Severe falciparum malaria in children: a comparative study of 1990 and 2000 WHO criteria for clinical presentation, prognosis and intensive care in Dakar, Senegal

Abstract

The relevance of WHO criteria for severe and complicated malaria has been debated for a while, especially as regards children. Recent data led WHO experts to modify the definition of severe malaria. The objective of this study was to evaluate retrospectively the significance of the new definition on severity, lethality and intensive care distribution in children admitted with falciparum malaria (in 1997-99) to Hôpital Principal de Dakar, Senegal. We used the paediatric risk of mortality score (PRISM) to compare the 2 definitions, WHO 2000 and WHO 1990. Finally, we evaluated the impact of the new definition in terms of major therapeutic interventions (MTIs): mechanical ventilation, haemodynamic support, transfusion, haemodialysis, and the use of sedatives. Among 311 patients, the frequencies of severe malaria cases and case-fatality rates thereof were 52% (n = 161) and 17% (n = 28) respectively using the 1990 WHO criteria, and 75% (n = 233) and 12% (n = 28) using the 2000 WHO criteria. Mean PRISM score among severe cases decreased with the new definition (6.5 versus 8.6). Both definitions predicted neurological sequelae and deaths with 100% sensitivity. One or more MTIs were required in severe malaria cases in 86% (n = 139) under the 1990 criteria and 73% (n = 170) under the 2000 criteria. In this area of low and seasonal transmission, the 2000 WHO definition of severe malaria proved broader and less specific, but was easier to apply and retained the high sensitivity of the earlier definition in identifying life-threatening infections.

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“…Five children aged 6 months or under (one of them aged 3 months) were suffering from severe malaria, confirming the existence of severe malaria among very young children as already pointed out in other studies [28,29]. The new WHO criteria increase the percentage of severe cases [30]. This percentage may have been underestimated in this survey as some criteria could not be included for practical reasons.…”

Fever and Shock in a Child: How ′good′ is a Good Blood Test?

“…Partially treated malaria can pose a serious diagnostic dilemma to the clinician due to the low level of peripheral parasitemia. Fortunately, most serious falciparum infections have a high level of peripheral parasitemia (higher than 5%), which can be easily detected in peripheral smears (1). In rare instances of severe falciparum infections, such as in our case, the parasite can remain sequestrated in the liver, spleen and maybe even the brain with low peripheral parasitemia and may avoid detection in a single blood smear examination.…”

“…In children, severe malaria can manifest itself as impaired level of consciousness (35%), convulsions (26%), respiratory distress (42%), jaundice (23%), severe anemia with a hemoglobin level of less than 50 g/L (20%), acidosis with a pH of less than 7.25 (21%), hypoglycemia (15%), prostration (9%), severe intravascular hemolysis and macroscopic hematuria (5%), cardiovascular collapse (3%), renal failure (3%), disseminated intravascular coagulation (3%) or pulmonary edema and acute respiratory distress syndrome (1%); hence, severe malaria can be misdiagnosed unless there is a high degree of clinical suspicion (1). Early diagnosis and treatment of malaria can further be delayed when laboratory investigations fail to confirm the clinical suspicion.…”

Outcome of life-threatening malaria in African children requiring endotracheal intubation

“…This could lead to misleading interpretations of severity and fatality rates [2,3,21,23-26,28]. In this series, the high lethality could be explained by the extreme severity of our cases, as reflected by the high frequency of MOD syndrome (91%), indisputable indications for resuscitation, and PRISM score in ventilated children (median PRISM h24 : 14, IQR: 10–19) twice as high as in our hospital's overall SM cases at the same period (median PRISM h24 : 7, IQR: 3–13), of which fatality rate was 12% [29,30]. However, the lethality in ventilated children was close to those seen in adults with malaria treated in ICU's [14-17,31].…”

“…In our setting, interventions such as efforts to increase hygiene and nurse ratios might reduce the occurrence of hospital-acquired infections. Another important issue was the higher rate of ALI/ARDS in mechanically-ventilated children than in other African paediatric series [2-4,29]. This discrepancy may result both from malaria and resuscitation, as observed in adults [31,41,42].…”