RESUMO
INTRODUCTION: Severe malaria remains a major cause of death and morbidity among adults in the Asiatic tropics. This study was planned to evaluate clinical profile and prognostic indicators of severe malaria in adults so as to improve insight into this highly prevalent disease. MATERIALS AND METHODS: This prospective observational study was conducted on 60 confirmed cases of malaria. Cases were divided into two groups: (a) study group: suffering from severe malaria and (b) control group: no severe manifestations. All cases were thoroughly studied for clinical features, laboratory evaluation, and outcome. Prognostic evaluation was also done by different score systems. RESULTS: In all, 40 cases suffer from severe malaria (study group), while 20 cases belong to the control group. The majority of our cases were males of age 21-40 years. The most common species of malaria in the study group was vivax (52.5%), followed by falciparum (25%) and mixed malaria species (22.5%). The clinical predictors for severe malaria were rural habitat, longer duration of fever, marked chills, tiredness, giddiness, nausea, vomiting, decreased urine output, jaundice, and altered sensorium. Extreme weakness (80%), jaundice (55%), renal failure (50%), and severe anemia (27.5%) were the most common presenting features in severe malaria. Two patients died of severe mixed malaria. The mortality rate was significantly associated with lower hemoglobin level (P = 0.002); higher total leukocyte count (P = 0.006), blood urea (P < 0.001), serum creatinine (P < 0.001), SGOT (P = 0.001), SGPT (P < 0.007), serum bilirubin (P = 0.003), and parasite density (P = 0.033); lower platelet count (P = 0.043); and those who had more APACHE II score (P = 0.003), SOFA score (P = 0.04), and Multiple Organ Dysfunction Score (P < 0.001) and lower Glasgow Coma Scale (P < 0.001). CONCLUSIONS: Manifestations of severe malaria is becoming increasingly more prevalent specifically in vivax and mixed malaria cases. Our study proposes that there are certain clinical predictors and prognostic indicators that should be kept in mind for better management of severe malaria.
RESUMO
BACKGROUND & OBJECTIVES: Recently, vivax malaria is also presenting as severe malaria causing multiorgan dysfunction similar to falciparum malaria. The present study was undertaken to evaluate the involvement of cardiovascular system in severe malaria. METHODS: This is a clinical prospective study conducted on the cases of severe malaria in S.P. Medical College and PBM Hospital, Bikaner, India. In total, 100 cases (45 males, 55 females; age range 13-75 yr) of severe malaria (P. vivax 60; P. falciparum 28; and mixed 12) diagnosed by peripheral blood smear examination, rapid card test and PCR were studied. Evaluation of cardiovascular system was done by clinical examination, chest Xray, ECG, high resolution transthoracic echocardiography and estimation of cardiac markers. RESULTS: In all, 17% cases (9 P. falciparum, 5 P. vivax and 3 mixed) were found to be suffering from cardiovascular involvement (11% circulatory failure, 7% congestive cardiac failure and 2% pulmonary edema). ECG showed sinus tachycardia in all the 17 patients, one had atrial ectopic and eight had non-specific ST-T changes. Cardiomegaly was seen in eight cases and pulmonary edema in two on X-ray chest. Echocardiography was within normal range but cardiac dimensions were increased in all the 17 cases. Troponin-I and CPK-MB were increased in 14 cases. Cardiovascular involvement in P. falciparum and mixed infection was associated with high parasite density but P. vivax infection was associated with relatively low parasite density. Involvement of cardiovascular system was associated with increased hospital stay (7.67 ± 2.23 vs 6.59 ± 0.87 days; p <0.001) and high mortality (5 died out of 17 patients). Significant ECG changes and cardiac markers indicate myocardial involvement in severe malaria. INTERPRETATION & CONCLUSION: The present study indicates involvement of cardiovascular system in severe malaria as evidenced by changes in ECG and cardiac markers (Trop 1 and CPK-MB). The present study also highlights that vivax malaria is no more benign and pathophysiology of vivax malaria should be re-evaluated.
