Abstract
BackgroundSevere malaria remains a major cause of death and morbidity amongst adults in the Asiatic tropics.MethodsA retrospective analysis of the clinical and laboratory data of 988 adult patients, hospitalized with Plasmodium falciparum malaria and prospectively recruited to malaria studies in western Thailand between 1986 and 2002, was performed to assess the factors associated with a fatal outcome. Different severity scores and classifications for defining severe malaria were compared and, using multiple logistic regression, simple models for predicting mortality developed.ResultsThe proportion of patients fulfilling the WHO 2000 definition of severe malaria was 78.1%, and their mortality was 10%. Mortality in patients given parenteral artesunate or artemether (16/317, 5%) was lower than in those given parenteral quinine (59/442, 13%) (P < 0.001). Models using parameter sets based on WHO 1990, 2000 and Adapted AQ criteria plus blood smear parasite-stage assessment gave the best mortality prediction. A malaria prognostic index (MPI), derived from the dataset using five clinical or laboratory variables gave similar prognostic accuracy.ConclusionsThe mortality of severe malaria in adults has fallen and the switch from quinine to artesunate has probably been an important contributor. Prognostic indices based on WHO 2000 definitions, and other simpler indices based on fewer variables, provide clinically useful predictions of outcome in Asian adults with severe malaria.
Highlights
Severe malaria remains a major cause of death and morbidity amongst adults in the Asiatic tropics
The malaria severity assessment score (MSA) score was defined as sum of 1 + 2 + 3 + 4, in which each variable was scored as 0 or 1, depending on its absence or presence, respectively [22]
Management The anti-malarial treatment regimens used in clinical studies in western Thailand changed over the 18 years as new anti-malarials were introduced and were: 1. Non-artemisinin-based parenteral treatment: Intravenous quinine dihydrochloride with or without a 20 mg salt/kg or 7 mg/kg loading dose followed by 10 mg/kg every 8 h followed by oral quinine salt 10 mg/kg every 8 h, combined, when the patient was able to take oral medication, with oral quinine alone or with oral tetracycline, doxycycline, mefloquine (alone or combined with sulphadoxinepyrimethamine (SP)) or single dose primaquine to give a total treatment course of 7 days
Summary
Years and studies Data from 988 adult (≥15 years) patients with asexual forms of P. falciparum present on peripheral blood slides, admitted to hospital with malaria and recruited to clinical research studies on the western border of Thailand between 1986 and 2002 were analysed. Patients were recruited at hospitals in Kanchanaburi (1986–1993; n = 571), Sangklaburi (1994–1995; n = 74), and Mae Sot (1995–2002; n = 343) and described in a series of papers [24]. Clinical and laboratory assessment As patients were recruited to a variety of studies, clinical and laboratory evaluations varied. All patients had a full history and examination performed and haematocrit and parasitaemia determined. Lumbar punctures were performed for the majority of patients with reduced GCS and cerebrospinal fluid cell, protein and glucose concentrations determined and Gram stains examined. Management The anti-malarial treatment regimens used in clinical studies in western Thailand changed over the 18 years as new anti-malarials were introduced and were: 1. Non-artemisinin-based parenteral treatment: Intravenous quinine dihydrochloride with or without a 20 mg salt/kg or 7 mg/kg loading dose followed by 10 mg/kg every 8 h followed by oral quinine salt 10 mg/kg every 8 h, combined, when the patient was able to take oral medication, with oral quinine alone or with oral tetracycline, doxycycline, mefloquine (alone or combined with sulphadoxinepyrimethamine (SP)) or single dose primaquine to give a total treatment course of 7 days
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