Glucose turnover in severe falciparum malaria

A detailed kinetic model of glycolysis in Plasmodium falciparum-infected red blood cells for antimalarial drug target identification

Upon infection by the malaria parasite Plasmodium falciparum, the glycolytic rate of a red blood cell increases up to 100-fold, possibly contributing to lactic acidosis and hypoglycemia in patients with severe malaria. This dramatic increase in glucose uptake and metabolism was correctly predicted by a newly constructed detailed enzyme kinetic model of glucose metabolism in the trophozoite-infected red blood cell. Subsequently, we expanded the model to simulate an infected red blood cell culture, including the different asexual blood-stage forms of the malaria parasite. The model simulations were in good agreement with experimental data, for which the measured parasitic volume was an important parameter. Upon further analysis of the model, we identified glucose transport as a drug target that would specifically affect infected red blood cells, which was confirmed experimentally with inhibitor titrations. This model can be a first step in constructing a whole-body model for glucose metabolism in malaria patients to evaluate the contribution of the parasite's metabolism to the disease state.

AMP-activated protein kinase (AMPK) is decreased in the mouse brain during experimental cerebral malaria

Cerebral malaria (CM) is a severe form of malaria caused by Plasmodium falciparum and P.vivax. CM affects the brain leading to coma and is the leading cause of death in malaria patients. The enzyme, adenosine 5'-monophosphate-activated protein kinase (AMPK), is an important metabolic sensor that helps in maintaining energy homeostasis during normal physiological as well as pathological conditions. In the present study, we studied the status of AMPK in the mouse model of CM. The C57BL/6 mice infected by rodent-specific P.berghei ANKA were used for the study. We found a statistically significant reduction in the gene expressions of Prkaa1 (α1 subunit) and Prkaa2 (α2 subunit) in the brains of CM mice compared to uninfected control. Also, there was a statistically significant reduction in the ratio of phospho-AMPK/AMPK protein levels in CM compared to uninfected control. There was no statistically significant decrease in phospho-ACC/ACC ratio in the brain compared to control. As AMPK is downregulated in CM, there is a possible involvement in neuronal cell death during CM pathogenesis, and therefore we feel that novel AMPK activating drugs might be helpful as an adjunctive therapy for conferring neuroprotection.

Simultaneous ATR-FTIR Based Determination of Malaria Parasitemia, Glucose and Urea in Whole Blood Dried onto a Glass Slide

New diagnostic tools that can detect malaria parasites in conjunction with other diagnostic parameters are urgently required. In this study, Attenuated Total Reflection Fourier transform infrared (ATR-FTIR) spectroscopy in combination with Partial Least Square Discriminant Analysis (PLS-DA) and Partial Least Square Regression (PLS-R) have been applied as a point-of-care test for identifying malaria parasites, blood glucose, and urea levels in whole blood samples from thick blood films on glass slides. The specificity for the PLS-DA was found to be 98% for parasitemia levels >0.5%, but a rather low sensitivity of 70% was achieved because of the small number of negative samples in the model. In PLS-R the Root Mean Square Error of Cross Validation (RMSECV) for parasite concentration (0-5%) was 0.58%. Similarly, for glucose (0-400 mg/dL) and urea (0-250 mg/dL) spiked samples, relative RMSECVs were 16% and 17%, respectively. The method reported here is the first example of multianalyte/disease diagnosis using ATR-FTIR spectroscopy, which in this case, enabled the simultaneous quantification of glucose and urea analytes along with malaria parasitemia quantification using one spectrum obtained from a single drop of blood on a glass microscope slide.

ASIATIC ACID INFLUENCES GLUCOSE HOMEOSTASIS IN P. BERGHEI MURINE MALARIA INFECTED SPRAGUE-DAWLEY RATS

Background:

Glucose homeostasis derangement is a common pathophysiology of malaria whose aetiology is still controversial. The Plasmodium parasite, immunological and inflammatory responses, as well as chemotherapeutics currently used cause hypoglycaemia in malaria. Anti-parasitic and anti-disease drugs are required to combat malaria while ameliorating the pathophysiology of the infection. Asiatic acid has anti-hyperglycaemic, antioxidant, pro-oxidant properties useful in glucose homeostasis but its influence in malaria is yet to be reported. Here we present findings on the influence of asiatic acid on glucose metabolism in vivo using P. berghei-infected Sprague Dawley rats.

Materials and Methods:

Acute as well as sub-chronic studies were carried out in vivo where physicochemical properties and glucose homeostasis were monitored after administration of asiatic acid (10mg/kg) in both non-infected and infected animals. Glucose metabolism associated biochemical changes in malaria were also investigated.

Results:

In acute studies, asiatic acid improved oral glucose response while in the sub-chronic state it maintained food and water intake and suppressed parasitaemia. Normoglycaemic control was maintained in infected animals through insulin suppression and increasing glucagon secretion, in both acute and chronic studies. Asiatic acid administration curtailed lactate concentration towards normal.

Conclusion:

Per oral post-infection asiatic acid administration preserved drinking and eating habits, inhibited sickness behaviour while suppressing parasitaemia. Reciprocal relationship between insulin and glucagon concentrations was maintained influencing glucose homeostasis positively and inhibition of hyperlactaemia in malaria.

Abbreviations: ip -intraperitoneal, po -per oral, ig -intragastric, AA-Asciatic acid, OGTT-oral glucose tolerance test, OS-oxidative stress, ROS-reactive oxygen species, NO-nitric oxide, ONOO^- - peroxynitrite, BRU-Biomedical Research Unit, SD-Sprague Dawley,

Quantitative analysis of drug effects at the whole-body level: a case study for glucose metabolism in malaria patients

We propose a hierarchical modelling approach to construct models for disease states at the whole-body level. Such models can simulate effects of drug-induced inhibition of reaction steps on the whole-body physiology. We illustrate the approach for glucose metabolism in malaria patients, by merging two detailed kinetic models for glucose metabolism in the parasite Plasmodium falciparum and the human red blood cell with a coarse-grained model for whole-body glucose metabolism. In addition we use a genome-scale metabolic model for the parasite to predict amino acid production profiles by the malaria parasite that can be used as a complex biomarker.

Adaptation of glucose metabolism to fasting in young children with infectious diseases: a perspective

Hypoglycemia is a frequently encountered complication in young children with infectious diseases and may result in permanent neurological damage or even death. Mortality rate in young children under 5 years of age is increased four- to six-fold when severe infectious disease is complicated by hypoglycemia. Young age, prolonged fasting and severity of disease are considered important risk factors. This perspective describes the combined results of recently conducted studies on the effect of these risk factors on glucose metabolism in children with different infectious diseases. The results of these studies have nutritional implications for the approach in clinical practice towards young children with infectious diseases and specific recommendations are made. A unique finding is the existence of infectious disease-related differences in the adaptation of glucose metabolism during fasting in young children.

Fasting predisposes to hypoglycemia in Surinamese children with severe pneumonia, and young children are more at risk

The objective of this study was to investigate glucose kinetics during controlled fasting in children with severe pneumonia. Plasma glucose concentration, endogenous glucose production and gluconeogenesis were measured in 12 Surinamese children (six young: 1-3 years, six older: 3-5 years) with severe pneumonia during a controlled 16 h fast using stable isotopes [6,6-(2)H2]glucose and (2)H2O at a hospital-based research facility. On admission, the glucose concentrations were comparable in both groups: young children: 5.1 ± 1.3 mmol/l, older children: 4.8 ± 0.6 mmol/l, p = 0.685, with a decrease during the first 8 h of fasting in the young children only to 3.6 ± 0.5, p = 0.04. Glucose production was comparable in both groups: young: 24.5 ± 8.3, older: 24.9 ± 5.9 µmol/kg(•)min, p = 0.926. Between 8 and 16 h of fasting, the glucose concentration decreased comparably in both groups (young: - 0.9 ± 0.7, p = 0.004; older: -1.0 ± 0.4 mmol/l, p = 0.001), as did glucose production (young: -6.8 ± 6.3, p = 0.003; older: -5.3 ± 3.4 µmol/kg(•)min, p = 0.001). Gluconeogenesis decreased in young children only: -5.0 ± 7.4, p = 0.029. We conclude that fasting predisposes to hypoglycemia in children with severe pneumonia. Young children are more at risk than older children. Glucose production is an important determinant of the plasma glucose concentration in young children with pneumonia, indicating an inability to reduce glucose usage. Our results are largely in agreement with the literature on the adaptation of glucose metabolism in children with malaria, although there seem to be disease-specific differences in the regulation of gluconeogenesis.

Hypoglycaemia and severe Plasmodium falciparum malaria among pregnant Sudanese women in an area characterized by unstable malaria transmission

BACKGROUND

Pregnant women are more susceptible to severe Plasmodium falciparum malaria, which can lead to poor maternal and fetal outcomes. Few data exist on the epidemiology of severe P. falciparum malaria in pregnant women.A hospital-based study was carried out to assess the pattern of severe P. falciparum malaria among pregnant women at the Kassala and Medani maternity hospitals, which are located in areas of unstable malaria transmission, in eastern and central Sudan, respectively. Pre-tested questionnaires were used to gather socio-demographic, clinical and obstetrical data. Suitable tests were performed for clinical and biochemical investigations.

RESULTS

Among 222 pregnant women diagnosed with malaria at the two hospitals, 40 (18.0%) women at mean (SD) gestational age of 29.3 (6.7) weeks fulfilled one or more of the WHO criteria for severe P. falciparum malaria. These were hypoglycaemia (14; 35.5%), severe anaemia (12; 30%), hypotension (10; 25%), jaundice (9; 22.5%), cerebral malaria (6; 15%), repeated convulsions (4; 10%), hyperparasitaemia (4; 10.0%) and more than one manifestation (9; 22.5%). While the mean (SD) presenting temperature was significantly lower for women presenting with hypoglycaemia [38.2(0.6) versus 38.8(0.7) °C, P = 0.04], other clinical and biochemical characteristics were not significantly different among women with different manifestations of severe P. falciparum malaria.

CONCLUSION

Preventive measures for pregnant women such as insecticide-treated bednets and chemoprophylaxis may be beneficial in areas of unstable malaria transmission. Early detection and prompt treatment of severe malaria, especially in pregnant women with hypoglycaemia, are needed.

Glucose metabolism in children: influence of age, fasting, and infectious diseases

This review describes the occurrence of hypoglycemia in young children as a common and serious complication that needs to be avoided because of the high risk of brain damage and mortality. Young age, fasting, and severe infectious disease are considered important risk factors. The limited data on the effect of these risk factors on glucose metabolism in children are discussed and compared with data on glucose metabolism in adults. The observations discussed may have implications for further research on glucose kinetics in young children with infectious disease.

Very young children with uncomplicated falciparum malaria have higher risk of hypoglycaemia: a study from Suriname

OBJECTIVE

To measure glucose kinetics and the influence of age, nutritional status and fasting duration in children with uncomplicated falciparum malaria (UFM) under the age of 5 years.

METHODS

Plasma glucose concentration, endogenous glucose production (EGP) and gluconeogenesis (GNG) were measured using [6,6-(2)H(2)]glucose and (2)H(2)O in 17 very young (<3 years) and 7 older (3-5 years) Surinamese children with UFM admitted to the Distrikt Hospital Stoelmanseiland and Diakonessen Hospital Paramaribo over 17 months.

RESULTS

Plasma glucose concentration was lower in the group of very young children than in the older children (P = 0.028). There were no differences in EGP and GNG between the groups. Overall GNG contributed 56% (median, range 17-87%) to EGP, with no differences between the groups (P = 0.240). Glucose clearance was lower in the older children (P = 0.026). Glucose concentration did not differ between children with weight for length/height less than -1.3 SD and children with weight for length/height greater than -1.3 SD (P = 0.266). Plasma glucose concentration was not predicted by fasting duration (P = 0.762).

CONCLUSIONS

Our data suggest a higher risk of hypoglycaemia in very young children with uncomplicated malaria as plasma glucose concentration was lower in this study group. Since this could not be attributed to an impaired EGP, and because glucose clearance was lower in the older children, we presume that older children were better capable of reducing glucose utilization during fasting. Studies on glucose kinetics are feasible in very young children with malaria and give more insight in the pathophysiology of hypoglycaemia.

Fever as a cause of hypophosphatemia in patients with malaria

Hypophosphatemia occurs in 40 to 60% of patients with acute malaria, and in many other conditions associated with elevations of body temperature. To determine the prevalence and causes of hypophosphatemia in patients with malaria, we retrospectively studied all adults diagnosed with acute malaria during a 12-year period. To validate our findings, we analyzed a second sample of malaria patients during a subsequent 10-year period. Serum phosphorus correlated inversely with temperature (n = 59, r = −0.62; P<0.0001), such that each 1°C increase in body temperature was associated with a reduction of 0.18 mmol/L (0.56 mg/dL) in the serum phosphorus level (95% confidence interval: −0.12 to −0.24 mmol/L [−0.37 to −0.74 mg/dL] per 1°C). A similar effect was observed among 19 patients who had repeat measurements of serum phosphorus and temperature. In a multiple linear regression analysis, the relation between temperature and serum phosphorus level was independent of blood pH, PCO2, and serum levels of potassium, bicarbonate, calcium, albumin, and glucose. Our study demonstrates a strong inverse linear relation between body temperature and serum phosphorus level that was not explained by other factors known to cause hypophosphatemia. If causal, this association can account for the high prevalence of hypophosphatemia, observed in our patients and in previous studies of patients with malaria. Because hypophosphatemia has been observed in other clinical conditions characterized by fever or hyperthermia, this relation may not be unique to malaria. Elevation of body temperature should be added to the list of causes of hypophosphatemia.

Hypoglycemia in falciparum malaria: is fasting an unrecognized and insufficiently emphasized risk factor?

Hypoglycemia is a frequently encountered complication in falciparum malaria that is usually ascribed to increased glucose use and impaired glucose production caused by the inhibition of gluconeogenesis. Here, in light of recent data showing that glucose production and gluconeogenesis are often increased in falciparum malaria, we review the causes and the risk factors leading to hypoglycemia in malaria. Fasting emerges as an important potential risk factor. Length of fasting should be included in studies on hypoglycemia in malaria. Full recognition of this risk factor for hypoglycemia in malaria could change both advice to the population, especially mothers, and treatment guidelines in the health sector.

Glucose, lactate, and pyruvate concentrations in dogs with babesiosis

OBJECTIVE

To document changes in glucose, lactate, and pyruvate concentrations in dogs with severe or complicated babesiosis; assess relationships among glucose, lactate, and pyruvate concentrations in those dogs; and compare clinical and laboratory variables in dogs with and without hypoglycemia and hyperlactatemia.

ANIMALS

20 dogs with naturally developing severe or complicated babesiosis.

PROCEDURE

Samples and measurements were obtained before treatment was initiated. Babesiosis was diagnosed by examination of blood smears. Arterial blood pressure measurement, parasite quantification, CBC count, serum biochemical analysis, urinalysis, venous blood gas analysis, and acid-base determination were performed. Glucose, lactate, and pyruvate concentrations were measured in samples of venous blood.

RESULTS

We detected a significant negative correlation between glucose and lactate concentrations. Glucose, lactate, and pyruvate concentrations all differed significantly between dogs that died and those that survived. Three of 5 dogs that died had concurrent hypoglycemia, hyperlactatemia, and hyperpyruvatemia. Hypoglycemic dogs differed significantly from normoglycemic dogs with regard to lactate, urea, and bicarbonate concentrations; lactate-to-pyruvate ratio; percentage parasitemia; and PCO2. Dogs with hyperlactatemia differed significantly from normolactatemic dogs with regard to clinical collapse; alanine transaminase activity; concentrations of bilirubin, urea, creatinine, and bicarbonate; percentage parasitemia; and PCO2.

CONCLUSIONS AND CLINICAL RELEVANCE

Abnormal carbohydrate metabolism is commonly evident in dogs with severe or complicated babesiosis and is often associated with changes in other clinical and laboratory variables. Significant differences were found between survivors and nonsurvivors. Hypoglycemia should be assessed and aggressively treated in dogs with babesiosis. Lactate concentration can be used as an indicator of disease severity.

Metabolic complications of severe malaria

Metabolic complications of malaria are increasingly recognized as contributing to severe and fatal malaria. Disorders of carbohydrate metabolism, including hypoglycaemia and lactic acidosis, are amongst the most important markers of disease severity both in adults and children infected with Plasmodium falciparum. Amino acid and lipid metabolism are also altered by malaria. In adults, hypoglycaemia is associated with increased glucose turnover and quinine-induced hyperinsulinaemia, which causes increased peripheral uptake of glucose. Hypoglycaemia in children results from a combination of decreased production and/or increased peripheral uptake of glucose, due to increased anaerobic glycolysis. Patients with severe malaria should be monitored frequently for hypoglycaemia and treated rapidly with intravenous glucose if hypoglycaemia is detected. The most common aetiology of hyperlactataemia in severe malaria is probably increased anaerobic glucose metabolism, caused by generalized microvascular sequestration of parasitized erythrocytes that reduces blood flow to tissues. Several potential treatments for hyperlactataemia have been investigated, but their effect on mortality from severe malaria has not been determined.

Influence of prolonged starvation on glucose kinetics in pregnant patients infected with Plasmodium falciparum

Hypoglycaemia is a recognised complication of malaria in pregnancy, but its pathophysiology is not well understood. We studied the influence of fasting on glucose production and gluconeogenesis by infusion of [6,6-(2)H(2)]glucose and ingestion of (2)H(2)O in 20 female subjects, eight pregnant patients with uncomplicated falciparum malaria, six pregnant controls matched for age and trimester and six non-pregnant controls matched for age. Infection with Plasmodium falciparum induced a significant increase in glucose production (16.7+/-0.3 vs. 12.4+/-0.8 micromol/kg/min; P=0.002) and gluconeogenesis (12.5+/-0.6 vs. 8.2+/-0.7 micromol/kg/min; P=0.001) without a change in the glucoregulatory hormone milieu, compared to the healthy pregnant controls. Extension of the fast from 20.30 to 24.30 h resulted in a rate of decline of glucose production that was similar in patients with malaria and healthy pregnant subjects, a decline that was steeper compared to the non-pregnant subjects (-0.283 and -0.426 vs. -0.065 micromol/kg/min/h; P=0.037). The plasma glucose concentration measured at 20.30 h of fasting in the malaria patients was intermediate between the value found in the pregnant and the non-pregnant controls (4.01+/-0.2 mmol/l) while it was significantly lower in the non-infected pregnant women compared to non-pregnant controls (3.59+/-0.14 vs. 4.70+/-0.29 mmol/l; P=0.009). Plasma glucose concentration declined at a similar rate in patients with malaria and pregnant controls but faster compared to the non-pregnant controls (-0.078 and -0.093 vs. -0.044 mmol/l/h; P < 0.05). We conclude that fasting is a major risk factor for hypoglycaemia in pregnancy. Non-severe Plasmodium falciparum infection in pregnant women results in higher glucose production and higher glucose levels, thereby, compared to healthy pregnant patients, delaying of the occurrence of hypoglycaemia due to fasting. The exact mechanism of hypoglycaemia in fasting pregnant women remains to be elucidated.

Alanine metabolism in acute falciparum malaria

We investigated the integrity of the gluconeogenic pathway in severe malaria using alanine metabolism as a measure. Alanine disposition and liver blood flow, assessed by indocyanine green (ICG) clearance, were measured simultaneously in 10 patients with falciparum malaria (six severe and four moderately severe malaria). After intravenous infusion of alanine (0.3 g/kg), glucose increments (AUC0-55 min) were lower in patients with severe malaria than in those with moderately severe malaria (median = 508 vs. 808 mmol/min/l; P = 0.055). There were no significant differences in the other metabolite increments (alanine, lactate and pyruvate; P >/= 0.27). The two fatal cases had markedly delayed alanine removal (larger AUC0-55 min), prolonged T(1/2) and slower clearance (P </= 0.007). Overall the increments in blood alanine correlated directly with lactate increments (rs = 0.84; P = 0.002) and inversely with glucose (rs = -0.70; P = 0.025). Between acute and convalescent studies, the increments (AUC0-55 min) of alanine and glucose were not significantly different (P >/= 0.07) but the increments of lactate and pyruvate were lower in convalescence. Thus, the ratio of the increments of alanine to those of lactate and pyruvate were significantly higher in the convalescent study (P </= 0.017). The mean (SD) ICG clearance during acute malaria was not significantly different to that in convalescence (21.6 +/- 9.3 vs. 34.1 +/- 15.5 ml/min/kg; P = 0.25). During the acute study, there was a significant inverse correlation between ICG clearance and the post-infusion increments of lactate (rs = -0.63, P = 0.049) and pyruvate (rs = -0.74, P = 0.014). These data indicate that alanine clearance is impaired in acute falciparum malaria in proportion to the severity of illness and suggest an important role for anaerobic glycolysis in the pathogenesis of hypoglycaemia in severe malaria.

Glucose and lactate turnover in adults with falciparum malaria: effect of complications and antimalarial therapy

Hypoglycaemia and lactic acidosis are potentially life-threatening, poorly understood sequelae of Plasmodium falciparum infections. We investigated relationships between clinical status, treatment, and glucose and lactate kinetics during management of falciparum malaria in 14 Vietnamese adults. Nine had severe malaria, of whom 4 were administered quinine (Group 1a) and 5 artesunate (Group 1b). Five uncomplicated cases received artesunate (Group 2). Glucose and lactate turnover were studied on 3 occasions: (i) immediately after initial antimalarial treatment, (ii) at parasite clearance a median of 3 days later, and (iii) at discharge from hospital a median of 9 days post-admission. Steady-state glucose and lactate kinetics were derived from plasma isotopic enrichment during a primed-continuous infusion of D-[6,6-D2]glucose and a parallel infusion of L-[1-13C]lactate. Group 1a patients had the lowest plasma glucose concentrations in the admission study (median [range] 3.9 [3.6-5.1] vs 6.3 [4.9-7.1] and 4.5 [4.3-5.5] mmol/L in Groups 1b and 2 respectively; P < 0.05 vs Group 1b), but glucose production rates and serum insulin concentrations that were similar to those in the other groups (P > 0.17). This was also the case at parasite clearance and suggested an inappropriate beta cell response. Group 1a patients had the highest admission lactate production (60 [36-77] vs 26 [21-47] and 22 [4-31] mumol/kg.min in Group 1b and 2 respectively; P < 0.05 vs Group 2). Amongst the 9 severe cases, there was an inverse association between plasma glucose and lactate production at admission and parasite clearance (P < 0.05), but no correlation between admission lactate production and serum bicarbonate (P = 0.73). The present data confirm previous studies showing that quinine depresses plasma glucose through stimulation of insulin secretion. It is hypothesized that the low plasma glucose activates Na+,K(+)-ATPase through increased plasma catecholamine concentrations, leading to accelerated glycolysis and increased lactate production in well-oxygenated tissues. In some severely ill patients with falciparum malaria, a raised plasma lactate on its own may, therefore, be an unreliable index of a developing acidosis.

Non-radioisotopic glucose turnover in children with falciparum malaria and enteric fever

To determine whether glucose turnover is increased in acute falciparum malaria compared to enteric fever in children, steady-state 6,6-D2-glucose turnover was measured in 9 Malaysian children with uncomplicated malaria (6 males and 3 females; median age 10 years, body weight 22 kg) and in 12 with uncomplicated enteric fever (8 males and 4 females; median age 10 years, body weight 24 kg) in acute illness, after quinine (5 malaria patients) and in convalescence. Baseline plasma glucose concentrations in malaria and enteric fever were similar (all values are medians [ranges in brackets]) 5.6 [3.2-11.3] vs. 5.5 [4.2-8.0] mmol/L), as were serum insulin levels (5.6 [0.4-26.5] vs. 6.8 [1.1-22.5] milliunits/L; P > 0.4). Glucose turnover in the malaria patients was higher than in patients with enteric fever (6.27 [2.71-6.87] vs. 5.20 [4.50-6.08] mg/kg.min; P = 0.02) and in convalescence (4.74 [3.35-6.79] mg/kg.min; P = 0.05 vs. acute malaria study), and fell after quinine together with a rise in serum insulin (P = 0.03). Basal plasma lactate concentrations were higher in enteric fever than in malaria (3.4 [1.8-6.4] vs. 0.8 [0.3-3.8] mmol/L; P < 0.0001) and correlated inversely with glucose turnover in this group (rs = -0.60; n = 12; P = 0.02). These data suggest that glucose turnover is 20% greater in malaria than in enteric fever. This might reflect increased non-insulin-mediated glucose uptake in falciparum malaria and/or impaired gluconeogenesis in enteric fever, and may have implications for metabolic complications and their clinical management in both infections.

Glucose metabolism in severe malaria: minimal model analysis of the intravenous glucose tolerance test incorporating a stable glucose label

Basal plasma glucose is usually increased in uncomplicated malaria, implying insulin resistance. If the infection progresses, the risk of hypoglycemia will increase as host glucose production becomes insufficient for host/parasite demand. To assess the relative contribution of insulin-mediated and non-insulin-mediated glucose disposal to plasma glucose levels in severe malaria, we studied six healthy controls (two males and four females; mean age, 38 years) and eight patients with complicated falciparum malaria (five males and three females; mean age, 31 years) who had a frequently sampled intravenous glucose tolerance test (FSIVGTT) in which 10% of the dextrose bolus was 6,6-D2-glucose. The minimal model was applied to native and labeled plasma glucose and serum insulin profiles over 4 hours postinjection. Basal plasma glucose concentrations in the patients were significantly greater than in the controls (median [range], 6.1 [2.1 to 8.5] v 4.3 [3.9 to 4.7] mmol/L, P = .03). Malaria-associated insulin resistance was confirmed by a lower insulin sensitivity index (SI) in patients (5.6 [2.4 to 17.4] v 16.0 [2.5 to 22.3] x 10(-4).min-1 per microU/mL in controls, P = .026). Glucose effectiveness ([SG] the ability of glucose to reduce its own plasma concentration) was higher in the patients (0.015 [0.006 to 0.024] v 0.008 [0.007 to 0.010] min-1 in controls, p = .019). Glucose disappearance at basal concentration was increased by a median of 42% in severe malaria patients, with the insulin-independent component comprising 81%, versus 67% in controls. Indices of beta-cell function were normal in malaria patients. These data demonstrate that basal plasma glucose utilization is increased approximately 50% in severe malaria, consistent with previously published isotope-turnover studies. Altered SG plays a major role. Prevention and treatment of early hypoglycemia should be based on adequate glucose replacement. Strategies that reduce insulin secretion or effects appear to be of minor importance.

The biological basis of malarial disease

In this review we summarise the arguments that inflammatory cytokines, triggered by material released from the parasite at schizogony (malarial toxin), might induce the illness and pathology seen in malaria. These pro-inflammatory cytokines can generate inducible nitric oxide synthase and cause nitric oxide to be released, as can low concentrations of malarial toxin itself provided interferon-gamma, which has only low activity in the absence of malarial toxin, is present. We suggest here that recently described hypermetabolic functions of these mediators provide a much more plausible explanation for malarial hyperlactataemia and hypoglycaemia, the chief prognostic indicators in falciparum malaria, than does hypoxia secondary to mechanical blockage of vessels by sequestering parasites, which is the dominant current theory. We also review the arguments that rationalise, through these mediators, the reversibility of the coma of cerebral malaria. Although not yet tested at a cellular level, the proposal that nitric oxide generated in cerebral vascular walls contributes to this coma continues to gather indirect support. In addition, new evidence incriminating nitric oxide in the mechanism of tolerance to endotoxin rationalises the raised nitric oxide generation seen in malarial tolerance.

Glucose homeostasis in children with falciparum malaria: precursor supply limits gluconeogenesis and glucose production

To evaluate glucose kinetics in children with falciparum malaria, basal glucose production and gluconeogenesis and an estimate of the flux of the gluconeogenic precursors were measured in Kenyan children with uncomplicated falciparum malaria before (n = 11) and during infusion of alanine (1.5 mg/kg.min; n = 6). Glucose production was measured by [6,6-2H2]glucose, gluconeogenesis by mass isotopomer distribution analysis of glucose labeled by [2-13C]glycerol. Basal plasma glucose concentration ranged from 2.1-5.5 mmol/L, and basal glucose production ranged from 3.3-7.3 mg/kg.min. Glucose production was largely derived from gluconeogenesis (73 +/- 4%; range, 52-93%). During alanine infusion, plasma glucose increased by 0.4 mmol/L (P = 0.03), glucose production increased by 0.8 mg/kg.min (P = 0.02), and gluconeogenesis increased by 0.8 mg/kg.min (P = 0.04). We conclude that glucose production in children with uncomplicated falciparum malaria is largely dependent on gluconeogenesis. However, gluconeogenesis is potentially limited by insufficient precursor supply. These data indicate that in children with falciparum malaria, gluconeogenesis fails to compensate in the presence of decreased glycogen flux to glucose, increasing the risk of hypoglycemia.

Glucose production and gluconeogenesis in adults with uncomplicated falciparum malaria

Although glucose production is increased in severe malaria, the influence of uncomplicated malaria on glucose production is unknown. Therefore, we measured in eight adult Vietnamese patients with uncomplicated falciparum malaria and eight healthy Vietnamese controls glucose production (by infusion of [6,6-2H2]glucose) and the fractional contribution of gluconeogenesis (by oral ingestion of 2H2O); glycogenolysis was calculated as the difference between the two. After 20 h of fasting, plasma glucose was 4.7 +/- 0.2 mmol/l in the patients and 4.3 +/- 0.2 mmol/l in the controls (not significant). Glucose production was approximately 25% higher in the patients (16.9 +/- 1.3 vs. 13.4 +/- 0.3 mumol.kg-1.min-1, P = 0.01). Fractional and absolute gluconeogenesis were increased in the patients (approximately 87 vs. approximately 59%, P < 0.001; and 14.6 +/- 1.3 vs. 7.9 +/- 0.2 mumol.kg-1.min-1, P < 0.001, respectively). The contribution of glycogenolysis to total glucose production was decreased in the patients: 2.3 +/- 0.5 vs. 5.5 +/- 0.4 mumol.kg-1.min-1 (P < 0.002). In conclusion, in adult patients with uncomplicated falciparum malaria, glucose production is increased by approximately 25% due to an increased rate of gluconeogenesis, whereas glycogenolysis is decreased. The mechanism by which these changes occur is uncertain. However, counterregulatory hormone and cytokine concentrations were increased in the patients.

The relationship between glucose production and plasma glucose concentration in children with falciparum malaria

The pathophysiology of hypoglycaemia in children with acute falciparum malaria, a frequent and serious complication, is unknown due to absence of data on glucose kinetics. We investigated the correlation between basal glucose production and plasma glucose concentration in 20 children (8 girls) with acute, uncomplicated falciparum malaria by infusion of [6,6-2H2]glucose. Median plasma glucose concentration was 4.5 (range 2.1-6.5) mmol/L and the median glucose production 5.0 (range 4.1-8.4) mg/kg/min. There was a positive correlation between basal glucose production and plasma glucose concentration (r = 0.53, P = 0.016). There was no correlation between the rate of glucose production and the plasma concentrations of alanine, lactate, counter-regulatory hormones or cytokines. It was concluded that, in children with acute uncomplicated falciparum malaria, endogenous glucose production is an important determinant of plasma glucose concentration, contrary to previous findings in adults with malaria, in whom peripheral uptake seems to be more important than glucose production in determining plasma glucose concentration.

The effect of plasma free fatty acids and long-chain triglycerides on glucose metabolism in uncomplicated falciparum malaria

To investigate the therapeutic potential of increased plasma free fatty acid (FFA) and triglyceride concentrations in hypoglycaemic patients receiving quinine, 32 untreated Thai adults with uncomplicated falciparum malaria were allocated at random to one of 4 regimens: 2 mg/kg/min dextrose infused over 60 min either alone (group A) or with a prior injection of 5000 units of heparin and simultaneous Intralipid infusion (group C), or 4 min/kg/min dextrose alone (group B) or with heparin and Intralipid (group D). Quinine (10 mg/kg) was also infused over 60 min in all cases. In patients of groups A and C, mean changes in plasma glucose concentrations from the beginning to the end of the infusion were 0.1 (SD 0.8) and 1.0 (SD 0.7) mmol/L respectively (P = 0.015). In groups B and D, plasma glucose increased by 1.8 (SD 1.2) and 2.2 (SD 0.4) mmol/L respectively (P < 0.5). Plasma FFA levels fell by approximately 50% during the infusion in groups A and B but increased by a similar percentage in groups C and D. Despite significant mean increases in plasma insulin during the infusion (from 12.2 milliunits (mu)/L in group A to 38.8 mu/L in group D), no rebound hypoglycaemia was observed in any patient during the ensuing 7 h. These data suggest that the glycaemic response to dextrose given at high rates, which match average glucose utilization in a severely ill patient with malaria, is not augmented by increased plasma FFA and long-chain triglycerides. However, this strategy increases the glycaemic efficacy of lower dextrose infusion rates and the combination could, therefore, reduce the volumes of hypertonic dextrose required to prevent hypoglycaemia in severely ill patients in whom optimal fluid balance is crucial.

Glycerol metabolism in severe falciparum malaria

Gluconeogenesis and liver blood flow (LBF) in severe falciparum malaria were assessed from the clearance and metabolic response to intravenously administered glycerol (0.3 g/kg) and Indocyanine Green ([ICG] 0.4 mg/kg), respectively. Fasting baseline blood glycerol concentrations (mean +/- SD) were significantly higher in acute malaria (133 +/- 65 mumol/L, n = 14), than in convalescence (65 +/- 31 mumol/L, n = 9, P = .01), but basal triacylglycerol concentrations were similar. Estimated glycerol turnover was also more than twice as high in acute malaria compared with convalescence (1.36 +/- 0.87 v 0.54 +/- 0.15 mumol.min-1.kg-1, P = .015). The increment in plasma glucose (AUC0-55 min) following glycerol infusion was greater during acute malaria compared with convalescence (median [range], +31.6 [-0.9 to +107.6] v +14.5 [-103 to +27.1] mmol.min-L-1, P < .05), but the insulin increments were similar (P = .9), indicating reduced tissue insulin sensitivity. The increment in venous lactate (AUC0-55 min) was higher in severely ill patients (17.2 [-7.8 to +53.4] mmol.min.L-1, n = 10) compared with patients with moderately severe malaria (-3.1 [-8.7 to 3.2] mmol.min-L-1, n = 4, P = .01). LBF estimated from ICG clearance was lower during acute illness than in convalescence (mean +/- SD, 15.5 +/- 2.3 v 18.6 +/- 2.9 mL.min-1.kg-1, P = .007) and correlated inversely with the basal venous lactate concentration (rs = .53, P < .05). LBFs less than 15 mL.min-1.kg-1 were associated with hyperlactatemia, and all four fatal cases had LBFs of less than 12 mL.min-1.kg-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic disturbances in Plasmodium coatneyi-infected rhesus monkeys

To investigate metabolic disturbances in an animal model of human malaria, four rhesus monkeys (Macaca mulatta) were infected with Plasmodium coatneyi, a parasite which induces cytoadherence of infected erythrocytes. When moribund or the parasitaemia had plateaued, the monkeys were sacrificed (3 animals) or treated with chloroquine (1 animal). Blood and cerebrospinal fluid (CSF) were sampled at intervals between inoculation and sacrifice or treatment. Arterial and CSF glucose and lactate rose during infection, indicating evolving insulin resistance. The arteriovenous difference in glucose concentration also increased, consistent with increased glucose consumption by parasitised tissues. Arterial plasma lactate rose but a positive arteriovenous concentration difference suggested tissue lactate uptake. The animal with the highest plasma lactate at sacrifice remained hyperglycaemic but also had the highest CSF lactate, the greatest cerebral sequestration and neurological depression, and biochemical and histological evidence of severe hepatic pathology. Serum cholesterol and corrected serum calcium fell consistently during infection; serum phosphate was also reduced in animals without renal impairment. These preliminary results indicate that lactic acidosis is a late complication of severe malaria and, by implication from this and other studies, hypoglycaemia occurs even later; other metabolic changes during P. coatneyi infection in rhesus monkeys also parallel those of severe falciparum malaria in humans. The model could be used in further studies of malaria-associated metabolic dysfunction and its management.