Complications of malaria

1. Complications of Malaria Dr. Chandan N Intern, Department of Paediatrics MIMS, Mandya

2. Cerebral malaria Renal failure Non cardiogenic pulmonary oedema Hypoglycemia Acidosis Haematologic abnormalities Algid malaria

3. Chronic complications Tropical splenomegaly Quartan malarial nephropathy

4. Cerebral malaria It is a serious complication of Plasmodium falciparum infection. Manifests as diffuse symmetric encephalopathy. Common in children and non immune adults. Despite treatment fatality rate is ~20%. Long term sequelae is rare with appropriate treatment.

5. Pathogenisis Usually develops after several days after patient has become ill, but may develop suddenly. Occurs with parasitaemia >5%.

6. Late schizonts secretes protein on the on surface of RBCs Proteins cause aggregation of non infected RBCs and capillary endothelium in brain Capillary plugging Anoxia, ischemia and haemorrhage

7. Clinical features Decreased level of consciousness - Severity ranges from drowsiness and severe head ache to delirium, hallucinations, or deep coma. Fever of 106-108 o F Seizures Contracted or unequal pupils, retinal haemorrhages , papilloedema , discrete spots of retinal calcification may be seen.

8. Muscle tone may be either increased or decreased. Abdominal and cremasteric reflexes absent. Plantar reflex may be flexor or extensor. Hemiplegia Cortical blindness Cerebral palsy Deafness

9. Investigations Lumbar puncture - Increased pressure and proteins - Minimal or no pleocytosis - Normal glucose. EEG findings are non specific.

10. Treatment Intravenous artesunate is the treatment of choice for sever P. falciparum malaria. Artesunate 2.4mg/kg bw i.v or i.m . given.

11. Renal failure Is a common complication of severe P. falciparum malaria. Results from deposition of haemoglobin in renal tubules decreased renal blood flow acute tubular necrosis ARF Blackwater fever is a clinical syndrome which consists of severe haemolysis , haemoglobinuria and renal failure. Renal failure requires either peritoneal dialysis or hemodialysis.

12. Non cardiogenic pulmonary oedema It is a complication of severe P. falciparum malaria may occur with P. vivax also. Mortality is >80%. Pathogenesis of respiratory distress is unclear. It is aggravated by over hydration with IV fluids.

13. Hypoglycemia An important and common complication of severe malaria. Associated with poor prognosis. Hypoglycemia occurs due to failure of hepatic gluconeogenesis. Quinine and quinidine also aggravates hypoglycemia.

14. Acidosis Important cause of death from severe malaria. Occurs due to anaerobic glycolysis in tissues sequesterated by parasites interfere with microcirculation, hypovolemia , lactate production by parasites and failure of hepatic and renal lactate clearance.

15. Haematologic abnormalities Anemia - accelerated destruction of RBCs by spleen - ineffective erythropoiesis Thrombocytopenia . <5% patients may have significant bleeding due to DIC. Jaundice

16. Relative incidence of severe complications of Falciparum malaria Complication Non pregnant adults Pregnant Women Children Anemia + ++ +++ Convulsions + + +++ Hypoglycemia + +++ +++ Jaundice +++ +++ + Renal failure +++ +++ - Pulmonary oedema ++ +++ +

17. Chronic complications of malaria Tropical splenomegaly ( Hyperreactive Malarial Splenomegaly) : Chronic or repeated malarial infections produce hypergammaglobulinemia ; normochromic, normocytic anemia; and in certain situations, splenomegaly

18. Quartan Malarial Nephropathy Rarely seen in chronic or repeated infections with P. malariae . Histology shows focal or segmental glomerulonephritis with splitting of capillary membrane. It usually responds poorly to treatment with either antimalarial agents or glucocorticoids and cytotoxic drugs.

19. References Nelson’s Textbook of Paediatrics , 18 th Edition. Harrison’s Principles of Internal Medicine, 17 th Edition. Guidelines for the treatment of Malaria, Second edition, WHO 2010.

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