SEVERE TROPICAL MALARIA IN INTENSIVE-CARE - CLINICAL FINDINGS, THERAPY AND PROGNOSTIC FACTORS

In a retrospective study we analyzed the clinical and blood chemical d ata of 12 patients with severe tropical malaria in the intensive care units of the University Hospital Zurich and the Stadtspital Triemli, Z urich, between 1991 and 1994. None of the 12 patients had been exposed to malaria before or had taken drugs for chemoprophylaxis. 7 patients survived, 5 died from complications of malaria. According to the crit eria of severe tropical malaria defined by the WHO, the following path ological clinical and blood chemical parameters were noted on admissio n: cerebral coma (2/12); blood hemoglobin <5 g/d1 (0/12), <8 g/d1 (2/1 2); serum creatinine >265 mu mol/l (3/12); blood glucose <2.2 mmol/l ( 0/12); circulatory collapse/shock (0/12); bleeding/signs of disseminat ed intravascular coagulation in b laboratory tests (4/12); acidosis wi th pH <7.25 (1/12). Further signs of severe tropical malaria were: hyp erparasitemia >5% (9/12); qualitative and quantitative disturbances of consciousness (6/12); thrombocytopenia 30x10(9)/1 (9/12); hyponatriem ia 125-135 mmol/l(9/12), <125 mmol/l (2/12); rhabdomyolysis with creat ine kinase >1000 U/1 (4/12). The basic treatment consisted of parenter al quinine hydrochloride in all patients; doxycycline was added in 8 c ases, clindamycin in 3. Adjuvant therapy with desferrioxamin was given in 3 cases. 6 patients had exchange transfusions. Parasitemia. cleare d in all patients within 5 to 6 days. Later in the course, 5 patients developed acute respiratory distress syndrome, 6 required hemofiltrati on due to oliguria, and one. became comatose. Due to the limited numbe r of patients, a clear association of a single clinical or blood chemi cal parameter with the fatal outcome was not evident. In particular, n o correlation was found between the degree of parasitemia on admission or during therapy, nor did the stage of circulating intraerythrocytic parasites serve as a prognostic factor. We conclude that the outcome of a case of severe tropical malaria is difficult to predict on the ba sis of the clinical presentation on admission. Deterioration of pulmon ary and renal function can occur late in the course of the disease and is not associated with persistent circulating parasites.