Abstract
Radical cure of Plasmodium vivax malaria in glucose-6-phosphate dehydrogenase (G6PD) deficient individuals employs weekly primaquine dosing. This is the only recommended regimen for this patient sub-group. If national malaria programs mandate daily primaquine dosing (the recommended regimen for G6PD normal individuals), then G6PD testing before prescription is necessary to avoid iatrogenic haemolysis in G6PD deficient individuals. In this case series, two P. vivax infected patients with unknown G6PD status from two different countries were prescribed primaquine as per national malaria program guidelines. During treatment both patients presented to the clinic with symptoms of anaemia after taking primaquine incorrectly. The clinical management of the iatrogenic severe haemolysis that occurred in these patients demonstrates the various adverse effects primaquine can cause, that other common medical treatments also have haemolytic potential, and how the diagnosis of G6PD deficiency can be elusive during acute haemolysis. Health care providers should provide careful instructions about primaquine dosing, be watchful for haemolysis, and have a high index of suspicion for G6PD deficiency in the presence of haemolysis if the G6PD status is previously unknown.
Highlights
Primaquine is the only treatment available for the radical cure of Plasmodium vivax malaria
The evidence supporting the safety of the 8-week regimen was derived from a study performed in the 1960’s where a weekly primaquine dose (45 mg) caused less haemolysis than a daily dose (30 mg) in glucose-6-phosphate dehydrogenase (G6PD) deficient adult patients of African descent[1]
The second case, presented with an elevated methaemoglobin[19], a nearly normal haematocrit and normal reticulocyte count indicating that the bulk of haemolysis occurred after primaquine had been stopped
Summary
Primaquine is the only treatment available for the radical cure of Plasmodium vivax malaria It is not widely used because G6PD deficient persons develop a dose dependent haemolysis when exposed to the daily doses in the 14-day regimen. The evidence supporting the safety of the 8-week regimen was derived from a study performed in the 1960’s where a weekly primaquine dose (45 mg) caused less haemolysis than a daily dose (30 mg) in G6PD deficient adult patients of African descent[1]. Initial blood work was performed (Table 1); malaria smear was negative, haematocrit was 15%, and G6PD fluorescent spot test (FST) was normal (not deficient). The patient’s clinical condition was stable, so he was discharged that day by request of the family They were counselled with the same information as for Case 1 and the G6PD deficiency card was given. For the same reasons as Case 1, the 8-week primaquine regimen was not prescribed
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