Complications of Malaria

Dr. Chandan NIntern,

Department of PaediatricsMIMS, Mandya

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

Chronic complications

• Tropical splenomegaly• Quartan malarial nephropathy

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.

Pathogenisis

• Usually develops after several days after patient has become ill, but may develop suddenly.

• Occurs with parasitaemia >5%.

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

Clinical features

• Decreased level of consciousness - Severity ranges from drowsiness and severe head ache to delirium, hallucinations, or deep coma.• Fever of 106-108oF • Seizures• Contracted or unequal pupils, retinal

haemorrhages, papilloedema, discrete spots of retinal calcification may be seen.

• 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

Investigations

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

Treatment

• Intravenous artesunate is the treatment of choice for sever P. falciparum malaria.

• Artesunate 2.4mg/kg bw i.v or i.m. given.

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.

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.

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.

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.

Haematologic abnormalities

• Anemia - accelerated destruction of RBCs by spleen - ineffective erythropoiesis• Thrombocytopenia.• <5% patients may have significant bleeding

due to DIC.• Jaundice

Relative incidence of severe complications of Falciparum malaria

Complication Nonpregnant adults

Pregnant Women Children

Anemia + ++ +++

Convulsions + + +++

Hypoglycemia + +++ +++

Jaundice +++ +++ +

Renal failure +++ +++ -

Pulmonary oedema ++ +++ +

Chronic complications of malaria

• Tropical splenomegaly (Hyperreactive Malarial Splenomegaly) :

• Chronic or repeated malarial infections produce hypergammaglobulinemia; normochromic, normocytic anemia; and in certain situations, splenomegaly

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.

References

• Nelson’s Textbook of Paediatrics, 18th Edition.• Harrison’s Principles of Internal Medicine, 17th

Edition.• Guidelines for the treatment of Malaria,

Second edition, WHO 2010.

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