SEVERE MALARIA IN CHILDREN: CLINICAL FEATURES AND PROGNOSTIC INDICATORS

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SEVERE MALARIA IN CHILDREN CLINICAL FEATURES
AND PROGNOSTIC INDICATORS

• A.Das, Chiranjib Ghosh, Supriya Choudhary
• Department of Pediatrics
• Gauhati Medical College

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INTRODUCTION

• 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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AIMS AND OBJECTIVES

• 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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MATERIALS AND METHODS

• 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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MATERIALS AND METHODS(contd)

• 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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MATERIALS AND METHODS (contd)

• Statistical analysis done using SPSS 11.1
  programme
• Sample 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.

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RESULTS AND OBSERVATIONS

Age Distribution of malaria cases
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RESULTS AND OBSERVATIONS(contd)

AGE GROUP RECOVERED N0 () DIED N0() TOTAL N0()
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
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RESULTS AND OBSERVATIONS(contd)
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

• Comparison of clinical features of severe malaria
  in
• two age groups

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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

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

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FEATURES FEATURES RECOVERED DIED TOTAL Chi- square value p-value COMMENT
Tachypnoea 17 18 37 11.761 0.001 Significant
Tachypnoea _ 44 9 51 11.761 0.001 Significant
Severe respiratory distres 5 15 20 23.902 0.000 Significant
Severe respiratory distres _ 56 12 68 23.902 0.000 Significant
Icterus 12 14 26 9.311 0.005 Significant
Icterus _ 49 13 62 9.311 0.005 Significant
Hepato- Megaly 51 19 70 2.015 0.165 Significant
Hepato- Megaly _ 10 8 18 2.015 0.165 Significant
Spleno- megaly 36 8 44 6.465 0.020 insignificant
Spleno- megaly _ 25 9 44 6.465 0.020 insignificant

• Association of clinical features with outcome
• (contd on next page)

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FEATURES FEATURES RECOVERED DIED TOTAL Chi-square value p- value COMMENT
Malarial hepatopathy 7 11 18 9.852 0.003 Significant
Malarial hepatopathy _ 54 16 70 9.852 0.003 Significant
Severe anaemia 35 6 41 9.295 0.003 Significant
Severe anaemia _ 26 21 47 9.295 0.003 Significant
Hyperleucocytosis 13 10 23 2.397 0.187 Insignificant
Hyperleucocytosis - 48 17 65 2.397 0.187 Insignificant
Cerebral malaria 22 24 46 20.932 0.000 Significant
Cerebral malaria _ 39 3 42 20.932 0.000 Significant
Hyperparasitemia 15 7 22 0.026 1.000 insignificant
Hyperparasitemia _ 12 5 17 0.026 1.000 insignificant
Association of clinical features with outcome
(contd)
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RESULTS AND OBSERVATIONS(contd)
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

• Comparison of complications of severe malaria in
  two age groups

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RESULTS AND OBSERVATIONS(contd)

• MORTALITY IN DIFFERENT COMPLICATIONS OF SEVERE
  MALARIA

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RESULTS AND OBSERVATIONS(contd)
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) 7

• Asociation of PEM with outcome
• p-value 0.001 (significant)

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RESULTS AND OBSERVATIONS(contd)
LAB PARAMETERS OUTCOME MEAN P-value COMMENTS
Hemoglobin Recovered 5.9 0.819 Insignificant
Hemoglobin Died 6.0 0.819 Insignificant
TLC(/mm3) Recovered 10575 0.208 Insignificant
TLC(/mm3) Died 12452 0.208 Insignificant
BLOOD SUGAR (mg) Recovered 74.8 0.099 Insignificant
BLOOD SUGAR (mg) Died 63.9 0.099 Insignificant
UREA(mg) Recovered 45.2 0.000 Significant
UREA(mg) Died 105-9 0.000 Significant
CREATININE (mg) Recovered 0.93 0.000 Significant
CREATININE (mg) Died 0.43 0.000 Significant

• Different laboratory parameters among outcome
  groups

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LAB PARAMETERS OUTCOME MEAN P-value COMMENTS
Bilirubin(mg) Recovered 11.23 0.818 INSIGNIFICANT
Bilirubin(mg) Died 12.35 0.818 INSIGNIFICANT
SGPT(U/L) Recovered 43.84 0.000 SIGNIFICANT
SGPT(U/L) Died 166.46 0.000 SIGNIFICANT
Parasite load(/mm3) Recovered 107130 0.533 INSIGNIFICANT
Parasite load(/mm3) Died 95433 0.533 INSIGNIFICANT

• Different laboratory parameters among outcome
  groups

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TOTAL BILIRUBIN Serum SGPT levels (U/L) Serum SGPT levels (U/L) Serum SGPT levels (U/L) Serum SGPT levels (U/L)
TOTAL BILIRUBIN MINIMUM MAXIMUM MEAN STANDARD DEVIATION
lt10 mg 22 298 115.4 90
gt10 mg 88 295 202.4 75

• Relation between SGPT and bilirubin levels
• in malarial hepatopathy

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CONCLUSION

• Severe malaria common gt 5 years
• Cerebral malaria and severe anaemia - most common
  presentations
• Cerebral malaria more common gt 5 years
• Acute 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
  evaluation
• Malnutrition- a significant contributor to poor
  outcome.
• Hyperparasitaemia did not influence the outcome
  of severe malaria in children.

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