Adrenal Insufficiency in Severe Falciparum Malaria: Its Outcome and Prediction by Discriminant Score

Introduction: Severe falciparum malaria (SFM) is acomplex syndrome which affect different organs of the bodywith variable severity. But adrenal insufficiency (AI) isa less described entity in SFM. The present study aimed atdescribing AI, its prediction with Discriminant Score (DS),effect of replacement of hydrocortisone in such cases.Material and Methods: This study was conducted in twosteps among two cohort of patients. In Step-1, AI has beendetected by cortisol assay among 142 consecutive cases ofSFM. Taking different clinical and biochemical variables,Discriminant Function Analysis was performed to find out aDS to predict AI. In Step-2 study DS has been validated in 74new cases of SFM. Patients with AI have been replaced withInj. hydrocortisone and compared with the patients withouthydrocortisone of Step-1 study.Results: Out of 142 cases of SFM, 50 (35.2%) patients had AIas defined by cortisol level <10ug/dl. DS of >0.35 could ableto discriminate AI with sensitivity, specificity, and predictivevalue of 92.5%, 91.6%, and 85.7% respectively. The mostcommon presentations are hypotension, hypoglycemia, andhyponatremia. After replacement of steroid the mortality waslow (7.4%) compared to without replacement (18.0%).Conclusion: The present study showed that AI is common inSFM and replacement of hydrocortisone is necessary in thosepatients for reduction of mortality. DS can be used to predictAI and patients with score >0.35 may be administered withlow dose steroid.

Predictive score of uncomplicated falciparum malaria patients turning to severe malaria

In acute uncomplicated falciparum malaria, there is a continuum from mild to severe malaria. However, no mathematical system is available to predict uncomplicated falciparum malaria patients turning to severe malaria. This study aimed to devise a simple and reliable model of Malaria Severity Prognostic Score (MSPS). The study was performed in adult patients with acute uncomplicated falciparum malaria admitted to the Bangkok Hospital for Tropical Diseases between 2000 and 2005. Total 38 initial clinical parameters were identified to predict the usual recovery or deterioration to severe malaria. The stepwise multiple discriminant analysis was performed to get a linear discriminant equation. The results showed that 4.3% of study patients turned to severe malaria. The MSPS = 4.38 (schizontemia) + 1.62 (gametocytemia) + 1.17 (dehydration) + 0.14 (overweight by body mass index; BMI) + 0.05 (initial pulse rate) + 0.04 (duration of fever before admission) - 0.50 (past history of malaria in last 1 year) - 0.48 (initial serum albumin) - 5.66. Based on the validation study in other malaria patients, the sensitivity and specificity were 88.8% and 88.4%, respectively. We conclude that the MSPS is a simple screening tool for predicting uncomplicated falciparum malaria patients turning to severe malaria. However, the MSPS may need revalidation in different geographical areas before utilized at specific places.

Is the Widal Test Still Useful? / 대한임상병리학회지

BACKGROUND: Widal test has been one of the most important diagnostic tests for typhoid and is still widely used. Widal test has been useful diagnostic tool for typhoid in endemic areas, while it has been largely abandoned in developed countries. Since 1990, occurrance of typhoid has been markedly decreased in Korea, we studied diagnostic usefulness and criteria of Widal test from 1990 to 1997. METHODS: Using rapid slide titration method (Stained Salmonella suspensions, Murex Biotech Ltd., Dartford, England), the Widal test was done in 116 nontyphoid salmonellosis patients, 75 patients with proven typhoid fever, and 173 cases of clinically suspected typhoid fever patients. Stastical analysis was done with discriminant analysis in culture proven salmonellosis. RESULTS: Fifty-four culture proven cases of Salmonella paratyphi (S. paratyphi) A and S. paratyphi B showed no significant cutoff value in O antibodies. Salmonella typhi (S. typhi) O titer at the 1:160 and above showed lower sensitivity (37.3% vs. 69.3%) and specificity (91.4% vs. 93.1%) compared to S. typhi H titer at the 1:320 and above in diagnosis of culture proven cases of typhoid. We applied D (0.01xH titer+0.001xO titer-1.635) score which result from discriminant analysis. Positive D score (> or =0.21) showed sensitivity of 72% and specificity of 92.2% in culture proven cases of typhoid. In clinically suspected patients, positive D score showed 39.3% of sensitivity. CONCLUSIONS: We concluded that the Widal test for O antibodies of S. paratyphi A and S. paratyphi B is not useful for diagnosis of paratyphoid fever. In the present study S. typhi H antibodies are more diagnostic than S. typhi O antibodies. We appled D score and positive D score showed increased sensitivity of Widal test than application of O antibody titer.