Distinguishing Malaria from Severe Pneumonia among Hospitalized Children who Fulfilled Integrated Management of Childhood Illness Criteria for Both Diseases: A Hospital-Based Study in Mozambique

Abstract

Abstract. Malaria and severe pneumonia in hospitalized young children may show striking clinical similarities, making differential diagnosis challenging. We investigated ways to increase diagnostic accuracy in patients hospitalized with clinical symptoms compatible with malaria and severe pneumonia, in an area with high a prevalence of infection with human immunodeficiency virus. A total of 646 children admitted at the Manhiça District Hospital in Manhiça, Mozambique who met the World Health Organization clinical criteria for severe pneumonia and malaria were recruited for 12 months and thoroughly investigated to ascertain an accurate diagnosis. Although symptom overlap between malaria and severe pneumonia was frequent among hospitalized children, true disease overlap was uncommon. Clinical presentation and laboratory determinations were ineffective in reliably distinguishing between the two diseases. Infection with human immunodeficiency virus differentially influenced the epidemiology and clinical presentation of these two infectious diseases, further challenging their discrimination on clinical grounds, and having a greater impact on the current burden and prognosis of severe pneumonia. Malaria and pneumonia in the study area. At the time of the study, malaria in Manhiça accounted for one-third of all outpatient visits, 19 half of the pediatric admissions, and 19% of all in-hospital pediatric deaths. 22 A total of 11.1% of all malaria admissions and 41.1% of severe malaria cases had severe respiratory findings. 22 Severe pneumonia accounted for 16% of hospitalizations among children less than two years of age, and had an associated case-fatality rate (CFR) of 11%. 23 Verbal autopsy studies confirmed from the community perspective that these two conditions are the leading causes of death in children less than five years of age. 24Procedures for recruited children and sample collection. This study was part of a larger project designed to describe the epidemiology and clinical characteristics of children less than five years of age admitted with respiratory distress. However, this analysis includes only patients simultaneously fulfilling at admission IMCI-defined clinical criteria for malaria (fever or a history of fever in the preceding 24 hours) and severe pneumonia (cough and/or breathing difficulties, plus chest indrawing with or without increased respiratory rate according to age group). Children fulfilling inclusion criteria and whose parents had signed an informed consent form underwent a series of standardized procedures. Anteroposterior chest radiographs were obtained on admission or otherwise within the first 48 hours of hospitalization according to severity. Pulse oximetry (Nellcor, Boulder, CO) was used to determine oxygen saturation, and nasopharyngeal aspirates were performed for diagnosis of respiratory viruses by using NPAK ® Kits (MPRO, Farmington Hills, MI). Venous blood was obtained at admission for malaria diagnosis, blood culture, full blood cell count, and biochemical determinations.HIV-spe...

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