The bedside prognostic index of Molyneux et al can be used at the time of presentation to predict outcome in children with cerebral malaria (Plasmodium falciparum malaria with unrousable coma).
Adverse outcomes in severe cerebral malaria in small children:
(1) death
(2) residual neurological sequelae
Testing performed to generate bedside index at time of presentation:
(1) blood glucose
(2) parasitemia in peripheral blood
(3) white blood cell count
(4) age
(5) Blantyre coma scale, with other causes of coma other than malaria excluded
(6) corneal reflexes
(7) signs of decerebration
(8) monitoring for convulsions
|
Indicator |
Relative Risk of Death or Sequelae |
|---|---|
|
blood glucose <= 2.2 mmol/L |
6.25 |
|
parasitemia > 1 million ring forms per µL |
3.64 |
|
white blood cell count > 15 billion per L (> 15,000 per µL) |
3.19 |
|
age <= 3 years |
1.72 |
|
Blantyre coma scale = 0 |
5.99 |
|
absent corneal reflexes |
2.69 |
|
signs of decerebration (hypertonicity, posturing, or opisthotonos) |
1.91 |
|
witnessed convulsions |
1.38 |
|
Parameter |
Finding |
Points |
|---|---|---|
|
blood glucose |
> 2.2 mmol/L |
0 |
|
|
<= 2.2 mmol/L |
1 |
|
parasitemia |
<= 1 * 10^6 per µL |
0 |
|
|
> 1 * 10^6 per µL |
1 |
|
white blood cell count |
< 15 * 10^9/L |
0 |
|
|
>= 15 * 10^9/L |
1 |
|
age of the patient |
>= 4 year of age |
0 |
|
|
<= 3 years of age |
1 |
|
Blantyre coma scale |
> 0 |
0 |
|
|
0 |
1 |
|
corneal reflexes |
present |
0 |
|
|
absent |
1 |
|
signs of decerebration |
absent |
0 |
|
|
present |
1 |
|
witnessed convulsions |
absent |
0 |
|
|
present |
1 |
index =
= SUM(number of indicators present)
Additional parameters correlating with adverse outcome, but not readily available:
(1) elevated plasma alanine aminotransferase
(2) elevated plasma 5'-nucleotidase
(3) elevated plasma lactate
(4) elevated lactate in CSF
Interpretation:
• minimum index: 0
• maximum index: 8
• When the index is >= 4, the relative risk of death or sequelae is 8.40
• The positive predictive value of an index >= 4 for an unfavorable outcome is 83% and the sensitivity is 66% (adverse outcomes can occur at scores of 1,2 or 3; children with scores of 4 or 5 can recover without sequelae)
• No children with scores of 0 had an unfavorable outcome.
• All children with scores of 6, 7 or 8 had unfavorable outcomes.
Specialty: Infectious Diseases
