Acute encephalopathies in underfive children admitted in paediatric wards of Muhimbili National hospital Dar es Salaam Tanzania 2009

Abstract

Acute Encephalopathy (AE) due to Central nervous system infections are the common cause of non-traumatic altered level of consciousness in underfive children and has high mortality rate. Cerebral Malaria and Acute Bacterial meningitis are commonest documented causes and remains the leading cause of mortality with high case fatality rate. There is need to identify other possible causes and whether HIV has influenced their outcome, besides identifying risk factors in the outcome of AE in children. Objectives: To determine the cause of acute encephalopathy in children admitted in paediatric wards and risk factors for poor outcome. Methodology: Determination of causes and risk factors for poor outcome in a descriptive hospital based study of 107 consecutively enrolled children aged two to sixty months with altered level of consciousness. Cerebrospinal fluid for biochemistry and microbiology was obtained, blood for culture, malaria microscopy, random blood glucose, chemistry and HIV antibody test or HIV -DNA PCR when indicated was taken. Data were recorded on daily coma score and other clinical features, laboratory findings, underlying disease and the children outcome. Results: During this study, a total of 107 children aged 2 -59 months were recruited of whom, 55 (51.4%) were males. Thirty nine percent of children were admitted in their first three days of illness. Eighty four (78.5%) children received treatment prior admission. Acute bacterial meningitis was found in 44(41.12%) children while

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vii cerebral malaria was in 32(29.91%). Haemophilus influenzae was observed microscopically in 77.8% of children; however, the positive CSF culture was 3.7% of all children. Children below 12 months were 34 (32%) and they were more prone to ABM (50%) while those above 24 months were prone to CM (57.58%), so age had significant correlation with ABM and CM distribution (p=0.003). Approximately 10% of children were discharged with neurological sequelae. Mortality rate was 60.7% in this study. Unfavorable prognostic indicators were; duration of illness prior admission (OR 5.35; Cl 1.15-24.95), age less than 12 months (OR 4.08; Cl 1.51-10.91), deep coma on admission (OR 13.42; Cl 2.77-64.88), status epilepticus (OR 10.5; Cl 1.31-83.9) and abnormal posture (OR 26.43; Cl 3.40-205.60). Conclusion: The most common cause of acute encephalopathy is acute bacterial meningitis followed by cerebral malaria with a high mortality rate. Haemophilus influenzae has been the commonest cause of acute bacterial meningitis. The use of antimalarial and antibiotics prior to admission may have hampered the detection of organisms and hence underestimate the burden of cerebral malaria and bacterial meningitis as well as eo-morbidity. Recommendation: With high mortality rate in this study, a larger study should be conducted to establish factors both at the community and health facility level to speed up presentation and early treatment of children with acute encephalopathy