Risk
stratification and mortality prediction in Falciparum Malaria
Khadanga S1
1Dr. Sagar Khadanga. Assistant Professor, Department of
General Medicine, AIIMS, Bhopal, Madhya Pradesh, India.
Address for
correspondence: Dr. Sagar Khadanga, E mail-
sagarkhadanga@yahoo.com
Abstract
Falciparum malaria has remained an important public health problem in
India over the years. WHO enumerates a list of complications to
diagnose severe falciparum malaria which was initially provided in 1990
and then revised in 2000. But the importance and prognosis of each
complication has not been assigned. Various strategies have been
employed for risk stratification in falciparum malaria by various
authors in different parts of world. Here we would like to discuss the
available literatures from India and some accomplished western
literatures to prognosticate severe falciparum malaria patients.
Keywords:
Falciparum malaria, Cerebral malaria, Glasgow coma scale, Jaundice,
Renal failure.
Introduction
Malaria is an important cause of morbidity and mortality in both
children and adults all over the world. More than two third of total
malaria cases are reported from Africa and South East Asian Region. Of
the 34 million reported cases of malaria in South East Asian Region,
India reports approximately two-third of all confirmed cases. In India
5 states account for more than 60% of these cases: Odisha,
Chhattisgarh, Madhya Pradesh, Jharkhand and West Bengal [1]. Around 50%
of the total malaria cases reported in India are due to Plasmodium
falciparum [2]. There was a need to identify the severe cases in
falciparum malaria where the mortality is high. WHO in 1990 published
the criteria to identify the severe cases [3]. But the importance of
each of the complication was not addressed and the clinicians faced
great difficulties in day today practice. So the clinicians all over
the world tried to formulate something which can address this problem
better. In 2000 WHO again published the guidelines to identify severe
falciparum malaria with some modification but the problem remained as
it was [4]. There are lots of researches regarding the prognostication
of severe falciparum malaria. Some has been too simple based on
clinical parameters only and some are more really complex requiring
sophisticated laboratory. Some of them have been validated by other
authors in different patient profile and many of them are not validated
by others. We will discuss here some of the easy to use literatures
from India and abroad which can influence our clinical practice.
Malaria Severity
Assessment Score (MSA) for adults by Mishra et al [5]
The score is based on four parameters namely severe anemia, acute renal
failure, respiratory distress and cerebral malaria. Points are given to
each of the parameter and the final score is calculated adding all the
four points. Thus the Malaria Score for Adults (MSA) = 1(severe
anaemia) + 2 (acute renal failure) + 3(Respiratory distress) + 4
(cerebral malaria). The MSA ranges from 0 to 10. The mortality was 2%
for MSA 0 – 2; 10% for MSA 3–4, 40% for MSA
5–6 and
90% for MSA 7 or more. The sensitivity is claimed to be 89.9%,
specificity 70.6% and positive predictive value 94.1% when 5 is taken
as the cut off value by the original authors. This appears to be one of
the simplest method of risk stratification.
APACHE II by Wilairatana
et al [6]
APACHE-II (Acute Physiology and Chronic Health Evaluation) score is
more popularly applied in patients of acute critical illness. APACHE II
score is the sum of the acute physiology score (vital signs,
oxygenation, laboratory values), Glasgow coma score, age and chronic
health points. Wilairatana et al in Bangkok, Thailand applied this
score to stratify the prognosis in patients of cerebral malaria. With
the cutoff point at a score of 24, the APACHE-II stratified the
patient’s mortality outcome with 95.8% accuracy. This appears
to
be most sensitive but with low specificity.
Clinical Scoring Index by
Teano R et al [7]
Teano R et al. proposed a Clinical Scoring Index for predicting outcome
in cerebral malaria with a possible score of 0-14. Level of
consciousness, multiple convulsion, labored respiration, circulatory
collapse and abnormal bleeding were the parameters taken for
calculating the score. With an optimum score of 7, it could predict the
mortality with a sensitivity of 92% and specificity of 95%.
Malaria Severity Score by
Mohapatra MK et al [8]
The authors devised Malaria Severity Score for severity assessment and
risk prediction of hospital mortality for falciparum malaria in adults.
There is a score for each organ dysfunction according to its severity
level and for each score there is a probability of mortality
(table-2,3). This appears to be a very good risk stratification scoring
system but it can have observer bias and a bit cumbersome to remember
for day to day practice.
GCBRS score by Mohapatro
BN et al [9]
There are five parameters and the initial alphabet of each parameter
are given the pneumonic of GCRBS. Glasgow coma score (GCS<11),
Creatinine (>3mg/dl), Respiratory rate (>24per minute),
Bilurubin
(>10 mg/dl) and Systolic BP (<90 mmHg) are taken into
account.
Out of these parameters, three can be identified at bedside and rest
two requires simple biochemical analysis. The GCRBS score has a
possible score of 0-10. Higher the score poorer is the
outcome.
At a cutoff score of 5 the prediction of mortality has a sensitivity of
85.3% and specificity of 95.6%. The greatest advantage of this scoring
system is that all the parameters are objective and has very minimal to
none observer bias (Table-4).
Conclusion
Risk stratification and mortality prediction in severe falciparum
malaria is the need of the hour. Of the above mentioned parameters any
one of the scoring system can be applied and none has a clear cut
advantage over the other. The GCRBS score seems to a very good working
tool as it is very easy to calculate, easy to remember and has been
developed in India. But it has to stand tall over the period of time
and has to be validated in different groups of patients.
Gohiya P[10] et al in this issue assessed prognostic indicators in
falciparum malaria. Biochemical parameters are also very useful in
addition to clinical symptoms & signs.
References
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How to cite this article?
Khadanga S. Risk stratification and mortality prediction in Falciparum
Malaria. Int J Med Res Rev 2014;2(3): 176-177.doi:10.17511/ijmrr.2014.i03.01