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Epidemics of malaria have occurred in highland areas of East Africa since the 1980s, but the clinical spectrum of severe malaria in these areas has not been described. Over a 17-month period from 2001 to 2002, we assessed 117 consecutive patients admitted to Kabale Hospital in highland Uganda who met the World Health Organization 2000 criteria for severe malaria. Sixty-six persons (56.4%) were age 5 years or older, and 51 (43.6%) were under 5 years of age. Fever, vomiting, and cough were the most frequent symptoms. Hepatomegaly and splenomegaly were infrequent. Prostration was the most frequent manifestation of severe malaria in children under 5 years of age (45.1%) and persons 5 years or older (65.2%), followed by respiratory distress (29.4%) and severe anemia (19.6%) in children under 5 years, and respiratory distress (15.2%) and impaired consciousness (13.6%) in persons 5 years or older. Strictly defined cerebral malaria was uncommon (3.4%). In a multivariate regression model, children under 5 years were more likely than persons 5 years or older to present with severe anemia (OR 5.2, 95% confidence interval [CI] 1.2–21.9) and respiratory distress (OR 3.5, 95% CI 1.3–11.1) and less likely to present with prostration (OR 0.3, 95% CI 0.1–0.7) and impaired consciousness (OR 0.2, 95% CI 0.0–0.9). In highland Uganda, severe malaria often occurs in persons older than 5 years of age. "Typical" signs like splenomegaly are frequently absent, prostration is the major manifestation, and other manifestations vary in frequency according to age.
Received November 5, 2004. Accepted for publication December 15, 2004.
Acknowledgments: We are indebted to the medical, nursing, laboratory, and records staff of Kabale Regional Referral hospital for their service in the recruitment, records, and management of patients, the study participants, and their parents/guardians.
Financial support: This study was supported by a Children’s Research Foundation Faculty Grant from Rainbow Babies and Children’s Hospital, Cleveland, Ohio.
Authors’ addresses: Richard Idro, Department of Pediatrics and Child Health, Makerere University Medical School/Mulago Hospital, P.O. Box 7051, Kampala, Uganda, Telephone: + 256-41-531875, Fax: + 256-41-530022. Edward Bitarakwate, Kabale Regional Referral Hospital, P.O. Box 7, Kabale, Uganda, Telephone: +256-486-22006, Fax: +256-486-22727. Sam Tumwesigire, Kabale Regional Referral Hospital, P.O. Box 7, Kabale, Uganda, Telephone: +256-486-22006, Fax: +256-486-22727. Chandy C. John, Rainbow Center for International Child Health, RBC 487, 11000 Euclid Ave., MS6008, Cleve-land, OH, 44113, Telephone: (216) 844 3645, Fax: (216) 844-8362, E-mail: chandy.john{at}case.edu.
Reprint requests: Chandy C. John, Rainbow Center for International Child Health, RBC 487, 11000 Euclid Ave., MS6008, Cleveland, OH, 44113, Telephone: (216) 844 3645, Fax: (216) 844-8362, E-mail: chandy.john{at}case.edu.
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