Brainstem auditory evoked potentials and somatosensory evoked potentials in cerebral malaria--a prognostic significance

OBJECTIVE

To study the changes in brainstem auditory evoked potentials (BAEPs) and somatosensory evoked potentials (SSEPs) in cerebral malaria and to see their prognostic significance.

METHODS

BAEPs and right median nerve SSEPs were performed in 25 adult patients of strictly defined cerebral malaria in acute stage in a semi-dark, sound proof chamber on four channel computerized multi-basis OTE-Biomedica machine in department of neurology, SP Medical College, Bikaner.

RESULTS

The abnormalities of BAEPs were delayed peak latency of wave III in 13/25 (52%) and wave V in 20/25 (80%) patients and delayed interpeak latencies (IPLs) of wave I-III in 9/25 (36%), wave I-V in 15/25 (60%) and wave III-V in 12/25 (48%) patients. In SSEPs delayed N20 was seen in 11/25 (44%); delayed IPLs of N13-N20 (central conduction time; CCT) in 12/25 (48%) patients. Distorted N20 was recorded in 12/25 (48%) patients. Both N13-N20 IPLs in SSEPs and wave III-V IPLs in BAEPs were delayed in five patients and all of them expired. Delayed N13-N20 with normal III-V IPLs was present in seven patients and two of them died, whereas delayed III-V IPLs with normal N13-N20 was present in seven patients, and one of them expired. In remaining six patients both the parameters were normal and one of them died.

CONCLUSIONS

The values of BAEPs and SSEPs were abnormal in patients of cerebral malaria and it was observed that BAEPs/SSEPs alone was not useful for predicting the outcome of coma, whereas abnormalities in both was predictive of worst prognosis. The changes in evoked potentials (BAEPs and SSEPs) could be due to either interruption of conduction in central pathways because of structural changes due to petechial hemorrhages and malarial granuloma at multiple levels in the brain including brainstem or due to metabolic abnormalities.

Mortality trends in falciparum malaria--effect of gender difference and pregnancy

Falciparum malaria in pregnancy is a significant health problem in India. Pregnant women constitute an important high risk group for malaria infection which may cause abortions, stillbirths, intra-uterine growth retardation (IUGR) and premature labour. In this hospital based study on 602 admitted patients of falciparum malaria which included 314 males, 243 non-pregnant females and 45 pregnant females, there was significantly increased mortality rate in females (18.4%) in comparison to males (7.64%, p < 0.001). The mortality rate was highly significant in pregnant females (37.77%) in comparison to non-pregnant females (14.81%) and males (7.64%; p < 0.001). Severe anaemia with Hb < 5 gm% was observed more commonly in pregnant patients (20.0%) in comparison to non-pregnant patients (4.11%). Incidence of malaria infection was more in primi gravida and second gravida. Pregnancy related complications in the form of preterm live births, intra-uterine death (IUD), still births and abortions were more in primi parous than multiparous patients. As the pregnancy is associated with increased incidence and adverse outcome of P.falciparum malaria infection, chemoprophylaxis should be made an integral part of antenatal care along with antianaemia therapy to reduce the risk of serious maternal and fetal complications.

Ophthalmoscopic abnormalities in adults with falciparum malaria

We studied 424 adults with falciparum malaria admitted over 28 months. They were divided into three groups: cerebral malaria (n = 214); severe non-cerebral malaria (n = 58); and uncomplicated malaria (n = 152). Fundus examination was done daily from admission to discharge, and weekly thereafter in those with persistent changes. All patients were treated by a protocol based on WHO guidelines. Ophthalmoscopic abnormalities were: retinal haemorrhages, 40 (9.43%) (25 cerebral malaria, 10 severe non-cerebral and five uncomplicated malaria); papilloedema, 17 (7.94%) cerebral malaria and two uncomplicated malaria; blurring of disc margins, 25 (11.68%) cerebral and seven non-cerebral; retinal oedema, six (2.80%) cerebral and five non-cerebral malaria; disc pallor, five patients all with cerebral malaria; vitreous haemorrhage and hard exudate in one patient each, both cerebral malaria. Retinal haemorrhage was associated with cerebral malaria and severe non-cerebral malaria, especially with severe anaemia (p < 0.001), as compared to uncomplicated malaria (p < 0.01). The association of papilloedema and cerebral malaria was highly significant compared to severe non-cerebral malaria (p < 0.001). None of these findings was associated with statistically significant mortality, except disc pallor in cerebral malaria (p < 0.05).

Importance of blood glucose level at the time of admission in severe and complicated malaria

A prospective study of blood glucose level at the time of admission was done on 532 cases of severe and complicated malaria admitted in classified malaria ward at PBM Hospital, Bikaner. Eleven patients had blood glucose level < 40 mg% (< 2.2 mmol/L) and all were unconscious with diagnosis of cerebral malaria. Four patients became conscious with i.v. infusion of 25% dextrose only without receiving any specific antimalarial treatment. Recognition of these patients of "falciparum malaria with hypoglycaemia" by blood glucose estimation at the time of admission can significantly affect the ultimate outcome. The mortality trend was more in patients having blood glucose level < 40 mg% (< 2.2 mmol/L) in comparison to group of patients having blood glucose level between 41 to 60 mg% (2.2 to 3.3 mmol/L) and was least in those having blood glucose level > 60 mg% (> 3.3 mmol/L).

Falciparum malaria and pregnancy

Falciparum malaria in pregnancy is a significant health problem in India. Pregnant women constitute an important high risk group for malaria infection which may cause abortion, still births, intra uterine growth retardation (IUGR), and pre-mature labour. Two hundred eighty-eight admitted female patients of falciparum malaria were included in the study out of which 45 were pregnant. The mortality rate was highly significant in pregnant females (37.77%) in comparison to non-pregnant females (14.81%); (p < 0.001). The incidence of various pernicious syndromes including cerebral malaria, severe anaemia (Hb < 5 g%) hepatic and renal failure were more in pregnant females in comparison to non-pregnant females. The incidence of infection was higher among primigravida and second gravida 30/45 (66.66%) as compared to multigravida 15/45 (33.33%) and the greater incidence of infection was seen during 14-28 wk of gestation 23/45 (51.11%). Pregnancy related complications in the form of preterm live birth (20%). Intra uterine death (IUD 31.11%), still births (13.33%) and abortions (11.11%) were more pronounced in primiparous women as compared to multiparous. Weight of placenta in majority of patients ranged between 200-400 g (22/31; 70.96%). Normal pregnancy continued in only 11 out of 45 pregnant females, out of which seven had low birth weight body (63.63%). As the pregnancy is associated with increased incidence and adverse outcome of falciparum malaria infection, chemoprophylaxis should be made an integral part of antenatal care along with antianaemic therapy to reduce the risk of serious maternal and fetal complications.

Exercise induced proteinuria as an early indicator of diabetic nephropathy

Diabetic nephropathy is a life threatening microvascular complication of diabetes characterized by presence of proteinuria and progressive impairment of renal function. This study was carried out on 25 patients of diabetes mellitus and 25 healthy individuals who served as controls. All the persons were asked to perform certain programmed amount of exercise and protein excretion rates were measured in urine collected over following three periods: just before exercise, just after exercise and one hour post exercise. It was observed that basal urinary protein excretion rate as well as exercise induced urinary protein levels were significantly higher in diabetics than in control (p < 0.001). Values were significantly higher in uncontrolled diabetes as compared to those with good metabolic control. Urinary protein values were also related to the duration of diabetes. Higher values were observed in patients having diabetes of more than 5 years as compared to those with less than 5 years duration. This test is good and easy to perform for early detection and management of diabetic nephropathy which is essential to reduce long term morbidity and mortality in diabetics.