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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 3  |  Page : 124-128

A review of presentations and outcome of severe malaria in a tertiary hospital in northwestern Nigeria


1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Birnin Kudu, Jigawa, Nigeria
3 Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
4 Department of Surgery, Cardiothoracic Unit, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
5 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission13-May-2020
Date of Decision20-Jun-2020
Date of Acceptance21-Jul-2020
Date of Web Publication29-Oct-2021

Correspondence Address:
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano
Nigeria
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DOI: 10.4103/smj.smj_44_20

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  Abstract 


Background: Severe malaria is a major public health challenge and a leading cause of morbidity and mortality in tropical countries. Severe malaria is defined as life-threatening manifestation in the presence of asexual forms of Plasmodium falciparum in the peripheral blood; it is also caused by Plasmodium vivax and Plasmodium knowlesi. Materials and Methods: This was a 2-year point retrospective review of cases of severe malaria seen in the Emergency Pediatric Unit of Federal Medical Centre, Birnin Kudu, Jigawa state, between August and November, for each of the years 2016 and 2017. Results: Two hundred and fifty-seven cases of severe malaria were recorded during the study period: 106 (41.2%) cases in 2016 and 151 (58.8%) cases in 2017. There were 156 (60.7%) males and 101 (39.3%) females with a male-to-female ratio of 1.5:1. Their ages ranged from 0.3 to 14.0 years, with a mean age of 4.4 ± 3.6 years. Prostration was the most common form of severe disease; this was followed by multiple convulsion and severe malarial anemia. The year 2017 recorded more cases of severe malaria in all the age groups and majority of the cases were 5 years and below; and these observations were statistically significant for those with hypoglycemia (χ2 = 9.834, df = 2, P = 0.007) and hyperparasitemia (χ2 = 6.226, df = 2, P = 0.044). Majority of the subjects fitted with more than one form of severe malaria; most had two to three combinations. This observation was also statistically significant (χ2 = 12.950, df = 6, P = 0.042). Conclusion: Severe malaria remains a huge strain on the health system; prostration, multiple convulsion, and severe malaria anemia are the most common forms.

Keywords: Children, plasmodium falciparum, severe malaria, symptoms


How to cite this article:
Aliyu I, Ibrahim HU, Idris U, Akhiwu H, Ibrahim UA, Mohammed II, Michael GC. A review of presentations and outcome of severe malaria in a tertiary hospital in northwestern Nigeria. Sahel Med J 2021;24:124-8

How to cite this URL:
Aliyu I, Ibrahim HU, Idris U, Akhiwu H, Ibrahim UA, Mohammed II, Michael GC. A review of presentations and outcome of severe malaria in a tertiary hospital in northwestern Nigeria. Sahel Med J [serial online] 2021 [cited 2021 Nov 28];24:124-8. Available from: https://www.smjonline.org/text.asp?2021/24/3/124/329517




  Introduction Top


Severe malaria is a major public health challenge and a leading cause of morbidity and mortality in tropical countries.[1] Severe malaria is defined as life-threatening manifestation in the presence of asexual forms of Plasmodium falciparum in the peripheral blood; it is also caused by Plasmodium vivax and Plasmodium knowlesi.

However, in sub-Saharan Africa, plasmodium falciparum is the most implicated.[1] Delay in treatment of simple malaria and increased malaria parasitization are some of the risk factors for severe malaria. These manifestations include loss of consciousness, multiple convulsions, respiratory distress, passage of dark colored or bloody urine, hypoglycemia, metabolic acidosis, severe anemia, hyperbilirubinemia, hyperparasitemia, prostration, abnormal bleeding, shock, and/or renal failure; cerebral malaria is reported to account for most mortality associated with severe malaria.[2]

However, evolving evidences have increasingly implicated P. vivax as a cause of severe malaria and significantly contribute to mortality.[1],[3] Mixed infections of P. falciparum/P. vivax are associated with high case fatality rates ranging from 3% to 50% in African children.[3],[4],[5]

In areas of hyperendemicity, children under the age of 5 years and pregnant women are the most vulnerable group of individuals susceptible to severe malaria.[6],[7] These children commonly present with fever, paleness of the body, convulsion, impaired consciousness, and respiratory distress.[8] Diagnosis of severe malaria by the World Health Organization (WHO) is defined by standard criteria in the presence of Plasmodium species via direct microscopy using thick and thin blood films. Management of severe malaria is quite challenging and this requires the availability of trained personnel, cost-effective treatment, blood transfusion services, and integrated health-care system. Effective management includes early suspicion, prompt diagnosis, and appropriate use of antimicrobials as well as supportive care.[2],[9],[10]

There are geographic variations in the pattern of severe malaria; malaria is endemic in our setting, but the peak of the disease is often between August and November.[5] Furthermore, over the years, the age distribution of affected children has progressively included older age children.

Severe malaria remains a significant cause of childhood morbidity and mortality in sub-Saharan Africa,[4],[5] but there are few reports from northern Nigeria.[10] This study therefore seeks to determine the common types of severe malaria, their age distribution, and outcome seen in our health institution.


  Materials and Methods Top


This was a 2-year retrospective review of cases of severe malaria seen in the Emergency Pediatric Unit of Federal Medical Centre, Birnin Kudu, Jigawa state, between August and November, for the years 2016 and 2017. The files of affected cases were retrieved and relevant informations were extracted such as their age, sex, and diagnosis and investigations such as the packed cell volume, random blood sugar, electrolyte and urea, and their outcome.

Ethical considerations

Permission to carry out the study was obtained from the Research and Ethics Committee of Federal Medical Centre, Birnin Kudu, Jigawa state, before the commencement of this study.

Data management

The data collected were entered into SPSS version 16 (SPSS Inc. Chicago Illinois USA). Quantitative variables such as age, weight height, hematocrit level, and duration and number of symptoms were summarized using descriptive statistics such as mean and standard deviation. Qualitative variables such as sex, parental socioeconomic class, risk factors, and outcome were presented in frequencies and percentages. Chi-square test or Fisher's exact test (where necessary) was used to determine the statistical significance of the clinical profile and outcome in the subjects. P < 0.05 considered statistically significant set at 95% confidence interval.


  Results Top


Two hundred and fifty-seven cases of severe malaria were recorded during the study period: 106 (41.2%) cases in 2016 (of 400 admissions during the study period – 26.5%) and 151 (58.8%) cases in 2017 (of 420 admissions – 36%). There were 156 (60.7%) males and 101 (39.3%) females with a male-to-female ratio of 1.5:1. Their ages ranged from 0.3 to 14.0 years, with a mean age of 4.4 ± 3.6 years. The temperature ranged from 33.5°C to 40.7°C, with a mean temperature of 38.4°C ± 1.1°C.

Prostration was the most common form of severe disease; this was followed by multiple convulsion and severe malarial anemia [Table 1].
Table 1: Common forms of severe malaria in the study population

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The year 2017 recorded more cases of severe malaria in all the age groups, and majority of the cases were 5 years and below [Table 2].
Table 2: Age ranges of the study population

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[Table 3] shows that all forms of severe malaria were mostly seen in those who were 5 years and below; and these observations were statistically significant for those with hypoglycemia (χ2 = 9.834, df = 2, P = 0.007) and hyperparasitemia (χ2 = 6.226, df = 2, P = 0.044)
Table 3: Comparing the age ranges with the disease distribution

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[Table 4] shows that majority of the subjects fitted with more than one form of severe malaria; most had two to three combinations. This observation was statistically significant (χ2 = 12.950, df = 6, P = 0.042).
Table 4: Comparing the age ranges with cases with more than one form of cerebral malaria

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Most subjects were successfully discharged home with only five mortalities recorded (2 in 2016 and 3 in 2017 with a case fatality of 1.88% and 1.98% in 2016 and 2017, respectively).


  Discussion Top


Malaria is one of the most important diseases contributing to significant morbidity and mortality among children and pregnant women in low- and middle-income countries. A world malaria report by the WHO in 2016 estimated that 429,000 malaria deaths occurred worldwide in 2015 and most of these deaths (92%) were in sub-Saharan Africa.[6],[7],[8] P. falciparum causes responsible for 500 million global morbidities globally, with about 1%–4% of the cases considered severe enough to require inhospital management and administration of parenteral antimalarial drugs.[1],[11]

In Nigeria, severe malaria accounts for 25% infant mortality, 30% under-five deaths, and about 11% maternal deaths annually.[12] Edelu et al.[13] in a 1-year retrospective study from Enugu Southeast Nigeria reported respiratory distress, severe anemia, and prostration as the most common presentations of severe falciparum malaria with severe malarial anemia related to the age of the patient, a similar observation was noticed in our with prostration, multiple seizures, and severe anemia been the most common presentations. The same study also reported abnormal bleeding, renal failure, and shock as the least features of severe malaria; however, hypoglycemia was the least observed in our study. A cross-sectional study[14] of 98 pediatric patients in a tertiary hospital of northeastern Nigeria showed that there is slight male preponderance in severe malaria morbidity and a mean age of 4 years, a similar observation was made in this study and that of Imoudu et al.[14] in a study done in Azare, Bauchi state. Fever was the most common finding; the study also revealed that loss of consciousness, cough, breathlessness, and reduction in urine volume are significant related to age. Similar studies carried in Zaria,[15] northwestern Nigeria, among 12 adults recorded 3 (25%) deaths. In their study, headache and fever were the common presenting complaints, while pyrexia and coma were the frequent clinical signs. However, Orimadegun et al.[16] reported more cases of severe malaria anemia in their study in Ibadan, southwestern Nigeria.

There were multiple manifestations of severe malaria of up to five complications per patient in five of the study subjects and a case fertility rate of 1.96%; similarly, most subjects had more than one form of severe malaria, and a case fatality of 1.94% was documented in our study with cerebral malaria accounting for most of the deaths. Imoudu et al.[14] reported a higher case fatality rate of 8.2% with dehydration and coma, the most likely predictor of death. Similarly, Oyedeji et al.[17] in southwestern Nigeria reported a fatality rate of 10.3%. The lower fatality recorded in our facility may be related to early presentation of the patients to the hospital, and this was a period when free parenteral antimalarials were made available; therefore, early commencement of treatment may have also contributed to the better outcome observed. This also showed an increasing disease burden from 26.5% to 36%, which was similarly documented by Orimadegun et al.[16]


  Conclusion Top


Severe malaria still remains a Hugh public health concern; children under the age of 5 years are most venerable. Prostration, multiple convulsions, and severe anemia were the most common forms of severe malaria in our setting; however, the case fatality remained low in our study, unlike studies from the southwestern part of the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Manning L, Laman M, Law I, Bona C, Aipit S, Teine D, et al. Features and prognosis of severe malaria caused by Plasmodium falciparum, Plasmodium vivax and mixed Plasmodium species in Papua New Guinean children. PLoS One 2011;6:e29203.  Back to cited text no. 1
    
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World Health Organization. Severe Malaria. Trop Med Int Health 2014;19:7-131. Available from: https://www.who.int/malaria/publications/atoz/who-severe-malaria-tmih-supplement-2014.pdf. [Last accessed on 2020 Feb 17].  Back to cited text no. 2
    
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Price RN, Douglas NM, Anstey NM. New developments in Plasmodium vivax malaria: Severe disease and the rise of chloroquine resistance. Curr Opin Infect Dis 2009;22:430-5.  Back to cited text no. 3
    
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Marsh K, Forster D, Waruiru C, Mwangi I, Winstanley M, Marsh V, et al. Indicators of life-threatening malaria in African children. N Engl J Med 1995;332:1399-404.  Back to cited text no. 5
    
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Marsh K, Snow RW. Malaria transmission and morbidity. Parassitologia 1999;41:241-6.  Back to cited text no. 6
    
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Imananagha K. The presenting complaints of children with severe malaria. Ann Trop Med Public Health 2010;3:68-71.  Back to cited text no. 7
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World Health Organization. World Malaria Report. Geneva: World Health Organization; 2016. p. 1-24. Available from: https://apps.who.int/iris/bitstream/handle/10665/254912/WHO-HTM-GMP-2017.4-eng.pdf; jsessionid=6CF2B331D7A9BEFAF35B8C5057F7FE37?sequence=1. [Last accessed on 2020 Feb 18].  Back to cited text no. 8
    
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Sarkar PK, Ahluwalia G, Vijayan VK, Talwar A. Critical care aspects of malaria. J Intensive Care Med 2010;25:93-103.  Back to cited text no. 9
    
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von Seidlein L, Olaosebikan R, Hendriksen IC, Lee SJ, Adedoyin OT, Agbenyega T, et al. Predicting the clinical outcome of severe falciparum malaria in african children: Findings from a large randomized trial. Clin Infect Dis 2012;54:1080-90.  Back to cited text no. 10
    
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Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature 2005;434:214-7.  Back to cited text no. 11
    
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National Population Commission, National Malaria Control Programme, ICF International. Nigeria Malaria Indicator Survey 2010. Abuja, Nigeria: NPC, NMCP, and ICF International; 2012.  Back to cited text no. 12
    
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Edelu BO, Ndu IK, Igbokwe OO, Iloh ON. Severe falciparum malaria in children in Enugu, South East Nigeria. Niger J Clin Pract 2018;21:1349-55.  Back to cited text no. 13
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Imoudu IA, Ahmad H, Yusuf MO, Umara T, Oloriegbe YY. Clinical profile and outcome of paediatric severe malaria in a north-eastern Nigerian tertiary hospital. Int J Trop Dis Health 2017;28:1-9.  Back to cited text no. 14
    
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Ogoina D, Obiako RO. Clinical presentation and outcome of severe malaria in adults in Zaria, Northern Nigeria. Ann Afr Med 2012;11:245-6.  Back to cited text no. 15
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Orimadegun AE, Fawole O, Okereke JO, Akinbami FO, Sodeinde O. Increasing burden of childhood severe malaria in a Nigerian tertiary hospital: Implication for control. J Trop Pediatr 2007;53:185-9.  Back to cited text no. 16
    
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Oyedeji OA, Oluwayemi IO, Afolabi AA, Bolaji O, Fadero FF. Severe malaria at a tertiary paediatric emergency unit in South West Nigeria. Res J Med Sci 2010;4:352-6.  Back to cited text no. 17
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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