Safety of lumbar puncture in comatose children with clinical features of cerebral malaria

Christopher A Moxon; Lei Zhao; Chenxi Li; Karl B Seydel; Ian J MacCormick; Peter J Diggle; Macpherson Mallewa; Tom Solomon; Nicholas A Beare; Simon J Glover; Simon P Harding; Susan Lewallen; Sam Kampondeni; Michael J Potchen; Terrie E Taylor; Douglas G Postels

doi:10.1212/WNL.0000000000003372

Safety of lumbar puncture in comatose children with clinical features of cerebral malaria

Neurology. 2016 Nov 29;87(22):2355-2362. doi: 10.1212/WNL.0000000000003372. Epub 2016 Oct 28.

Authors

Christopher A Moxon¹, Lei Zhao¹, Chenxi Li¹, Karl B Seydel¹, Ian J MacCormick¹, Peter J Diggle¹, Macpherson Mallewa¹, Tom Solomon¹, Nicholas A Beare¹, Simon J Glover¹, Simon P Harding¹, Susan Lewallen¹, Sam Kampondeni¹, Michael J Potchen¹, Terrie E Taylor¹, Douglas G Postels²

Affiliations

¹ From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
² From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY. douglas.postels@ht.msu.edu.

Abstract

Objective: We assessed the independent association of lumbar puncture (LP) and death in Malawian children admitted to the hospital with the clinical features of cerebral malaria (CM).

Methods: This was a retrospective cohort study in Malawian children with clinical features of CM. Allocation to LP was nonrandom and was associated with severity of illness. Propensity score-based analyses were used to adjust for this bias and assess the independent association between LP and mortality.

Results: Data were available for 1,075 children: 866 (80.6%) underwent LP and 209 (19.4%) did not. Unadjusted mortality rates were lower in children who underwent LP (15.3% vs 26.7% in the no-LP group) but differences in covariates between the 2 groups suggested bias in LP allocation. After propensity score matching, all covariates were balanced. Propensity score-based analyses showed no change in mortality rate associated with LP: by inverse probability weighting, the average risk reduction was 2.0% at 12 hours (95% confidence interval -1.5% to 5.5%, p = 0.27) and 1.7% during hospital admission (95% confidence interval -4.5% to 7.9%, p = 0.60). Undergoing LP did not change the risk of mortality in subanalyses of children with severe brain swelling on MRI or in those with papilledema.

Conclusion: In comatose children with suspected CM who were clinically stable, we found no evidence that LP increases mortality, even in children with objective signs of raised intracranial pressure.

MeSH terms

Adolescent
Brain / diagnostic imaging
Child
Child, Preschool
Female
Hospitalization
Humans
Infant
Magnetic Resonance Imaging
Malaria, Cerebral / diagnostic imaging
Malaria, Cerebral / mortality*
Malaria, Cerebral / physiopathology
Malaria, Cerebral / therapy
Malawi / epidemiology
Male
Papilledema / complications
Papilledema / mortality
Papilledema / physiopathology
Papilledema / therapy
Propensity Score
Retrospective Studies
Risk
Severity of Illness Index
Spinal Puncture / adverse effects*

Abstract

MeSH terms

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