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Am. J. Trop. Med. Hyg., 78(4), 2008, pp. 552-555
Copyright © 2008 by The American Society of Tropical Medicine and Hygiene

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Impaired Clinical Response in a Patient with Uncomplicated Falciparum Malaria Who Received Poor-Quality and Underdosed Intramuscular Artemether

Valy Keoluangkhot, Michael D. Green, Leonard Nyadong, Facundo M. Fernández, Mayfong Mayxay, AND Paul N. Newton*
Adult Infectious Disease Ward, Mahosot Hospital, Vientiane, Lao PDR; Wellcome Trust–Mahosot Hospital–Oxford Tropical Medicine Research Collaboration, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR; Francophone Institute for Tropical Medicine, Vientiane, Lao PDR; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia; Department of Post Graduate and Research, University of Health Sciences, Vientiane, Lao PDR; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom

We describe an adult with uncomplicated Plasmodium falciparum malaria who did not improve clinically despite 5 days of intramuscular artemether therapy. He was prescribed a lower dose (kg body weight) than that recommended, and a vial from the packet contained only 74% of the artemether dose as stated by the manufacturer. The combination of underdosing, poor-quality drug, and the intrinsic low bioavailability of artemether may have contributed to his poor clinical response. Analysis of the packaging and chemical "fingerprinting" of the artemether suggested that the drug was genuine but was either substandard or had deteriorated after manufacture.

Received July 21, 2007. Accepted for publication January 8, 2008.

Acknowledgments: The authors thank Kunming Pharmaceutical Corp., Chanthala Vilayhong, Professor Nicholas White, and an anonymous reviewer for their help. M.M. and P.N.N. are supported by the Wellcome Trust (U.K.). L.N. is supported by the U.S. Pharmacopeia. F.M.F. acknowledges support from WPRO/WHO and NSF for this work.

Financial support: This work was supported by the Wellcome Trust of Great Britain.

* Address correspondence to Paul N. Newton, Wellcome Trust–Mahosot Hospital–Oxford Tropical Medicine Research Collaboration, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR. E-mail: paul{at}tropmedres.ac

Authors’ addresses: Valy Keoluangkhot, Adult Infectious Disease Ward and Wellcome Trust–Mahosot Hospital–Oxford Tropical Medicine Research Collaboration, Mahosot Hospital, Vientiane, and Francophone Institute for Tropical Medicine, Vientiane, Lao PDR, Telephone/fax: +856 21 242168. Michael D. Green, Division of Parasitic Diseases, CDC, Atlanta, GA. Leonard Nyadong and Facundo M. Fernández, School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, GA. Mayfong Mayxay, Wellcome Trust–Mahosot Hospital–Oxford Tropical Medicine Research Collaboration, Mahosot Hospital, Vientiane, Lao PDR, Telephone/fax: +856 21 242168, and Department of Post Graduate and Research, Faculty of Medical Science, National University of Laos, Lao PDR. Paul N. Newton, Wellcome Trust–Mahosot Hospital–Oxford Tropical Medicine Research Collaboration, Mahosot Hospital, Vientiane, Lao PDR, Telephone/fax: +856 21 242168, and Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Churchill Hospital, Oxford, OX3 7LJ, United Kingdom.






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Copyright © 2008 by the American Society of Tropical Medicine and Hygiene.