Defining Criteria

Finding

cerebral malaria (unrousable coma)

unrousable coma not attributable to any other cause in a patient with falciparum malaria. Coma should persist at least 30 minutes after a generalized convulsion to make the distinction from transient post-ictal coma.

severe normocytic anemia

normocytic anemia with hematocrit < 15% or hemoglobin < 5 g/dL in the presence of parasitemia > 10,000 parasites per µL. If microcytic indices seen, need to consider iron deficiency anemia,  thalassemia and hemoglobinopathy.

renal failure

urine output < 400 mL in 24 hours in adults, or 12 mL per kg in children, failing to improve after rehydration, and with serum creatinine > 265 µmol/L (3 mg/dL)

pulmonary edema, ARDS

hypoglycemia

whole blood glucose < 2.2 mmol/L (< 40 mg/dL)

circulatory collapse, shock

hypotension (systolic blood pressure < 50 mm Hg in children 1-5 years old; < 70 mm Hg in adults) with cold, clammy skin or a core-to-skin temperature difference > 10 °C

spontaneous bleeding. DIC

spontaneous bleeding from gums, nose, GI tract or other sites, with laboratory evidence of DIC

repeated generalized seizures

more than 2 observed seizures (>=3) within 24 hours despite cooling

acidemia or acidosis

arterial pH < 7.25, plasma bicarbonate < 15 mmol/L

malarial hemoglobinuria

need to exclude hemoglobinuria due to antimalarial medications and to G6PD deficiency

Additional Criteria

Finding

impaired consciousness but rousable

impaired consciousness less marked than unrousable coma, can localize a painful stimulus

prostration and extreme weakness

patient unable to sit or walk, with no other obvious neurological explanation

hyperparasitemia

very high parasite densities are associated with increased risk of severe disease but is affected by the immune status (more than 5% parasitemia in non-immune is serious, but may be well tolerated in semi-immune children); > 500,000 per µL

jaundice

total bilirubin > 50 µmol/L (> 3 mg/dL)

hyperpyrexia

rectal temperature > 40 °C

post-mortem evidence of severe malaria

neuropathologic evidence of venules and capillaries packed with erythrocytes containing malarial parasites