Descriptive Acute Respiratory Distress Syndrome (ARDS) in adults with imported severe Plasmodium falciparum malaria: A 10 year-study in a Portuguese tertiary care hospital

Background Acute respiratory distress syndrome (ARDS) is a severe complication of malaria that remains largely unstudied. We aim to describe the development of ARDS associated with severe P. falciparum malaria, its management and impact on clinical outcome. Methods Retrospective observational study of adult patients admitted with severe P. falciparum malaria in an Intensive Care Unit (ICU) of a tertiary care hospital from Portugal from 2008 to 2018. A multivariate logistic regression analysis was used to identify factors associated with the development of ARDS, defined according to Berlin Criteria. Prognosis was assessed by case-fatality ratio, nosocomial infection and length of stay. Results 98 patients were enrolled, of which 32 (33%) developed ARDS, a median of 2 days after starting antimalarial medication (IQR 0-4, range 0-6). Length of stay in ICU and in hospital were significantly longer in patients who developed ARDS: 13 days (IQR 10-18) vs 3 days (IQR 2-5) and 21 days (IQR 15-30.5) vs 7 days (IQR 6-10), respectively. Overall case-fatality ratio in ICU was 4.1% and did not differ between groups. The risk of ARDS development is difficult to establish. Conclusion ARDS is a hard to predict late complication of severe malaria. A low threshold for ICU admission and monitoring should be used. Ideally patients should be managed in a centre with experience and access to advanced techniques.