severe malaria in children: clinical features and prognostic indicators
DESCRIPTION
SEVERE MALARIA IN CHILDREN: CLINICAL FEATURES AND PROGNOSTIC INDICATORS. A.Das, Chiranjib Ghosh, Supriya Choudhary* Department of Pediatrics Gauhati Medical College. INTRODUCTION. Malaria is a serious problem in north eastern states of India. N E states contribute 8.5 -11% of total cases - PowerPoint PPT PresentationTRANSCRIPT
A.Das, Chiranjib Ghosh, Supriya
Choudhary*
Department of PediatricsGauhati Medical College
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•Malaria is a serious problem in north eastern states of India.•N E states contribute 8.5 -11% of total cases• 13 -15 % of national malarial mortality.•Assam reports the maximum.•Manifestations of severe malaria vary in different regions. Depends on endemicity.•A recent change noted in the spectrum of manifestations of severe malaria in south east region.
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The present study was undertaken to observe
Manifestations of severe malaria in children and features associated with adverse outcome.Difference in clinical manifestations in younger (upto 5 years)and older (above 5 years) children.Effect of malnutrition on ultimate prognosis.Incidence of hepatopathy & ARF in children and its outcome.
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Place of study: Department of Pediatrics, Gauhati medical college and hospital.
Study period: October 2005 to September 2006.
Inclusion criteria: Slide positive confirmed cases of severe malaria according to WHO 2000 definition.
Data collection: was done in a standard proforma.
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Clinical assesment was done according to WHO 2000 criteria for severe and complicated malaria.
Glassgow coma scale and Blantyre coma scale was used for assesment of state of consciousness.
DIAGNOSIS: done by study of thick and thin peripheral blood smear.
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INVESTIGATIONS:
Peripheral blood smear,hemoglobin,blood sugar level done in all cases. Blood urea,serum creatinine,TLC and estimation of parasite load ,Serum bilirubin (total &fraction),SGPT,prothrombin time,serum lactate done whenever possible. Markers of viral hepatitis, CSF analysis, urine analysis and chest X- ray done whenever necessary.
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Statistical analysis done using SPSS 11.1 programmeSample T- test used to calculate significance of difference of means.Z- test used to calculate significance of difference of proportions.Chi-Square test used to calculate association of variables.Multivariate analysis done to determine individual influence of various factors on outcome. 7
Age Distribution of malaria cases
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AGE GROUP
RECOVEREDN0 (%)
DIEDN0(%)
TOTALN0(%)
Upto 5 years
23(26.1)
10(11.4)
33(37.5)
Above 5 Years
38(43.2)
17(19.3)
55(62.5)
OUTCOME OF MALARIA CASES 9
Comparison of clinical features of severe malaria in two age groups
CLINICAL FEATURES
UPTO 5 YEARS
ABOVE 5 YEARS
Value of Z
COMMENT
VOMITING 20 (60.6)
19 (34.5)
2.38 Significant
DIARRHOEA 0 3 (5.5) 1.36 Insignificant
DYSPNOEA 10 (30.3)
9 (16.4) 1.53 Insignificant
H/O FITS 9 (27.3) 6 (10.9) 1.97 Significant
HYPOTENSION 2 (6) 1 (1.8) 1.06 Insignificant
JAUNDICE 8 (24.2) 18 (32.7)
0.84 Insignificant
TACHYPNOEA 21 (63.6)
14 (25.5)
3.54 Significant
DEEP BREATHING 11 (33.3)
9 (16.4) 0.793 Insignificant
DEHYDRATION 17 (51.5)
34 (61.8)
0.947 Insignificant
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Comparison of clinical features of severe malaria in two age groups(contd)
CLINICAL FEATURES UPTO 5 YEARS
ABOVE 5 YEARS
Value of Z
COMMENT
UNABLE TO DRINK 21(63.6)
36(65.5)
0.17 Insignificant
UNABLE TO SIT 32(96.9)
46(83.6)
1.91 Insignificant
UNABLE TO LOCALIZE PAIN
18(54.6)
33(60) 0.51 Insignificant
ABNORMAL POSTURE 7(21.2) 3(5.5) 2.25 Significant
ABSENT CORNEAL REFLEX
7(21.2) 1(1.8) 1.6 Insignificant
AGITATION 2(6) 4(7.3) 0.22 Insignificant
OLIGURIA 6(18.2) 10(18.2)
0 Insignificant
HEPATOMEGALY 30(90.9)
40(72.7)
2.04 Significant
SPLENOMEGALY 20(60.6)
24(43.6)
1.71 Insignificant
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Association of clinical features with outcome
(contd on next page)
FEATURES
RECOVERED
DIED
TOTAL
Chi- square value
p-value
COMMENT
Tachypnoea
+ 17 18 37 11.761
0.001 Significant _ 44 9 51
Severe respiratory distres
+ 5 15 20 23.902
0.000 Significant _ 56 12 68
Icterus + 12 14 26 9.311 0.005 Significant _ 49 13 62
Hepato-Megaly
+ 51 19 70 2.015 0.165 Significant _ 10 8 18
Spleno-megaly
+ 36 8 44 6.465 0.020 insignificant _ 25 9 44
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Association of clinical features with outcome (contd)
FEATURES
RECOVERED
DIED
TOTAL
Chi-square value
p- value
COMMENT
Malarial hepatopathy
+
7 11 18 9.852 0.003
Significant
_ 54 16
70
Severe anaemia
+ 35 6 41 9.295 0.003
Significant
_ 26 21 47
Hyperleucocytosis
+ 13 10
23 2.397 0.187
Insignificant
- 48 17
65
Cerebral malaria
+ 22 24
46 20.932
0.000
Significant
_ 39 3 42
Hyperparasitemia
+ 15 7 22 0.026 1.000
insignificant_ 12 5 17 13
Comparison of complications of severe malaria in two age groups
FEATURES TOTAL NO
% UPTO 5 YEARS
ABOVE 5 YEARS
Value of Z
COMMENT
Cerebral malaria
46 52.3
12(36.4)
36(65.5)
2.66 SIGNIFICANT
Severe anemia 40 45.5
19(57.6)
21(38.2)
1.77 Insignificant
Malarial hepatopathy
18 19.3
5(15.2) 13(21.8)
0.94 Insignificant
Hypoglycemia 7 7.9 4(12.1) 3(5.5) 1.11 Insignificant
Acute renal failure
5 5.7 2(6.1) 3(5.5) 0.12 Insignificant
Prostration 5
5.7 2(6.1) 3(5.5) 0.12 Insignificant
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MORTALITY IN DIFFERENT COMPLICATIONS OF SEVERE MORTALITY IN DIFFERENT COMPLICATIONS OF SEVERE MALARIAMALARIA15
Asociation of PEM with outcomep-value 0.001 (significant)
PEM RECOVERED
DIED TOTAL
No PEM 23 (74%)
8 (25%)
31
Grade 1 & 2 PEM
35 (70%)
15(30%)
50
Grade 3 & 4 PEM
3 (42%)
4(58%)
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Different laboratory parameters among outcome Different laboratory parameters among outcome groupsgroups
LAB PARAMETERS
OUTCOME MEAN
P-value
COMMENTS
Hemoglobin% Recovered 5.9 0.819 InsignificantDied 6.0
TLC(/mm3) Recovered 10575
0.208 Insignificant
Died 12452
BLOOD SUGAR (mg%)
Recovered 74.8 0.099 InsignificantDied 63.9
UREA(mg%) Recovered 45.2 0.000 Significant
Died 105-9
CREATININE (mg%) Recovered 0.93 0.000 Significant
Died 0.43
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Different laboratory parameters among outcome Different laboratory parameters among outcome groupsgroups
LAB PARAMETERS
OUTCOME
MEAN
P-value
COMMENTS
Bilirubin(mg%) Recovered 11.23 0.818 INSIGNIFICANTDied 12.35
SGPT(U/L) Recovered 43.84 0.000 SIGNIFICANT
Died 166.46
Parasite load(/mm3)
Recovered 107130
0.533 INSIGNIFICANT
Died 95433
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Relation between SGPT and bilirubin Relation between SGPT and bilirubin levels levels
in malarial hepatopathyin malarial hepatopathy
TOTAL BILIRUBIN
Serum SGPT levels (U/L)
MINIMUM
MAXIMUM MEAN
STANDARD DEVIATION
<10 mg%
22 298 115.4 90
>10 mg%
88 295 202.4 75
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Severe malaria common > 5 yearsCerebral malaria and severe anaemia - most common presentationsCerebral malaria more common > 5 yearsAcute renal failure and hepatopathy – fairly common complications.Cerebral malaria –the most common underlying cause of death.
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Respiratory distress occurred even in absence of pneumonia, cardiac failure and severe anemia.Metabolic acidosis as a cause needs further evaluationMalnutrition- a significant contributor to poor outcome.Hyperparasitaemia did not influence the outcome of severe malaria in children.
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