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Year : 2016 | Volume : 4 | Issue : 1 | Page : 10 - 13  


Original Articles
A clinical study of falciparum malaria with special reference to its complications among malaria patients
  1. Divya Reddy1, K. N. Sudha Ramana2

1Consultant Physician, Titan Hospital (Unit of bristlecon Group of hospitals), Hayathnagar, Hyderabad

2Professor of Medicine and Dean, Malla Reddy Medical College for Women, Hyderabad

Corresponding Author:

Dr. K. N. Sudha Ramana

Email: sudharamanakn1951@gmail.com

 

Abstract:

 

Back ground: Malaria is the most common cause of hemolytic anemia and other causes of anemia include defective erythropoiesis and reticulocyte production. Other hematological complications include thrombocytopenia and platelet dysfunction. Coagulopathy abnormalities are also in severe malaria

Objectives: To study complications of falciparum malaria.

Material and methods: A total of 100 cases of laboratory confirmed and admitted cases of falciparum malaria during the study period of two years, who fulfilled inclusion and exclusion criteria were studied. Complete relevant history, thorough clinical examination was carried out to assess complications.

Results: The most common complication of falciparum malaria was renal and hepatic involvement. Among 31 patients with complications, 17 had single complication, 5 had two complications, 5 had three complications, and 4 patients had 4 complications. Elevated blood urea and creatinine was noted in 18 patients among 100 cases .Out of them 88.8 % had longer duration of hospital stay. Elevated bilirubin levels were seen in 18 patients.

Conclusion: Falciparum malaria is associated with other complications which include cerebral malaria, renal involvement, hepatopathy, respiratory manifestations, which may lead to increase in the mortality if not detected early and treated properly and adequately.

Key words: Falciparum malaria, complications, renal involvement

INTRODUCTION:

 

Malaria is the most common cause of hemolytic anemia and other causes of anemia include defective erythropoiesis and reticulocyte production. Other hematological complications include thrombocytopenia and platelet dysfunction. Coagulopathy abnormalities are also in severe malaria. 1

In the past, chloroquine was effective for treating nearly all cases of malaria. In recent studies, Chloroquine – resistant falciparum malaria has been observed with increasing frequency across the country. The continued treatment of such cases with chloroquine is probably one of the factors responsible for increased proportion of P. falciparum relative to P. vivax. There have been great advances in medical field and we have also been able to understand malaria better. There has been a lot of development in ant malarial drugs. Even with these advances we are not able to completely control or eradicate malaria. Still many deaths occur due to malaria. In the last few decades an effort has been made to produce an effective malaria vaccine. These are still at developmental stages. 2

In India steps were taken to control malaria such as: National Malaria Control programme in 1953. This was a huge success. So Government came out with National malaria eradication programme in 1958. Malaria re-emerged in 1960. Later government came with MPO in 19771. Even with all these efforts the mortality due to malaria in India is 22 per 1000 cases. 1

Among all the four species of the malaria parasite, plasmodium falciparum is known to cause complications which involve any system of the body especially the central nervous system.

 

MATERIAL AND METHODS

 

Institutional Ethics Committee permission was obtained. Informed consent was taken from all patients who were included in the study.

Study settings: Department of General Medicine, MNR Medical College and Hospital, Sangareddy

Sample size: A total of 100 cases of laboratory confirmed and admitted cases of falciparum malaria during the study period of two years, who fulfilled inclusion and exclusion criteria were studied.

Patients with chronic liver disease, fever due to any other cause including other plasmodium species, chronic kidney disease, mixed plasmodium infections, and any chronic neurological disorders were excluded from the study.

Complete relevant history, thorough clinical examination was carried out to assess complications.

A detailed history was taken followed by a detailed clinical examination to assess clinical severity and complications as per the clinical proforma attached.

Investigations: Renal function tests, Liver function testsRandom blood sugar, Complete urine examination

Once the patient was diagnosed to have malaria, they were started on Anti-Malarial drugs. Other supportive treatment was given according to the patient’s conditions and presence of complications.

During the hospital stay; patients were observed and followed up till the discharge for clinical profile, complications, haematological abnormalities.

Data was recorded in the Microsoft excel worksheet and analyzed using the percentages.

RESULTS

 

Table 1: Complications in falciparum malaria

Type of complication

Percentage

Cerebral malaria

7

Pulmonary edema

3

Bleeding manifestation

4

Hepatic involvement

18

Renal involvement

18

Hypoglycemia (< 70 mg/dl)

5

 

The most common complication of falciparum malaria was renal and hepatic involvement in 18% each of the patients followed by the dreaded complication i.e. cerebral malaria in 7% of patients. Only 3% had shown the involvement of lungs in the form of pulmonary edema. Hypoglycemia was noted in 5% of patients.

 

 

Table 2: distribution of complicated cases

Number of patients

Number of complications

17 patients

1

5 patients

2

5 patients

3

4 patients

4

 

Among 31 patients with complications, 17 had single complication, 5 had two complications, 5 had three complications, and 4 patients had 4 complications.

Average duration of hospital stay was 6-9 days for complicated cases whereas it was only 3-5 days for uncomplicated cases.

Cerebral malaria was seen in 7 cases out of 100. 3 of them presented with altered sensorium and 4 presented with seizures. Among 7 patients with cerebral malaria 3 had extensor plantar. All of them had longer duration of hospital stay.

Out of 4 patients who presented with bleeding manifestations 2 had microscopic hematuria and 2 had petechiae.

Table 3: Incidence of renal involvement in malaria its effect on hospital stay

Elevated blood urea and creatinine

Percentage

Number of cases with prolonged hospital stay

Present

18

16 (88%)

Absent

82

17 (20.7%)

 

Elevated blood urea and creatinine was noted in 18 patients among 100 cases .Out of them 88.8 % had longer duration of hospital stay.

Table 4: Incidence of hepatic involvement in malaria its effect on hospital stay

Elevated bilirubin

Percentage

Number of cases with prolonged hospital stay

Present

18

15 (83.3%)

Absent

82

18 (21.9%)

 

Elevated bilirubin levels were seen in 18 patients. Out of them 83.3 % had prolonged hospital stay.

 

 

Table 5: Complications of falciparum malaria and its effect on duration of hospital stay

Type of case

Number of patients

Number of cases with prolonged hospital stay

Cerebral malaria

7

7 (100%)

Pulmonary edema

3

3 (100%)

Hepatic involvement

18

16 (88.8%)

Renal involvement

18

15 (83.3%)

 

It was observed that all cases with cerebral malaria and pulmonary edema had prolonged duration of hospital stay. With hepatic and renal involvement, it was 88.8% and 83.3% respectively.

All cases had complete recovery. There was no mortality rate.

DISCUSSION

 

In the present study 69% of the patients had uncomplicated malaria and 31 % of the patients had complicated malaria, as stated above.

Cerebral malaria was seen in 7%, pulmonary edema was seen in 3%, bleeding manifestation was seen in 4%, Hepatopathy seen in 18%, renal involvement seen in 18, Hypoglycemia seen in 5%. Among 31 patients with complications, 17 had single complication, 5 had two complications, 5 had three complications, 4 patients had 4 complications .There was no mortality in the present study and all of them had complete recovery.

Preetam et al 3 in their study reported abnormal liver function tests in 35% subjects while abnormal kidney function tests were observed in 32.5% patients.

Srinivas et al 4: Cerebral malaria (48.6%), Anemia (45.9%), ARF (29.7%), ARDS (13.5).

  1. Bag et al 5: Cerebral malaria remains the single most important cause of high mortality in complicated falciparum malaria. Even though cerebral malaria remains the single most important cause of high mortality in complicated malaria, extra cerebral presentation is also equally life threatening.

Navy et al 6: Complications like cerebral malaria, pulmonary edema, renal failure, gastroenteritis are common in acute falciparum malaria.

Satapathy et al 7: Study done in severe falciparum malaria among 242 patients cerebral malaria was the most common complication seen.

Bone marrow was done in 3 patients; and it showed dimorphic picture with hyper cellular marrow and erythroid hyperplasia and was negative for malaria parasite. Wheatherall 8 et al 68% of the patients showed normocellular and 18% showed hyper cellular bone marrow. These results are not comparable to our study as bone marrow aspiration was done in only few cases in our study. In the present study; PT was elevated in 24 % of the total cases. In a study conducted by S. Roy et al 9 PT was increased in 11.6% of cases. In a study of severe falciparum malaria cases by R. Clemens et al 10 PT was prolonged in 22.7% of the cases this was similar to the observations in our study. Out of 24 patients with elevated PT 3 had bleeding manifestations and 12 patients (50%) had longer duration of hospital stay. In our study APTT was found to be increased in 6 % of the patients.

In a study conducted by S. Roy et al 9 APTT was increased in 6 % of the patients this was similar to what we observed in our study. And 4 patients with increased APTT had bleeding manifestations. 3 (50%) patients had prolonged hospital stay.

Pukrittayakamee et al 11: Conventional indices of coagulation (prothrombin time, partial thromboplastin time, fibrinogen, fibrin degradation products) were usually within the normal range but reduced plasma concentrations of antithrombin III (AT-III) levels were noted in all groups, and the incidence was significantly higher in patients with severe and moderate malaria. Activation of coagulation is a common and sensitive measure of disease activity in falciparum malaria. It is not a specific feature, nor is there evidence to suggest it has a primary pathological role in severe infections.

 

CONCLUSION:

Severe anemia and other hematological abnormalities are the poor prognostic factors and are also responsible for longer hospital stay as compared to patients with uncomplicated malaria .Falciparum malaria is associated with other complications which include cerebral malaria, renal involvement, hepatopathy, respiratory manifestations, which may lead to increase in the mortality if not detected early and treated properly and adequately.

 

REFERENCES:

 

  1. of India “Annual Report” Ministry of Health and Family welfare; New Delhi.
  2. Nadjm B, Behrens RH (2012). "Malaria: An update for physicians". Infectious Disease Clinics of North America 26 (2): 243–59.
  3. Preetam et al.Study of Clinical Profile of malaria in Tertiary Referral Centre in Central India; JAPI oct 2001
  4. Srinivas SV et al ; Clinical profile of falciparum malaria with special reference to complications and outcome; APRIL 2010 RGUHS.
  5. Bag et al study: Indian journal of pediatrics: 1994: study of complicated falciparum malaria.
  6. Naval Hospital: navy Medical Department; Guide to Malaria prevention and Control 2001; chapter 3.
  7. Satapathy et al study: Indian journal of pediatrics 2004.
  8. Wheatherall; Importance of anaemia in cerebral and uncomplicated malaria; role of complications dyserythropoiesis and; Quarterly Journal of Medicine 1986; 58; 305 – 323.
  9. Roy; Hematological profile in Patients with acute falciparum malaria; JAPI 2002 Poster Presentation No. 114.
  10. R Clemons, C Pnamoolsinsap, R Lorinz, S pokrittayakanee, H.L.Bock et al ; Activation of coagulation cascade in severe falciparum malaria through the intrinsic pathway. Br. Jasna of Hemotol vol.87; 100-105.
  11. Activation of the coagulation cascade in falciparum Malaria S. Pukrittayakamee ; Transactions of the Royal Society of Tropical Medicine and Hygiene 1989;83(6).






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