Severe vivax malaria: a prospective exploration at a tertiary healthcare centre in Southwestern India

Abstract

Plasmodium vivax is recognized to cause severe malaria and mortality. We aimed to determine the proportion of disease severity, the spectrum of complications, underlying non-infectious comorbidities and predictors of severity in monoinfection P. vivax malaria among adults at a tertiary healthcare centre in Southwestern India. A prospective cohort study was conducted among microscopically confirmed monoinfection P. vivax acute malaria patients aged, ≥18 years. Cases with pregnancy and concomitant febrile illnesses including mixed malaria were excluded. Cases were distinguished as either 'severe' or 'non-severe' P. vivax malaria as per the definitions laid by the World Health Organization. Of total 511 acute P. vivax cases studied, 23.9% (122/511) had severe malaria. The proportion of severity did not vary between microscopy alone and additional nPCR proved monoinfection P. vivax subgroups. There was no significant difference (p = 0.296) in the occurrence of non-infectious comorbidities among non-severe (9.0%, 35/389) and severe (12.3%, 15/122) vivax groups. Multiple complications despite early parasite clearance resulted in delayed casualty in two cases, indicating overall case fatality rate of 3/1000 cases. Age >40 years, rising respiratory rate, total bilirubin, serum creatinine and falling hemoglobin were the independent predictors of disease severity in this vivax malaria cohort. Total and direct bilirubin and serum urea had good discriminatory performance for severe vivax malaria. Total bilirubin should be considered as an important prognostic marker while managing P. vivax malaria. Patients with multiple complications must be treated cautiously as there may be delayed deterioration leading to mortality despite parasite clearance.

Keywords: Malaria; Plasmodium vivax; complicated malaria; severe malaria.

Figure 1.

Patient’s selection and study outcomes.

Figure 2.

Kaplan–Meier plot showing cumulative survival probability during hospitalization for non-severe and severe vivax groups.

Figure 3.

ROC curve depicting discriminatory efficacy of total bilirubin (AUC, 95% CI = 0.900, 0.853–0.946), direct bilirubin (AUC, 95% CI = 0.855, 0.798–0.912) and serum urea (AUC, 95% CI = 0.736, 0.674–0.797) for severe vivax malaria.