S Mishra, S Mohanty
S Mishra, S Mohanty. Problems In Management Of Severe Malaria. The Internet Journal of Third World Medicine. 2002 Volume 1 Number 1.
Malaria has become a major global problem affecting more than 2000 million population and causing 1.5 million deaths annually 1. In India the problem is enormous and almost half of the population is exposed to this dreadful disease. During the last decade, there has been a resurgence of malaria in India which has affected the economic growth by denting the national exchequer as well as causing deaths in thousands2. Malaria in India usually affects mostly patients who are at the prime of their life. It is a matter of great concern that the country is losing these people who could have been saved by prevention of malaria transmission, by early diagnosis or by instituting early therapy. Whenever, a case of malaria is adequately and successfully treated, malaria does not usually have a residual deficit and these patients recover fully.
Malaria, particularly pernicious malaria (falciparum malaria) poses a diagnostic dilemma at early stage as the disease can mimic many other conditions1. Even after proper diagnosis, it can pose problem due to associated complications which unless anticipated earlier or diagnosed at proper stage can cause death.
The aim of WHO's Roll Back Malaria programme has been early diagnosis and prompt treatment to reduce the mortality to a great extent. There is a great need for early diagnosis and recognition of the complications of malaria at local centre, and if warranted, to be sent to a higher centre for management of the complications at an early stage to avoid mortality due to complications.
There are certain difficulties in the diagnosis and management of malaria. We like to make a brief review of these issues.
Difficulty In The Diagnosis And Treatment Of Malaria
Problems in the management of malaria
In many dedicated and advanced centres, it has been seen that despite institution of proper therapy for severe and complicate malaria, the death rates are high as many of these patients are brought to hospital quite late in irreversible state. In cerebral malaria, if acute renal failure sets in, the mortality is approximately 40% and in the presence of acute lung injury, it reaches almost 80 to 90% even in most advanced centres 1 .
Prevention of ARDS by prophylactic artificial respiratory support is still controversial.10 .
At times, despite early diagnosis and institution of prompt therapy, patients proceed to have MODS with disastrous outcome. Most of the complications can be anticipated, viz. anaemia in presence of haemolysis, ARDS in presence of ARF etc. But there is no marker or scale to predict the complications. The estimation of TNF, thromboxane B orIL-6 may be raised in the severely ill patients; but in most centres these facilities are not available, and if available it cannot be repeated frequently due to prohibitive cost factor.
Considering the above facts, it can be said that the therapeutic challenge can be met with institution of proper agent at proper dose, proper route of administration, rate of infusion, duration of therapy, correction of electrolytes, calories, antibiotics and supportive therapy as indicated. Anticipation, close monitoring with recognition of the complications at an early stage will be of immense value.
There are certain differences in the presentation of severe malaria in the children 1,2,10,12
Clinical Features Of Severe Malaria In Pregnant Women
Pregnant women are more prone to develop multiple complications of malaria. There are several factors that make pregnant women more vulnerable to malaria and its complications including mortality7,8, 13,14:
Malaria parasites are preferentially sequestrated in the placenta,
Safety Of Antimalarials During Pregnancy
Management Of Various Complications In Severe Malaria
Severe anaemia in malaria is due to
Anaemia due to acute malaria is usually normochromic normocytic in nature. The presence of microcytic hypochromic anaemia indicates either iron deficiency, nutritional anaemia or hemoglobinopathies; which are not uncommon in tropical countries. The preexisting anaemia due to nutritional deficiency or haemogloboinopathy may be aggravated in malaria. Severe anaemia (Haemoglobin below 5 g/dl) or a rate of fall of more than 2g in 24 hrs may induce cerebral anoxia and cardiac failure. Patients with heavy parasitemia, pregnancy or delivery, and children are vulnerable to develop severe anemia.
Indications of blood transfusion in severe malaria
The presence of severe or rapidly progressing anaemia in malaria needs prompt treatment, as it is associated with poor prognosis.
Blood transfusion of whole blood or packed cell is indicated when haemoglobin is below 5 g/dl; a rate of fall of > 2g in 24 hrs; haematocrit < 20 or in patients with features of cerebral anaoxia.
Volume overload must be avoided by giving only packed cells. Injection furosemide 20-to 40 mg should be administered prior to blood transfusion when impending cardiac failure is suspected or already present.
No specific management is needed to reduce hyperbilirubinemia. However when associated with very high bilirubin levels ( > 28 mg/dl) in children, exchange transfusion is needed. Severe haemolysis may lead to consequent anaemia, which may need blood transfusion, if severe. 21
Dose modification in severe malaria in the presence of jaundice?
The management of this rare complication is maintenance of good hydration, blood transfusion, if associated with severe anemia or thrombocytopenia. If associated with renal failure, consider for haemodialysis or peritoneal dialysis. Quinine should not be discontinued or reduced in the first 48 hours of therapy.
Patients with G6PD deficiency are prone to this complication when on quinine therapy.
The newer antimalarials are quite effective and useful in both uncomplicated and complicated malaria.16,17 . However, it should be used with caution, as these have neurological and cardiovascular side effects 18,19 . It may have deleterious effect in pregnancy and infancy.
Severe P. vivax malaria usually does not cause much problem other than haemolysis and anaemia. But acute complications include splenic rupture and at times hepatic dysfunction. Though cerebral malaria has been described in P vivax malaria, the authenticity of these reports is questionable. Probably mixed infections with P falciparum were missed.