Abstract:
Objectives: Perturbed hemodynamic function complicates severe malaria. The Fluid
Expansion as Supportive Therapy trial demonstrated that fluid resuscitation, involving
children with severe malaria, was associated with increased mortality, primarily due to
cardiovascular collapse, suggesting that myocardial dysfunction may have a role. The
aim of this study was to characterize cardiac function in children with severe malaria.
Design: A prospective observational study with clinical, laboratory, and
echocardiographic data collected at presentation (T0) and 24 hours (T1) in children with
severe malaria. Cardiac index and ejection fraction were calculated at T0 and T1. Cardiac
troponin I and brain natriuretic peptide were measured at T0. We compared clinical and
echocardiographic variables in children with and without severe malarial anemia
(hemoglobin < 5 mg/dL) at T0 and T1.
Setting: Mbale Regional Referral Hospital.
Patients: Children 3 months to 12 years old with severe falciparum malaria.
Interventions: Usual care.
Measurements and main results: We enrolled 104 children, median age 23.3 months,
including 61 children with severe malarial anemia. Cardiac troponin I levels were
elevated (> 0.1 ng/mL) in n equals to 50, (48%), and median brain natriuretic peptide
was within normal range (69.1 pg/mL; interquartile range, 48.4-90.8). At T0, median
Cardiac index was significantly higher in the severe malarial anemia versus nonsevere
malarial anemia group (6.89 vs 5.28 L/min/m) (p = 0.001), which normalized in both
groups at T1 (5.60 vs 5.13 L/min/m) (p = 0.452). Cardiac index negatively correlated
with hemoglobin, r equals to -0.380 (p < 0.001). Four patients (3.8%) had evidence of
depressed cardiac systolic function (ejection fraction < 45%). Overall, six children died,
none developed pulmonary edema, biventricular failure, or required diuretic treatment.
Conclusions: Elevation of cardiac index, due to increased stroke volume, in severe
malaria is a physiologic response to circulatory compromise and correlates with anemia.
Following whole blood transfusion and antimalarial therapy, cardiac index in severe
malarial anemia returns to normal. The majority (> 96%) of children with severe malaria
have preserved myocardial systolic function. Although there is evidence for myocardial
injury (elevated cardiac troponin I), this does not correlate with cardiac dysfunction.