Doxycycline After Malaria Diagnosis

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QUESTION

My daughter is 24 and in rural Uganda for 4 months. She has been diagnosed with malaria (plasmodium falciparum) and is taking treatment now. Treatment is 3 tablets of Neosidar tablets contain of sulfadoxine BP and of pyrimethamine followed tonight and for the next 3 days by 4 tablets of Lumarten in the morning and at bedtime with milk. Lumarten is a mix of artemether and lumefantrine. Her doctor in Entebbe recommended she should stop taking doxycycline: “the doxy is like a lock on the door, and now someone has broken the lock, so it’s better to treat the malaria as it comes (while still using nets, bug spray, long sleeves, etc. to avoid bites) rather than keep taking the doxy every day.”

Should she stop taking doxycycline and should she be taking the Lumarten with milk? Thank you very much.

ANSWER

I am not personally familiar with Lumarten, but these antimalarials are often taken with food. Of more concern is that she has been given a sulfadoxine-pyramethamine treatment—these are no longer recommended as first line treatment against malaria, and so she should just take the artemisinin-based combination therapy (artemether-lumefantrine is such a combination therapy).

In terms of the doxycycline, I do not understand the doctor’s advice. There is no harm in continuing to take doxycycline after having malaria, and in fact it might prevent re-infection! Of course this depends on how long she is still in Uganda for—the doxy must be taken for four weeks after leaving the malarial area, so if she is returning home soon, she should weigh up the continued preventive benefit against the inconvenience of a long continuation of taking the medication. In general, I don’t like the doctor’s attitude that your daughter should just accept continuing infections with malaria, and “treat them as they come.” It’s much better to use all available methods for prevention. One thing to consider is that dairy products inhibit the uptake of doxycycline, so if your daughter was also taking her doxy with milk (some doctors mistakenly advise this, to prevent stomach upsets when taking the medication), that might have been one reason why she still got infected.

Malaria Fever and Recovery

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QUESTION

My 21 year old daughter spent 4 months on a study abroad program in Dakar. A week before returning home she started having night fevers and would complain of retrosternal pain and rib and neck and shoulder pain. The next day she would be fine.

The episodes came every other day and eventually it occurred to her that it might be malaria. It was evening so she went to a pharmacy for a rapid diagnostic test which they didn’t have but they felt she had malaria based on her symptoms and gave her a 3 day course of artesunate-mefloquine.

She returned to the United States and a day after taking her last dose, she was seen by a physician and tests were done which showed that she had contracted Plasmodium falciparum malaria. Other than the smears, all her lab tests and CXR were normal and there were no abnormal findings on physical exam, in fact she was the picture of health.

We were told that she was cured and that no follow up was necessary and that she could continue with her planned trip to Thailand the next day. About 6 hours before boarding the plane to Bangkok she developed fever of 100.9 but had absolutely no other symptoms or pain. About an hour later she had a bout of diarrhea. She had one more low grade fever on the flight (99.8). I spoke to another physician who seems more familiar with malaria and was told that she is not actually cured and may continue to have episodic fevers and symptoms for a while or it’s possible she was just suffering from an ordinary garden variety gastrointestinal bug.

I have many questions. I understand that her malaria is the most virulent type. How is it that all her lab work and physical exam is normal 1 day after completing treatment? Can we expect it to remain normal? What causes the episodic fevers if she is supposedly cured? She is on doxycycline again prophylactically (which she was on in Senegal) while in Thailand. Should she be on something else since she did contract malaria on doxycycline? (She took it religiously). Thanks for any advice. She will be seeing a physician in Bangkok ASAP, but since I won’t be there to ask questions, I am hoping you can give me some answers. Your site is the best information I have found on malaria.

ANSWER

Many thanks for the comprehensive information you have provided regarding your daughter’s condition. Even though your daughter did have the most virulent form of malaria, she was very smart to seek treatment relatively promptly, and lucky to receive appropriate medication (artemisinin-based combination therapies, such as artesunate-mefloquine, are recommended by the World Health Organization as first-line treatment against malaria). It is likely due to this prompt and effective action that her lab tests and blood parameters were all normal so soon after treatment; had she waited longer for treatment, the consequences could have been much more severe. No resistance to this medication has been detected in Africa as of yet, so she should be fully cured and thus her health should remain stable; a blood smear, where her blood is examined under a microscope, can determine this; this is a very standard procedure so could easily be carried out in Thailand if she wants.

Fever is a side effect of the body’s immune system responding to a disease threat, so it is not uncommon for some symptoms to carry on after treatment. In addition, mild side effects of anti-malarial medication can often mimic the symptoms of malaria itself, including fever and nausea.

Given also the (entirely reasonable) possibility of an additional, unrelated stomach bug, I suspect that your daughter has successfully beaten off this malaria attack, and while she should remain vigilant if similar symptoms arise again, her health in the future should not be adversely affected at all by this episode.

Also, as mentioned briefly above, medical professionals in Thailand should be well equipped to diagnose and treat malaria if she suspects she has been reinfected. It is worth noting that malaria in south-east Asia has shown signs of resistance to mefloquine (as well as other drugs, such as chloroquine and sulfadoxine-pyrimethamine), so if she does require treatment while there, she should make sure the medication they provide does not contain any of the afore-mentioned compounds.

Regarding doxycycline, it’s great that your daughter took it religiously—that is certainly the first step towards protection. Randomized placebo controlled trials have shown it is between 92-96% effective in preventing P. falciparum malaria, which is very good, but obviously not 100% perfect – even when taken perfectly, some infections do occur. In addition, there is some data which suggests that dairy products, taken together with doxycycline, may limit  the uptake of the drug. This is rarely communicated to patients, who are instead contrarily told sometimes that taking the pills together with dairy products can reduce side effects! As such, please let your daughter know that she should avoid dairy products for 2-3 hours around the time she takes her doxycycline.

Severe Head Pain with Malaria

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QUESTION

Can severe head pain be a symptom of mistreated malaria? My son just returned from an 8 month trip to Ghana. He had malaria 3 times and typhoid 1 time. He is now dealing with a severe head pain in his frontal lobe.

He took doxycycline every day and when he got really sick, he took Coartem. He was finally sent home because they couldn’t figure out why he has such severe head pains. Where do we go from here? He has an MRI scheduled and an appointment with an Infectious Disease Doctor. I am afraid they will not know what to do to help him. I am seeking more advice. Hopeful…CT

ANSWER

Severe head pain is not associated with mistreated malaria, nor indeed is considered a possible lasting effect of malaria infection. You are doing the right thing by going to see a doctor, including one who is an infectious disease specialist—I hope they also have experience with tropical medicine, since in the US and Europe, many very well-trained doctors are still not very familiar with the types of infections which are more commonly observed in the tropics.

Your son was right to take Coartem when he had malaria, but do you know whether he went to a clinic for diagnosis first? The symptoms of malaria are very general, such as fever, chills, nausea and aches, and many people in malarial areas (particularly visitors) often assume they have malaria when in fact their symptoms could be caused by a number of other things.

Secondly, doxycycline is considered a very effective preventive medication against malaria, but only if taken properly. Since doxycycline can cause mild stomach upset, many people take it with milk, which can lessen these symptoms; however, the calcium in the milk can bind to the drug, preventing successful absorption and reducing its efficacy as a malaria preventive.

If your son had a diet high in diary products or took antacids while in Ghana, this could explain why he suffered several malarial episodes. Alternatively, if he took the drug regularly and correctly, and particularly if he did not seek diagnosis via blood test from a clinic, that may be an indication that he wasn’t suffering from malaria at all, and other causes should be explored.

Finally, one of the very well-described side effects of doxycycline is its tendency to cause people to become very sun sensitive. While this usually manifests itself in skin sensitivity, it could also be that your son has become more visually sensitive to light, which in itself could lead to severe headaches. I hope he feels better soon!