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Kumwenda M, Assies R, Snik I, Chatima G, Langton J, Chimalizeni Y, Romaine ST, van Woensel JB, Pallmann P, Carrol ED, Calis JC. Identifying critically ill children in Malawi: A modified qSOFA score for low-resource settings. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002388. [PMID: 38271303 PMCID: PMC10810502 DOI: 10.1371/journal.pgph.0002388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024]
Abstract
In low-resource settings, a reliable bedside score for timely identification of children at risk of dying, could help focus resources and improve survival. The rapid bedside Liverpool quick Sequential Organ Failure Assessment (LqSOFA) uses clinical parameters only and performed well in United Kingdom cohorts. A similarly quick clinical assessment-only score has however not yet been developed for paediatric populations in sub-Saharan Africa. In a development cohort of critically ill children in Malawi, we calculated the LqSOFA scores using age-adjusted heart rate and respiratory rate, capillary refill time and Blantyre Coma Scale, and evaluated its prognostic performance for mortality. An improved score, the Blantyre qSOFA (BqSOFA), was developed (omitting heart rate, adjusting respiratory rate cut-off values and adding pallor), subsequently validated in a second cohort of Malawian children, and compared with an existing score (FEAST-PET). Prognostic performance for mortality was evaluated using area under the receiver operating characteristic curve (AUC). Mortality was 15.4% in the development (N = 493) and 22.0% in the validation cohort (N = 377). In the development cohort, discriminative ability (AUC) of the LqSOFA to predict mortality was 0.68 (95%-CI: 0.60-0.76). The BqSOFA and FEAST-PET yielded AUCs of 0.84 (95%-CI:0.79-0.89) and 0.83 (95%-CI:0.77-0.89) in the development cohort, and 0.74 (95%-CI:0.68-0.79) and 0.76 (95%-CI:0.70-0.82) in the validation cohort, respectively. We developed a simple prognostic score for Malawian children based on four clinical parameters which performed as well as a more complex score. The BqSOFA might be used to promptly identify critically ill children at risk of dying and prioritize hospital care in low-resource settings.
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Affiliation(s)
- Mercy Kumwenda
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Paediatrics and Child Health, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Roxanne Assies
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
| | - Ilse Snik
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Gloria Chatima
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Yamikani Chimalizeni
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sam T. Romaine
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Job B.M. van Woensel
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Enitan D. Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Job C.J. Calis
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
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O'Brien NF, Chetcuti K, Fonseca Y, Vidal L, Raghavan P, Postels DG, Chimalizeni Y, Ray S, Seydel KB, Taylor TE. Cerebral Metabolic Crisis in Pediatric Cerebral Malaria. J Pediatr Intensive Care 2023; 12:278-288. [PMID: 37970136 PMCID: PMC10631841 DOI: 10.1055/s-0041-1732444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022] Open
Abstract
Cerebral metabolic energy crisis (CMEC), often defined as a cerebrospinal fluid (CSF) lactate: pyruvate ratio (LPR) >40, occurs in various diseases and is associated with poor neurologic outcomes. Cerebral malaria (CM) causes significant mortality and neurodisability in children worldwide. Multiple factors that could lead to CMEC are plausible in these patients, but its frequency has not been explored. Fifty-three children with CM were enrolled and underwent analysis of CSF lactate and pyruvate levels. All 53 patients met criteria for a CMEC (median CSF LPR of 72.9 [interquartile range [IQR]: 58.5-93.3]). Half of children met criteria for an ischemic CMEC (median LPR of 85 [IQR: 73-184]) and half met criteria for a nonischemic CMEC (median LPR of 60 [IQR: 54-79]. Children also underwent transcranial doppler ultrasound investigation. Cerebral blood flow velocities were more likely to meet diagnostic criteria for low flow (<2 standard deviation from normal) or vasospasm in children with an ischemic CMEC (73%) than in children with a nonischemic CMEC (20%, p = 0.04). Children with an ischemic CMEC had poorer outcomes (pediatric cerebral performance category of 3-6) than those with a nonischemic CMEC (46 vs. 22%, p = 0.03). CMEC was ubiquitous in this patient population and the processes underlying the two subtypes (ischemic and nonischemic) may represent targets for future adjunctive therapies.
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Affiliation(s)
- Nicole F. O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, United States
| | - Karen Chetcuti
- Department of Radiology, College of Medicine, Chichiri, Blantyre, Malawi
| | - Yudy Fonseca
- Division of Critical Care Medicine, Department of Pediatrics, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Lorenna Vidal
- Division of Neuroradiology, Department of Radiology Children's Hospital of Philadelphia, Clinical Instructor at Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Prashant Raghavan
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Douglas G. Postels
- Department of Neurology, George Washington University/Children's National Medical Center, Washington, District of Columbia, United States
| | - Yamikani Chimalizeni
- Department of Pediatrics and Child Health, University of Malawi, Malawi College of Medicine, Chichiri, Blantyre, Malawi
| | - Stephen Ray
- Department of Paediatric, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Karl B. Seydel
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
- Blantyre Malaria Project, Blantyre, Malawi
| | - Terrie E. Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
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Ngai M, Hawkes MT, Erice C, Weckman AM, Wright J, Stefanova V, Opoka RO, Namasopo S, Conroy AL, Kain KC. Intestinal Injury in Ugandan Children Hospitalized With Malaria. J Infect Dis 2022; 226:2010-2020. [PMID: 35942812 DOI: 10.1093/infdis/jiac340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/07/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe malaria is associated with multiple organ dysfunction syndrome (MODS), which may involve the gastrointestinal tract. METHODS In a prospective cohort study in Uganda, we measured markers of intestinal injury (intestinal fatty-acid binding protein [I-FABP] and zonula occludens-1 [ZO-1]) and microbial translocation (lipopolysaccharide binding protein [LBP] and soluble complement of differentiation 14 [sCD14]) among children admitted with malaria. We examined their association with biomarkers of inflammation, endothelial activation, clinical signs of hypoperfusion, organ injury, and mortality. RESULTS We enrolled 523 children (median age 1.5 years, 46% female, 7.5% mortality). Intestinal FABP was above the normal range (≥400 pg/mL) in 415 of 523 patients (79%). Intestinal FABP correlated with ZO-1 (ρ = 0.11, P = .014), sCD14 (ρ = 0.12, P = .0046) as well as markers of inflammation and endothelial activation. Higher I-FABP levels were associated with lower systolic blood pressure (ρ = -0.14, P = .0015), delayed capillary refill time (ρ = 0.17, P = .00011), higher lactate level (ρ = 0.40, P < .0001), increasing stage of acute kidney injury (ρ = 0.20, P = .0034), and coma (P < .0001). Admission I-FABP levels ≥5.6 ng/mL were associated with a 7.4-fold higher relative risk of in-hospital death (95% confidence interval, 1.4-11, P = .0016). CONCLUSIONS Intestinal injury occurs commonly in children hospitalized with malaria and is associated with microbial translocation, systemic inflammation, tissue hypoperfusion, MODS, and fatal outcome.
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Affiliation(s)
- Michelle Ngai
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael T Hawkes
- Department of Paediatrics, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Department of Medical Microbiology and Immunology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Clara Erice
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea M Weckman
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julie Wright
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Veselina Stefanova
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda
| | - Sophie Namasopo
- Department of Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda.,Department of Paediatrics, Kabale District Hospital, Kabale, Uganda
| | - Andrea L Conroy
- Ryan White Center for Paediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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O'Brien NF, Fonseca Y, Johnson HC, Postels D, Birbeck GL, Chimalizeni Y, Seydel KB, Bernard Gushu M, Phiri T, June S, Chetcuti K, Vidal L, Goyal MS, Taylor TE. Mechanisms of Transcranial Doppler Ultrasound phenotypes in paediatric cerebral malaria remain elusive. Malar J 2022; 21:196. [PMID: 35729574 PMCID: PMC9210743 DOI: 10.1186/s12936-022-04163-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background Cerebral malaria (CM) results in significant paediatric death and neurodisability in sub-Saharan Africa. Several different alterations to typical Transcranial Doppler Ultrasound (TCD) flow velocities and waveforms in CM have been described, but mechanistic contributors to these abnormalities are unknown. If identified, targeted, TCD-guided adjunctive therapy in CM may improve outcomes. Methods This was a prospective, observational study of children 6 months to 12 years with CM in Blantyre, Malawi recruited between January 2018 and June 2021. Medical history, physical examination, laboratory analysis, electroencephalogram, and magnetic resonance imaging were undertaken on presentation. Admission TCD results determined phenotypic grouping following a priori definitions. Evaluation of the relationship between haemodynamic, metabolic, or intracranial perturbations that lead to these observed phenotypes in other diseases was undertaken. Neurological outcomes at hospital discharge were evaluated using the Paediatric Cerebral Performance Categorization (PCPC) score. Results One hundred seventy-four patients were enrolled. Seven (4%) had a normal TCD examination, 57 (33%) met criteria for hyperaemia, 50 (29%) for low flow, 14 (8%) for microvascular obstruction, 11 (6%) for vasospasm, and 35 (20%) for isolated posterior circulation high flow. A lower cardiac index (CI) and higher systemic vascular resistive index (SVRI) were present in those with low flow than other groups (p < 0.003), though these values are normal for age (CI 4.4 [3.7,5] l/min/m2, SVRI 1552 [1197,1961] dscm-5m2). Other parameters were largely not significantly different between phenotypes. Overall, 118 children (68%) had a good neurological outcome. Twenty-three (13%) died, and 33 (19%) had neurological deficits. Outcomes were best for participants with hyperaemia and isolated posterior high flow (PCPC 1–2 in 77 and 89% respectively). Participants with low flow had the least likelihood of a good outcome (PCPC 1–2 in 42%) (p < 0.001). Cerebral autoregulation was significantly better in children with good outcome (transient hyperemic response ratio (THRR) 1.12 [1.04,1.2]) compared to a poor outcome (THRR 1.05 [0.98,1.02], p = 0.05). Conclusions Common pathophysiological mechanisms leading to TCD phenotypes in non-malarial illness are not causative in children with CM. Alternative mechanistic contributors, including mechanical factors of the cerebrovasculature and biologically active regulators of vascular tone should be explored.
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Affiliation(s)
- Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43502, USA.
| | - Yudy Fonseca
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43502, USA
| | - Hunter C Johnson
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43502, USA
| | - Douglas Postels
- Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA
| | - Gretchen L Birbeck
- Department of Neurology, University of Rochester, Rochester, NY, USA.,University Teaching Hospitals Children's Hospital, Lusaka, Zambia
| | - Yamikani Chimalizeni
- Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Chichiri, Blantyre 3, Malawi
| | - Karl B Seydel
- Dept of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| | - Montfort Bernard Gushu
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Tusekile Phiri
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Sylvester June
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Karen Chetcuti
- Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Chichiri, Blantyre 3, Malawi
| | - Lorenna Vidal
- Department of Radiology, Division of Neuroradiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Manu S Goyal
- Washington University School of Medicine, St. Louis, MO, USA
| | - Terrie E Taylor
- Dept of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
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Postels DG. Leveling the Playing Field: Combining Pediatric Neurology and Global Health. Pediatr Neurol 2021; 120:61-62. [PMID: 34020114 DOI: 10.1016/j.pediatrneurol.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Douglas G Postels
- Division of Neurology, The George Washington University/Children's National Medical Center, Washington District of Columbia; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
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EEG markers predictive of epilepsy risk in pediatric cerebral malaria - A feasibility study. Epilepsy Behav 2020; 113:107536. [PMID: 33232892 PMCID: PMC7736081 DOI: 10.1016/j.yebeh.2020.107536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Cerebral malaria (CM) affects 500,000 million children annually, 10% whom develop epilepsy within two years. Acute identification of biomarkers for post-CM epilepsy would allow for follow-up of the highest risk populations in resource-limited regions. We investigated the utility of electroencephalogram (EEG) and clinical metrics obtained during acute CM infection for predicting epilepsy. METHODS We analyzed 70 EEGs recorded within 24 h of admission for CM hospitalization obtained during the Blantyre Malaria Project Epilepsy Study (2005-2007), a prospective cohort study of pediatric CM survivors. While all studies underwent spectral analyses for comparisons of mean power band frequencies, a subset of EEGs from the 10 subjects who developed epilepsy and 10 age- and sex-matched controls underwent conventional visual analysis. Findings were tested for relationships to epilepsy outcomes. RESULTS Ten of the 70 subjects developed epilepsy. There were no significant differences between groups that were analyzed via visual EEG review; however, spectral EEG analyses revealed a significantly higher gamma-delta power ratio in CM survivors who developed epilepsy (0.23 ± 0.10) than in those who did not (0.16 ± 0.06), p = 0.003. Excluding potential confounders, multivariable logistic-regression analyses found relative gamma power (p = 0.003) and maximum temperature during admission (p = 0.03) significant and independent predictors of post-CM epilepsy, with area under receiver operating characteristics (AUROC) curve of 0.854. CONCLUSIONS We found that clinical and EEG metrics acquired during acute CM presentation confer risk of post-CM epilepsy. Further studies are required to investigate the utility of gamma activity as a potential biomarker of epileptogenesis and study this process over time. Additionally, resource limitations currently prevent follow-up of all CM cases to surveil for epilepsy, and identification of acute biomarkers in this population would offer the opportunity to allocate resources more efficiently.
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Abah SE, Burté F, Howell SA, Lagunju I, Shokunbi WA, Wahlgren M, Sodeinde O, Brown BJ, Holder AA, Fernandez-Reyes D. Depleted circulatory complement-lysis inhibitor (CLI) in childhood cerebral malaria returns to normal with convalescence. Malar J 2020; 19:167. [PMID: 32336276 PMCID: PMC7184698 DOI: 10.1186/s12936-020-03241-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 04/17/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cerebral malaria (CM), is a life-threatening childhood malaria syndrome with high mortality. CM is associated with impaired consciousness and neurological damage. It is not fully understood, as yet, why some children develop CM. Presented here is an observation from longitudinal studies on CM in a paediatric cohort of children from a large, densely-populated and malaria holoendemic, sub-Saharan, West African metropolis. METHODS Plasma samples were collected from a cohort of children with CM, severe malarial anaemia (SMA), uncomplicated malaria (UM), non-malaria positive healthy community controls (CC), and coma and anemic patients without malaria, as disease controls (DC). Proteomic two-dimensional difference gel electrophoresis (2D-DIGE) and mass spectrometry were used in a discovery cohort to identify plasma proteins that might be discriminatory among these clinical groups. The circulatory levels of identified proteins of interest were quantified by ELISA in a prospective validation cohort. RESULTS The proteome analysis revealed differential abundance of circulatory complement-lysis inhibitor (CLI), also known as Clusterin (CLU). CLI circulatory level was low at hospital admission in all children presenting with CM and recovered to normal level during convalescence (p < 0.0001). At acute onset, circulatory level of CLI in the CM group significantly discriminates CM from the UM, SMA, DC and CC groups. CONCLUSIONS The CLI circulatory level is low in all patients in the CM group at admission, but recovers through convalescence. The level of CLI at acute onset may be a specific discriminatory marker of CM. This work suggests that CLI may play a role in the pathophysiology of CM and may be useful in the diagnosis and follow-up of children presenting with CM.
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Affiliation(s)
| | - Florence Burté
- Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
| | - Steven A Howell
- Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
| | - Ikeoluwa Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
- Childhood Malaria Research Group, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Wuraola A Shokunbi
- Childhood Malaria Research Group, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
- Department of Haematology, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Mats Wahlgren
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Olugbemiro Sodeinde
- Department of Paediatrics, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
- Childhood Malaria Research Group, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
- Department of Computer Science, Faculty of Engineering, University College London, Gower Street, London, WC1E 6BT, UK
| | - Biobele J Brown
- Department of Paediatrics, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
- Childhood Malaria Research Group, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | | | - Delmiro Fernandez-Reyes
- Department of Paediatrics, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria.
- Childhood Malaria Research Group, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria.
- Department of Computer Science, Faculty of Engineering, University College London, Gower Street, London, WC1E 6BT, UK.
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Postels DG, Soldatos A, LaRovere KL. Outcomes measures in children after acute central nervous system infections and malaria. Curr Opin Pediatr 2019; 31:756-762. [PMID: 31693584 DOI: 10.1097/mop.0000000000000823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Acute central nervous system (CNS) infections in children result in significant mortality and neurologic morbidity worldwide. This article summarizes the recent pediatric literature published on outcomes measures used after acute infectious meningitis, encephalitis, and cerebral malaria, and highlights ongoing research efforts to standardize outcomes measurements. Search terms were geared toward functional, cognitive, behavioral, and other outcome assessments. RECENT FINDINGS Recent data suggest that, depending on microbiological cause, there are differences in currently used outcome measures following acute CNS infections. Outcomes assessments include a variety of formal psychological tests (structured interviews and neuropsychological tests of cognitive and motor functioning) and dichotomized or ordinal scales. Standardization of outcome measures, however, is lacking. Global efforts to standardize outcomes that encompass both the child and family are ongoing. SUMMARY Centers worldwide can track and measure a variety of cognitive, behavioral, and functional outcomes after acute CNS infections. Standardized documentation and coding of clinically important outcomes is needed. Further research to evaluate effective practices using acute adjunctive and rehabilitation therapies will be aided by outcome measure standardization.
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Affiliation(s)
- Douglas G Postels
- Department of Neurology, Children's National Health System, Washington, District of Columbia
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
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MRI demonstrates glutamine antagonist-mediated reversal of cerebral malaria pathology in mice. Proc Natl Acad Sci U S A 2018; 115:E12024-E12033. [PMID: 30514812 DOI: 10.1073/pnas.1812909115] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The deadliest complication of Plasmodium falciparum infection is cerebral malaria (CM), with a case fatality rate of 15 to 25% in African children despite effective antimalarial chemotherapy. No adjunctive treatments are yet available for this devastating disease. We previously reported that the glutamine antagonist 6-diazo-5-oxo-l-norleucine (DON) rescued mice from experimental CM (ECM) when administered late in the infection, a time by which mice had already suffered blood-brain barrier (BBB) dysfunction, brain swelling, and hemorrhaging. Herein, we used longitudinal MR imaging to visualize brain pathology in ECM and the impact of a new DON prodrug, JHU-083, on disease progression in mice. We demonstrate in vivo the reversal of disease markers in symptomatic, infected mice following treatment, including the resolution of edema and BBB disruption, findings usually associated with a fatal outcome in children and adults with CM. Our results support the premise that JHU-083 is a potential adjunctive treatment that could rescue children and adults from fatal CM.
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O'Brien NF, Mutatshi Taty T, Moore-Clingenpeel M, Bodi Mabiala J, Mbaka Pongo J, Ambitapio Musungufu D, Uchama M, Yotebieng M. Transcranial Doppler Ultrasonography Provides Insights into Neurovascular Changes in Children with Cerebral Malaria. J Pediatr 2018; 203:116-124.e3. [PMID: 30224088 DOI: 10.1016/j.jpeds.2018.07.075] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/14/2018] [Accepted: 07/24/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate neurovascular changes in pediatric patients with cerebral malaria. STUDY DESIGN African children with cerebral malaria were enrolled and underwent daily transcranial Doppler ultrasound (TCD) examinations through hospital day 8, discharge, or death. Neurologic outcomes were assessed 2 weeks after enrollment. RESULTS In total, 160 children with cerebral malaria and 155 comparison patients were included. In patients with cerebral malaria, TCD flow changes characterized as hyperemia were seen in 42 (26%), low flow in 46 (28%), microvascular obstruction in 35 (22%), cerebral vasospasm in 21 (13%), and isolated posterior hyperemia in 7 (4%). Most had a single neurovascular phenotype observed throughout participation. Among comparison patients, 76% had normal TCD findings (P < .001). Impaired autoregulation was present in 80% of cases (transient hyperemic response ratio 1.01 ± 0.03) but improved through day 4 (1.1 ± 0.02, P = .014). Overall mortality was 24% (n = 39). Neurologic deficits were evident in 21% of survivors. Children meeting criteria for vasospasm were most likely to survive with sequelae, and children meeting criteria for low flow were most likely to die. Autoregulation was better in children with a normal neurologic outcome (1.09, 95% CI 1.06-1.12) than in others (0.98, 95% CI 0.95-1) (P ≤ .001). CONCLUSIONS Several distinct changes in TCD measurements were identified in children with cerebral malaria that permitted phenotypic grouping. Groups had distinct associations with neurologic outcomes. Validation of pathogenic mechanisms associated with each phenotype may aid in developing TCD as a portable, easy-to-use tool to help guide targeted adjunctive therapy in cerebral malaria aimed at causative mechanisms of injury on an individual level.
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Affiliation(s)
- Nicole Fortier O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH.
| | - Tshimanga Mutatshi Taty
- Department of Pediatrics, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Joseph Bodi Mabiala
- Department of Pediatrics, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jean Mbaka Pongo
- University of Science and Technology, General Referral Hospital of Lodja, Lodja, Democratic Republic of the Congo
| | - Davin Ambitapio Musungufu
- Department of Pediatrics, Medical Evangelical Center of Nyankunde, Bunia, Democratic Republic of the Congo
| | - Mananu Uchama
- Department of Pediatrics, Medical Evangelical Center of Nyankunde, Bunia, Democratic Republic of the Congo
| | - Marcel Yotebieng
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH
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11
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Crehan C, Colbourn T, Heys M, Molyneux E. Evaluation of 'TRY': an algorithm for neonatal continuous positive airways pressure in low-income settings. Arch Dis Child 2018. [PMID: 29514813 DOI: 10.1136/archdischild-2017-313867] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Non-invasive respiratory support using bubble continuous positive airway pressure (bCPAP) is useful in treating babies with respiratory distress syndrome. Despite its proven clinical and cost-effectiveness, implementation is hampered by the inappropriate administration of bCPAP in low-resource settings. A clinical algorithm-'TRY' (based on Tone: good; Respiratory distress; Yes, heart rate above 100 beats/min)-has been developed to correctly identify which newborns would benefit most from bCPAP in a teaching hospital in Malawi. OBJECTIVE To evaluate the reliability, sensitivity and specificity of TRY when employed by nurses in a Malawian district hospital. METHODS Nursing staff in a Malawian district hospital baby unit were asked, over a 2-month period, to complete TRY assessments for every newly admitted baby with the following inclusion criteria: clinical evidence of respiratory distress and/or birth weight less than 1.3 kg. A visiting paediatrician, blinded to nurses' assessments, concurrently assessed each baby, providing both a TRY assessment and a clinical decision regarding the need for CPAP administration. Inter-rater reliability was calculated comparing nursing and paediatrician TRY assessment outcomes. Sensitivity and specificity were estimated comparing nurse TRY assessments against the paediatrician's clinical decision. RESULTS Two hundred and eighty-seven infants were admitted during the study period; 145 (51%) of these met the inclusion criteria, and of these 57 (39%) received joint assessments. The inter-rater reliability was high (kappa 0.822). Sensitivity and specificity were 92% and 96%, respectively. CONCLUSIONS District hospital nurses, using the TRY-CPAP algorithm, reliably identified babies that might benefit from bCPAP and thus improved its effective implementation.
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Affiliation(s)
- Caroline Crehan
- Institute of Global Health, University College London, London, UK
| | - Tim Colbourn
- Institute of Global Health, University College London, London, UK
| | - Michelle Heys
- Institute of Global Health, University College London, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
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12
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Children with cerebral malaria or severe malarial anaemia lack immunity to distinct variant surface antigen subsets. Sci Rep 2018; 8:6281. [PMID: 29674705 PMCID: PMC5908851 DOI: 10.1038/s41598-018-24462-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/28/2018] [Indexed: 01/08/2023] Open
Abstract
Variant surface antigens (VSAs) play a critical role in severe malaria pathogenesis. Defining gaps, or “lacunae”, in immunity to these Plasmodium falciparum antigens in children with severe malaria would improve our understanding of vulnerability to severe malaria and how protective immunity develops. Using a protein microarray with 179 antigen variants from three VSA families as well as more than 300 variants of three other blood stage P. falciparum antigens, reactivity was measured in sera from Malian children with cerebral malaria or severe malarial anaemia and age-matched controls. Sera from children with severe malaria recognized fewer extracellular PfEMP1 fragments and were less reactive to specific fragments compared to controls. Following recovery from severe malaria, convalescent sera had increased reactivity to certain non-CD36 binding PfEMP1s, but not other malaria antigens. Sera from children with severe malarial anaemia reacted to fewer VSAs than did sera from children with cerebral malaria, and both of these groups had lacunae in their seroreactivity profiles in common with children who had both cerebral malaria and severe malarial anaemia. This microarray-based approach may identify a subset of VSAs that could inform the development of a vaccine to prevent severe disease or a diagnostic test to predict at-risk children.
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13
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Kampondeni SD, Birbeck GL, Seydel KB, Beare NA, Glover SJ, Hammond CA, Chilingulo CA, Taylor TE, Potchen MJ. Noninvasive measures of brain edema predict outcome in pediatric cerebral malaria. Surg Neurol Int 2018; 9:53. [PMID: 29576904 PMCID: PMC5858047 DOI: 10.4103/sni.sni_297_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/19/2017] [Indexed: 12/29/2022] Open
Abstract
Background: Increased brain volume (BV) and subsequent herniation are strongly associated with death in pediatric cerebral malaria (PCM), a leading killer of children in developing countries. Accurate noninvasive measures of BV are needed for optimal clinical trial design. Our objectives were to examine the performance of six different magnetic resonance imaging (MRI) BV quantification measures for predicting mortality in PCM and to review the advantages and disadvantages of each method. Methods: Receiver operator characteristics were generated from BV measures of MRIs of children admitted to an ongoing research project with PCM between 2009 and 2014. Fatal cases were matched to the next available survivor. A total of 78 MRIs of children aged 5 months to 13 years (mean 4.0 years), of which 45% were males, were included. Results: Areas under the curve (AUC) with 95% confidence interval on measures from the initial MRIs were: Radiologist-derived score = 0.69 (0.58–0.79; P = 0.0037); prepontine cistern anteroposterior (AP) dimension = 0.70 (0.56–0.78; P = 0.0133); SamKam ratio [Rt. parietal lobe height/(prepontine AP dimension + fourth ventricle AP dimension)] = 0.74 (0.63–0.83; P = 0.0002); and global cerebrospinal fluid (CSF) space ascertained by ClearCanvas = 0.67 (0.55–0.77; P = 0.0137). For patients with serial MRIs (n = 37), the day 2 global CSF space AUC was 0.87 (0.71–0.96; P < 0.001) and the recovery factor (CSF volume day 2/CSF volume day 1) was 0.91 (0.76–0.98; P < 0.0001). Poor prognosis is associated with radiologist score of ≥7; prepontine cistern dimension ≤3 mm; cisternal CSF volume ≤7.5 ml; SamKam ratio ≥6.5; and recovery factor ≤0.75. Conclusion: All noninvasive measures of BV performed well in predicting death and providing a proxy measure for brain volume. Initial MRI assessment may inform future clinical trials for subject selection, risk adjustment, or stratification. Measures of temporal change may be used to stage PCM.
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Affiliation(s)
- Samuel D Kampondeni
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Imaging Sciences, Division of Diagnostic and Interventional Neuroradiology, University of Rochester Medical Center, Rochester, New York
| | - Gretchen L Birbeck
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Strong Epilepsy Center, University of Rochester, Rochester, New York, USA
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, Michigan State University, Michigan, USA
| | - Nicholas A Beare
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon J Glover
- School of Medicine, University of St. Andrews, North Haugh, St. Andrews, UK
| | | | - Cowles A Chilingulo
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, Michigan State University, Michigan, USA
| | - Michael J Potchen
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Imaging Sciences, Division of Diagnostic and Interventional Neuroradiology, University of Rochester Medical Center, Rochester, New York
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14
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Lemos MP, Taylor TE, McGoldrick SM, Molyneux ME, Menon M, Kussick S, Mkhize NN, Martinson NA, Stritmatter A, Randolph-Habecker J. Pathology-Based Research in Africa. Clin Lab Med 2018; 38:67-90. [PMID: 29412886 PMCID: PMC5894888 DOI: 10.1016/j.cll.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The process of conducting pathology research in Africa can be challenging. But the rewards in terms of knowledge gained, quality of collaborations, and impact on communities affected by infectious disease and cancer are great. This report reviews 3 different research efforts: fatal malaria in Malawi, mucosal immunity to HIV in South Africa, and cancer research in Uganda. What unifies them is the use of pathology-based approaches to answer vital questions, such as physiology, pathogenesis, predictors of clinical course, and diagnostic testing schemes.
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Affiliation(s)
- Maria P Lemos
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, E4-203, Seattle, WA 98101, USA
| | - Terrie E Taylor
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Suzanne M McGoldrick
- Seattle Genetics, Seattle Children's Hospital, Fred Hutchinson Cancer Research Center, 21823 30th Dr SE, Bothell, WA 98021, USA
| | - Malcolm E Molyneux
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L35QA, UK
| | - Manoj Menon
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue, M1-B140, Seattle, WA 98109, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue, M1-B140, Seattle, WA 98109, USA; Department of Medicine, University of Washington, 1100 Fairview Avenue, M1-B140, Seattle, WA 98109, USA
| | - Steve Kussick
- PhenoPath Laboratories, 551 North 34th Street #100, Seattle, WA 98103, USA
| | - Nonhlanhla N Mkhize
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), National Health Laboratory Service (NHLS), Johannesburg, South Africa; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil A Martinson
- Perinatal HIV Research Unit (PHRU), MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa; Johns Hopkins University, Center for Tuberculosis Research, Baltimore, MD, USA
| | - Andrea Stritmatter
- Pacific Northwest University of Health Sciences, 200 University Parkway, Room BHH 423, Yakima, WA 98901, USA
| | - Julie Randolph-Habecker
- Pacific Northwest University of Health Sciences, 200 University Parkway, Room BHH 423, Yakima, WA 98901, USA.
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15
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Spatial statistical modelling of capillary non-perfusion in the retina. Sci Rep 2017; 7:16792. [PMID: 29196702 PMCID: PMC5711887 DOI: 10.1038/s41598-017-16620-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/10/2017] [Indexed: 11/21/2022] Open
Abstract
Manual grading of lesions in retinal images is relevant to clinical management and clinical trials, but it is time-consuming and expensive. Furthermore, it collects only limited information - such as lesion size or frequency. The spatial distribution of lesions is ignored, even though it may contribute to the overall clinical assessment of disease severity, and correspond to microvascular and physiological topography. Capillary non-perfusion (CNP) lesions are central to the pathogenesis of major causes of vision loss. Here we propose a novel method to analyse CNP using spatial statistical modelling. This quantifies the percentage of CNP-pixels in each of 48 sectors and then characterises the spatial distribution with goniometric functions. We applied our spatial approach to a set of images from patients with malarial retinopathy, and found it compares favourably with the raw percentage of CNP-pixels and also with manual grading. Furthermore, we were able to quantify a biological characteristic of macular CNP in malaria that had previously only been described subjectively: clustering at the temporal raphe. Microvascular location is likely to be biologically relevant to many diseases, and so our spatial approach may be applicable to a diverse range of pathological features in the retina and other organs.
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16
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Keita Alassane S, Nicolau-Travers ML, Menard S, Andreoletti O, Cambus JP, Gaudre N, Wlodarczyk M, Blanchard N, Berry A, Abbes S, Colongo D, Faye B, Augereau JM, Lacroux C, Iriart X, Benoit-Vical F. Young Sprague Dawley rats infected by Plasmodium berghei: A relevant experimental model to study cerebral malaria. PLoS One 2017; 12:e0181300. [PMID: 28742109 PMCID: PMC5524346 DOI: 10.1371/journal.pone.0181300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 06/14/2017] [Indexed: 02/06/2023] Open
Abstract
Cerebral malaria (CM) is the most severe manifestation of human malaria yet is still poorly understood. Mouse models have been developed to address the subject. However, their relevance to mimic human pathogenesis is largely debated. Here we study an alternative cerebral malaria model with an experimental Plasmodium berghei Keyberg 173 (K173) infection in Sprague Dawley rats. As in Human, not all infected subjects showed cerebral malaria, with 45% of the rats exhibiting Experimental Cerebral Malaria (ECM) symptoms while the majority (55%) of the remaining rats developed severe anemia and hyperparasitemia (NoECM). These results allow, within the same population, a comparison of the noxious effects of the infection between ECM and severe malaria without ECM. Among the ECM rats, 77.8% died between day 5 and day 12 post-infection, while the remaining rats were spontaneously cured of neurological signs within 24-48 hours. The clinical ECM signs observed were paresis quickly evolving to limb paralysis, global paralysis associated with respiratory distress, and coma. The red blood cell (RBC) count remained normal but a drastic decrease of platelet count and an increase of white blood cell numbers were noted. ECM rats also showed a decrease of glucose and total CO2 levels and an increase of creatinine levels compared to control rats or rats with no ECM. Assessment of the blood-brain barrier revealed loss of integrity, and interestingly histopathological analysis highlighted cyto-adherence and sequestration of infected RBCs in brain vessels from ECM rats only. Overall, this ECM rat model showed numerous clinical and histopathological features similar to Human CM and appears to be a promising model to achieve further understanding the CM pathophysiology in Humans and to evaluate the activity of specific antimalarial drugs in avoiding/limiting cerebral damages from malaria.
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Affiliation(s)
- Sokhna Keita Alassane
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
- UFR Sciences de la Santé, Université Gaston Berger, St Louis, Sénégal
| | - Marie-Laure Nicolau-Travers
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
| | - Sandie Menard
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Olivier Andreoletti
- UMR INRA ENVT 1225, Interactions Hôte Agent Pathogène, Ecole Nationale Vétérinaire de Toulouse, 23 Chemin des Capelles, Toulouse, France
| | - Jean-Pierre Cambus
- Laboratoire Hématologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Noémie Gaudre
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Myriam Wlodarczyk
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Nicolas Blanchard
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Antoine Berry
- Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Sarah Abbes
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
| | | | - Babacar Faye
- UFR Sciences de la Santé, Université Gaston Berger, St Louis, Sénégal
| | - Jean-Michel Augereau
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
| | - Caroline Lacroux
- UMR INRA ENVT 1225, Interactions Hôte Agent Pathogène, Ecole Nationale Vétérinaire de Toulouse, 23 Chemin des Capelles, Toulouse, France
| | - Xavier Iriart
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
- Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Françoise Benoit-Vical
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
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17
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Moxon CA, Zhao L, Li C, Seydel KB, MacCormick IJ, Diggle PJ, Mallewa M, Solomon T, Beare NA, Glover SJ, Harding SP, Lewallen S, Kampondeni S, Potchen MJ, Taylor TE, Postels DG. Safety of lumbar puncture in comatose children with clinical features of cerebral malaria. Neurology 2016; 87:2355-2362. [PMID: 27794112 PMCID: PMC5135026 DOI: 10.1212/wnl.0000000000003372] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 08/17/2016] [Indexed: 11/15/2022] Open
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.
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Affiliation(s)
- Christopher A Moxon
- 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
| | - Lei Zhao
- 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
| | - Chenxi Li
- 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
| | - Karl B Seydel
- 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
| | - Ian J MacCormick
- 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
| | - Peter J Diggle
- 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
| | - Macpherson Mallewa
- 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
| | - Tom Solomon
- 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
| | - Nicholas A Beare
- 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
| | - Simon J Glover
- 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
| | - Simon P Harding
- 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
| | - Susan Lewallen
- 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
| | - Sam Kampondeni
- 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
| | - Michael J Potchen
- 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
| | - Terrie E Taylor
- 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 G Postels
- 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.
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18
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MacCormick IJC, Maude RJ, Beare NAV, Borooah S, Glover S, Parry D, Leach S, Molyneux ME, Dhillon B, Lewallen S, Harding SP. Grading fluorescein angiograms in malarial retinopathy. Malar J 2015; 14:367. [PMID: 26403288 PMCID: PMC4583163 DOI: 10.1186/s12936-015-0897-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 09/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malarial retinopathy is an important finding in Plasmodium falciparum cerebral malaria, since it strengthens diagnostic accuracy, predicts clinical outcome and appears to parallel cerebral disease processes. Several angiographic features of malarial retinopathy have been described, but observations in different populations can only be reliably compared if consistent methodology is used to capture and grade retinal images. Currently no grading scheme exists for fluorescein angiographic features of malarial retinopathy. METHODS A grading scheme for fluorescein angiographic images was devised based on consensus opinion of clinicians and researchers experienced in malarial retinopathy in children and adults. Dual grading were performed with adjudication of admission fluorescein images from a large cohort of children with cerebral malaria. RESULTS A grading scheme is described and standard images are provided to facilitate future grading studies. Inter-grader agreement was >70 % for most variables. Intravascular filling defects are difficult to grade and tended to have lower inter-grader agreement (>57 %) compared to other features. CONCLUSIONS This grading scheme provides a consistent way to describe retinal vascular damage in paediatric cerebral malaria, and can facilitate comparisons of angiographic features of malarial retinopathy between different patient groups, and analysis against clinical outcomes. Inter-grader agreement is reasonable for the majority of angiographic signs. Dual grading with expert adjudication should be used to maximize accuracy.
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Affiliation(s)
- Ian J C MacCormick
- Department of Eye and Vision Science, University of Liverpool, Liverpool, UK. .,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. .,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - Richard J Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.
| | - Nicholas A V Beare
- Department of Eye and Vision Science, University of Liverpool, Liverpool, UK. .,St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
| | - Shyamanga Borooah
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. .,Department of Ophthalmology, University of Edinburgh, Edinburgh, UK. .,Princess Alexandra Eye Pavilion, Edinburgh, UK.
| | - Simon Glover
- School of Medicine, University of St Andrews, St Andrews, UK.
| | - David Parry
- Liverpool Ophthalmic Reading Centre, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
| | - Sophie Leach
- Liverpool Ophthalmic Reading Centre, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
| | - Malcolm E Molyneux
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. .,Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Baljean Dhillon
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. .,Department of Ophthalmology, University of Edinburgh, Edinburgh, UK. .,Princess Alexandra Eye Pavilion, Edinburgh, UK.
| | - Susan Lewallen
- Kilimanjaro Centre for Community Ophthalmology, Cape Town, South Africa.
| | - Simon P Harding
- Department of Eye and Vision Science, University of Liverpool, Liverpool, UK. .,St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
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19
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Seydel KB, Kampondeni SD, Valim C, Potchen MJ, Milner DA, Muwalo FW, Birbeck GL, Bradley WG, Fox LL, Glover SJ, Hammond CA, Heyderman RS, Chilingulo CA, Molyneux ME, Taylor TE. Brain swelling and death in children with cerebral malaria. N Engl J Med 2015; 372:1126-37. [PMID: 25785970 PMCID: PMC4450675 DOI: 10.1056/nejmoa1400116] [Citation(s) in RCA: 269] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Case fatality rates among African children with cerebral malaria remain in the range of 15 to 25%. The key pathogenetic processes and causes of death are unknown, but a combination of clinical observations and pathological findings suggests that increased brain volume leading to raised intracranial pressure may play a role. Magnetic resonance imaging (MRI) became available in Malawi in 2009, and we used it to investigate the role of brain swelling in the pathogenesis of fatal cerebral malaria in African children. METHODS We enrolled children who met a stringent definition of cerebral malaria (one that included the presence of retinopathy), characterized them in detail clinically, and obtained MRI scans on admission and daily thereafter while coma persisted. RESULTS Of 348 children admitted with cerebral malaria (as defined by the World Health Organization), 168 met the inclusion criteria, underwent all investigations, and were included in the analysis. A total of 25 children (15%) died, 21 of whom (84%) had evidence of severe brain swelling on MRI at admission. In contrast, evidence of severe brain swelling was seen on MRI in 39 of 143 survivors (27%). Serial MRI scans showed evidence of decreasing brain volume in the survivors who had had brain swelling initially. CONCLUSIONS Increased brain volume was seen in children who died from cerebral malaria but was uncommon in those who did not die from the disease, a finding that suggests that raised intracranial pressure may contribute to a fatal outcome. The natural history indicates that increased intracranial pressure is transient in survivors. (Funded by the National Institutes of Health and Wellcome Trust U.K.).
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Affiliation(s)
- Karl B Seydel
- From the Department of Osteopathic Medical Specialties, College of Osteopathic Medicine (K.B.S., L.L.F., T.E.T.), Department of Radiology (M.J.P., C.A.H.), and Department of Neurology and Ophthalmology, International Neurologic and Psychiatric Epidemiology Program (G.L.B.), Michigan State University, East Lansing; the Blantyre Malaria Project (K.B.S., S.D.K., D.A.M., F.W.M., L.L.F., T.E.T.) and Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., M.E.M.), Queen Elizabeth Central Hospital (S.D.K., C.A.C.) and the Department of Anatomy (S.J.G.), University of Malawi College of Medicine - both in Blantyre, Malawi; the Department of Immunology and Infectious Diseases, Harvard School of Public Health (C.V., D.A.M.), and the Department of Pathology, Brigham and Women's Hospital (D.A.M.) - both in Boston; the Department of Radiology, University of California San Diego, San Diego (W.G.B.); and the Liverpool School of Tropical Medicine, Liverpool, United Kingdom (M.E.M.)
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20
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Thakur KT, Zunt JR. Approach to the international traveler with neurological symptoms. FUTURE NEUROLOGY 2015. [DOI: 10.2217/fnl.14.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT International travelers commonly contract illnesses while abroad, with the highest risk in those who spend extended time in developing countries. As travel to worldwide destinations becomes more accessible, neurologists should be aware of travel-related infections and noninfectious conditions presenting with neurological manifestations. Travelers may present with a myriad of neurologic symptoms, including confusion, headache, weakness and sensory symptoms. In this review, we discuss the general approach to the returning traveler with neurological symptoms and discuss the differential diagnosis of symptoms commonly encountered in practice.
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Affiliation(s)
- Kiran T Thakur
- Division of Neuroinfectious Disease & Neuroimmunology, Department of Neurology, Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 6–113, Baltimore, MD 21205, USA
| | - Joseph R Zunt
- Department of Neurology, Global Health, Medicine (Infectious Diseases) & Epidemiology, University of Washington, Seattle, WA, USA
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21
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Pelle KG, Oh K, Buchholz K, Narasimhan V, Joice R, Milner DA, Brancucci NM, Ma S, Voss TS, Ketman K, Seydel KB, Taylor TE, Barteneva NS, Huttenhower C, Marti M. Transcriptional profiling defines dynamics of parasite tissue sequestration during malaria infection. Genome Med 2015; 7:19. [PMID: 25722744 PMCID: PMC4342211 DOI: 10.1186/s13073-015-0133-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/15/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND During intra-erythrocytic development, late asexually replicating Plasmodium falciparum parasites sequester from peripheral circulation. This facilitates chronic infection and is linked to severe disease and organ-specific pathology including cerebral and placental malaria. Immature gametocytes - sexual stage precursor cells - likewise disappear from circulation. Recent work has demonstrated that these sexual stage parasites are located in the hematopoietic system of the bone marrow before mature gametocytes are released into the bloodstream to facilitate mosquito transmission. However, as sequestration occurs only in vivo and not during in vitro culture, the mechanisms by which it is regulated and enacted (particularly by the gametocyte stage) remain poorly understood. RESULTS We generated the most comprehensive P. falciparum functional gene network to date by integrating global transcriptional data from a large set of asexual and sexual in vitro samples, patient-derived in vivo samples, and a new set of in vitro samples profiling sexual commitment. We defined more than 250 functional modules (clusters) of genes that are co-expressed primarily during the intra-erythrocytic parasite cycle, including 35 during sexual commitment and gametocyte development. Comparing the in vivo and in vitro datasets allowed us, for the first time, to map the time point of asexual parasite sequestration in patients to 22 hours post-invasion, confirming previous in vitro observations on the dynamics of host cell modification and cytoadherence. Moreover, we were able to define the properties of gametocyte sequestration, demonstrating the presence of two circulating gametocyte populations: gametocyte rings between 0 and approximately 30 hours post-invasion and mature gametocytes after around 7 days post-invasion. CONCLUSIONS This study provides a bioinformatics resource for the functional elucidation of parasite life cycle dynamics and specifically demonstrates the presence of the gametocyte ring stages in circulation, adding significantly to our understanding of the dynamics of gametocyte sequestration in vivo.
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Affiliation(s)
- Karell G Pelle
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA 02115 USA
| | - Keunyoung Oh
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115 USA
| | - Kathrin Buchholz
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA 02115 USA
| | - Vagheesh Narasimhan
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115 USA
| | - Regina Joice
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA 02115 USA
| | - Danny A Milner
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA 02115 USA ; Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115 USA
| | - Nicolas Mb Brancucci
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA 02115 USA ; Swiss Tropical and Public Health Institute, 4051 Basel, Switzerland
| | - Siyuan Ma
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115 USA
| | - Till S Voss
- Swiss Tropical and Public Health Institute, 4051 Basel, Switzerland
| | - Ken Ketman
- Program in Cellular and Molecular Medicine, Children's Hospital, Boston, MA 02115 USA
| | - Karl B Seydel
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48825 USA ; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, 3 Malawi
| | - Terrie E Taylor
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48825 USA ; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, 3 Malawi
| | - Natasha S Barteneva
- Program in Cellular and Molecular Medicine, Children's Hospital, Boston, MA 02115 USA ; Department of Pediatrics, Harvard Medical School, Boston, MA 02115 USA
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115 USA ; The Broad Institute of Harvard and MIT, Cambridge, MA 02142 USA
| | - Matthias Marti
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA 02115 USA
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22
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Postels DG, Li C, Birbeck GL, Taylor TE, Seydel KB, Kampondeni SD, Glover SJ, Potchen MJ. Brain MRI of children with retinopathy-negative cerebral malaria. Am J Trop Med Hyg 2014; 91:943-9. [PMID: 25200262 DOI: 10.4269/ajtmh.14-0216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Our goals were to understand the brain magnetic resonance imaging (MRI) findings in children with retinopathy-negative cerebral malaria (CM) and investigate whether any findings on acute MRI were associated with adverse outcomes. We performed MRI scans on children admitted to the hospital in Blantyre, Malawi with clinically defined CM. Two hundred and seventeen children were imaged during the study period; 44 patients were malarial retinopathy-negative; and 173 patients were retinopathy-positive. We compared MRI findings in children with retinopathy-negative and retinopathy-positive CM. In children who were retinopathy-negative, we identified MRI variables that were associated with death and adverse neurologic outcomes. On multivariate analysis, cortical diffusion weighted imaging (DWI) abnormality and increased brain volume were strongly associated with neurologic morbidity in survivors. Investigations to explore the underlying pathophysiologic processes responsible for these MRI changes are warranted.
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Affiliation(s)
- Douglas G Postels
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Chenxi Li
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Gretchen L Birbeck
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Terrie E Taylor
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Karl B Seydel
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Sam D Kampondeni
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Simon J Glover
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Michael J Potchen
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; Department of Neurology, University of Rochester, Rochester, New York; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan; Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Anatomy, University of St. Andrews, St. Andrews, Scotland; Department of Imaging Sciences, University of Rochester, Rochester, New York
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23
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Mace KE, Gueye AS, Lynch MF, Tassiba EM, Rowe AK. An evaluation of methods for assessing the quality of case management for inpatients with malaria in Benin. Am J Trop Med Hyg 2014; 91:354-60. [PMID: 24865676 DOI: 10.4269/ajtmh.13-0389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
To improve healthcare quality for hospitalized patients with malaria in Benin, a feasible and valid evaluation method is needed. Because observation of inpatients is challenging, chart abstraction is an attractive option. However, the quality of inpatient charts is unknown. We employed three methods in five hospitals to assess 11 signs of malaria and severe disease: 1) chart abstraction (probability sample of inpatients), 2) chart abstraction compared to interviews of inpatients and health workers (HWs), and 3) abstraction from charts of recently discharged inpatients compared to interviews with HWs. Method 1 showed that of 473 malaria signs (from 43 charts), 178 (38%, 95% confidence interval 24-51%) were documented. Method 2 showed that 96% (45 of 47) of documented signs were valid. Method 3 suggests that 65% (36 of 55) of non-documented signs were assessed (but not documented) by HWs. Chart abstraction was feasible and documented data were valid, but results should be interpreted cautiously in consideration of low levels of documentation.
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Affiliation(s)
- Kimberly E Mace
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Population Services International, Cotonou, Benin
| | - Abdou Salam Gueye
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Population Services International, Cotonou, Benin
| | - Michael F Lynch
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Population Services International, Cotonou, Benin
| | - Esther M Tassiba
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Population Services International, Cotonou, Benin
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Population Services International, Cotonou, Benin
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Joice R, Narasimhan V, Montgomery J, Sidhu AB, Oh K, Meyer E, Pierre-Louis W, Seydel K, Milner D, Williamson K, Wiegand R, Ndiaye D, Daily J, Wirth D, Taylor T, Huttenhower C, Marti M. Inferring developmental stage composition from gene expression in human malaria. PLoS Comput Biol 2013; 9:e1003392. [PMID: 24348235 PMCID: PMC3861035 DOI: 10.1371/journal.pcbi.1003392] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 10/30/2013] [Indexed: 01/12/2023] Open
Abstract
In the current era of malaria eradication, reducing transmission is critical. Assessment of transmissibility requires tools that can accurately identify the various developmental stages of the malaria parasite, particularly those required for transmission (sexual stages). Here, we present a method for estimating relative amounts of Plasmodium falciparum asexual and sexual stages from gene expression measurements. These are modeled using constrained linear regression to characterize stage-specific expression profiles within mixed-stage populations. The resulting profiles were analyzed functionally by gene set enrichment analysis (GSEA), confirming differentially active pathways such as increased mitochondrial activity and lipid metabolism during sexual development. We validated model predictions both from microarrays and from quantitative RT-PCR (qRT-PCR) measurements, based on the expression of a small set of key transcriptional markers. This sufficient marker set was identified by backward selection from the whole genome as available from expression arrays, targeting one sentinel marker per stage. The model as learned can be applied to any new microarray or qRT-PCR transcriptional measurement. We illustrate its use in vitro in inferring changes in stage distribution following stress and drug treatment and in vivo in identifying immature and mature sexual stage carriers within patient cohorts. We believe this approach will be a valuable resource for staging lab and field samples alike and will have wide applicability in epidemiological studies of malaria transmission.
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Affiliation(s)
- Regina Joice
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Vagheesh Narasimhan
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Jacqui Montgomery
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Amar Bir Sidhu
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
| | - Keunyoung Oh
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Evan Meyer
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Willythssa Pierre-Louis
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Karl Seydel
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States of America
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Danny Milner
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Kim Williamson
- Department of Biology, Loyola University Chicago, Chicago, Illinois, United States of America
| | - Roger Wiegand
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
| | - Daouda Ndiaye
- Faculty of Medicine and Pharmacy, Cheikh Anta Diop University, Dakar, Senegal
| | - Johanna Daily
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, New York, United States of America
| | - Dyann Wirth
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
| | - Terrie Taylor
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States of America
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts, United States of America
- * E-mail: (CH); (MM)
| | - Matthias Marti
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
- * E-mail: (CH); (MM)
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Postels DG, Chimalizeni YF, Mallewa M, Boivin MJ, Seydel KB. Pediatric cerebral malaria: a scourge of Africa. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.12.84] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cerebral malaria, defined as an otherwise unexplained coma in a patient with Plasmodium falciparum parasitemia, affects up to 1 million people per year, the vast majority of them being children living in sub-Saharan Africa. Despite optimal treatment, this condition kills 15% of those affected and leaves 30% of survivors with neurologic sequelae. The clinical diagnosis is hampered by its poor specificity, but the presence or absence of a malarial retinopathy in cerebral malaria has proven to be important in the differentiation of underlying coma etiology. Both antimalarials and intense supportive care are necessary for optimal treatment. As of yet, clinical trials of adjunctive therapies have not improved the high rates of mortality and morbidity. Survivors are at high risk of neurologic sequelae including epilepsy, neurodisabilities and cognitive–behavioral problems. The neuroanatomic and functional bases of these sequelae are being elucidated. Although adjunctive therapy trials continue, the best hope for African children may lie in disease prevention. Strategies include bednets, chemoprophylaxis and vaccine development.
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Affiliation(s)
| | - Yamikani F Chimalizeni
- Department of Pediatrics, University of Malawi College of Medicine, Private Bag 360, Blantyre 3, Malawi
| | - Macpherson Mallewa
- Department of Pediatrics, University of Malawi College of Medicine, Private Bag 360, Blantyre 3, Malawi
| | | | - Karl B Seydel
- Michigan State University, East Lansing, MI 48824, USA
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Postels DG, Taylor TE, Molyneux M, Mannor K, Kaplan PW, Seydel KB, Chimalizeni YF, Kawaza K, Birbeck GL. Neurologic outcomes in retinopathy-negative cerebral malaria survivors. Neurology 2012; 79:1268-72. [PMID: 22914840 DOI: 10.1212/wnl.0b013e31826aacd4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Patients surviving retinopathy-positive cerebral malaria (CM) are at high risk for the development of epilepsy, developmental disabilities, and behavioral abnormalities. We aimed to establish whether retinopathy-negative CM is also a risk factor for these outcomes. METHODS Between 2005 and 2007, survivors of CM and concurrently hospitalized controls in Blantyre, Malawi, were followed to assess the development of neurologic abnormalities. At discharge and every 3 months thereafter, incident cases of epilepsy and developmental disabilities were ascertained using screening questionnaires and confirmatory neurologic examinations. Incident cases of epilepsy and developmental disabilities were compared in retinopathy-negative CM survivors to controls and retinopathy-positive CM survivors. RESULTS Thirty-five retinopathy-negative CM survivors were enrolled. Their neurologic outcomes were compared to 132 retinopathy-positive CM survivors and 272 controls. Compared to survivors of retinopathy-positive CM, children without malaria retinopathy have an equal odds of adverse neurologic outcome (odds ratio [OR] = 1.0, 95% confidence interval [CI] 0.4-2.2). Eleven of 35 survivors of retinopathy-negative CM had at least 1 adverse neurologic outcome compared to 2 of 272 controls (OR 61.9, 95% CI 13.0-295.5). In retinopathy-negative CM survivors, a Blantyre Coma Scale score ≤ 1 on admission was associated with an adverse outcome. CONCLUSIONS Compared with controls, children surviving either retinopathy-negative or -positive CM are at similar high risk for adverse neurologic outcomes. Studies to evaluate preventive and therapeutic strategies in children with both retinopathy-negative and -positive CM are needed to improve mortality, morbidity, or both.
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Affiliation(s)
- Douglas G Postels
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan, USA.
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Roca-Feltrer A, Kwizombe CJ, Sanjoaquin MA, Sesay SSS, Faragher B, Harrison J, Geukers K, Kabuluzi S, Mathanga DP, Molyneux E, Chagomera M, Taylor T, Molyneux M, Heyderman RS. Lack of decline in childhood malaria, Malawi, 2001-2010. Emerg Infect Dis 2012; 18:272-8. [PMID: 22305090 PMCID: PMC3310453 DOI: 10.3201/eid1802.111008] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Despite increased control activities, malaria did not substantially decline. In some areas of Africa, health facility data have indicated declines in malaria that might have resulted from increasingly effective control programs. Most such reports have been from countries where malaria transmission is highly seasonal or of modest intensity. In Malawi, perennial malaria transmission is intense, and malaria control measures have been scaled up during the past decade. We examined health facility data for children seen as outpatients and parasitemia-positive children hospitalized with cerebral malaria in a large national hospital. The proportion of Plasmodium falciparum–positive slides among febrile children at the hospital declined early in the decade, but no further reductions were observed after 2005. The number of admissions for cerebral malaria did not differ significantly by year. Continued surveillance for malaria is needed to evaluate the effects of the increased malaria control efforts.
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Molecular correlates of experimental cerebral malaria detectable in whole blood. Infect Immun 2010; 79:1244-53. [PMID: 21149594 DOI: 10.1128/iai.00964-10] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Cerebral malaria (CM) is a primary cause of deaths caused by Plasmodium falciparum in young children in sub-Saharan Africa. Laboratory tests based on early detection of host biomarkers in patient blood would help in the prognosis and differential diagnosis of CM. Using the Plasmodium berghei ANKA murine model of experimental cerebral malaria (ECM), we have identified over 300 putative diagnostic biomarkers of ECM in the circulation by comparing the whole-blood transcriptional profiles of resistant mice (BALB/c) to those of two susceptible strains (C57BL/6 and CBA/CaJ). Our results suggest that the transcriptional profile of whole blood captures the molecular and immunological events associated with the pathogenesis of disease. We find that during ECM, erythropoiesis is dysfunctional, thrombocytopenia is evident, and glycosylation of cell surface components may be modified. Furthermore, analysis of immunity-related genes suggests that slightly distinct mechanisms of immunopathogenesis may operate in susceptible C57BL/6 and CBA/CaJ mice. Furthermore, our data set has allowed us to create a molecular signature of ECM composed of a subset of circulatory markers. Complement component C1q, β-chain, nonspecific cytotoxic cell receptor protein 1, prostate stem cell antigen, DnaJC, member 15, glutathione S-transferase omega-1, and thymidine kinase 1 were overexpressed in blood during the symptomatic phase of ECM, as measured by quantitative real-time PCR analysis. These studies provide the first host transcriptome database that is uniquely altered during the pathogenesis of ECM in blood. A subset of these mediators of ECM warrant validation in P. falciparum-infected young African children as diagnostic markers of CM.
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Pathogenic roles of CD14, galectin-3, and OX40 during experimental cerebral malaria in mice. PLoS One 2009; 4:e6793. [PMID: 19710907 PMCID: PMC2728507 DOI: 10.1371/journal.pone.0006793] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 08/04/2009] [Indexed: 12/05/2022] Open
Abstract
An in-depth knowledge of the host molecules and biological pathways that contribute towards the pathogenesis of cerebral malaria would help guide the development of novel prognostics and therapeutics. Genome-wide transcriptional profiling of the brain tissue during experimental cerebral malaria (ECM ) caused by Plasmodium berghei ANKA parasites in mice, a well established surrogate of human cerebral malaria, has been useful in predicting the functional classes of genes involved and pathways altered during the course of disease. To further understand the contribution of individual genes to the pathogenesis of ECM, we examined the biological relevance of three molecules – CD14, galectin-3, and OX40 that were previously shown to be overexpressed during ECM. We find that CD14 plays a predominant role in the induction of ECM and regulation of parasite density; deletion of the CD14 gene not only prevented the onset of disease in a majority of susceptible mice (only 21% of CD14-deficient compared to 80% of wildtype mice developed ECM, p<0.0004) but also had an ameliorating effect on parasitemia (a 2 fold reduction during the cerebral phase). Furthermore, deletion of the galectin-3 gene in susceptible C57BL/6 mice resulted in partial protection from ECM (47% of galectin-3-deficient versus 93% of wildtype mice developed ECM, p<0.0073). Subsequent adherence assays suggest that galectin-3 induced pathogenesis of ECM is not mediated by the recognition and binding of galectin-3 to P. berghei ANKA parasites. A previous study of ECM has demonstrated that brain infiltrating T cells are strongly activated and are CD44+CD62L− differentiated memory T cells [1]. We find that OX40, a marker of both T cell activation and memory, is selectively upregulated in the brain during ECM and its distribution among CD4+ and CD8+ T cells accumulated in the brain vasculature is approximately equal.
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30
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Picot S, Bienvenu AL, Konate S, Sissoko S, Barry A, Diarra E, Bamba K, Djimdé A, Doumbo OK. Safety of epoietin beta-quinine drug combination in children with cerebral malaria in Mali. Malar J 2009; 8:169. [PMID: 19630971 PMCID: PMC2723129 DOI: 10.1186/1475-2875-8-169] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 07/24/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral malaria carries an unacceptable case fatality rate in children despite timely and adequate chemotherapy. To improve the survival rate, adjunctive therapies previously tested mainly focused on the modulation of the inflammatory response, without definitive effect in humans. In this context, a new adjunctive strategy using a neuroprotective drug: erythropoietin (epoietin-beta, Epo) was proposed. METHODS An open-labelled study including cerebral malaria children (Blantyre coma score below 3) was conducted in Mali. The objective was to assess the short-term safety (seven days) of erythropoietin at high doses (1,500 U/kg/day during three days) combined to quinine. RESULTS 35 patients with unrousable coma were included in the study. None of expected side effects of erythropoietin were observed during the seven days follow-up. No significant increase in the case fatality rate (7/35 patients) was observed compared to other studies with mortality rates ranging from 16 to 22% in similar endemic areas. CONCLUSION These data provide the first evidence of the short-term safety of erythropoietin at high doses combined to quinine. A multicentre study is needed to assess the potential of Epo as an adjunctive therapy to increase the survival during cerebral malaria. CLINICAL REGISTRATION NUMBER: ClinicalTrials.gov ID: NCT00697164.
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Affiliation(s)
- Stéphane Picot
- Malaria Research Unit, EA 4170, University Lyon 1, Faculty of Medicine, Lyon, France.
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