Early indicators of high disease severity in imported falciparum malaria and their implications for supportive therapy.

Abstract

In imported falciparum malaria various life-threatening complications involving multiple organ systems can ensue rapidly and unpredictably. Early recognition of high disease severity is mandatory to provide optimal care, thereby reducing mortality. However, validated tools allowing precise assessment of disease severity are unavailable for imported malaria. This study aimed to identify indicators of high disease severity apparent on admission. Fifty-four adult cases of severe imported falciparum malaria treated between 2001 and 2015 on various intensive care units of the Charité University Hospital, Berlin, were retrospectively grouped according to their admission coma-acidosis malaria (CAM) score. The association of sociodemographic and clinical parameters with disease severity was assessed by multivariable logistic regression. Nineteen female (35%) and 35 male (65%) patients (median age: 44 years) were enrolled. The admission CAM score was 0 in n=24, 1 in n=15, 2 in n=10, 3 in n=3, and 4 in n=2 subjects. Thus, 5 patients (9.3%) had a predicted mortality risk of >20%. Higher maximum heart rates (p=0.002), lower baseline haematocrit (p<0.001), increased oxygen demand (p<0.001), and infiltrates on the admission chest X-ray (p=0.019) were independently associated with higher disease severity in multivariable analysis. In addition to the prognostic key parameters metabolic acidosis and impaired consciousness reflected by the CAM score, symptoms of respiratory distress and shock as well as profound anaemia help identify patients with highest disease severity. These indicators may guide clinicians to prompt targeted interventions at the earliest possible stage and may thus help improving survival.