Spectrum of malaria complications in an intensive care unit

Malaria remains a major health concern in tropical and subtropical countries. A large number of cases of malaria have been reported from the State of Orissa, India. Severe malaria cases are reported throughout the year, but they are more common during the high transmission season. The last decade has witnessed a changing pattern of presentations and complications across the country. Severe falciparum malaria is an important cause of multiple organ failure in Indian intensive care unit (ICU) patients.

All patients with severe falciparum malaria above the age of 14 years admitted to the ICU were included in this study. The clinical spectrum of severe falciparum malaria in a tertiary care level III ICU was analysed from December 1998 to June 2008. In all, there were 301 patients with severe malaria admitted to the ICU during that period.

Most patients (66.9 percent) had a history of fever for less than seven days. The age distribution of the patients was 38.24 +/- 14.24 years. The Sequential Organ Failure Assessment score at admission to the ICU was 10.44 +/- 4.26. The median duration of ICU stay was three days (range 0-15 days) and 42 percent of the patients required ventilator support. Approximately 48 percent and 42 percent of patients required blood component transfusion and renal replacement therapy, respectively. The rate of single organ involvement was relatively low and multi-organ dysfunction was very common. Jaundice with acute renal failure (ARF) was the most common presentation (13.28 percent), followed by cerebral malaria with jaundice and ARF (6.37 percent), and jaundice, ARF and acute respiratory distress syndrome (ARDS) (5.31 percent). The overall mortality rate was 35.4 percent. Multivariate logistic regression analysis was conducted to estimate the association of the complications with mortality. Shock, ARF, seizure and ARDS were associated with higher mortality.

Severe falciparum malaria is a common cause of multi-organ failure in the ICUs in eastern India. There has been no change in the pattern of presentations over the last ten years in the east Indian state of Orissa. Apart from early diagnosis and treatment, good supportive care is the mainstay for better outcome in these cases.