title: Clinical features of severe malaria associated with death: a 13-year observational study in the Gambia.
abstract: BACKGROUND
  Severe malaria (SM) is a major cause of death in sub-Saharan Africa. Identification of both specific and sensitive clinical features to predict death is needed to improve clinical management.
  
  
  METHODS
  A 13-year observational study was conducted from 1997 through 2009 of 2,901 children with SM enrolled at the Royal Victoria Teaching Hospital in The Gambia to identify sensitive and specific predictors of poor outcome in Gambian children with severe malaria between the ages 4 months to 14 years. We have measured the sensitivity and specificity of clinical features that predict death or development of neurological sequelae.
  
  
  RESULTS
  Impaired consciousness (odds ratio {OR} 4.4 [95% confidence interval {CI}, 2.7-7.3]), respiratory distress (OR 2.4 [95%CI, 1.7-3.2]), hypoglycemia (OR 1.7 [95%CI, 1.2-2.3]), jaundice (OR 1.9 [95%CI, 1.2-2.9]) and renal failure (OR 11.1 [95%CI, 3.3-36.5]) were independently associated with death in children with SM. The clinical features that showed the highest sensitivity and specificity to predict death were respiratory distress (area under the curve 0.63 [95%CI, 0.60-0.65]) and impaired consciousness (AUC 0.61[95%CI, 0.59-0.63]), which were comparable to the ability of hyperlactatemia (blood lactate>5 mM) to predict death (AUC 0.64 [95%CI, 0.55-0.72]). A Blantyre coma score (BCS) of 2 or less had a sensitivity of 74% and specificity of 67% to predict death (AUC 0.70 [95% C.I. 0.68-0.72]), and sensitivity and specificity of 74% and 69%, respectively to predict development of neurological sequelae (AUC 0.72 [95% CI, 0.67-0.76]).The specificity of this BCS threshold to identify children at risk of dying improved in children less than 3 years of age (AUC 0.74, [95% C.I 0.71-0.76]).
  
  
  CONCLUSIONS
  The BCS is a quantitative predictor of death. A BCS of 2 or less is the most sensitive and specific clinical feature to predict death or development of neurological sequelae in children with SM.
authors.affiliation: Malaria Programme, MRC Laboratories, Banjul, The Gambia.
authors.forename: Muminatou
authors.initials: M
authors.lastname: Jallow
authors.forename: Climent
authors.initials: C
authors.lastname: Casals-Pascual
authors.forename: Hans
authors.initials: H
authors.lastname: Ackerman
authors.forename: Brigitte
authors.initials: B
authors.lastname: Walther
authors.forename: Michael
authors.initials: M
authors.lastname: Walther
authors.forename: Margaret
authors.initials: M
authors.lastname: Pinder
authors.forename: Fatou
authors.initials: F
authors.lastname: Sisay-Joof
authors.forename: Stanley
authors.initials: S
authors.lastname: Usen
authors.forename: Mariatou
authors.initials: M
authors.lastname: Jallow
authors.forename: Ismaela
authors.initials: I
authors.lastname: Abubakar
authors.forename: Rasaq
authors.initials: R
authors.lastname: Olaosebikan
authors.forename: Aminata
authors.initials: A
authors.lastname: Jobarteh
authors.forename: David J
authors.initials: DJ
authors.lastname: Conway
authors.forename: Kalifa
authors.initials: K
authors.lastname: Bojang
authors.forename: Dominic
authors.initials: D
authors.lastname: Kwiatkowski
mesh_terms: D002675:Child, Preschool; D005260:Female; D005714:Gambia / Q000453:epidemiology; D006801:Humans; D008288:Malaria / Q000453:epidemiology / Q000401:mortality / Q000503:physiopathology*; D008297:Male