Malaria Site: Complications Of P. falciparum Malaria

History, Aetiology, Pathophysiology, Clinical Features, Diagnosis, Treatment, Complications And Control Of Malaria

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Complications of P. falciparum Malaria

Severe falciparum malaria is defined by the demonstration of asexual forms of P. falciparum in a patient with a potentially fatal manifestation or complication of malaria in whom other diagnoses have been excluded.

Even though the complications are almost unique to P. falciparum infection, that DOES NOT mean that all cases of P. falciparum malaria invariably develop complications. The case fatality of P. falciparum malaria is around 1 per cent and this accounts form 1 to 3 million deaths per year all over the world. 80% of these deaths are caused by cerebral malaria.

Most complications of P. falciparum malaria develop gradually after days of illness. However, acute pulmonary oedema may sometimes develop suddenly, even after the treatment is started.

Predisposing factors for complications of P. falciparum malaria:

(1.) Extremes of age. (2.) Pregnancy, especially in primigravidae and in 2^nd half of pregnancy. (3.) Immunosuppressed - patients on steroids, anti-cancer drugs, immunosuppressant drugs. (4.) Immunocompromised - patients with advanced tuberculosis and cancers. (5.) Splenectomy. (6.) Lack of previous exposure to malaria (non-immune) or lapsed immunity (7.) Pre-existing organ failure.

Severe manifestations and complications of P. falciparum malaria

In a patient with falciparum malaria in whom other diseases have been excluded, the presence of one or more of the following manifestations is sufficient for a diagnosis of severe falciparum malaria.

1. Cerebral malaria: C.N.S. dysfunction in falciparum malaria could be multi factorial. Therefore, to differentiate from various causes of transient cerebral dysfunction, a strict definition of cerebral malaria has been developed.	For a diagnosis of cerebral malaria, the following criteria should be met: (i.) Deep, unarousable coma: Motor response to noxious stimuli is non-localising or absent. (ii.) Exclusion of other encephalopathies: Coma should persist for more than 30 minutes after a generalized convulsion to exclude transient post-ictal coma. Hypoglycemia, meningoencephalitis, eclampsia, intoxications, head injuries, cerebrovascular accidents and metabolic disorders should be excluded as the cause of coma. *(iii.) Confirmation of P. falciparum* infection:** Asexual forms of P. falciparum must be demonstrated in peripheral blood or bone marrow smear during life, or in a brain smear after death.
2. Severe anemia	Hematocrit less than 15% (hemoglobin less than 3.1 mmol/l or 5g/dl).
3. Metabolic (Lactic) Acidosis	Metabolic acidosis is defined by an arterial blood pH of <7.35 with a plasma bicarbonate concentration of <22 mmol/L; hyperlactatemia is defined as a plasma lactate concentration of 2-5 mmol/L and lactic acidosis is characterized by a pH <7.25 and a plasma lactate >5 mmol/L.
4. Jaundice	Serum bilirubin of more than 50m mol/l (3 mg/dl).
5. Renal failure	Urine output of less than 400 ml in 24 hours or <12ml/kg per 24 hours in children and a serum creatinine of more than 265 m mol/l (> 3.0 mg/dl), failing to improve after rehydration.
6. Pulmonary edema or ARDS	Breathlessness, bilateral crackles, and other features of pulmonary oedema.
7. Hypoglycemia	Blood glucose concentration of less than 2.2 mmol/l (less than 40 mg/dl).
8. Hypotension and shock	Systolic blood pressure <50 mmHg in children 1-5 years or <80 mm Hg in adults; core-skin temperature difference >10⁰C
9. Bleeding and clotting disturbances	Significant bleeding and haemorrhage from the gums, nose, gastrointestinal tract, retinal haemorrhages and/or evidence of disseminated intravascular coagulation.
10. Hyperpyrexia	Rectal temperature above 40⁰C
11. Fluid, electrolyte or acid-base disturbances	Requiring intravenous fluid therapy; arterial pH <7.25 or plasma bicarbonate <15 mmol/L, venous lactate >6mmol/L
12. Haemoglobinuria	Macroscopic black, brown or red urine; not associated with effects of oxidant drugs or enzyme defects (like G6PD deficiency)
13. Hyperparasitemia	Density of asexual forms of P. falciparum in the peripheral smear exceeding 5% of erythrocytes (more than 250,000 parasites per m l at normal red cell counts)
14. Complicating or associated infections	Aspiration bronchopneumonia, septicemia, urinary tract infection etc.
15. Vomiting of oral drugs	Patients with persistent vomiting may have to be admitted for parenteral therapy.
16. Impaired consciousness	Various levels of impairment may indicate severe infection although not falling into the definition of cerebral malaria. These patients are generally arousable.
17. Extreme weakness	Prostration, dehydration, needs support
18. Convulsions	More than two generalized seizures in 24 hours with regaining of consciousness.
19. Other indicators of poor prognosis	Leukocyte count >12,000/cumm; high C.S.F. lactate and low C.S.F. glucose; low antithrombin III levels; peripheral schizontemia

Complications of Malaria

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Cerebral Malaria

Dr. B.S. Kakkilaya's Malaria Web Site
Last Updated: April 14, 2006

B. S. Kakkilaya 2006-2008
malariasite.com 2006-2008

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