Progression of skeletal muscle damage during treatment of severe falciparum malaria

To assess the relationship between severity of malaria and progression of skeletal muscle damage during initial treatment, we studied 28 Thai adults with slide-positive falciparum malaria. Six had uncomplicated malaria (Group 1), 12 had severe non-cerebral malaria (Group 2) and ten had cerebral malaria (Group 3). There were no significant differences between baseline serum creatine kinase (CK) levels in the three groups (P=0.071). There was no change in serum CK during the first 48 h of treatment in Group 1 cases. In Group 2 patients, the median peak serum CK was nine times that at baseline while in Group 3, serum CK peaked at a median concentration 20 times that at presentation. In Groups 2 and 3, the peak serum CK occurred at least 24 h after presentation in more than half the patients, and was independent of intramuscular injections and convulsions during initial therapy. These longitudinal data suggest that: (i) severe falciparum malaria is associated with skeletal muscle damage that increases during initial therapy especially in patients with coma; (ii) the effect of other major treatment or infection-specific factors that are associated with muscle damage does not diminish this relationship; and (iii) cerebral malaria in combination with a high baseline and rising serum CK should pre-empt monitoring and management strategies aimed at preserving renal function including renal dialysis.