severe malaria in children: clinical features and prognostic indicators

A.Das, Chiranjib Ghosh, Supriya

Choudhary*

Department of PediatricsGauhati Medical College

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•Malaria is a serious problem in north eastern states of India.•N E states contribute 8.5 -11% of total cases• 13 -15 % of national malarial mortality.•Assam reports the maximum.•Manifestations of severe malaria vary in different regions. Depends on endemicity.•A recent change noted in the spectrum of manifestations of severe malaria in south east region.

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The present study was undertaken to observe

Manifestations of severe malaria in children and features associated with adverse outcome.Difference in clinical manifestations in younger (upto 5 years)and older (above 5 years) children.Effect of malnutrition on ultimate prognosis.Incidence of hepatopathy & ARF in children and its outcome.

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Place of study: Department of Pediatrics, Gauhati medical college and hospital.

Study period: October 2005 to September 2006.

Inclusion criteria: Slide positive confirmed cases of severe malaria according to WHO 2000 definition.

Data collection: was done in a standard proforma.

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Clinical assesment was done according to WHO 2000 criteria for severe and complicated malaria.

Glassgow coma scale and Blantyre coma scale was used for assesment of state of consciousness.

DIAGNOSIS: done by study of thick and thin peripheral blood smear.

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INVESTIGATIONS:

Peripheral blood smear,hemoglobin,blood sugar level done in all cases. Blood urea,serum creatinine,TLC and estimation of parasite load ,Serum bilirubin (total &fraction),SGPT,prothrombin time,serum lactate done whenever possible. Markers of viral hepatitis, CSF analysis, urine analysis and chest X- ray done whenever necessary.

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Statistical analysis done using SPSS 11.1 programmeSample T- test used to calculate significance of difference of means.Z- test used to calculate significance of difference of proportions.Chi-Square test used to calculate association of variables.Multivariate analysis done to determine individual influence of various factors on outcome. 7

Age Distribution of malaria cases

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AGE GROUP

RECOVEREDN0 (%)

DIEDN0(%)

TOTALN0(%)

Upto 5 years

23(26.1)

10(11.4)

33(37.5)

Above 5 Years

38(43.2)

17(19.3)

55(62.5)

OUTCOME OF MALARIA CASES 9

Comparison of clinical features of severe malaria in two age groups

CLINICAL FEATURES

UPTO 5 YEARS

ABOVE 5 YEARS

Value of Z

COMMENT

VOMITING 20 (60.6)

19 (34.5)

2.38 Significant

DIARRHOEA 0 3 (5.5) 1.36 Insignificant

DYSPNOEA 10 (30.3)

9 (16.4) 1.53 Insignificant

H/O FITS 9 (27.3) 6 (10.9) 1.97 Significant

HYPOTENSION 2 (6) 1 (1.8) 1.06 Insignificant

JAUNDICE 8 (24.2) 18 (32.7)

0.84 Insignificant

TACHYPNOEA 21 (63.6)

14 (25.5)

3.54 Significant

DEEP BREATHING 11 (33.3)

9 (16.4) 0.793 Insignificant

DEHYDRATION 17 (51.5)

34 (61.8)

0.947 Insignificant

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Comparison of clinical features of severe malaria in two age groups(contd)

CLINICAL FEATURES UPTO 5 YEARS

ABOVE 5 YEARS

Value of Z

COMMENT

UNABLE TO DRINK 21(63.6)

36(65.5)

0.17 Insignificant

UNABLE TO SIT 32(96.9)

46(83.6)

1.91 Insignificant

UNABLE TO LOCALIZE PAIN

18(54.6)

33(60) 0.51 Insignificant

ABNORMAL POSTURE 7(21.2) 3(5.5) 2.25 Significant

ABSENT CORNEAL REFLEX

7(21.2) 1(1.8) 1.6 Insignificant

AGITATION 2(6) 4(7.3) 0.22 Insignificant

OLIGURIA 6(18.2) 10(18.2)

0 Insignificant

HEPATOMEGALY 30(90.9)

40(72.7)

2.04 Significant

SPLENOMEGALY 20(60.6)

24(43.6)

1.71 Insignificant

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Association of clinical features with outcome

(contd on next page)

FEATURES

RECOVERED

DIED

TOTAL

Chi- square value

p-value

COMMENT

Tachypnoea

+ 17 18 37 11.761

0.001 Significant _ 44 9 51

Severe respiratory distres

+ 5 15 20 23.902

0.000 Significant _ 56 12 68

Icterus + 12 14 26 9.311 0.005 Significant _ 49 13 62

Hepato-Megaly

+ 51 19 70 2.015 0.165 Significant _ 10 8 18

Spleno-megaly

+ 36 8 44 6.465 0.020 insignificant _ 25 9 44

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Association of clinical features with outcome (contd)

FEATURES

RECOVERED

DIED

TOTAL

Chi-square value

p- value

COMMENT

Malarial hepatopathy

+

7 11 18 9.852 0.003

Significant

_ 54 16

70

Severe anaemia

+ 35 6 41 9.295 0.003

Significant

_ 26 21 47

Hyperleucocytosis

+ 13 10

23 2.397 0.187

Insignificant

- 48 17

65

Cerebral malaria

+ 22 24

46 20.932

0.000

Significant

_ 39 3 42

Hyperparasitemia

+ 15 7 22 0.026 1.000

insignificant_ 12 5 17 13

Comparison of complications of severe malaria in two age groups

FEATURES TOTAL NO

% UPTO 5 YEARS

ABOVE 5 YEARS

Value of Z

COMMENT

Cerebral malaria

46 52.3

12(36.4)

36(65.5)

2.66 SIGNIFICANT

Severe anemia 40 45.5

19(57.6)

21(38.2)

1.77 Insignificant

Malarial hepatopathy

18 19.3

5(15.2) 13(21.8)

0.94 Insignificant

Hypoglycemia 7 7.9 4(12.1) 3(5.5) 1.11 Insignificant

Acute renal failure

5 5.7 2(6.1) 3(5.5) 0.12 Insignificant

Prostration 5

5.7 2(6.1) 3(5.5) 0.12 Insignificant

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MORTALITY IN DIFFERENT COMPLICATIONS OF SEVERE MORTALITY IN DIFFERENT COMPLICATIONS OF SEVERE MALARIAMALARIA15

Asociation of PEM with outcomep-value 0.001 (significant)

PEM RECOVERED

DIED TOTAL

No PEM 23 (74%)

8 (25%)

31

Grade 1 & 2 PEM

35 (70%)

15(30%)

50

Grade 3 & 4 PEM

3 (42%)

4(58%)

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Different laboratory parameters among outcome Different laboratory parameters among outcome groupsgroups

LAB PARAMETERS

OUTCOME MEAN

P-value

COMMENTS

Hemoglobin% Recovered 5.9 0.819 InsignificantDied 6.0

TLC(/mm3) Recovered 10575

0.208 Insignificant

Died 12452

BLOOD SUGAR (mg%)

Recovered 74.8 0.099 InsignificantDied 63.9

UREA(mg%) Recovered 45.2 0.000 Significant

Died 105-9

CREATININE (mg%) Recovered 0.93 0.000 Significant

Died 0.43

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Different laboratory parameters among outcome Different laboratory parameters among outcome groupsgroups

LAB PARAMETERS

OUTCOME

MEAN

P-value

COMMENTS

Bilirubin(mg%) Recovered 11.23 0.818 INSIGNIFICANTDied 12.35

SGPT(U/L) Recovered 43.84 0.000 SIGNIFICANT

Died 166.46

Parasite load(/mm3)

Recovered 107130

0.533 INSIGNIFICANT

Died 95433

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Relation between SGPT and bilirubin Relation between SGPT and bilirubin levels levels

in malarial hepatopathyin malarial hepatopathy

TOTAL BILIRUBIN

Serum SGPT levels (U/L)

MINIMUM

MAXIMUM MEAN

STANDARD DEVIATION

<10 mg%

22 298 115.4 90

>10 mg%

88 295 202.4 75

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Severe malaria common > 5 yearsCerebral malaria and severe anaemia - most common presentationsCerebral malaria more common > 5 yearsAcute renal failure and hepatopathy – fairly common complications.Cerebral malaria –the most common underlying cause of death.

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Respiratory distress occurred even in absence of pneumonia, cardiac failure and severe anemia.Metabolic acidosis as a cause needs further evaluationMalnutrition- a significant contributor to poor outcome.Hyperparasitaemia did not influence the outcome of severe malaria in children.

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