Tropical Splenomegaly Syndrome Medication

Updated: Oct 16, 2023
  • Author: Mundeep K Kainth, DO, MPH, FAAP; Chief Editor: Vikramjit S Kanwar, MBBS, MBA, MRCP(UK)  more...
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Medication Summary

Antimalarial drugs have been the only drugs to be used in hyperreactive malarial splenomegaly (HMS) and have been shown to be effective in treatment. Clinical trials that address the drug of choice, efficacy, or duration of treatment or prophylaxis are lacking. The specific drug of choice is based on the pattern and prevalence of drug resistance in the patient's geographic area. In endemic areas, treatment may need to be long term, although the exact duration is unknown and has not been studied. Response may take weeks to months and relapses are common when therapy is discontinued. The therapy may have to be continued for months to years, but the exact duration or endpoint are not established. In expatriates with HMS, brief courses of treatment may be adequate. [24]

Chloroquine and proguanil appear to be equally effective. Eradication of parasitemia may be the underlying mechanism. Pyrimethamine may be an alternative. [36]

Owing to the emergence of drug resistance, drugs that have been efficacious in the past may no longer be effective. Unfortunately, no reliable data are available and clinical trials have not been performed. Fixed-dose drug combinations may be an alternative if response is not seen to the above drugs and if drug resistance is suspected. Atovaquone-proguanil (Malarone) or artemether-lumefantrine (Coartem) and can be used in children. Other combinations include quinine sulfate plus doxycycline or tetracycline or clindamycin.

Use of mefloquine may be considered but this drug may rarely cause severe neuropsychiatric reactions.

The success of these alternative antimalarial drugs in treating acute drug-resistant malaria may not be reflected in treating HMS. [32]

The age to initiate chemoprophylaxis in endemic areas, which population to prophylax, and the duration of prophylaxis are unknown.

The response to therapy is guided by the size of spleen, a decrease in serum IgM levels, improvement of anemia, and general improvement in the patient's well-being.


Antimalarial Agents

Class Summary

Because epidemiologic and other data suggest that HMS is related to malarial infection, antimalarial drugs have been used and have been effective.

Chloroquine phosphate (Aralen Phosphate)

4-aminoquinolone widely used to treat malaria until recently, when resistant strains became major problems. Chloroquine and related drugs gametocidal (for species except for P falciparum) and schizonticidal (for parasites in blood but not tissue).

Well absorbed PO. Best taken with food to decrease GI distress.

Atovaquone/proguanil (Malarone)

Atovaquone selectively inhibits parasite mitochondrial electron transport. Proguanil metabolite cycloguanil disrupts deoxythymidylate synthesis by inhibiting dihydrofolate reductase in the malaria parasite.


Can have significant side effects, including night terrors. Used only for chloroquine resistance and as a last-line option.

Quinidine gluconate

For severe parasitemia and complicated malaria. Intensive care unit (ICU) admission and cardiac monitoring are required.

Pyrimethamine and sulfadoxine (Fansidar)

Combination product containing sulfadoxine 500 mg and 25 mg pyrimethamine. Mechanism of action for pyrimethamine same as that of proguanil (ie, inhibits dihydrofolate reductase). Pyrimethamine therapy, perhaps shortened, may rapidly decrease size of spleen.

Sulfonamides act in synergy with pyrimethamine; used together. Administer with folinic acid to decrease adverse effects. Employed primarily as a prophylactic medication for malaria and toxoplasmosis.