Burden, features, and outcome of neurological involvement in acute falciparum malaria in Kenyan children.
BACKGROUND
Plasmodium falciparum appears to have a particular propensity to involve the brain but the burden, risk factors, and full extent of neurological involvement have not been systematically described.


OBJECTIVE
To determine the incidence and describe the clinical phenotypes and outcomes of neurological involvement in African children with acute falciparum malaria.


METHODS
A review of records of all children younger than 14 years admitted to a Kenyan district hospital with malaria from January 1992 through December 2004. Neurological involvement was defined as convulsive seizures, agitation, prostration, or impaired consciousness or coma.


METHODS
The incidence, pattern, and outcome of neurological involvement.


RESULTS
Of 58,239 children admitted, 19,560 (33.6%) had malaria as the primary clinical diagnosis. Neurological involvement was observed in 9313 children (47.6%) and manifested as seizures (6563/17,517 [37.5%]), agitation (316/11,193 [2.8%]), prostration (3223/15,643 [20.6%]), and impaired consciousness or coma (2129/16,080 [13.2%]). In children younger than 5 years, the mean annual incidence of admissions with malaria was 2694 per 100,000 persons and the incidence of malaria with neurological involvement was 1156 per 100,000 persons. However, readmissions may have led to a 10% overestimate in incidence. Children with neurological involvement were older (median, 26 [interquartile range {IQR}, 15-41] vs 21 [IQR, 10-40] months; P<.001), had a shorter duration of illness (median, 2 [IQR, 1-3] vs 3 [IQR, 2-3] days; P<.001), and a higher geometric mean parasite density (42.0 [95% confidence interval {CI}, 40.0-44.1] vs 30.4 [95% CI, 29.0-31.8] x 10(3)/microL; P<.001). Factors independently associated with neurological involvement included past history of seizures (adjusted odds ratio [AOR], 3.50; 95% CI, 2.78-4.42), fever lasting 2 days or less (AOR, 2.02; 95% CI, 1.64-2.49), delayed capillary refill time (AOR, 3.66; 95% CI, 2.40-5.56), metabolic acidosis (AOR, 1.55; 95% CI, 1.29-1.87), and hypoglycemia (AOR, 2.11; 95% CI, 1.31-3.37). Mortality was higher in patients with neurological involvement (4.4% [95% CI, 4.2%-5.1%] vs 1.3% [95% CI, 1.1%-1.5%]; P<.001). At discharge, 159 (2.2%) of 7281 patients had neurological deficits.


CONCLUSIONS
Neurological involvement is common in children in Kenya with acute falciparum malaria, and is associated with metabolic derangements, impaired perfusion, parasitemia, and increased mortality and neurological sequelae. This study suggests that falciparum malaria exposes many African children to brain insults.
Idro
Richard
R
Centre for Geographic Medicine Research, Kenya Medical Research Institute/Wellcome Trust Research Labs, Kilifi, Kenya. ridro@kilifi.kemri-wellcome.org
Ndiritu
Moses
M
Ogutu
Bernhards
B
Mithwani
Sadik
S
Maitland
Kathryn
K
Berkley
James
J
Crawley
Jane
J
Fegan
Gregory
G
Bauni
Evasius
E
Peshu
Norbert
N
Marsh
Kevin
K
Neville
Brian
B
Newton
Charles
C
D000208:Acute Disease; D002648:Child; D002675:Child, Preschool; D017281:Cost of Illness; D005260:Female; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D007223:Infant; D007630:Kenya; D016015:Logistic Models; D016779:Malaria, Cerebral / Q000175:diagnosis / Q000453:epidemiology* / Q000503:physiopathology; D016778:Malaria, Falciparum / Q000175:diagnosis / Q000503:physiopathology*; D008297:Male; D010641:Phenotype; D012307:Risk Factors; D016019:Survival Analysis