Severe and complicated malaria in KwaZulu-Natal.

OBJECTIVE: To describe severe and complicated malaria, including the common complications, causes of death and predictors of poor outcome.
DESIGN: Retrospective case series.
SETTING: King Edward VIII Hospital, Durban, Natal, a referral centre. PATIENTS: One hundred and forty-three consecutive patients (88 males, 55 females; median age 25 years, range 2-86 years) admitted with a microscopic diagnosis of Plasmodium falciparum malaria from 1984 to 1991. MAIN OUTCOME MEASURES: A univariate analysis comparing survival and death for categorical and continuous data for various complications was performed using the t-test or chi 2-test (or Fisher's exact test in the case of small cell sizes). Variables that showed significance on univariate analysis (P < 0.1) were used in a multivariate analysis to determine which contributed independently to survival or death.
RESULTS: The case fatality rate was 11.1% (15/135) and the commonest complications were hyperparasitaemia (30%), renal failure (17%), acidaemia (14%), jaundice (10.4%) and cerebral malaria (6%). The commonest complications in patients who died were renal failure (10 patients), cerebral malaria (7), hyperparasitaemia (6) and severe anaemia (5). Multivariate analysis using a logistic regression model showed a high parasite load and cerebral malaria (relative risks of 11.9 and 51.8 respectively) and high urea levels to be the significant predictors of poor outcome (95% confidence intervals 1.53-91.9, 2.74-100.0 and 1.01-1.09, respectively).
CONCLUSIONS: Patients with high parasite densities, cerebral involvement and renal dysfunction need urgent attention with parenteral chemotherapy, intravenous fluid replacement and early referral to a tertiary hospital with facilities for intensive monitoring and supportive treatment.