Comparison of quinine and rabeprazole with quinine monotherapy in the treatment of uncomplicated falciparum malaria

OBJECTIVE

This study was conducted to assess the effect of combination treatment of quinine and rabeprazole in the treatment of uncomplicated Plasmodium falciparum malaria.

METHODS

The study included 50 patients of uncomplicated P. falciparum malaria. Group 1 (25 patients) received quinine and placebo (Q+P) while Group 2 (25 patients) received quinine and rabeprazole (Q+R). Diagnosis was confirmed by peripheral blood film (PBF) and rapid diagnostic test (RDT). Temperature was recorded every 6 h. All patients were followed-up on Days 7, 14, 21, 28 for detailed clinical and parasitological examination.

RESULTS

A total of 20 patients in each group completed the treatment and followed-up for 28 days. While two patients in Group 1 (Q+P) and one patient in Group 2 (Q+R) were lost in follow-up; and seven (Q+P = 4, Q+R =3) patients were withdrawn from the study. Fever clearance time (FCT) of the two groups was also almost similar (Group 1 : 2 = 52.8 : 51.3 h). No statistically significant difference was observed in early treatment failure (ETF) either of the groups. None of the patients in both the groups showed late clinical failure (LCF) or late parasitological failure (LPF). However, there was a significant difference in the parasite clearance rates of the two groups (p<0.05).

CONCLUSION

The study results suggest that addition of rabeprazole to quinine regimen resulted in an increase in the parasite elimination rate, which may be helpful in reducing the duration of treatment and increasing patient compliance.

Effects of Plasmodium falciparum infection on the pharmacokinetics of quinine and its metabolites in pregnant and non-pregnant Sudanese women

PURPOSE

The study aimed to investigate the effects of Plasmodium falciparum infection on the pharmacokinetics of quinine and its metabolites in pregnant and non-pregnant Sudanese women.

METHODS

In a case-control study, nine pregnant and eight non-pregnant Sudanese women infected with P. falciparum were treated with intramuscular artemether. Before being given artemether, they received a single dose of quinine hydrochloride as intravenous infusion. Blood samples were collected frequently and analysed for quinine and its metabolites (phase I). One week later (after clearance of parasitaemia) the quinine part of the protocol was repeated (phase II).

RESULTS

During phase I, the AUCs (mean ± SD) of quinine and its major metaboplite, 3-hydroxyquinine, in pregnant women were 428.2 ± 132.4 and 27.8 ± 14.1 μmol l(-1) h(-1) respectively. In non-pregnant women the AUCs of quinine and 3-hydroxyquinine were 517.8 ± 100.0 and 32.3 ± 15.3 μmol l(-1) h(-1). In pregnant women the mean (90% confidence interval) AUC ratios of phase I to phase II of quinine and 3-hydroxyquinine were 1.6 (0.61, 4.22) and 1.01 (0.18, 5.60). In non-pregnant women, the AUC ratios of phase I to phase II of quinine and 3-hydroxyquinine were 1.93 (1.74, 2.15) and 1.19 (0.95, 1.47).

CONCLUSIONS

Plasmodium falciparum infection significantly increased plasma concentration of quinine in non-pregnant women and showed the same trend in pregnant women.

Malaria in pregnancy: update on emergency management

BACKGROUND

Pregnancy complicates the diagnosis, treatment, and clinical course of malaria. This clinical problem may be encountered in emergency department patients due to international travel.

CASE REPORT

A primigravida woman at 20 weeks gestation presented to the Emergency Department with episodic fever, chills, headache, and nausea after travel to India and Asia. She had not taken malaria prophylaxis. After hospitalization, she developed acute respiratory distress syndrome and required intensive care management. Although she ultimately recovered from severe infection with Plasmodium vivax, she was not able to sustain her pregnancy and suffered a miscarriage.

CONCLUSION

This case illustrates the serious nature of malaria in the pregnant patient. For this high-risk group, there is an increased incidence of severe anemia, as well as acute respiratory distress syndrome and pulmonary edema. A guideline is presented for the initial choice of anti-malarial drug treatment for the pregnant patient.

In vitro susceptibility of Plasmodium falciparum to monodesethylamodiaquine, quinine, mefloquine and halofantrine in Abidjan (Côte d'Ivoire)

BACKGROUND

Malaria is the primary cause of hospitalization in Côte d'Ivoire. Early treatment is one of the strategies to control this illness. However, the spread of resistance of Plasmodium falciparum to antimalarial drugs can seriously compromise this strategy.

OBJECTIVES

The aim of this study was to assess the in vitro susceptibility of P. falciparum to monodesethylamodiaquine and aminoalcohols in Abidjan (Côte d'Ivoire).

METHODS

We assessed the in vitro susceptibility of isolates collected from patients with uncomplicated malaria by using the WHO optical microtest technique.

RESULTS

The proportions of resistance to monodesethylamodiaquine, méfloquine and halofantrine were 12.5%, 15.6% and 25.9%, respectively. For quinine, none of isolates showed evidence of in vitro resistance. However, two isolates (6.1%) had IC(50) values above 300 nM. The IC(50) of each drug was positively and significantly correlated to that of the other three drugs, and the correlation was higher between halofantrine and mefloquine.

CONCLUSIONS

Our results showed that the in vitro chloroquine resistance reported in previous studies has been extended to other antimalarial drugs investigated in this study except for quinine. Therefore, it is necessary to implement a long-term monitoring system of antimalarial drug resistance.

[Joseph-François Bourdier from La Moulière and his work in the five-year fever]

J.-F. Bourdier was one of the doctors of the Faculty of Paris. As a medical doctor for the Archduchess Marie-Louise, he was also able to conduct his scientific research. In 1808, during the difficult time of the Continental System, J.-F. N. took part in the research work on a substitute for cinchona and tested some treatments. However, being not a chemist, he could not make any chemical analysis. Then, the chemists Caventou and Pelletier discovered quinine in 1820.

[Contagious diseases in the Austro-Hungarian Army during the First World War]

Before the WWI significantly more loss was caused to armies by various epidemies, than by weapons. Although as a result of development of medical sciences in the WWI this rate changed, the main epidemies namely cholera, malaria and trachoma still ravaged quite often. In spite of the fact, that alimentation of Austro-Hungarian soldiers gradually deteriorated during the war, so they fell victims more easily to diseases, the sanitary service successfully prevented outbreaks of larger epidemies.

Efficacy and safety of quinine-artesunate in an HIV-positive patient with severe falciparum malaria

Severe falciparum malaria is a medical emergency that is associated with a high rate of mortality, even when treated in an Intensive Care Unit. Until recently, intravenous quinine was the standard treatment; however, artemisin derivatives are now regarded as the first-line treatment for multidrug-resistant falciparum malaria. Although several studies have demonstrated the superiority of Artesunate, this drug is not licensed in many countries. This article describes the case of an HIV-positive patient, who returned from Africa and presented with 10% parasitemia and clinical signs of severe falciparum malaria; this individual was successfully treated with a combination of artesunate and quinine. Artesunate was imported from the foreign market, and written consent for its administration was obtained in advance. Parasite clearance was rapidly achieved; however, on day IV, the patient developed acute respiratory distress syndrome that required mechanical ventilation. The patient was extubated on day XIV and discharged on day XXV. Due to its rapid action, artesunate was likely responsible for the good clinical outcome in this case; however, in order to clarify the role of this new combination therapy, further studies are required.

Blackwater fever: the rise and fall of an exotic disease

After several descriptions by Hippocrates and a single possible medieval description by Gilles de Corbeil, a severe febrile illness accompanied by the passage of dark urine burst upon the medical scene in West Africa in 1819, described by an English surgeon named Tidlie. Most of his patients died within a few days. Further reports appeared from tropical regions until the turn of the century, J. Farrell Easmon having given the condition the name blackwater fever in 1884. Controversy raged about its relationship to malaria, as well as over its treatment with cinchona bark and quinine. Evidence evolved that it was a complication of falciparum malaria in which hemoglobinuria causing acute renal failure resulted from massive quinine-induced lysis of red blood cells. People with red cell abnormalities such as glucose-6-phosphate dehydrogenase deficiency proved particularly prone to developing it. Its incidence fell as more mildly acting antimalarial drugs replaced quinine. Several enigmatic issues bedeviled understanding of it, but a careful analysis of its historical development has enabled resolution of each of these.

Effectiveness of quinine versus artemether-lumefantrine for treating uncomplicated falciparum malaria in Ugandan children: randomised trial

OBJECTIVE

To compare the effectiveness of oral quinine with that of artemether-lumefantrine in treating uncomplicated malaria in children.

DESIGN

Randomised, open label effectiveness study.

SETTING

Outpatient clinic of Uganda's national referral hospital in Kampala.

PARTICIPANTS

175 children aged 6 to 59 months with uncomplicated malaria.

INTERVENTIONS

Participants were randomised to receive oral quinine or artemether-lumefantrine administered by care givers at home.

MAIN OUTCOME MEASURES

Primary outcomes were parasitological cure rates after 28 days of follow-up unadjusted and adjusted by genotyping to distinguish recrudescence from new infections. Secondary outcomes were adherence to study drug, presence of gametocytes, recovery of haemoglobin concentration from baseline at day 28, and safety profiles.

RESULTS

Using survival analysis the cure rate unadjusted by genotyping was 96% for the artemether-lumefantrine group compared with 64% for the quinine group (hazard ratio 10.7, 95% confidence interval 3.3 to 35.5, P=0.001). In the quinine group 69% (18/26) of parasitological failures were due to recrudescence compared with none in the artemether-lumefantrine group. The mean adherence to artemether-lumefantrine was 94.5% compared with 85.4% to quinine (P=0.0008). Having adherence levels of 80% or more was associated with a decreased risk of treatment failure (0.44, 0.19 to 1.02, P=0.06). Adverse events did not differ between the two groups.

CONCLUSIONS

The effectiveness of a seven day course of quinine for the treatment of uncomplicated malaria in Ugandan children was significantly lower than that of artemether-lumefantrine. These findings question the advisability of the recommendation for quinine therapy for uncomplicated malaria in Africa.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00540202.

[Availability of antimalarial agents in Dutch hospitals]

OBJECTIVE

To investigate the availability of antimalarial agents for the treatment of falciparum malaria in all Dutch hospital pharmacies, including changes in the situation over a period of two years.

DESIGN

Descriptive.

METHOD

In the period October 2006 to March 2007 all Dutch hospital pharmacies were questioned about the availability of antimalarial agents, by means of a telephone survey. The survey was repeated at the end of 2008.

RESULTS

The percentage of hospitals that had quinine in stock increased from 72 (62 of the 86 hospitals responding) to 80 (73 of 91 hospitals). In 2008 artesunate was in stock in 7 hospitals. At the end of 2008 18 Dutch hospitals had no medication available for the treatment of severe malaria tropica; 6 hospitals had no agents for the treatment of malaria at all.

CONCLUSION

The ideal situation, in which every hospital in the Netherlands has a supply of adequate agents for the treatment of severe malaria, has not yet been achieved.

[Case report: two imported Plasmodium falciparum cases]

A 23 year-old Pakistani man presented at the emergency clinic of Tepecik Research and Training Hospital with the symptoms such as fever (39.3 degrees C), blurred consciousness, subicteric sclera and splenomegalia. In the laboratory examination, a slightly increase of the liver enzymes and anemia were detected. The gametocytes and trophozoites of Plasmodium falciparum were seen in a bone marrow aspiration and treatment was started with quinine and doxycycline but since resistance was detected to these medicines, mefloquine was chosen as alternative therapy. He was cured and discharged. The second case was also a Pakistani 20-year old man and he was a friend of first case. He presented at our hospital with the symptoms such as fever (39.4 degrees C), closed consciousness, icteric sclera and systolic soufflé in all cardiac foci. During the laboratory examination, severe anemia and trombocytopenia, and an increase in the liver enzymes were found. P. falciparum gametocytes and young trophozoites were seen in a blood smear stained with Giemsa. For treatment, mefloquine was used but unfortunately the patient died due to an adult respiratory distress syndrome (ARDS) complication. In this study, two cases with different clinical manifestations were presented to emphasize the importance of timing in starting the correct treatment.

The Sergent brothers and the antimalarial campaigns in Algeria (1902-1948)

Edmond and Etienne Sergent, "the Sergent brothers", were both born in Algeria. They both studied medicine at the Algiers Medical School and then followed the Course of Microbiology of Emile Roux at the Institut Pasteur in Paris (1899-1900). From 1900, they were put in charge of a permanent mission aimed at antimalarial control in Algeria, which was supervised by the Institut Pasteur. The first campaign was carried out during the summer of 1902 at a station of the East Algerian Railway Company. The success of this mission lead to the creation of the Antimalaric Department of Algeria in 1904, which was directed by Etienne Sergent for the duration his life. This antimalarial programme was progressively extended to many other locations. The programme was optimized between 1927 and 1947, in the experimental field study of the Ouled Mendil Marsh, where global environmental measures and drainage lead to settlement of farms, the families of which did not suffered from malaria. At a time when neither insecticides nor synthetic antimalarial drug existed, antimalarial control measures that were developed tended to target human reservoirs and the mosquito vectors. The extension of the programme across the Algerian territory lead to a decrease of both malaria endemicity and extension of affected areas.

Artemisinin derivatives versus quinine in treating severe malaria in children: a systematic review

BACKGROUND

The efficacy of intravenous quinine, which is the mainstay for treating severe malaria in children, is decreasing in South East Asia and Africa. Artemisinin derivatives are a potential alternative to quinine. However, their efficacy compared to quinine in treating severe malaria in children is not clearly understood. The objective of this review was to assess the efficacy of parenteral artemisinin derivatives versus parenteral quinine in treating severe malaria in children.

METHODS

All randomized controlled studies comparing parenteral artemisinin derivatives with parenteral quinine in treating severe malaria in children were included in the review. Data bases searched were: The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2007), MEDLINE (1966 to February 2008), EMBASE (1980 to February 2008), and LILACS (1982 to February 2008). Dichotomous variables were compared using risk ratios (RR) and the continuous data using weighted mean difference (WMD).

RESULTS

Twelve trials were included (1,524 subjects). There was no difference in mortality between artemisinin derivatives and quinine (RR = 0.90, 95% CI 0.73 to 1.12). The artemisinin derivatives resolved coma faster than quinine (WMD = -4.61, 95% CI: -7.21 to -2.00, fixed effect model), but when trials with adequate concealment only were considered this differences disappeared. There was no statistically significant difference between the two groups in parasite clearance time, fever clearance time, incidence of neurological sequelae and 28th day cure rate. One trial reported significantly more local reactions at the injection site with intramuscular quinine compared to artemether. None of the trials was adequately powered to demonstrate equivalence.

CONCLUSION

There was no evidence that treatment of children with severe malaria with parenteral artemisinin derivatives was associated with lower mortality or long-term morbidity compared to parenteral quinine. Future studies require adequately powered equivalence trial design to decide whether both drugs are equally effective.

Testing intra-hemocelic injection of antimicrobials against Encephalitozoon sp. (Microsporidia) in an insect host

Encephalitozoon spp. are the primary microsporidial pathogens of humans and domesticated animals. In this experiment, we test the efficacy of four commercial antimicrobials against an Encephalitozoon sp. in an insect host by intra-hemocelic injection. All four antimicrobials, viz., thiabendazole, quinine, albendazole, and fumagillin, significantly reduced but did not eliminate microsporidia spore counts in the grasshopper host. Among these four drugs, thiabendazole was most effective in reducing the microsporidia spore level up to 90%, followed by quinine (70%), albendazole (62%), and fumagillin (59%). No control or quinine-treated animals died, whereas 45% of albendazole animals died. Despite the high mortality induced by albendazole, this drug significantly reduced spore counts, a result not seen in previous per os trials. Among the treatment groups, grasshoppers injected with thiabendazole lost a significant mass. Our study suggests that quinine and related alkaloids should be further examined for antimicrosporidial activity.

[Automated erythrocytapheresis as treatment of severe malaria. Study of 6 patients]

BACKGROUND AND OBJECTIVE

The high mortality attributable to severe malaria by Plasmodium falciparum is related to the grade of parasitemia. Automated erithrocytapheresis (AE) is a safe alternative to exchange transfussion, with the same potential benefits but less undesirable side effects. Literature on this technique is scarce, consisting of isolated reports or short series. The objective of this study is to describe the clinical picture and outcome observed in 6 severely ill malaria patients in whom EA was applied as complimentary therapeutic technique.

PATIENTS AND METHOD

An observational prospective descriptive study was carried out of all inpatients with severe malaria in a single hospital between 1996 and 2006 in whom clinical, epidemiological and parsitological data were analyzed.

RESULTS

This series included 2 women and 4 men, with a median age of 43 years. In all cases, the infection was acquired in West Sub-Saharan Africa. No patient had received antimalarial prophylaxis and all were infected by Plasmodium falciparum. The grade of parasitemia was between 10% and 35%. The number of severity criteria was between one and 4, the more frequent being hyperbilirrubinemia. All patients received conventional intravenous treatment. The total length of admission oscillated between 5 and 37 days, while the length of stay in the Intensive Care Unit varied between one and 17 days. All patients survived.

CONCLUSIONS

AE is a safe technique, with the same advantages that blood exchange but lacking many of its disadvantages. A isolated parasitemia above 10%, or when a parasitaemia above of 5% is associated with any additional World Health Organization-2000 criteria of clinical severity, should constitute an indication for AE.

Rare presentation of a common disease of tropics

A 19 years male presented with fever, oliguria and purpuric lesions involving both hands. The patient was diagnosed as a case of purpura fulminans with disseminated intravascular coagulation due to complicated falciparum malaria. The case is presented to sensitize the physicians to keep malaria as a differential in cases of fever with purpura fulminans.

Intravenous artesunate for severe malaria

(1) Plasmodium falciparum malaria can be fatal in non-immune individuals. Artemisinin derivatives are effective in the treatment of simple malaria attacks, but what is their role in treating severe malaria? (2) It has been estimated that intravenous quinine halves the mortality rate due to malaria. However, it has frequent dose-dependent adverse effects (tinnitus, hearing disorders, dizziness), and carries a risk of rare life-threatening reactions. Intravenous quinine has been a standard treatment for many years; (3) A very large trial has been conducted among adults and children in Southeast Asia. The mortality rate was lower with intravenous artesunate: 15% versus 22% with intravenous quinine. Other, smaller trials have provided similar results. The two treatments have similar adverse effects; (4) In practice, in Southeast Asia, intravenous artesunate has the best risk-benefit balance of the treatments available for severe malaria. Elsewhere, in the absence of parasite resistance, quinine remains the standard treatment. Comparisons with artesunate are awaited.