1. A.Das, Chiranjib Ghosh, Supriya Choudhary* Department of Pediatrics Gauhati Medical College 1

2. Malaria is a serious problem in north eastern states of India. N E states contribute 8.5 -11% of total cases 13 -15 % of national malarial mortality. Assam reports the maximum. Manifestations of severe malaria vary in different regions. Depends on endemicity. A recent change noted in the spectrum of manifestations of severe malaria in south east region. 2

3. The present study was undertaken to observe  Manifestations of severe malaria in children and features associated with adverse outcome.  Difference in clinical manifestations in younger (upto 5 years)and older (above 5 years) children.  Effect of malnutrition on ultimate prognosis.  Incidence of hepatopathy & ARF in children and its outcome. 3

4.  Place of study: Department of Pediatrics, Gauhati medical college and hospital.  Study period: October 2005 to September 2006.  Inclusion criteria: Slide positive confirmed cases of severe malaria according to WHO 2000 definition.  Data collection: was done in a standard proforma. 4

5.  Clinical assesment was done according to WHO 2000 criteria for severe and complicated malaria.  Glassgow coma scale and Blantyre coma scale was used for assesment of state of consciousness.  DIAGNOSIS: done by study of thick and thin peripheral blood smear. 5

6.  INVESTIGATIONS:  Peripheral blood smear,hemoglobin,blood sugar level done in all cases.  Blood urea,serum creatinine,TLC and estimation of parasite load,Serum bilirubin (total &fraction),SGPT,prothrombin time,serum lactate done whenever possible.  Markers of viral hepatitis, CSF analysis, urine analysis and chest X- ray done whenever necessary. 6

7.  Statistical analysis done using SPSS 11.1 programme  Sample T- test used to calculate significance of difference of means.  Z- test used to calculate significance of difference of proportions.  Chi-Square test used to calculate association of variables.  Multivariate analysis done to determine individual influence of various factors on outcome. 7

8. Age Distribution of malaria cases 8

9. AGE GROUP RECOV ERED N0 (%) DIED N0(%) TOTAL N0(%) Upto 5 years 23(26.1)10(11.4)33(37.5) Above 5 Years 38(43.2)17(19.3)55(62.5) OUTCOME OF MALARIA CASES 9

10. Comparison of clinical features of severe malaria in two age groups CLINICAL FEATURESUPTO 5 YEARS ABOVE 5 YEARS Value of Z COMMENT VOMITING20 (60.6)19 (34.5)2.38Significant DIARRHOEA 03 (5.5)1.36Insignificant DYSPNOEA10 (30.3)9 (16.4)1.53Insignificant H/O FITS9 (27.3)6 (10.9)1.97Significant HYPOTENSION2 (6)1 (1.8)1.06Insignificant JAUNDICE8 (24.2)18 (32.7)0.84Insignificant TACHYPNOEA21 (63.6)14 (25.5)3.54Significant DEEP BREATHING11 (33.3)9 (16.4)0.793Insignificant DEHYDRATION17 (51.5)34 (61.8)0.947Insignificant 10

11. Comparison of clinical features of severe malaria in two age groups(contd) CLINICAL FEATURESUPTO 5 YEARS ABOVE 5 YEARS Value of ZCOMMENT UNABLE TO DRINK21(63.6)36(65.5)0.17Insignificant UNABLE TO SIT32(96.9)46(83.6)1.91Insignificant UNABLE TO LOCALIZE PAIN 18(54.6)33(60)0.51Insignificant ABNORMAL POSTURE7(21.2)3(5.5)2.25Significant ABSENT CORNEAL REFLEX 7(21.2)1(1.8)1.6Insignificant AGITATION2(6)4(7.3)0.22Insignificant OLIGURIA6(18.2)10(18.2)0Insignificant HEPATOMEGALY30(90.9)40(72.7)2.04Significant SPLENOMEGALY20(60.6)24(43.6)1.71Insignificant 11

12. Association of clinical features with outcome (contd on next page) FEATURESRECOV ERED DIEDTOTALChi- square value p-valueCOMMENT Tachypnoea + 1718 3711.7610.001Significant _ 449 51 Severe respiratory distres + 515 2023.9020.000Significant _ 5612 68 Icterus + 1214 269.3110.005Significant _ 4913 62 Hepato- Megaly + 5119 702.0150.165Significant _ 108 18 Spleno- megaly + 368 446.4650.020insignificant _ 259 44 12

13. Association of clinical features with outcome (contd) FEATURESRECOV ERED DIEDTOTALChi- square value p- value COMMENT Malarial hepatopathy + 7 11 18 9.852 0.003Significant _ 54 16 70 Severe anaemia + 35 6 41 9.295 0.003Significant _ 26 21 47 Hyperleucocyt osis + 13 10 23 2.397 0.187Insignificant - 48 17 65 Cerebral malaria + 22 24 46 20.932 0.000Significant _ 39 3 42 Hyperparasite mia + 15 7 22 0.026 1.000insignificant _ 12 5 17 13

14. Comparison of complications of severe malaria in two age groups FEATURESTOTAL NO %UPTO 5 YEARS ABOVE 5 YEARS Value of Z COMMENT Cerebral malaria 4652.312(36.4)36(65.5)2.66SIGNIFICANT Severe anemia 4045.519(57.6)21(38.2)1.77Insignificant Malarial hepatopathy 1819.35(15.2)13(21.8)0.94Insignificant Hypoglycemia 77.94(12.1)3(5.5)1.11Insignificant Acute renal failure 55.72(6.1)3(5.5)0.12Insignificant Prostration 55.72(6.1)3(5.5)0.12Insignificant 14

15. MORTALITY IN DIFFERENT COMPLICATIONS OF SEVERE MALARIA 15

16. Asociation of PEM with outcome p-value 0.001 (significant) PEMRECOVEREDDIEDTOTAL No PEM 23 (74%) 8 (25%) 31 Grade 1 & 2 PEM 35 (70%) 15(30%) 50 Grade 3 & 4 PEM 3 (42%) 4(58%) 7 16

17. Different laboratory parameters among outcome groups LAB PARAMETERSOUTCOMEMEANP-valueCOMMENTS Hemoglobin%Recovered 5.90.819Insignificant Died 6.0 TLC(/mm3)Recovered 105750.208Insignificant Died 12452 BLOOD SUGAR (mg%)Recovered 74.80.099Insignificant Died 63.9 UREA(mg%)Recovered 45.20.000Significant Died 105-9 CREATININE (mg%)Recovered 0.930.000Significant Died 0.43 17

18. Different laboratory parameters among outcome groups LAB PARAMETERSOUTCOMEMEANP-valueCOMMENTS Bilirubin(mg%)Recovered11.230.818INSIGNIFICANT Died12.35 SGPT(U/L)Recovered43.840.000SIGNIFICANT Died166.46 Parasite load(/mm3)Recovered1071300.533INSIGNIFICANT Died95433 18

19. Relation between SGPT and bilirubin levels in malarial hepatopathy TOTAL BILIRUBIN Serum SGPT levels (U/L) MINIMUMMAXIMUMMEANSTANDARD DEVIATION <10 mg% 22 298115.4 90 >10 mg% 88 295202.4 75 19

20.  Severe malaria common > 5 years  Cerebral malaria and severe anaemia - most common presentations  Cerebral malaria more common > 5 years  Acute renal failure and hepatopathy – fairly common complications.  Cerebral malaria –the most common underlying cause of death. 20

21.  Respiratory distress occurred even in absence of pneumonia, cardiac failure and severe anemia.  Metabolic acidosis as a cause needs further evaluation  Malnutrition- a significant contributor to poor outcome.  Hyperparasitaemia did not influence the outcome of severe malaria in children. 21

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