Clinical Profile of admitted
children with malarial fever: a retrospective study
Tarakeswara Rao P 1 ,
Prudhvi K 2
1Dr Pikala Tarakeswara Rao, Professor, 2Dr Prudhvi Krishna,
Postgraduate, both authors are affiliated with Department of
Pediatrics, Maharaja Institute of Medical Sciences, Vizianagram,
Andhrapradesh, India
Address for
correspondence: Dr Pikala Tarakeswara Rao, Email:
ptrao1971@gmail.com
Abstract
Introduction:
Malaria continues to be a major public health problem in developing
country like India. India contributes to 77% of the total malarial
cases in Southeast Asia. Objective: The present retrospective study was
conducted to find out the clinical profile in admitted pediatric
patients of malarial fever. Methods:
108 hospitalized laboratory diagnosed malarial pediatric cases admitted
to tertiary care hospital from 1st August 2013 to 30th Nov 2015 were
studied. Records of all the patients who were discharged with the
diagnosis of malaria were retrieved, compiled and analyzed. Results: Plasmodium
falciparum was commonest implicating agent found in 68(63%) of 108
children. Fever was the main presenting complains in all cases. Common
clinical manifestations noted were organomegaly (63.9%), pallor
(43.5%), altered sensorium (21.3%), convulsions (18.5%), clinical
icterus (10.2%) and circulatory collapse. Mortality occurred only in
children below 5 years with Plasmodium falciparum malaria. Conclusion:
Plasmodium falciparum infection is common infecting species. Multi
organ involvement and severe manifestations commonly observed in
falciparum infection. Simple febrile seizures and respiratory symptoms
are common with vivax infection. Isolated tender hepatomegaly observed
in 9.3% of patients. Mortality noted with plasmodium falciparum malaria
in children below 5yrs.
Key words:
Malaria, clinical profile, plasmodium falciparum
Manuscript received: 4th
August 2016, Reviewed:
14th August 2016
Author Corrected;
26th August 2016,
Accepted for Publication: 13th September 2016
Introduction
Malaria is common parasitic infection causing high mortality and
morbidity in children. Globally 69% of total malarial deaths are in
children below 5yrs of age in 2015[1]. Mortality due to malaria in
India is reported to be around 20.6% in pediatric age group. 60-65% of
malaria in india is due to plasmodium falciparum and 35% are due to
plasmodium vivax. It is caused by four different species of plasmodium.
Severity of clinical manifestations varies with species causing the
infection and age of the host. Traditionally severe clinical
manifestations are usually reported with plasmodium falciparum. Few
recent studies also reported severe manifestations with vivax malaria
in children [2]. There is paucity of data of severe manifestations due
to vivax in children. Most of the data on profile of severe malaria in
children are reported from Africa and few from India [2,3]. The
clinical features of malaria in children in endemic areas are
nonspecific and vary significantly. The aim of our study was to find
out the spectrum of clinical manifestations, infecting species, age
distribution and mortality in admitted patients of malaria in our set
up.
Material
and Methods
The present retrospective observational study was conducted at
Pediatric Department of tertiary care hospital of vizianagram. Case
records of confirmed malaria patients admitted from 1st August 2013 to
30th November 2015 were retrieved from Medical Record Department and
data was collected in a printed preformed proforma. Permission from
institutional research and ethical committee was taken before
commencement of the study.
The diagnosis and confirmation of species of P. falciparum and P. vivax
malaria were obtained from the case sheets Diagnosis was done by thick
and thin film of peripheral blood smear examination under oil immersion
with Giemsa stain and Rapid diagnostic test.
The inclusion and exclusion criteria for the study were as follow:
Inclusion Criteria
• Children in age group of below 14 years.
• Peripheral smear or rapid malaria antigen
test (RMAT) positive for Plasmodium vivax and plasmodium falciparum
malaria.
Exclusion Criteria
• Patient presenting with fever (Malarial parasite
negative on peripheral smear and/or RMAT negative) but treated
empirically like malaria.
A total of 108 hospitalized children below 14 yrs of age with positive
peripheral smear or RMAT positive fulfilled the inclusion and exclusion
criteria and were included in the study.
Results
Out of 108 children admitted with malaria 73(67.6%) were males and
35(32.4%) were female with male to female ratio 1:2 (Table 1). Majority
of children in the present study are under 5 years of age. 47.2%, 29.6%
and 23.1% of children are infected with malaria in <5yrs,
5-10yrs and 10-14 yrs age groups respectively. The age of patients
ranged from eight months to fourteen years with mean age of 4.5 years.
In the present study P. falciparum was the main infecting species in
all age groups (Table 2). Maximum malaria cases were due to Pf (63%);
Pv was documented in 17.6% and mixed infection in 19.4% cases. Fever
was the presenting complaint present in all the cases. Mean duration
between appearance of the fever and admission was 6 days. Organomegaly
was commonest clinical sign present in 63.9% of patients. Isolated
splenomegaly and hepatomegaly was seen in 28.7% and 9.3% of children.
Hepatosplenomegaly was observed in 25.9% of cases. Pallor was second
common clinical sign noted in 43.5% of children. Pallor was observed in
thirty five cases of plasmodium falciparum malaria. Respiratory
symptoms were seen more in Pv group while hemoglobinuria was common in
Pf group (Table 3). Other clinical features noted were: impaired
consciousness (21.3%), convulsions (18.5%), icterus (10.2%), pain
abdomen, cola colored urine(8.3%), .Of the 23 children with impaired
consciousness, nineteen had multiple convulsions. Eleven children had
hypotensive shock requiring ionotropic support. Out of 108 patients six
patients died and two patients left against medical advice.
Table-1: Gender
distribution of cases
Plasmodium
species
|
Female
|
Male
|
TOTAL
(Percentage)
|
|
Plasmodium
falcifarum
|
19
|
49
|
68 (63%)
|
|
Plasmodium
vivax
|
8
|
11
|
19 (17.6%)
|
|
mixed
|
9
|
12
|
21 (19.4%)
|
|
Total
|
35 (32.4%)
|
73 (67.6%)
|
108
|
Table-2: Age distribution
of malarial cases
Age
group
|
Pf
|
Pv
|
Mixed
|
Total
|
|
<5yrs
|
32 (29.6%)
|
12 (11.1%)
|
7 (6.5%)
|
51 (47.2%)
|
|
5-10yrs
|
23 (21.3%)
|
5 (4.6%)
|
4 (3.7%)
|
32 (29.6%)
|
|
>10yrs
|
13 (12%)
|
2 (1.9%)
|
10 (9.3%)
|
25 (23.1%)
|
Table-3: Clinical
features of admitted malarial patients
|
Clinical features
|
N=108
|
Pf
|
Pv
|
Pv/Pf
|
%
|
|
Fever
|
108
|
68
|
19
|
21
|
100%
|
|
Pallor
|
47
|
40
|
02
|
5
|
43.5%
|
|
Splenomegaly
|
31
|
22
|
05
|
4
|
28.7%
|
|
Hepatomegaly
|
10
|
09
|
0
|
01
|
9.26%
|
|
Hepato Splenomegaly
|
28
|
24
|
01
|
3
|
25.9%
|
|
Icterus
|
11
|
06
|
0
|
05
|
10.2%
|
|
ALOC
|
23
|
16
|
02
|
05
|
21.3%
|
|
Convulsions
|
20
|
11
|
04
|
05
|
18.5%
|
|
shock
|
11
|
07
|
0
|
04
|
10.2%
|
|
Cola urine
|
09
|
07
|
0
|
02
|
8.3%
|
|
Resp.Symptoms
|
15
|
04
|
09
|
02
|
13.9%
|
|
Death
|
06
|
06
|
0
|
0
|
5.5%
|
Discussion
Malaria continues to be common cause of morbidity and mortality in
children. Globally 60% of clinical malarial cases and 80% of deaths
occur in young children [4]. In the present study majority of children
are under the age of 5 years (47.2%). Clinical manifestations of
malaria may be severe in infants and young children due to lack of
partial immunity resulting due repeated malarial infections.
Boys were more affected than females in the present study with only
32.4% of females being affected. Kumari M et al. found similar results
in their study with 34.0% girls were affected with malaria [5].
Plasmodium falcifarum is the most frequent implicating species
accounting for 64% of cases. P vivax and mixed infections accounted for
17.6% and 19.4% of cases respectively. Study by P verma et al in 179
children observed p falcifarum malaria in 57.8% of cases and p vivax
and mixed infection in 13.7% and 27.4% of children respectively [6]. In
the present study p falcifarum is common agent in all the age groups.
This is in contrast to studies which have found high prevalence of p
vivax [7]. In the present study p vivax is found in 17.6% of children.
Species infecting the children may vary even in the same country
because of different prevailing ecologic conditions resulting
in breeding of different vectors. Study of prevalence of malaria in
agency areas of Andhra Pradesh showed p falcifarum to be frequent
infecting agent in all seasons [8].
Fever was the presenting complaint found in all the admitted cases.
Mean duration of onset of fever and admission was 5 days. Similar
observation were made by studies done by Taksande et al[9] and, Kaushik
et al [2].
Pallor in malaria is due to combination of multiple factors. Rapid
destruction and removal of RBC by spleen and ineffective erythropoeisis
is mainly responsible. Pallor was observed in 40(58.8%) compared to
5(23.8%) of mixed infections. This correlated with finding of studies
in Thailand where they found that likelihood of developing pallor was
1.8 times less in mixed malaria as compared to falcifarum malaria [10].
Pallor was noted in 96% of falcifarum malaria cases by Gohiya et al. in
their study [11].
Organomegaly was noted in 63.9% of children. Enlargement of spleen
alone and along with enlargement of liver was seen in 46/68 (67.6%),
6/19(31.5%) and 7/21 (21.4%) cases of p falcifarum, p vivax and mixed
infections respectively. Enlargement of spleen is due vascular
congestion and endothetial proliferation. High spleen palpable rate
indicate high endemicity of malaria. Majority of the patients enrolled
in this study are drawn from high transmission areas of malaria.
Splenomegaly was recorded in 59% of P.vivax, 68.8% of
P.falciparum and 73.6% mixed P. infected patients in study of 502
malaria patients who are above 12yrs of age [12]. Hepatomegaly was
tender in majority of cases and seen in 35.2% of cases. In 102 children
below 12 yrs study splenomegaly was found in 97.16% of cases and
hepatomegaly in 51.7% of cases by Saira Merchant et al [13]. Similar
observation made by Gohiya P et al in 150 children of falcifarum
malaria in children [11].
High colored urine found in 8.3% of patients. These children had
history of intake of inadequate doses of quinine prescribed by local
practitioners. In our study colacolored urine was observed in
falcifarum and mixed infections. Haemoglobinuria can also occur in
patients with normal erythrocyte G6PD levels who receive quinine for
severe malaria [14]. Cola coloured urine improved on treatment for
malaria. All the children who exhibited cola colored urination had
clinical icterus. Icterus is found in 10.2% of children with falcifarum
and mixed infection. Intravascular haemolysis contributing to these
clinical observed features. Study done by Chaudhary et al observed
icterus in 49% of cases which is quite high compared to our study [15].
Altered level of sensorium was found in 21.3% of children of which
18.5% had convulsions. Febrile seizures noted in vivax malaria below
5yrs. Rapid rise and higher fever trends are seen in vivax malaria due
to lower fever threshold despite low parasitemia[16].
Respiratory symptoms (cough, distress) observed in 9/19(47.3%) of vivax
malaria. Sequestration of P vivax infested RBC and greater inflammatory
response to parasite leading to capillary alveolar dysfunction noted in
vivax malaria [17]. This might perhaps explain respiratory
manifestations observed in our study.
Death had occurred in 6 patients. All the patients were Plasmodium
falcifarum positive and expired within 72hrs of admission. All the
patients who expired had altered sensorium, severe anemia and shock.
Conclusion
P falcifarum malaria is still a major problem affecting the health of
children in this area. Severe manifestations are observed with mono
falcifarum malaria. Respiratory manifestations are more commonly
observed in vivax malaria whereas mixed infections are presenting with
less severe symptoms.
Funding:
Nil, Conflict of
interest: Nil
Permission from IRB:
Yes
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How to cite this article?
Tarakeswara Rao P, Prudhvi K. Clinical Profile of admitted children
with malarial fever: a retrospective study. Int J Pediatr
Res.2016;3(9):678-682.doi:10.17511/ijpr.2016.9.09.