Treatment of Relapsed Plasmodium vivax with High-Dose Atovaquone-Proguanil in the Setting of Long-Term Rifampin Use.
Basil A McIntosh, Shreena P Advani, Andrea C Morales-Lara et al.
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Case in brief
A 58-year-old man with prior treated malaria developed relapsed Plasmodium vivax infection while receiving rifampin-based therapy for latent tuberculosis. Because rifampin-induced hepatic enzyme induction was expected to reduce atovaquone-proguanil concentrations, clinicians selected atovaquone-proguanil 2,000 mg/800 mg daily for 6 days, alongside primaquine 30 mg daily for 14 days. Parasitemia resolved completely, and clinical cure was sustained at follow-up.
What made this case unusual
The treatment approach used double the standard dose of both atovaquone-proguanil components and double the standard treatment duration in the setting of long-term rifampin use.
Diagnostic / clinical pearl
When treating relapsed P. vivax during rifampin therapy, consider the potential for enzyme induction to lower atovaquone-proguanil concentrations; this case reports successful treatment with an increased-dose regimen plus primaquine.