Introduction
Materials and methods
Study population and design
Setting
Data collection
Patient management
Criteria | Definition | Number of patients (%) |
---|---|---|
Unrousable coma | Glasgow Coma Scale score ≤9; exclude other causes; should persist ≥30 minutes after a generalized convulsion | 3 (2,5) |
Impaired consciousness | Mental clouding, rousable | 11 (9) |
Multiple seizures | Three or more convulsions observed within 24 hours | 0 (0) |
Respiratory distress | Acidotic breathing, pulmonary oedema, or acute respiratory distress syndrome, on the basis of radiographic densities, hypoxaemia, and positive end-expiratory pressure | 4 (3.3) |
Circulatory collapse or shock | Systolic blood pressure <80 mmHg despite adequate volume repletion | 5 (4.1) |
Abnormal bleeding | Spontaneous bleeding from gums, nose, gastrointestinal tract, or laboratory evidence of disseminated intravascular coagulation | 4 (3.3) |
Jaundice/hyperbilirubinaemia | Icteric sclera/buccal mucosa, or serum bilirubin >50 μmol/l (>3 mg/dl) | 17 (13.9) |
Severe anaemia | Heemoglobin concentration <5 g/l, or haematocrit <15% | 0 (0) |
Hypoglycaemia | Whole blood glucose concentration <2.2 mmol/l (<40 mg/dl) | 3 (2.5) |
Renal failure | Serum creatinine >265 μmol/l, oliguria (<400 ml/24 hours) despite adequate rehydration | 5 (4.1) |
Hyperparasitaemia | More than 5% parasitized erythrocytes or >250,000 parasites/μl (in nonimmune individuals) | 13 (10.7) |
Acidosis | Plasma bicarbonate <15 mmol/l or base excess under -10, or acidaemia (arteria/capillaryl pH <7.25) | 4 (3.3) |
Macroscopic haemoglobinuria | Dark or red urine; exclude haematuria, haemolysis not secondary to glucose-6-phosphate dehydrogenase deficiency | ND |
Number of patients (%) | |
---|---|
Monitoring and basic supportive care | 122 (100) |
Continuous monitoring (ECG, oxygen status, blood pressure) | 122 (100) |
Intravenous fluid and electrolyte replacement | 86 (70.5) |
Oxygen supply | 32 (26.2) |
Central venous catheterization | 37 (30.3) |
Arterial catheterization | 9 (7.4) |
Advanced supportive care | 27 (22.1) |
Transfusion of blood products | 20 (16.4) |
Inotropic drug therapy | 5 (4.1) |
Noninvasive ventilatory support | 4 (3.3) |
Invasive ventilation | 3 (2.5) |
Renal replacement therapy | 4 (3.3) |
Total parenteral nutrition | 12 (9.8) |
Drug treatment
Definition of complications
Data handling and statistical analysis
Results
Patient characteristics
All malaria patients (n = 122 [100%]) | Noncomplicated malaria (n = 88 [100%]) | Complicated malaria (n = 34 [100%]) |
P
| |
---|---|---|---|---|
Demographics | ||||
Age (years; mean ± SD) | 38.4 ± 11.1 | 37.1 ± 10.2 | 42 ± 12.8 | 0.049 |
Male sex (n [%]) | 88 (72.1) | 62 (70.5) | 26 (76.5) | 0.506 |
Return from Sub-Saharan Africa (n [%]) | 107 (87.7) | 76 (86,4) | 31 (91.2) | 0.350 |
Nonimmune patients (n [%]) | 88 (72.1) | 62 (70.5) | 26 (76.5) | 0.506 |
Compliant chemoprophylaxis users (n [%]) | 24 (19.7) | 17 (19.3) | 7 (20.6) | 0.874 |
Latency period (arrival-admission; days; median [IQR]) | 10 (6–15) | 10 (7–15) | 8 (4–14) | 0.778 |
Initial signs and symptoms | ||||
Fever (>37°C; n [%]) | 118 (96.7) | 84 (95.5) | 34 (100) | 0.265 |
Headache (n [%]) | 71 (58.2) | 57 (64.8) | 14 (41.2) | 0.018 |
Chills (n [%]) | 43 (35.2) | 31 (35.2) | 12 (35.3) | 0.994 |
Diarrhoea (n [%]) | 46 (37.7) | 29 (33) | 17 (50) | 0.082 |
Nausea (n [%]) | 47 (38.5) | 31 (35.2) | 16 (47.1) | 0.229 |
Vomiting (n [%]) | 29 (23.8) | 20 (22.7) | 9 (26.5) | 0.687 |
Jaundice (n [%]) | 11 (9) | 0 (0) | 11 (32.4) | 0.000 |
Confusion (n [%]) | 5 (4.1) | 0 (0) | 5 (14.7) | 0.001 |
Vertigo (n [%]) | 25 (20.5) | 14 (15.9) | 11 (32.4) | 0.044 |
Myalgias (n [%]) | 47 (38.5) | 34 (38.6) | 13 (38.2) | 0.967 |
Abdominal pain (n [%]) | 10 (8.2) | 6 (6.8) | 4 (11.8) | 0.893 |
Simplified Acute Physiology Score II (median [IQR]) | 13 (9–20) | 13 (9–17) | 27 (17–36) | 0.000 |
IMC/ICU length of stay (days; median [IQR]) | 5 (3–6) | 4 (2–5) | 6 (5–8) | 0.000 |
Hospital length of stay (days; median [IQR]) | 6 (5–8) | 5.5 (4–7) | 8 (7–10) | 0.000 |
Laboratory results
Parameter | All malaria patients (n = 122 [100%]) | Noncomplicated malaria (n = 88 [100%]) | Complicated malaria (n = 34 [100%]) |
P
| Numbers of patients tested |
---|---|---|---|---|---|
Haemoglobin (g/dl; mean ± SD) | 13.7 ± 2 | 14 ± 1.9 | 12.9 ± 2.3 | 0.007 | 122 |
Platelet count (× 109/l; mean ± SD) | 89 ± 51 | 104 ± 49 | 50 ± 32 | 0.000 | 122 |
White blood cell count (× 109/l; mean ± SD) | 5.4 ± 2.2 | 5.1 ± 2.0 | 6.1 ± 2.5 | 0.023 | 122 |
Plasma prothrombin time (%; mean ± SD) | 78 ± 17 | 79 ± 16 | 73 ± 17 | 0.066 | 122 |
Serum sodium (mmol/l; mean ± SD) | 134 ± 4.7 | 135 ± 4.2 | 131 ± 4.6 | 0.000 | 122 |
Serum potassium (mmol/l; mean ± SD) | 3.9 ± 0.5 | 3.8 ± 0.4 | 3.9 ± 0.7 | 0.739 | 122 |
Serum glucose (mg/dl; mean ± SD) | 119 ± 32 | 124 ± 38 | 117 ± 29 | 0.287 | 122 |
Total bilirubin (mg/dl; mean ± SD) | 1.5 ± 1.8 | 0.9 ± 0.4 | 2.8 ± 2.7 | 0.000 | 98 |
C-reactive protein (mg/l; mean ± SD) | 102 ± 63 | 82 ± 45 | 151 ± 73 | 0.000 | 113 |
Serum aspartate aminotransferase (U/l, median [IQR]) | 37 (27–72) | 33 (26–59) | 61 (35–88) | 0.001 | 122 |
Serum alanine aminotransferase (U/l; mean ± SD) | 60 ± 39 | 56 ± 36 | 72 ± 44 | 0.045 | 122 |
Serum creatinine (mg/dl; median [IQR]) | 1.1 (0.9–1.3) | 1 (0.9–1.2) | 1.2 (1.1–1.8) | 0.000 | 122 |
Serum urea (mg/dl [mean ± SD]) | 40 ± 32 | 29 ± 11 | 67 ± 48 | 0.000 | 122 |
Serum alkaline phosphatase (U/l [mean ± SD]) | 83 ± 36 | 81 ± 31 | 88 ± 46 | 0.457 | 96 |
γ-Glutamyl transferase (U/l; mean ± SD) | 68 ± 89 | 60 ± 92 | 85 ± 79 | 0.213 | 99 |
Lactate dehydrogenase (U/l; mean ± SD) | 333 ± 202 | 259 ± 81 | 524 ± 282 | 0.000 | 122 |
Complications
Complication | Present on admission (n) | Developing during ICU stay (n) |
---|---|---|
Unrousable coma | 0 | 3 |
Respiratory distress | 2 | 2 |
Circulatory collapse or shock | 0 | 5 |
Abnormal bleeding/disseminated intravascular coagulation | 4 | 0 |
Hypoglycaemia | 0 | 3 |
Acidosis | 2 | 2 |
Renal failure | 2 | 3 |
Multiple seizures | 0 | 0 |
Severe anaemia | 0 | 0 |
Treatment
Prognostic factors
Variable | Coefficient | Standard error | Odds ratio | 95% confidence interval |
P
|
---|---|---|---|---|---|
Haemoglobin (g/dl; mean ± SD) | -0.374 | 0.174 | 0.688 | 0.489–0.967 | 0.031 |
Platelet count (× 109/l, mean ± SD) | -0.032 | 0.012 | 0.968 | 0.946–0.991 | 0.007 |
Serum sodium (mmol/l; mean ± SD) | -0.213 | 0.085 | 0.808 | 0.685–0.954 | 0.012 |
Discussion
Conclusion
Key messages
-
Hospitalized patients with imported falciparum malaria may benefit from early treatment in the IMC/ICU.
-
During therapy it is important to monitor for treatment complications and nosocomial infections.
-
Further studies with improved design are necessary to confirm our findings.