This was a retrospective study done on 110 patients hospitalized with
India accounts for 77% of the total malaria in south-east Asia with
Also, malaria case management remains a vital component of malaria control strategies. The WHO guidelines for the treatment of malaria recommend chloroquine (except in areas of chloroquine resistance) as first-line treatment for uncomplicated
The present study was done to evaluate the clinical manifestations and outcome in patients hospitalized with
This was a retrospective study done using data collected from the medical records of three tertiary care centres. One of the hospitals was in Chandigarh, a union territory in the northern region of India, whereas two of the hospitals were in Gujarat (Sola, Ahmedabad and Surat), a state in the western region of India. Records of patients admitted to the ward or intensive care unit of the respective hospitals, from May to December 2012, with a diagnosis of
Adults and children, with smear-positive
A case record form was developed and used to retrieve data from the inpatient records. The first three authors were responsible for extracting data from the medical records of their respective hospitals.
Ethics committee approval was obtained from all three hospitals for retrieval of data from the medical records. The confidentiality of the patients’ record and identity of the treating physician was adequately protected using codes.
Information extracted from the records included patient’s age, sex, the presenting complaints, findings on clinical examination, hematological and biochemical investigations, treatment given, course in the hospital, and outcome.
In the absence of guidelines to classify severe
The data was pooled at the coordinating centre at the National Institute for Research in Reproductive Health, Mumbai. Data entry and analysis were done using Microsoft Excel 2007. Descriptive statistics in terms of proportions for qualitative variables were applied for analysis of data.
Medical records of a total of 110 patients hospitalized for
Age of patients.
Age in years | Number of patients |
---|---|
0–12 | 24 |
13–20 | 21 |
21–40 | 43 |
41–60 | 17 |
>60 | 5 |
| |
Total | 110 |
The presenting symptoms are summarised in Table
Symptoms of patients hospitalized with
Symptom | Number ( |
---|---|
Fever | 110 |
Chills | 86 |
Headache | 53 |
Bodyache | 44 |
Seizures | 03 |
Nineteen of 110 patients (17.2%) hospitalized with
Hematological parameters of patients with severe
No. | Hb (g/dL) | Total count 103/mm3 | Platelet count 103/mm3 | Blood sugar mg/dL | Blood urea nitrogen mg/dL | Serum creatinine mg/dL | Serum bilirubin mg/dL |
Serum ALT IU/L |
---|---|---|---|---|---|---|---|---|
1 | 8.0 | 5.9 | 90 | 94 | 24 | 0.9 | 1.0/0.4 | 40 |
2 | 7.0 | 4.8 | 12 | 90 | 38 | 1.2 | 0.9/0.3 | 30 |
3 | 9.5 | 7.6 | 50 | 105 | 94 | 1.6 | 10.3/6.5 | 360 |
4 | 4.5 | 9.9 | 121 | 65 | 90 | 1.5 | 3.1/1.8 | 107 |
5 | 9.6 | 6.2 | 110 | 120 | 120 | 3.2 | 3.6/2.2 | 97 |
6 | 6.8 | 4.8 | 26 | 60 | 60 | 0.8 | 1.0/0.6 | 40 |
7 | 6.9 | 8.4 | 87 | 138 | 28 | 0.7 | 1.4/0.8 | 38 |
8 | 8.4 | 5.0 | 96 | 90 | 52 | 1.3 | 16.4/10.9 | 520 |
9 | 7.2 | 3.7 | 80 | 130 | 30 | 0.8 | 8.4/6.4 | 368 |
10 | 9.7 | 4.5 | 96 | 105 | 42 | 1.4 | 4.2/3.1 | 287 |
11 | 4.8 | 7.2 | 120 | 110 | 22 | 0.9 | 1.6/1.0 | 89 |
12 | 3.8 | 9.1 | 110 | 95 | 19 | 1.0 | 1.4/0.9 | 75 |
13 | 8.6 | 9.8 | 23 | 70 | 42 | 1.1 | 6.8/4.3 | 356 |
14 | 8.4 | 10.0 | 75 | 95 | 38 | 1.5 | 1.8/1.2 | 98 |
15 | 7.8 | 6.8 | 68 | 128 | 36 | 1.4 | 5.6/3.9 | 276 |
16 | 9.5 | 5.6 | 15 | 112 | 28 | 1.1 | 1.2/0.6 | 40 |
17 | 10.0 | 8.7 | 35 | 96 | 25 | 1.3 | 1.6/1.1 | 52 |
18 | 5.0 | 9.6 | 45 | 102 | 35 | 1.4 | 1.7/1.2 | 60 |
19 | 4.6 | 10.2 | 20 | 88 | 40 | 1.2 | 1.0/0.3 | 42 |
Severe
Chandigarh | Sola, Ahmedabad | Surat | Total | |
---|---|---|---|---|
Total number hospitalized with |
22 | 59 | 29 | 110 |
Number with severe |
7 | 6 | 6 | 19 |
Cerebral malaria | 1 | 2 | 0 | 3 |
Circulatory collapse | 1 | 0 | 0 | 1 |
Acute renal failure | 1 | 0 | 0 | 1 |
Jaundice | 2 | 2 | 4 | 8 |
Acute respiratory distress syndrome | 1 | 0 | 1 | 2 |
Severe anemia | 1 | 2 | 2 | 5 |
Thrombocytopenia | 7 | 23 | 8 | 38 |
Hyperparasitemia | 0 | 0 | 1 | 1 |
Metabolic acidosis | 0 | 0 | 1 | 1 |
The treatment and outcome of patients with severe disease is given in Table
Treatment and outcome of patients with severe disease.
Chandigarh | Sola | Surat | |
---|---|---|---|
Patients with severe malaria | 7 (33.33%) | 6 (10.17%) | 6 (20.08%) |
Artesunate alone | 4 | 0 | 1 |
Chloroquine | 0 | 5 | 5 |
Artemisinin-based combination therapy (ACT) | 3 | 1 | 0 |
Primaquine | 0 | 6 | 5 |
Packed cell transfusion | 1 | 2 | 2 |
Platelet transfusion | 3 | 0 | 0 |
Ventilation | 2 | 0 | 1 |
Dialysis | 1 | 0 | 0 |
Sequelae | 1 | 0 | 0 |
Death | 0 | 0 | 0 |
The five patients with severe anemia received packed cell transfusions. Three patients with thrombocytopenia (platelet counts of 12,000/cu·mm, 26,000/cu·mm, and 23,000/cu·mm) had bleeding manifestations and received platelet transfusions. Two patients with ARDS required ventilation. The one patient with acute renal failure required dialysis, with indications being anuria and hyperkalemia.
All patients with
Nineteen of 110 (17.2%) hospitalized patients with
Severe anemia (hemoglobin < 5 G/dL) necessitating packed red cell transfusion was seen in five of nineteen patients with severe malaria in this study. The low parasite biomass of
Thrombocytopenia was seen in 34.55% of patients hospitalized with
Cerebral malaria was seen in three of nineteen patients with severe
One patient each from Chandigarh and Surat had acute respiratory distress syndrome (ARDS) and required ventilatory support. ARDS is considered to be the most severe form of acute lung injury in malaria and has been reported most commonly with
Clinical jaundice with hepatic dysfunction was seen in eight of nineteen patients with severe
The WHO guidelines recommend that severe
There was wide variation in the therapy for severe disease in the three centres. Chloroquine was used as the antimalarial of choice in Sola even in patients with severe disease. In Surat, both artesunate and chloroquine were used in patients with severe
Drug resistance to the first-line drug chloroquine has been reported from Papua New Guinea, Indonesia, parts of Asia including India, and South America [
WHO guidelines recommend primaquine for 14 days for radical cure in
There were no deaths in any of the patients hospitalized with
The limitations of this study are as follows: it is a retrospective study with a small sample size and uses data retrieved from the medical records. The problem of mixed infection has not been addressed adequately since this was a retrospective study and PCR is not done routinely at the three centres. A prospective multicentric study with an additional centre in Mumbai is under way and will no doubt clarify the picture better.
The authors declare that they have no conflict of interests.
This study was done as part requirement of an “Idea to Manuscript-Outcomes Research Workshop” funded by the Indian Council of Medical Research and held in Mumbai, India, in April 2012. The study was presented as a paper at the Sixth International Annual Conference of the South Asian Chapter of the American College of Clinical Pharmacology held in Mumbai, India, from 21 to 22 April 2013. The authors also thank