalarials for confirmed cases
  • 旅遊 prophylaxis 自費
  • Anopheles maculatus + others local (rare local transmission)
  • Mostly imported cases (returning travelers)

227.3.0.9 9⃣ Future Antimalarials

  • Tafenoquine + atovaquone-proguanil combination prophylaxis
  • KAF156 (cabamiquine) — Novartis, Phase 3
  • DSM265, DSM450 — antimalarial new mechanisms
  • Triple ACTs for artemisinin resistance
  • mRNA + whole-sporozoite vaccines

227.3.0.10 10. Eradication Strategy

  • WHO 2030 global elimination goals
  • Mass drug administration in some settings
  • Vector control (LLIN — long-lasting insecticidal nets)
  • Indoor residual spraying
  • Surveillance + response
  • Vaccine + chemoprevention + vector control combined