Severe Malaria in Neonates Masquerading as Septicaemia

Abstract

Background: Malaria was once thought to be rare in the neonatal period, especially in neonates of semi-immune mothers in holoendemic areas. As a result, ill neonates admitted to newborn special care units are often presumed to have neonatal sepsis. Consequently, blood films for malaria parasites are not routinely included in the sepsis screening protocol for such neonates. Objective: To highlight the manifestations of, and the significant morbidity associated with malaria in the newborn. Patients and Methods: In a prospective study, all consecutive term neonates admitted for presumed sepsis during a five-month rainy season period (April to August 2002) to the Ebonyi State University Teaching Hospital, Abakaliki period were investigated for septicaemia and malaria. Septicaemia was diagnosed by positive blood culture, while malaria parasitaemia was diagnosed on Giemsa stained blood smears. Results: Eighty four neonates were screened for sepsis and malaria parasitaemia during the study period. Out of this number, 28 (33.3 percent) had positive blood smears for malaria parasites alone, 10 (11.9 percent) had septicaemia alone, while four neonates (4.8 percent) had both malaria and septicaemia. Plasmodium falciparum was found in all positive blood smears. Twenty-four (75.0 percent) of the 32 neonates with positive malaria parasitaemia had congenital malaria, while the remaining eight (25 percent) most probably had acquired malaria. None of the neonates had transfusional malaria. Parasite densities were uniformly low. Infected neonates weighed 230g less than the non-infected (p< 0.005). Babies of primiparae were infected with malaria parasite in significantly greater proportion than those of the multiparae (p< 0.01). The presenting features in the 28 babies with neonatal malaria alone, included fever in 24 (85.7 percent), refusal of feeds in 23 (82.1 percent), respiratory distress in 19 (67.9 percent) and jaundice in 15 (53.6 percent). The features in the 10 babies with septicaemia alone, included refusal of feeds in 10 (100.0 percent), respiratory distress in 10 (100.0 percent), jaundice in 10 (100.0 percent) and fever in five (50.0 percent). Fever was significantly more prevalent in neonatal malaria than in septicaemia (p<0.05). Maternal weekly pyrimethamine prophylaxis appeared to be effective in preventing infection as 28 (35.4 percent) of the 79 neonates whose mothers had prophylaxis had parasitaemia compared with four (80.0 percent) of the five neonates whose mothers who did not (p< 0.05). Good clinical response to chloroquine sulphate was recorded in 32 (86.5 percent) of 37 babies. Six (7.1 percent) other neonates with neither septicemia nor malaria responded to anti-malarial trial. One neonate died of malaria. Conclusions: These data show that malaria can cause significant morbidity and even mortality in neonates, with its clinical signs being similar to that of neonatal sepsis. A high index of suspicion is therefore, required for the diagnosis which should be considered as a possibility in critically ill neonates in malarious areas, despite regular maternal anti-malarial prophylaxis with pyrimethamine. Initial work-up for presumed neonatal sepsis in such areas should routinely include blood film for malaria parasites. Key words: malaria, newborn, septicaemia