Tropical Medicine and Infectious Disease Article Clinical Features and Mortality Associated with Severe Malaria in Adults in Southern Mauritania Boushab Mohamed Boushab 1, Mohamed Salem Ould Ahmedou Salem 2, Ali Ould Mohamed Salem Boukhary 2,3,4 , Philippe Parola 3,4 and Leonardo Basco 3,4,* 1 Department of Internal Medicine and Infectious Diseases, Kiffa Regional Hospital, Assaba, Mauritania; [email protected] 2 Unité de Recherche Génomes et Milieux, Faculté des Sciences et Techniques, Université de Nouakchott Al-Aasriya, Nouveau Campus Universitaire, BP 5026, Nouakchott, Mauritania; [email protected] (M.S.O.A.S.); [email protected] (A.O.M.S.B.) 3 Institut de Recherche pour le Développement (IRD), Aix-Marseille Université, IRD, AP-HM, SSA, VITROME, 13005 Marseille, France; [email protected] 4 Institut Hospitalo-Universitaire (IHU)-Méditerranée Infection, 13005 Marseille, France * Correspondence: [email protected] Abstract: Severe malaria in adults is not well-studied in Sahelian Africa. Clinical features and mortality associated with severe Plasmodium falciparum malaria in adult patients hospitalized in Kiffa, southern Mauritania, were analysed. Patients over 15 years old admitted for severe malaria between August 2016 and December 2019 were included in the present retrospective study. The World Health Organization (WHO) criteria were used to define severe malaria. The presenting clinical characteristics and outcome were compared. Of 4266 patients hospitalized during the study period, 573 (13.4%) had a positive rapid diagnostic test for malaria, and 99 (17.3%; mean age, 37.5 years; range 15–79 years; sex-ratio M/F, 2.1) satisfied the criteria for severe malaria. On admission, the following signs and symptoms were observed in more than one-fourth of the patients: fever (98%), impairment of consciousness (81.8%), multiple convulsions (70.7%), cardiovascular collapse (61.6%), respiratory distress (43.4%), severe anaemia ≤ 80 g/L (36.4%), haemoglobinuria (27.3%), and renal Citation: Boushab, B.M.; Ould Ahmedou failure (25.3%). Patients were treated with parenteral quinine or artemether. Fourteen (14.1%) patients Salem, M.S.; Ould Mohamed Salem Boukhary, A.; Parola, P.; Basco, L. Clinical died. Multiple convulsions, respiratory distress, severe anaemia, haemoglobinuria, acute renal failure, Features and Mortality Associated with jaundice, and abnormal bleeding occurred more frequently (p < 0.05) in deceased patients. Mortality Severe Malaria in Adults in Southern due to severe falciparum malaria is high among adults in southern Mauritania. An adoption of the Mauritania. Trop. Med. Infect. Dis. WHO-recommended first-line treatment for severe malaria, such as parenteral artesunate, is required 2021, 6, 1. https://dx.doi.org/10.3390/ to lower the mortality rate associated with severe malaria. tropicalmed6010001 Keywords: artesunate; drug resistance; malaria; quinine; rapid diagnostic test; Plasmodium falci- Received: 23 November 2020 parum; Sahel Accepted: 15 December 2020 Published: 22 December 2020 Publisher’s Note: MDPI stays neu- 1. Introduction tral with regard to jurisdictional claims in published maps and institutional Malaria is one of the major public health problems in Mauritania [1]. Plasmodium affiliations. falciparum infections occur mostly in the Sahelian south of the country, where transmission is seasonal (generally from July to October or November) and malaria represents the first cause of outpatient consultation (25%), hospitalization (35.5%), and mortality (39%) [2]. By contrast, Plasmodium vivax infections predominate in the Saharan northern region of the Copyright: © 2020 by the authors. Li- country, including Nouakchott, the capital city, and Atar, an oasis city [3,4]. censee MDPI, Basel, Switzerland. This Clinical manifestations of malaria disease vary between children and adults [5]. Signs article is an open access article distributed and symptoms in patients can range from mild febrile syndrome to life-threatening con- under the terms and conditions of the ditions with severe anaemia, pulmonary oedema, metabolic acidosis, acute renal failure, Creative Commons Attribution (CC BY) and/or cerebral malaria [6]. Malaria infection may also be asymptomatic in an unknown license (https://creativecommons.org/ proportion of human populations in an endemic area. On a global scale, a small proportion licenses/by/4.0/). Trop. Med. Infect. Dis. 2021, 6, 1. https://dx.doi.org/10.3390/tropicalmed6010001 https://www.mdpi.com/journal/tropicalmed Trop. Med. Infect. Dis. 2021, 6, x FOR PEER REVIEW 2 of 10 Trop. Med. Infect. Dis. 2021, 6, 1 and/or cerebral malaria [6]. Malaria infection may also be asymptomatic in an unknown2 of 10 proportion of human populations in an endemic area. On a global scale, a small propor- tion of malarial infections lead to severe and complicated malaria, mostly in African chil- drenof malarial [7]. The infections underlying lead tomechanisms severe and complicatedof pathogenesis malaria, are mostlypoorly inunderstood. African children Current [7]. therapyThe underlying of severe mechanisms malaria relies of pathogenesisprimarily on rapid are poorly parenteral understood. administration Current of therapy antima- of larialsevere drugs malaria and reliesintensive primarily supportive on rapid care. parenteral administration of antimalarial drugs andAlthough intensive supportivesevere malaria care. cases are commonly observed in the Sahelian regions of the country,Although there are severe no published malaria cases clinical are commonlystudies on observedsevere malaria in the in Sahelian Mauritanian regions adults, of the exceptcountry, for there a single are nocase published report from clinical Aioun studies El Atrouss on severe [8]. malariaThe aim in of Mauritanian the present adults,study wasexcept to describe for a single the caseepidemiological report from Aiounand clinical El Atrouss aspects [8 ].of The severe aim and of the complicated present study malaria was into Mauritanian describe the adults epidemiological in Kiffa, situated and clinical in southern aspects Mauritania, of severe and and complicated compare the malaria present- in ingMauritanian clinical manifestations adults in Kiffa, and situated clinical in outcome. southern Mauritania, and compare the presenting clinical manifestations and clinical outcome. 2. Patients and Methods 2. Patients and Methods 2.1. Study Site 2.1. Study Site Kiffa (16°37’N 11°24’W) is the third largest city of the country, located in the Assaba Kiffa (16◦37’N 11◦24’W) is the third largest city of the country, located in the Ass- region in southern Mauritania, approximately 600 km southeast of the capital city, Nouak- aba region in southern Mauritania, approximately 600 km southeast of the capital city, chott (Figure 1). According to the latest official population census in 2013, there were Nouakchott (Figure1). According to the latest official population census in 2013, there 325,896 inhabitants in the Assaba region and 50,208 inhabitants (20,632 children aged less were 325,896 inhabitants in the Assaba region and 50,208 inhabitants (20,632 children aged than 15 years old; 26,411 adults aged 15–59 years old; and 3165 seniors aged > 60 years less than 15 years old; 26,411 adults aged 15–59 years old; and 3165 seniors aged > 60 years old) in the city of Kiffa [9]. The mean minimum and maximum temperatures between old) in the city of Kiffa [9]. The mean minimum and maximum temperatures between January and December were 21.0 °C and 30.5 °C (range, 10.4–46.1 °C) in 2016, 23.1 °C and January and December were 21.0 ◦C and 30.5 ◦C (range, 10.4–46.1 ◦C) in 2016, 23.1 ◦C and 36.6 °C (range, 11.5–46.8 °C) in 2017, 17.6 °C and 32.1 °C (range, 9.9–47.1 °C) in 2018, and 36.6 ◦C (range, 11.5–46.8 ◦C) in 2017, 17.6 ◦C and 32.1 ◦C (range, 9.9–47.1 ◦C) in 2018, and 24.924.9 °C◦C and and 37.2 37.2 °C◦C (range, (range, 18–43 18–43 °C)◦C) in in 2019, 2019, respectively respectively [10]. [10]. The The total total annual rainfall waswas 339 339 mm, mm, 250 250 mm, mm, 327 327 mm, mm, and and 347 347 mm mm in in 2016, 2016, 2017, 2017, 2018, 2018, and and 2019, 2019, respectively. respectively. RainfallRainfall occurred occurred only only between between June June and and Septem Septemberber or or October October (peak (peak in in July July or August). FigureFigure 1. 1. MapMap showing showing the the location of the study sitesite (Kiffa)(Kiffa) inin southernsouthernMauritania. Mauritania. Previous Previous studies stud- ieson on severe severe malaria malaria were were conducted conducted in Kaedi in Kaedi and and Aïoun Aïoun El Atrouss El Atrouss [8,11 [8,11,12].,12]. Nouakchott Nouakchott is the is capital the capital city of Mauritania. city of Mauritania. 2.2. Patients A retrospective study was performed in adult patients with severe and complicated malaria hospitalized between August 2016 and December 2019 based on individual patient records, including socio-demographic information, clinical history, presenting signs and Trop. Med. Infect. Dis. 2021, 6, 1 3 of 10 symptoms, laboratory examinations, and outcome. Although a retrospective study design has several disadvantages, in the present study, the fact that clinical information was recorded by the same attending physician tends to reduce selection and information bias. Moreover, we considered the retrospective design to be more appropriate in a situation where reliable data were unavailable from an earlier study in the Mauritanian population. All malaria-infected patients with severe manifestations and without any concomitant chronic disease were hospitalized in the wards of the Department of Internal Medicine and Infectious Diseases of Kiffa Regional Hospital. This is the largest hospital outside the capital city of Nouakchott with a capacity of 150 beds. The hospital conducts an average of 43,000 medical consultations and 2700 surgical operations every year. About 8000 patients are hospitalized every year. Most patients in the eastern region of the country requiring tertiary care are referred to and hospitalized at Kiffa Regional Hospital.