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Hypoglycemia is one of the tricky complications of falciparum
malaria and may often go unnoticed, adding to the morbidity and mortality. Hypoglycemia in
malaria may be asymptomatic. On the other, many of the clinical manifestations of
hypoglycemia are caused by malaria itself or by some of its other complications.
Therefore, hypoglycemia, which is easily treatable, may be missed. Added to this,
hypoglycemia can occur repeatedly and hence continuous monitoring of blood glucose levels
is needed.
Causes: 1.
Increased consumption of glucose by the host and the growing parasites. (2.) Failure of
hepatic gluconeogenesis and glycogenolysis as a result of impaired liver function and
acidemia and hyperinsulinemia (3.) Stimulation of pancreatic insulin secretion by drugs
like quinine. More than one of these factors may be at play in a given patient.
It occurs commonly in the following
three situations:
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Severe falciparum infection, especially in
young children.
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Pregnancy with falciparum malaria.
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Treatment with quinine (or quinidine), as
a result of drug induced hyperinsulinemia.
In pregnancy, hypoglycemia may
develop even without severe falciparum infection or treatment with quinine. Patients may
have sweating, anxiety, feeling of coldness, breathlessness, confusion, dilation of
pupils, laboured and noisy breathing, tachycardia, convulsions and if protracted, coma. It
may be easily confused with cerebral malaria. Hypoglycemia can cause fetal bradycardia and
fetal distress. Treatment with 25-50% dextrose injection results in a dramatic recovery
and prognosis in these patients is generally good.
In cases of severe falciparum
infection, it is usually associated with severe anemia, jaundice, hyperparasitemia and
there may be lactic acidosis. In such cases, mortality tends to be high. The usual
symptoms and signs of hypoglycemia may be absent or may be indistinguishable from that of
malaria itself. Sweating is inconstant, pupils may be normal, breathing may be cyclical or
stertorous and deep and there may be decerebrate posturing. There is alteration in the
level of consciousness and convulsions can occur. Administration of 25-50% dextrose
results in an improvement in the respiration and level of consciousness.
Hypoglycemia tends to be recurrent
and this calls for regular monitoring of blood glucose in all patients who have had
hypoglycemia or who are at risk for developing hypoglycemia.
Treatment:
[See Treatment of Severe P.
falciparum malaria]
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Administration of 25-50% dextrose 100 ml,
(1 ml/kg for children), intravenously followed by a continuous infusion of 5-10% dextrose.
It is better to presume hypoglycemia in all cases of falciparum malaria presenting with
altered sensorium, convulsions and coma and treat them with dextrose, after collecting
blood for glucose estimation.
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Regular monitoring of blood glucose, once
in 4-6 hours.
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In cases of hypoglycemia due to quinine
induced hyperinsulinemia, the drug may have to be stopped. Continuous infusion of 5-10%
dextrose is helpful, specially since drug induced hypoglycemia can be recurrent and
protracted. In severe cases, drugs that inhibit pancreatic insulin secretion, like
octreotide, may be needed (50 microgram or higher, twice or thrice a day, subcutaneously).
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