Clinical presentation & survival outcome of severe malaria among hospitalized children- a single centre observational study

Introduction: Malaria is characterized by paroxysms of fever, chills, sweats, fatigue, anaemia& splenomegaly. Fatality rates around 10-30 % have been reported among children mainly due to cerebral malaria &anaemia followed by respiratory infections, diarrheal disease & malnutrition. Methodology: This study was done in Department of pediatrics, S.C.B medical college & S.V.P. P.G.I.P., Cuttack, from October 2013 to September 2015 with Objectives to study the clinical presentation & survival outcome of severe malaria in children of age group 1 to 14 yrs. A detailed history of illness, clinical examination, investigations, treatment & responses to therapy of each case were noted in standard proforma. Results: A total of 134 children with severe malaria were studied. Maximum number of cases were seen in age group of 1-5 years (40.29%) followed by age group of 5-10 years (33.58%). Male: Female ratio was 1.6:1.Fever was present in 100% of cases, altered sensorium in 50%, convulsion in 49% & jaundice in 35.82%. Most of the cases were due to p. Falciparum (80.59%). Out of 41cases of severe anemia, 22(53.65%) survived. Out of 8 cases with respiratory distress, 1(0.74%) survived. Out of 67 cases with CNS involvement, 45(67.16%) survived. Out of 25 cases with Hepatopathy, 25(18.65%) survived. Out of 47 cases of single organ involvement 45 cases survived & 2 cases died. Out of 60 cases of multiple organ involvement 36 cases survived. Conclusion: Awareness about the changing spectrum of severe malaria is of great importance to every level for healthcare provider.


Introduction
Malaria is characterized by paroxysms of fever, chills, sweats, fatigue, anaemia & splenomegaly [1]. Malaria is almost as old as human race & has been described since 5th century B.C. by Hippocrates. Even Charak & Susruta of ayurvedic period gave vivid description of its association with mosquito bite [2]. It is caused by intracellular plasmodium protozoa transmitted to humans by female anopheles mosquito. Malaria is characterized by paroxysms of fever, chills, sweats, fatigue, anaemia& splenomegaly. Malaria is of overwhelming importance in the developing world today, with an estimated 300-500 million cases & more than 1 million deaths each year [3]. Approximately half of global population is at risk of malaria. Fatality rates around 10-30 % have been reported among children referred to hospital with severe malaria mainly due to cerebral malaria &anaemia followed by respiratory infections, diarrheal disease & malnutrition [6]. Severe falciparum malaria is defined as acute malaria with signs of severity/ occurrence of vital organ dysfunction.
In addition to "traditional" sepsis, severe falciparum malaria is an important etiology of MODS. While uncomplicated falciparum malaria causes a mortality of about 0.1%, once vital organs dysfunction occurs mortality risk rises steeply [7].
There is a paucity of studies on the different clinical presentations & organ involvements in severe malaria among children. Hence this study was made to analyse the varied clinical presentations of severe malaria among children &its outcome.

Aims & Objectives
To study the clinical presentation & survival outcome of severe malaria in children of age group 1 to 14 yrs.

Materials and Methods
This study was done in the Department of paediatrics, S.C.B medical college &S.V.P. P.G.I.P., Cuttack, a tertiary care referral hospital from October 2013 to September 2015. It's a direct observation prospective study.
Inclusion criteria: All children between 1-14 years of age admitted to Paediatrics indoor of S.C.B.M.C. and S.V.P.P.G.I.P., Cuttack during the study period with a primary diagnosis of malaria who satisfy any 1 of WHO Criteria for severe malaria were included [8].
Exclusion criteria: Children with suspected malaria treated as severe malaria but laboratory studies were suggestive of malaria negative & those children with similar presentation diagnosed to be due to other aetiopathological cause were excluded from the study.
In our study 134 number of cases fulfilling the inclusion criteria were taken in to study.

Methodology
A detailed history of illness, clinical examination, investigations, treatment & responses to therapy of each case were noted in standard proforma. Necessary Investigations done to reach the final diagnosis. The data were noted in tabulate form & results were interpreted by using statistical analysis.
Blood smear preparation: Third or fourth finger of left hand is pricked at distal part of palmar aspect under all aseptic conditions (area to be pricked is wiped with alcohol& allowed to dry).
Microscopic examination of blood film: Thin blood films-At least 100 fields to be examined for 10 min before discarding as MP negative. Thick blood film-It concentrates 20-30 layers of red cells on a small surface, & detects parasitemia as low as 20 parasites/ml.

Results
A total of 134 children with severe malaria were studied, result of which are tabulated as below.   Mean S. Creatinine level was 1.44 mg%. Serum Bilirubin of< 3 mg/dl was found in 68.65%, 3-5 mg/dl was found in 10.44%, between 5-10 mg/dl was found in 8.95% &>15mg/dl in 3.73% patients. Mean bilirubin level was 3.38mg/dl. CRP was raised in 86.56% of patients.  Most of the cases were due to p. falciparum which accounts for 80.59%, followed by mixed infection (P.f + P.v) accounting for 17.91% cases and the least by P. vivax around 1.49% of cases. The table shows significant association of anaemia, involvement of respiratory system , CNS , hepatic, renal , multiorgan system, including Shock on survival.

Discussion
In our study majority were between1-5 years (40.29%) & between 5-10 years (33.58%) which was similar to other studies [9,10]. We observed that males outnumbered females in all age groups. There were a total of 83 males (61.94%) & 51 females (38.05%) with the male: female ratio of 1.62:1 which was similar to other studies [10,11,12,13,14,15]. The sex difference may be explained due to medical care seeking behaviour in different socioeconomic status ethnic groups, attitude of parents especially mothers towards male children, more outdoor activity of males & better clothing of females in India.
Presence of raised serum bilirubin not only indicates hemolysis but also liver dysfunction. Prostration, defined as the inability to sit unsupported (for children over 6 months of age) or the inability to drink or breast--feed in younger children was found in 20.89% of the cases as against around 40% in other studies [13,21].
Shock as described as SBP< 70 mm Hg or need of Isotonic IV Fluid bolus ≥ 40ml/kg in 1hr need for vasoactive drug to maintain BP in normal range (dopamine > 5µg/kg/min or dobutamine, epinephrine, or norepinephrine at any dose was found in 17.1%) as against 10% in other studies [14,22]. Pallor was found in 84.32% cases similar to other study [14].
Out of 25.37% cases of severe anemia 14.17% died whereas11.19% cases survived. Severe anemia was a major predictor of fatal outcome with a significant p value <0.05 which matches other studies [17,22,26].We observed that out of 5.97% with respiratory distress only 1survived while 7 did not.
Respiratory distress was another key presenting feature of childhood malaria with a very high mortality rate (66.7%) which was similar to other studies [ 1718, 27,28 ]. Among 50% patients of CNS involvement 16.41% died whereas 33.58% cases survived which matched other studies [10,19].Out of 107 patients with organ dysfunction 59.70% survived whereas 20.17% did not.
All 27 patients (20.14%) without any organ dysfunction survived. Multi organ involvement was associated with higher morbidity& mortality which was similar to other studies [19,28].

Conclusion
Awareness about the changing spectrum of severe malaria is of great importance to every level healthcare provider. Today, in India with any level of transmission the possibility of falciparum malaria should always be suspected in a patient presenting with fever along with jaundice or renal failure. P. vivax is emerging as an important cause of malarial morbidity &mortality. Besides shock, cerebral malaria & severe anemia which have been implicated even in the past as predictors of complications in severe malaria, hepatic involvement& renal failure also have emerged with significant impact over the course of the disease.