Serum TNF alpha levels: a prognostic marker for assessment of severity of malaria.

Complicated Plasmodium falciparum infection is associated with a 6.4% mortality rate in India, yet its prognostication is incompletely understood. The conventional prognostic markers of falciparum malaria include clinical, haematological and biochemical parameters. However these factors are non-specific. Hence there is a need of an accurate inexpensive objective marker for prognosticating falciparum malaria infection outcomes. Angiopoietins, angiogenic factors, eotaxins, adhesion molecules and inflammatory cytokines have been studied for prognostication of this common disease. Determination of the first four is technically difficult and requires a high level of expertise and equipment. Intermediary cytokines have the most promising role. This study was conducted with the aim to evaluate the serum level of TNF-α in patients with P. falciparum malaria and carry out statistical analysis of levels of serum TNF-α with parasite index, age, severity of anaemia, hypoglycaemia, hepatic and renal dysfunction. In our study the average TNF alpha level in 91healthy controls was 46.42 pg/ml whereas that in mild falciparum malaria was 100.45 pg/ml, in severe malaria - 278.63 pg/ml and in cerebral malaria it was 532.6 pg/ml. The mean TNF alpha level was significantly different in severe malaria and cerebral malaria compared to that in healthy controls (p < 0.02). The difference in levels of TNF alpha was significantly higher in falciparum malaria patients with anaemia, altered liver functions, hyperparasitemia, leucocytosis, hepatosplenomegaly and hypoglycaemia. The TNF levels did not correlate well with haemolysis markers and patients with altered renal function. Hence a raised TNF alpha can predict the likelihood of oncoming anaemia, hypoglycaemia, altered hepatic function and leucocytosis but not the grades of malaria. The duration of stay in hospital and change in parasite index between the 5(th) day and the 1(st) day of admission was used a clinical outcome marker in this study. The analysis showed that serum TNF alpha was raised significantly (p= 0.001) in patients with longer duration stay in hospital. The cytokine was significantly raised in patients having disorientation /cognitive disorder /coma and ARDS (p= 0.001, 0.0023 respectively). The study concluded that serum TNF alpha if done at time of admission and on day 3 can indicate the severity of disease and its complications.