Utility of qSOFA and modified SOFA in severe malaria presenting as sepsis.

Prapit Teparrukkul,Gumphol Wongsuvan,Viriya Hantrakun,Arjen M Dondorp,Mallika Imwong,Nittaya Teerawattanasook,Nicholas Pj Day,Direk Limmathurotsakul,T Eoin West,Florian B Mayr

doi:10.1371/journal.pone.0223457

Abstract

Sepsis can be caused by malaria infection, but little is known about the utility of the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) and SOFA score in malaria. We conducted a prospective observational study from March 2013 to February 2017 to examine adults admitted with community-acquired infection in a tertiary-care hospital in Ubon Ratchathani, Northeast Thailand (Ubon-sepsis). Subjects were classified as having sepsis if they had a modified SOFA score ≥2 within 24 hours of admission. Serum was stored and later tested for malaria parasites using a nested PCR assay. Presence of severe malaria was defined using modified World Health Organization criteria. Of 4,989 patients enrolled, 153 patients (3%) were PCR positive for either Plasmodium falciparum (74 [48%]), P. vivax (69 [45%]), or both organisms (10 [7%]). Of 153 malaria patients, 80 were severe malaria patients presenting with sepsis, 70 were non-severe malaria patients presenting with sepsis, and three were non-severe malaria patients presenting without sepsis. The modified SOFA score (median 5; IQR 4–6; range 1–18) was strongly correlated with malaria severity determined by the number of World Health Organization severity criteria satisfied by the patient (Spearman’s rho = 0.61, p<0.001). Of 80 severe malaria patients, 2 (2.5%), 11 (14%), 62 (77.5%) and 5 (6%), presented with qSOFA scores of 0, 1, 2 and 3, respectively. Twenty eight-day mortality was 1.3% (2/153). In conclusion, qSOFA and SOFA can serve as markers of disease severity in adults with malarial sepsis. Patients presenting with a qSOFA score of 1 may also require careful evaluation for sepsis; including diagnosis of cause of infection, initiation of medical intervention, and consideration for referral as appropriate.

Highlights

Sepsis is a life-threatening acute organ dysfunction caused by a dysregulated host response to infection with any organism; including bacterial, fungal, viral and parasitic agents [1, 2]
From May 2015 to August 2016, 937 enrolled patients were sequentially tested for malaria infection using FilmArray platform; 25 (3%) were positive
She had PCR positive for malaria by the FilmArray platform, which was later confirmed as P. vivax (PV) infection by nested PCR assay. We identified another patient (39-year-old male) with blood film and nested PCR assay positive for Plasmodium falciparum (PF), who had a final diagnosis of both severe PF infection and dengue hemorrhagic shock

Summary

Introduction

Sepsis is a life-threatening acute organ dysfunction caused by a dysregulated host response to infection with any organism; including bacterial, fungal, viral and parasitic agents [1, 2]. The mechanisms that lead to life-threatening organ failure from malaria may differ from those of classic bacterial sepsis [6, 7]. A recent study showed that malaria patients with organ failure (defined as qSOFA 2) are at high risk of death [2]. The study found that patients presenting with a qSOFA score of 1 was associated with increased risk of death, an observation that may have important implications for triage in lowresource settings [2]

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Results

Conclusion