Correlation between malarial Retinopathy and diagnosis of Cerebral Malaria in Comatose children admitted at Webuye sub County Hospital

Abstract

Background: Malaria is a common cause of morbidity in children. Cerebral malaria accounts for more than half of the children admitted in coma. In malaria endemic areas, parasitemia in a child with coma may not necessarily mean that cerebral malaria is the cause of the coma. Malarial retinopathy, detected by fundoscopy, is a “signature” of malaria that can confirm if malaria is the cause of coma(Koram K.A and Molyneux M.E, 2007). Objective: To identify the retinal findings of children admitted with coma at Webuye sub county Hospital and describe their clinical associations. Study design and methodology: The study was carried out at Webuye sub county hospital. Children aged 9 months to 12 years admitted to Paediatrics ward in coma were recruited into the study after guardians gave written informed consent. The study design was cross sectional. Direct fundoscopy was done within 24 hours of admission after application of tropicamide 1%. The researchers doing fundoscopy were blinded to laboratory results of the children. Laboratory work up included blood slide for malaria parasites (Bs for Mps), cerebrospinal fluid analysis, random blood sugar, sickling test, and complete blood count. The Bs for Mps slides were re-read by another microscopist. Children were treated according to WHO and Ministry of Health protocols. Data was collected using pretested interviewer administered questionnaire, entered into EPi-info v 10, cleaned and then exported to STATA v 10 where analysis was done using Fisher’s exact test. Descriptive statistics were used for continuous data while frequency listings were used for categorical variables. Results were considered significant at 0.05 α-level. Results: 51 comatose children were studied of whom 72.6% were males. Their median age was 5 years (IQR 3, 6). The mean temperature at admission was 38.00C. On fundoscopy, 33.3% of the children had normal retinal findings, 45.1% had retinal whitening, 25.5% had retinal haemorrhages, 13.7% had vessel changes, and 3.9% had papilledema while 3.9% had optic atrophy. Of the children with cerebral malaria, 69.5% had malaria retinopathy. Having malaria retinopathy correlated with laboratory diagnosis of malaria (p=0.005) and a final diagnosis of cerebral malaria (p=0.011). However, there was no correlation between malaria retinopathy and duration of coma (p=0.441) even though coma took longer to resolve in those who had malaria retinopathy. More children without retinopathy made complete recovery without obvious neurological sequalae (94.6% as compared to 81.3% in those with retinopathy). This rate of recovery however was not statistically significant (p=0.178). More children with retinopathy (18.8%) died as compared to those without retinopathy (5.3%). This was not statistically significant (p=0.178). Conclusions: Malaria retinopathy occurs in 69.5% of children with cerebral malaria. There was correlation between laboratory diagnosis of cerebral malaria and malaria retinopathy. Recommendation: There should be training for general clinicians to increase the use of direct fundoscopy to assist in diagnosis of malaria in children admitted in coma in malaria endemic area. The use of fundoscopy should be irrespective of their malaria parasitemic status. Limitation: No indirect fundoscopy was done in this study that could lead to missing of retinal signs in the peripheral retina