Table 1 Indicators of severe malaria and poor prognosis

Manifestation

Features

Cerebral malaria

Unrousable coma not attributable to any other cause, with a Glasgow Coma Scale score ≤ 9. Coma should persist for at least 30 min after a generalized convulsion

Severe anemia

Hematocrit <15% or hemoglobin < 50 g/l in the presence of parasite count >10 000/μl

Renal failure

Urine output <400 ml/24 hours in adults (<12 ml/kg/24 hours in children) and a serum creatinine>265 μmol/l (> 3.0 mg/dl) despite adequate volume repletion

Pulmonary edema and acute respiratory distress syndrome

The acute lung injury score is calculated on the basis of radiographic densities, severity of hypoxemia, and positive end-expiratory pressure [26]

Hypoglycemia

Whole blood glucose concentration <2.2 mmol/l (<40 mg/dl)

Circulatory collapse (algid malaria)

Systolic blood pressure <70 mmHg in patients > 5 years of age (< 50 mmHg in children aged 1–5 years), with cold clammy skin or a core-skin temperature difference >10°C

Abnormal bleeding and/or disseminated intravascular coagulation

Spontaneous bleeding from gums, nose, gastrointestinal tract, or laboratory evidence of disseminated intravascular coagulation

Repeated generalized convulsions

≥ 3 convulsions observed within 24 hours

Acidemia/acidosis

Arterial pH <7.25 or acidosis (plasma bicarbonate <15 mmol/l)

Macroscopic hemoglobinuria

Hemolysis not secondary to glucose-6-phosphate dehydrogenase deficiency

Added World Health Organization criteria from 2000 [12]

Impaired consciousness

Rousable mental condition

Prostration or weakness

Hyperparasitemia

> 5% parasitized erythrocytes or > 250 000 parasites/μl (in nonimmune individuals)

Hyperpyrexia

Core body temperature >40°C

Hyperbilirubinemia

Total bilirubin >43 μmol/l (> 2.5 mg/dl)