CHRONIC SALICYLATE POISONING AND SEVERE MALARIA

Background Salicylates continue to be marketed and to be used in devel oping countries as over-the-counter (OTC) antipyretics in children, wh ereas in developed countries they are no longer used in children becau se of safety concerns. The presenting signs of salicylate poisoning, e specially chronic (repeated administration of therapeutic or excessive doses for longer than 12 h), can include metabolic acidosis, hypoglyc aemia, lethargy, and coma and fits. These signs are also common in sev ere malaria in African children. Admission of two probable cases of ch ronic salicylate poisoning prompted us to look for other cases among c hildren presenting to our hospital in Kenya, apparently with severe ma laria. Methods All children admitted to Kilifi District Hospital betwe en July and September, 1994, who had a positive blood film for Plasmod ium falciparum, and one or more of coma, prostration, or respiratory d istress were eligible, As well as routine tests for malaria and routin e biochemistry, salicylate concentrations were measured, Management of children (aged 6 months to 10 years)in the community was assessed by a cross-sectional survey of 463 households and by interviews with moth ers 2 days after they had bought OTC drugs for a child with fever. Fin dings Data were available for 143 of 154 children with initial primary diagnoses of severe malaria. 129 (90%) had detectable (>1 mg/dL) sali cylate. Six of these had salicylate concentrations of 20 mg/dL or high er. All six had neurological impairment and metabolic acidosis and-fou r were, or became, hypoglycaemic. OTC drugs were the first line treatm ent in 188 (74%) of 254 fever episodes during the 2 weeks before the c ross-sectional survey, Of 250 mothers who bought drugs for a febrile c hild, 236 (94%) bought a preparation containing salicylates and 50 (21 %) gave a dose higher than the manufacturer's recommended maximum. Int erpretation These cases suggest that in some children salicylate poiso ning may cause or contribute to the development of metabolic acidosis and hypoglycaemia, complications of severe malaria associated with hig h mortality.