A forty year old white female was admitted to the hospital for high fever and chills three days after returning from a one month long stay in Uganda.

A native born U.S. citizen she had been regularly visiting Uganda for two to four week long stays as a Christian missionary for the last several years. Although on some prior visits she had taken antimalarial prophylaxis, on more recent visits, including this one, she had not taken prophylaxis in part because of the expense (Malarone). She did use a mosquito net at night and was unaware of any mosquito bites. She had no significant underlying medical illnesses.

She had become ill with fever, malaise, and abdominal cramping two days before departing Uganda and remained ill on her airplane flight back to the United States. In the three days prior to seeking care upon arrival in the U.S. she had had continued episodes of high fever with chills and had had nausea and vomiting.

At the time of her emergency room presentation laboratory evaluation included WBC 3.4 (L), Hgb 13.9, Plts 17 (L), AST 90 (H), Alt 118 (H), Bil 4.7 (H), Bicarb 26, Glu 111 (H), Creat 0.6, INR 1.1, PTT 30, fibrinogen 478, and D-Dimer >5250 (H). A blood smear for malaria was positive (see left) showing a high parasitemia (15%). CXR did not show significant abnormality.

She was begun on antimalarial therapy but within the first day of hospitalization became progressively obtunded. She was urgently transferred to a tertiary care facility for potential exchange transfusion and continued care.

Of the choices below what would be the most effective pharmaceutical therapy in this case of severe malaria?