A Retrospective Analysis of Outcome in Malaria Patients Admitted into a Multidisciplinary Intensive Care Unit of a Tertiary Care Teaching Hospital.

INTRODUCTION: Malaria is a significant public health problem with people worldwide at risk for the disease. It is a mosquito-borne disease causing high-grade fever, chills, and flu-like illness. The World Health Organization (WHO) recommends the case with severe malaria should be admitted in the intensive care unit (ICU). Severe malaria is a medical emergency and often managed in ICU with regard to the definition of hyperparasitemia. The WHO amended the criteria for definition of severe malaria in 2006, 2010, and 2015.
METHODS: All patients had a full workup for fever that included three smears for malarial parasites, serology for dengue, leptospirosis, scrub typhus, enteric fever, blood, urine, sputum or endotracheal cultures, and other tests as clinically indicated. A diagnosis was made when a patient is tested positive for malarial antigen with a rapid diagnostic test and other causes of fever excluded. Patients were treated with intravenous Artesunate along with enteral Doxycycline.
RESULTS: Of total patients, the vasopressor requirements being Dopamine (7.40%), nor adrenaline (7.40%) and vasopressin (3.70%). None received packed red blood cell transfusions, whereas 14.81% had platelet transfusions. 66.66% required Noninvasive ventilation, none required invasive mechanical ventilation (IMV) and both noninvasive and IMV. None of the patients had received hemodialysis. The mean duration of ICU and hospital stay was 4.14 and 6.26 days, respectively. No deaths were observed during the study period.
CONCLUSION: In our study, we hereby conclude the incidence of clinical features is in agreement with other studies with no in-hospital mortality. Copyright:

INTRODUCTION

Malaria is a significant public health problem with people worldwide at risk for the disease. It is a mosquito-borne disease causing high-grade fever, chills, and flu-like illness. The World Health Organization (WHO) recommends the case with severe malaria to be admitted in the intensive care unit (ICU). Severe malaria is a medical emergency and often managed in an ICU[1] with regard to the definition of hyperparasitemia. The WHO amended the criteria for definition of severe malaria in 2006, 2010, and in 2015.[2] A person is considered non immune to malaria if he comes from nonendemic country and stays in malaria affected area for <2 years.[3] Among nonimmune people, there can be a correlation between the parasite density, the severity of the disease, and its complications. In such cases even after initial appropriate treatment, the clinical condition may deteriorate due to exacerbation of systemic inflammatory response leading to organ dysfunction.[4]

METHODS

All patients admitted to the multidisciplinary ICU of a tertiary care teaching hospital in South India with acute febrile illness over a 1-year period (2019–2020) were considered. All patients had a full workup for fever that included three smears for malarial parasites, serology for dengue, leptospirosis, scrub typhus, enteric fever, blood, urine, sputum or endotracheal cultures, and other tests as clinically indicated. A diagnosis was made when a patient is tested positive for the malarial antigen with a rapid diagnostic test and other causes of fever excluded. Patients were treated with intravenous Artesunate along with enteral Doxycycline.

Organ support was provided to patients depending upon the organ dysfunction. Respiratory support included noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV), cardiovascular support included vasopressor therapy for patients in shock, and renal replacement therapy for those with acute kidney injury.

Severity of illness scores (Acute Physiology and Chronic Health Evaluation II, APACHE-II) and Sequential Organ Failure Assessment (SOFA) scores were calculated at admission. The primary outcome of interest was in-hospital mortality. The other outcomes were the duration of ICU and hospital stay.

RESULTS

During the study period, 27 were diagnosed with malaria based on clinical features, a positive rapid diagnostic test, and exclusion of other diagnoses.

Baseline patient characteristics are summarized in Table 1. Of 27 patients, the mean age was 47.8 years, 17 (62.97%) were male and 10 (37.03%) were female patients. The incidence of symptoms includes fever (14.81%), bleeding (40.74%), rashes (29.62%), breathlessness (51.85%), myalgia (33.33%), splenomegaly (81.48%), headache (37.03%), and vomiting (14.81%). The mean scores of APACHE-II and SOFA at admission were 11.83 and 8.29, respectively.

Table 1

Demographic and clinical profile of patients with malaria

Variable	Mean
Age (years)	47.8
Other demographic characteristics	n (%)
Sex
Male	17 (62.97)
Female	10 (37.03)
Symptoms and signs
Fever	4 (14.81)
Bleeding	11 (40.74)
Rashes	8 (29.62)
Breathlessness	14 (51.85)
Myalgia	9 (33.33)
Encephalopathy	2 (7.40)
Splenomegaly	22 (81.48)
Headache	10 (37.03)
Vomiting	4 (14.81)
Comorbidities
COPD	5 (18.51)
Asthma	10 (37.03)
CKD	2 (7.40)
Hypertension	5 (18.51)
Diabetes	14 (51.85)
Severity illness scores
APACHE	11.83
SOFA	8.29

SOFA=Sequential organ failure assessment, CKD=Chronic kidney disease, COPD=Chronic obstructive pulmonary disease, APACHE=Acute Physiology and Chronic Health Evaluation

Laboratory parameters are summarized in Table 2. Laboratory analysis showed a mean values of TLC – 15762.92 cells/mm3, platelets – 1.32 lakh/mm3, serum creatinine – 0.90 mg/dl, serum sodium – 135.17 meq/l, lactate – 1.54 mmol/l, total bilirubin – 1.91 mg/dl, INR-1.61, PTT-19.96 sec, SGOT, and SGPT were 52.3 IU and 46.4 IU, respectively.

Table 2

Laboratory investigations of the patients

Variable	Mean
Hemoglobin (gm/dl)	13.32
Total leukocyte count (/mm3)	15,762.92
Platelet count (lakh/mm3)	1.32
Serum creatinine (mg/dl)	0.90
Serum sodium (meq/l)	135.17
Serum bicarbonate (meq/l)	21.70
Serum lactate (mmol/l)	1.54
Total bilirubin (mg/dl)	1.91
INR	1.61
PTT (s)	19.96
SGOT (IU)	52.3
SGPT (IU)	46.4

SGOT=Serum glutamic-oxaloacetic transaminase, PTT=Partial thromboplastin time, SGPT=Serum glutamic-pyruvic transaminase, INR=International normalized ratio

Data on interventions and outcome during hospitalization are summarized in Table 3. Among the total patients, two patients each required dopamine and Nor-adrenaline, whereas, one patient was given vasopressin. None received packed red blood cell transfusions, whereas four patients (14.81%) received platelet transfusions. Nineteen patients (66.66%) required noninvasive ventilation, none required IMV. None of the patients had received hemodialysis.

Table 3

Interventions and outcomes in the patients

Variable	n (%)
Vasopressor requirement
Dopamine	2 (7.40)
Noradrenaline	2 (7.40)
Vasopressin	1 (3.70)
Transfusion requirements
Platelet transfusion	4 (14.81)
Other supports
NIV	19 (66.66)
Outcome measures (mean)
Primary outcome measure
Mortality
Secondary outcome measures (days)
Length of ICU stay	0
Length of hospital stay	6.26

NIV=Noninvasive ventilation, ICU=Intensive care unit

The mean duration of the ICU and hospital stay was 4.14 and 6.26 days, respectively. No deaths were observed during the study period.

DISCUSSION

In a case series report of Kochar et al., in complicated Plasmodium vivax malaria cases, the mean age group of the patients was 29.65 ± 11.72 years.[5] In our study, the mean age was 47.8 years.

Dondorp et al. conducted a multicenter clinical trial in 1050 patients and demonstrated a statistically significant association between the mortality and age group. It was observed that in children aged ≤10 years, the mortality was 6.1%, in patients aged 11–20 years, the mortality was 21.9%, and among adults aged 21–50 years and >50 years, the mortality was 26.7%, and 36.5%, respectively.[6] However, in this study, no mortality was observed.

In a prospective study by Body et al. conducted in 711 severe malaria patients, it was observed that thrombocytopenia was most common in vivax malaria compared to falciparum malaria.[7] Similar results were observed in this study with the mean platelets of the patients at 1.32 lakh/mm3.

Regarding the signs and symptoms, Ozen et al. reported the case of cerebral malaria in 4-year-old child with intractable seizures.[8] In another prospective study by Mohapatra et al. in 110 patients, the authors observed atypical presentations such as migranous headache in 4.5%, myalgia in 6.3%, urticarial rash in 1.8%, relative bradycardia in 13.6%, and postural hypotension in 2.7% of patients and also observed complications such as jaundice in 7.2%, cerebral involvement in 9.2% of patients, and severe anemia in 7.2% patients.[9] The patients in our hospital included in this study presented with fever (14.81%), bleeding (40.74%), rashes (29.62%), breathlessness (51.85%), myalgia (33.33%), splenomegaly (81.48%), headache (37.03%), and vomiting (14.81%), The admission APACHE-II and SOFA mean scores was 11.83 and 8.29, respectively.

In a retrospective analysis by Mehta et al., in 402 malaria patients, the authors observed renal failure in 24 patients with requirement of dialysis in 95% of the cases with renal failure.[10] However, none of the patients in this study required hemodialysis. In another retrospective analysis by Prakash et al., in malaria patients with renal failure, out of 577 malaria cases, 93 patients were identified with renal failure and other complications such encephalopathy in 57.9% cases, hypotension in 42% cases, jaundice in 36.8% cases, and intravascular haemolysis in 42% cases.[11]

In our study, the vasopressor requirements include dopamine (7.40%), nor-adrenaline (7.40%), and vasopressin (3.70%). None received packed red blood cell transfusions, whereas 14.81% of patients received platelet transfusions. Among the study participants, 66.66% required NIV, none required IMV, and both noninvasive and IMV.

In a prospective study conducted by Body et al. in 711 severe malaria patients, it was observed that plasmodium malaria cases with multi-organ dysfunction had 82% mortality, vivax malaria cases with multi-organ dysfunction had 58% mortality and found the commonest organ combination to be renal failure with thrombocytopenia.[7] In a case report of a 60-year-old vivax positive malaria by Beg et al., concluded that Plasmodium vivax malaria can cause acute renal failure, which occurs more commonly in Plasmodium falciparum malaria. However, the prognosis of acute renal failure in Plasmodium vivax malaria is favourable.[12] The mean duration of ICU and hospital stay was 4.14 and 6.26 days, respectively. No deaths were observed during the study period.

CONCLUSION

In our study, we hereby conclude that the incidence of clinical features is in agreement with other studies with no in-hospital mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.