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Ramtohul P, Chehaibou I, Bonnin S, Burlacu R, Gaudric A, Tadayoni R. PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH SEVERE PLASMODIUM FALCIPARUM MALARIA. Retin Cases Brief Rep 2024; 18:47-50. [PMID: 36007187 DOI: 10.1097/icb.0000000000001330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE To report a case of bilateral paracentral acute middle maculopathy lesions on spectral domain-optical coherence tomography(OCT) secondary to severe Plasmodium falciparum malaria. METHODS Retrospective case report. Spectral domain-OCT, ultra-widefield fluorescein angiography, and OCT angiography were performed and analyzed. RESULTS A 54-year-old healthy man presented with acute vision loss in both eyes few days after being diagnosed with severe Plasmodium falciparum malaria. Ophthalmoscopic examination was unremarkable, but near-infrared reflectance imaging showed patchy hyporeflective areas located at the terminal tips of the venous branches. Corresponding spectral-domain OCT demonstrated alternating bands of hyperreflectivity involving the inner nuclear layer, consistent with skip paracentral acute middle maculopathy lesions. Optical coherance tomography angiography illustrated corresponding flow signal loss at the level of the deep capillary plexus. Ultra-widefield fluorescein angiography showed peripheral retinal vein staining and capillary nonperfusion. CONCLUSION Paracentral acute middle maculopathy may be an OCT manifestation of malarial retinopathy associated with severe Plasmodium falciparum infection.
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Affiliation(s)
- Prithvi Ramtohul
- Centre Hospitalier Universitaire de l'Hôpital Nord, Marseille, France
- Université de Paris, Ophthalmology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Ismael Chehaibou
- Université de Paris, Ophthalmology Department, AP-HP, Hôpital Lariboisière, Paris, France
- Ophthalmology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France; and
| | - Sophie Bonnin
- Université de Paris, Ophthalmology Department, AP-HP, Hôpital Lariboisière, Paris, France
- Ophthalmology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France; and
| | - Ruxandra Burlacu
- Université de Paris, Internal Medicine Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Alain Gaudric
- Université de Paris, Ophthalmology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Ramin Tadayoni
- Université de Paris, Ophthalmology Department, AP-HP, Hôpital Lariboisière, Paris, France
- Ophthalmology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France; and
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Mukherji P, Shilpy N, Gupta RK. Ocular fundal changes in children suffering from cerebral malaria. Indian J Ophthalmol 2023; 71:3394-3398. [PMID: 37787241 PMCID: PMC10683685 DOI: 10.4103/ijo.ijo_3389_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/04/2023] [Accepted: 06/15/2023] [Indexed: 10/04/2023] Open
Abstract
Purpose To assess the frequency and distribution of retinal changes in children suffering from cerebral malaria (CM), study the correlation between fundal changes and severity of disease, visual outcome, and survival of patients. Methods An observational, cross-sectional study was done on pediatric patients, suffering from CM in a tertiary care center in eastern India. A complete ophthalmological examination was done and findings were tabulated. Their hospital admission records were checked for severity of coma, recovery, and prognosis. Data were analyzed with SPSS software, and P value < 0.05 was considered statistically significant. Results Total 113 children of age group 0-18 years (mean age 7.88 ± 0.56 years) were enrolled in the study. Seventy-seven children (68.14%) had retinal changes. Most common retinal signs associated with malarial retinopathy were white centered hemorrhage and papilledema (53.09% each), followed by retinal whitening (51.33%) and vessel changes (39.82%). The correlation between the presence of white centered retinal hemorrhages and visual prognosis was found to be statistically significant (P = 0.001). Patients with Grade 4 parasitemia showed maximum retinal signs with a significant correlation between the severity of papilledema and parasite load (P = 0.037). Eighty-six patients (76.11%) survived and 27 patients (23.89%) died. All 27 patients who died showed all four signs of malarial retinopathy. Out of these, patients with retinal whitening suffered from severe coma, and this correlation was found to be statistically significant (P = 0.002). Conclusion Presence of retinal signs in patients with CM is associated with severe disease (high parasite load), poor visual outcome, and increased mortality.
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Affiliation(s)
- Payal Mukherji
- Department of Ophthalmology, Regional Institute of Ophthalmology (RIO), Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India
| | - Neha Shilpy
- Department of Ophthalmology, Regional Institute of Ophthalmology (RIO), Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India
| | - Rajiv Kumar Gupta
- Department of Ophthalmology, Regional Institute of Ophthalmology (RIO), Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India
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3
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Wilson KJ, Dhalla A, Meng Y, Tu Z, Zheng Y, Mhango P, Seydel KB, Beare NAV. Retinal imaging technologies in cerebral malaria: a systematic review. Malar J 2023; 22:139. [PMID: 37101295 PMCID: PMC10131356 DOI: 10.1186/s12936-023-04566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/20/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Cerebral malaria (CM) continues to present a major health challenge, particularly in sub-Saharan Africa. CM is associated with a characteristic malarial retinopathy (MR) with diagnostic and prognostic significance. Advances in retinal imaging have allowed researchers to better characterize the changes seen in MR and to make inferences about the pathophysiology of the disease. The study aimed to explore the role of retinal imaging in diagnosis and prognostication in CM; establish insights into pathophysiology of CM from retinal imaging; establish future research directions. METHODS The literature was systematically reviewed using the African Index Medicus, MEDLINE, Scopus and Web of Science databases. A total of 35 full texts were included in the final analysis. The descriptive nature of the included studies and heterogeneity precluded meta-analysis. RESULTS Available research clearly shows retinal imaging is useful both as a clinical tool for the assessment of CM and as a scientific instrument to aid the understanding of the condition. Modalities which can be performed at the bedside, such as fundus photography and optical coherence tomography, are best positioned to take advantage of artificial intelligence-assisted image analysis, unlocking the clinical potential of retinal imaging for real-time diagnosis in low-resource environments where extensively trained clinicians may be few in number, and for guiding adjunctive therapies as they develop. CONCLUSIONS Further research into retinal imaging technologies in CM is justified. In particular, co-ordinated interdisciplinary work shows promise in unpicking the pathophysiology of a complex disease.
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Affiliation(s)
- Kyle J Wilson
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK.
- Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi.
| | - Amit Dhalla
- Department of Ophthalmology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Yanda Meng
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK
| | - Zhanhan Tu
- School of Psychology and Vision Sciences, College of Life Science, The University of Leicester Ulverscroft Eye Unit, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK
| | - Yalin Zheng
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK
- St. Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Priscilla Mhango
- Department of Ophthalmology, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Karl B Seydel
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nicholas A V Beare
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK.
- St. Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, UK.
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MacCormick IJC, Lewallen S, Beare N, Harding SP. Measuring the Impact of Malaria on the Living Human Retina. Methods Mol Biol 2022; 2470:731-748. [PMID: 35881386 DOI: 10.1007/978-1-0716-2189-9_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Retinal examination and imaging are relatively simple methods for studying the dynamic impact of cerebral malaria on the microcirculation of the central nervous system. Retina and brain are affected similarly by Plasmodium falciparum. Unlike the brain, the human retina can be directly observed using commercially available clinical instruments in the setting of a critical care unit, and this can be done repeatedly and non-invasively. Additional information about blood-tissue barriers can be gained from fluorescein angiography. Non-ophthalmologist clinician scientists are usually unfamiliar with ophthalmoscopy and retinal imaging, and some readers may feel that these techniques are beyond them. This chapter aims to quell these fears by providing a step-by-step description of how to examine and photograph the human retina in children with cerebral malaria.
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Affiliation(s)
- Ian James Callum MacCormick
- Centre for Inflammation Research, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK.
| | - Susan Lewallen
- Kilimanjaro Centre for Community Ophthalmology, Division of Ophthalmology, University of Cape Town, Observatory, South Africa
| | - Nicholas Beare
- Department of Eye and Vision Science, University of Liverpool, Liverpool, UK
- St. Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, members of Liverpool Health Partners, Liverpool, UK
| | - Simon Peter Harding
- Department of Eye and Vision Science, University of Liverpool, Liverpool, UK
- St. Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, members of Liverpool Health Partners, Liverpool, UK
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Mita-Mendoza NK, Magallon-Tejada A, Parmar P, Furtado R, Aldrich M, Saidi A, Taylor T, Smith J, Seydel K, Daily JP. Dimethyl fumarate reduces TNF and Plasmodium falciparum induced brain endothelium activation in vitro. Malar J 2020; 19:376. [PMID: 33087130 PMCID: PMC7579885 DOI: 10.1186/s12936-020-03447-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 10/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background Cerebral malaria (CM) is associated with morbidity and mortality despite the use of potent anti-malarial agents. Brain endothelial cell activation and dysfunction from oxidative and inflammatory host responses and products released by Plasmodium falciparum-infected erythrocytes (IE), are likely the major contributors to the encephalopathy, seizures, and brain swelling that are associated with CM. The development of adjunctive therapy to reduce the pathological consequences of host response pathways could improve outcomes. A potentially protective role of the nuclear factor E2-related factor 2 (NRF2) pathway, which serves as a therapeutic target in brain microvascular diseases and central nervous system (CNS) inflammatory diseases such as multiple sclerosis was tested to protect endothelial cells in an in vitro culture system subjected to tumour necrosis factor (TNF) or infected red blood cell exposure. NRF2 is a transcription factor that mediates anti-oxidant and anti-inflammatory responses. Methods To accurately reflect clinically relevant parasite biology a unique panel of parasite isolates derived from patients with stringently defined CM was developed. The effect of TNF and these parasite lines on primary human brain microvascular endothelial cell (HBMVEC) activation in an in vitro co-culture model was tested. HBMVEC activation was measured by cellular release of IL6 and nuclear translocation of NFκB. The transcriptional and functional effects of dimethyl fumarate (DMF), an FDA approved drug which induces the NRF2 pathway, on host and parasite induced HBMVEC activation was characterized. In addition, the effect of DMF on parasite binding to TNF stimulated HBMVEC in a semi-static binding assay was examined. Results Transcriptional profiling demonstrates that DMF upregulates the NRF2-Mediated Oxidative Stress Response, ErbB4 Signaling Pathway, Peroxisome Proliferator-activated Receptor (PPAR) Signaling and downregulates iNOS Signaling and the Neuroinflammation Signaling Pathway on TNF activated HBMVEC. The parasite lines derived from eight paediatric CM patients demonstrated increased binding to TNF activated HBMVEC and varied in their binding and activation of HBMVEC. Overall DMF reduced both TNF and CM derived parasite activation of HBMVEC. Conclusions These findings provide evidence that targeting the NRF2 pathway in TNF and parasite activated HBMVEC mediates multiple protective pathways and may represent a novel adjunctive therapy to improve infection outcomes in CM.
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Affiliation(s)
- Neida K Mita-Mendoza
- Department of Microbiology & Immunology and Infectious Diseases, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ariel Magallon-Tejada
- Seattle Biomedical Research Institute, Seattle, WA, USA.,Department of Research in Parasitology, Gorgas Memorial Research Institute for Health Studies, Panama City, Panama
| | - Priyanka Parmar
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Raquel Furtado
- Department of Microbiology & Immunology and Infectious Diseases, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Margaret Aldrich
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alex Saidi
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre 3, Malawi
| | - Terrie Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre 3, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Joe Smith
- Seattle Children's Research Institute, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Karl Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre 3, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Johanna P Daily
- Department of Microbiology & Immunology and Infectious Diseases, Albert Einstein College of Medicine, Bronx, NY, USA. .,Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
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6
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MacCormick IJC, Barrera V, Beare NAV, Czanner G, Potchen M, Kampondeni S, Heyderman RS, Craig AG, Molyneux ME, Mallewa M, White VA, Milner D, Hiscott P, Taylor TE, Seydel KB, Harding SP. How Does Blood-Retinal Barrier Breakdown Relate to Death and Disability in Pediatric Cerebral Malaria? J Infect Dis 2020; 225:1070-1080. [PMID: 32845969 PMCID: PMC8922008 DOI: 10.1093/infdis/jiaa541] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/24/2020] [Indexed: 11/25/2022] Open
Abstract
Background In cerebral malaria, the retina can be used to understand disease pathogenesis. The mechanisms linking sequestration, brain swelling, and death remain poorly understood. We hypothesized that retinal vascular leakage would be associated with brain swelling. Methods We used retinal angiography to study blood-retinal barrier integrity. We analyzed retinal leakage, histopathology, brain magnatic resonance imaging (MRI), and associations with death and neurological disability in prospective cohorts of Malawian children with cerebral malaria. Results Three types of retinal leakage were seen: large focal leak (LFL), punctate leak (PL), and vessel leak. The LFL and PL were associated with death (odds ratio [OR] = 13.20, 95% confidence interval [CI] = 5.21–33.78 and OR = 8.58, 95% CI = 2.56–29.08, respectively) and brain swelling (P < .05). Vessel leak and macular nonperfusion were associated with neurological disability (OR = 3.71, 95% CI = 1.26–11.02 and OR = 9.06, 95% CI = 1.79–45.90). Large focal leak was observed as an evolving retinal hemorrhage. A core of fibrinogen and monocytes was found in 39 (93%) white-centered hemorrhages. Conclusions Blood-retina barrier breakdown occurs in 3 patterns in cerebral malaria. Associations between LFL, brain swelling, and death suggest that the rapid accumulation of cerebral hemorrhages, with accompanying fluid egress, may cause fatal brain swelling. Vessel leak, from barrier dysfunction, and nonperfusion were not associated with severe brain swelling but with neurological deficits, suggesting hypoxic injury in survivors.
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Affiliation(s)
- Ian J C MacCormick
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, a member of Liverpool Health Partners, Liverpool, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Valentina Barrera
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, a member of Liverpool Health Partners, Liverpool, UK.,NHS Blood and Transplant, Tissue and Eye Services R&D, Liverpool UK
| | - Nicholas A V Beare
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, a member of Liverpool Health Partners, Liverpool, UK.,St. Paul's Eye Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Gabriela Czanner
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, a member of Liverpool Health Partners, Liverpool, UK.,Department of Applied Mathematics, Liverpool John Moores University, Liverpool, UK
| | - Michael Potchen
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Samuel Kampondeni
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Robert S Heyderman
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Division of Infection & Immunity, University College London, London, UK
| | - Alister G Craig
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Malcolm E Molyneux
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Macpherson Mallewa
- Department of Paediatrics and Child Health, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Valerie A White
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Dan Milner
- American Society for Clinical Pathology, Chicago, IL, USA
| | - Paul Hiscott
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, a member of Liverpool Health Partners, Liverpool, UK
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, USA
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, USA
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, a member of Liverpool Health Partners, Liverpool, UK.,St. Paul's Eye Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
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Eggenberger ER. Infectious Optic Neuropathies. Continuum (Minneap Minn) 2020; 25:1422-1437. [PMID: 31584544 DOI: 10.1212/con.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews common infectious optic neuropathies, focusing on the more common and globally important entities. RECENT FINDINGS Novel infections continue to emerge and drift geographically over time; not infrequently, these have important neurologic or ocular features. Malarial retinal findings comprise a relatively specific set of findings and serve as an invaluable aid in the diagnosis of cerebral malaria. Therapy continues to evolve and is best formulated in concert with an infectious disease expert. SUMMARY Infectious optic neuropathies are less common than inflammatory or ischemic optic neuropathies; may present with varied, overlapping, and nonspecific clinical appearances; and comprise an important differential consideration demanding specific therapy.
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Koki G, Ngoulou W, Nomo AF, Nguefack S, Epee E, Bella AL. [Retinal manifestations of neuro-malaria or "malarial retinopathy" in Yaoundé]. J Fr Ophtalmol 2019; 42:753-761. [PMID: 31202776 DOI: 10.1016/j.jfo.2019.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/18/2022]
Abstract
AIM Contribute to the improvement of diagnostic and prognostic approaches to treating children with neuro-malaria in Yaoundé. PATIENTS AND METHOD A prospective and analytical study carried out in 2 hospitals of Yaoundé from October 2015 to March 2016. All patients aged 3 months to 15 years hospitalized for neuro-malaria in one of the 2 hospitals benefited from a fundus examination. The variables studied were: age, sex, Glasgow or Blantyre score, fundus examination and parasitaemia. For statistical analysis, we used the software R 3.3.0, Chi2, exact of Fisher or Kolmogorov-Smirnov tests with a significance P<5%. RESULTS Out of the 178 children hospitalized during the study period, 44 had neuro-malaria (24.71%) and 26 (46 diseased eyes) among them presented retinal lesions at a frequency of 14.60%. The mean age was 5.54±3.49 years with a sex ratio of 1.09. The under 5-years-old were the most affected with 31 (70.45%) cases. The fundus lesions of 26 (59.09%) were retinal hemorrhages in 24 (54.54%), retinal whitening and vessel discoloration in 8 (18.18%) respectively. Papillary edema was associated in 4 (9.09%). Macular involvement was noted in 9 cases. These lesions were correlated with age, depth of coma, duration, and clinical course. The rate of parasitaemia did not affect their occurrence. CONCLUSION Retinal lesions are frequent and serious during neuro-malaria in our environment, especially in children under five. They must therefore be an emphasis in the systematic exam to rule it out for a better prognostic evaluation and a fast and adequate multidisciplinary management.
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MESH Headings
- Adolescent
- Cameroon/epidemiology
- Child
- Child, Preschool
- Eye Infections, Parasitic/complications
- Eye Infections, Parasitic/diagnosis
- Eye Infections, Parasitic/epidemiology
- Female
- Humans
- Infant
- Malaria/complications
- Malaria/diagnosis
- Malaria/epidemiology
- Malaria, Cerebral/complications
- Malaria, Cerebral/diagnosis
- Malaria, Cerebral/epidemiology
- Malaria, Falciparum/complications
- Malaria, Falciparum/diagnosis
- Malaria, Falciparum/epidemiology
- Male
- Plasmodium falciparum/physiology
- Prognosis
- Retinal Diseases/diagnosis
- Retinal Diseases/epidemiology
- Retinal Diseases/parasitology
- Retinal Hemorrhage/diagnosis
- Retinal Hemorrhage/epidemiology
- Retinal Hemorrhage/parasitology
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Affiliation(s)
- G Koki
- Faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun.
| | - W Ngoulou
- Faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - A F Nomo
- Faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - S Nguefack
- Faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun; Hôpital gynéco-obstétrique et pédiatrique de Yaoundé, Cameroun
| | - E Epee
- Faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - A L Bella
- Faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun; Hôpital gynéco-obstétrique et pédiatrique de Yaoundé, Cameroun
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Karesh JW, Mazzoli RA, Heintz SK. Ocular Manifestations of Mosquito-Transmitted Diseases. Mil Med 2019; 183:450-458. [PMID: 29635625 DOI: 10.1093/milmed/usx183] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 12/22/2017] [Indexed: 11/13/2022] Open
Abstract
Of the 3,548 known mosquito species, about 100 transmit human diseases. Mosquitoes are distributed globally throughout tropical and temperate regions where standing water sources are available for egg laying and the maturation of larva. Female mosquitoes require blood meals for egg production. This is the main pathway for disease transmission. Mosquitoes carry several pathogenic organisms responsible for significant ocular pathology and vision loss including West Nile, Rift Valley, chikungunya, dengue viruses, various encephalitis viruses, malarial parasites, Francisella tularensis, microfilarial parasites, including Dirofilaria, Wuchereria, and Brugia spp., and human botfly larvae. Health care providers may not be familiar with many of these mosquito-transmitted diseases or their associated ocular findings delaying diagnosis, treatment, and recovery of visual function. This article aims to provide an overview of the ocular manifestations associated with mosquito-transmitted diseases.
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Affiliation(s)
- James W Karesh
- The Vision Center of Excellence, Walter Reed National Military Medical Center, 8960 Brown Drive, Building 2, 1st Floor, Room 1403-A, Bethesda, MD 20889-5629
| | - Robert A Mazzoli
- The Vision Center of Excellence, Walter Reed National Military Medical Center, 8960 Brown Drive, Building 2, 1 st Floor, Room 1403-A, Bethesda, MD 20889-5629.,Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 98431
| | - Shannon K Heintz
- The Vision Center of Excellence, Walter Reed National Military Medical Center, 8960 Brown Drive, Building 2, 1st Floor, Room 1403-A, Bethesda, MD 20889-5629
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Rocha Cabrera P, Rodríguez Talavera I, Losada Castillo MJ, Alemán Valls R, Lorenzo Morales J. Detachment of retinal pigment epithelium in retinopathy due to malaria. ACTA ACUST UNITED AC 2018; 93:406-410. [PMID: 29807845 DOI: 10.1016/j.oftal.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/18/2018] [Accepted: 03/23/2018] [Indexed: 11/17/2022]
Abstract
CASE REPORT A 45-year-old man was diagnosed with malaria with neurological involvement. Two months later he referred metamorphopsia in the left eye. Malarial retinopathy was observed in the fundus examination. The Optic Coherence Tomography (OCT) of the macula showed parafoveal pigment epithelium detachment (DEP). Specific anti-malarial treatment was initiated, with the disappearance of the retinopathy being observed. DISCUSSION Plasmodium falciparum is responsible for the retinopathy in neurological malaria. A funduscopic examination and macular OCT should be performed in these patients, as it is associated with a higher mortality when there is a retinal involvement.
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Affiliation(s)
- P Rocha Cabrera
- Servicio de Oftalmología, Hospital San Juan de Dios, Tenerife, España.
| | | | | | - R Alemán Valls
- Servicio de Medicina Interna, Hospital Universitario de Canarias, La Laguna, Tenerife, España
| | - J Lorenzo Morales
- Instituto de Enfermedades Tropicales y Salud Pública, La Laguna, Tenerife, España
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Tshimangani T, Pongo J, Bodi Mabiala J, Yotebieng M, O'Brien NF. Pediatric Acute Severe Neurologic Illness and Injury in an Urban and a Rural Hospital in the Democratic Republic of the Congo. Am J Trop Med Hyg 2018; 98:1534-1540. [PMID: 29512478 DOI: 10.4269/ajtmh.17-0784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Empirical knowledge suggests that acute neurologic disorders are common in sub-Saharan Africa, but studies examining the true burden of these diseases in children are scarce. We performed this prospective, observational study to evaluate the prevalence, clinical characteristics, treatment approaches, and outcomes of children suffering acute neurologic illness or injury (ANI) in an urban and rural site in the Democratic Republic of the Congo. Over 12 months, 471 out of 6,563 children admitted met diagnostic criteria for ANI, giving a hospital-based prevalence of 72/1,000 admissions. Two hundred and seventy-two children had clinical findings consistent with central nervous system infection but lacked complete diagnostic evaluation for definitive classification. Another 151 children were confirmed to have cerebral malaria (N = 109, 23% of admissions), bacterial meningitis (N = 38, 8% of admissions), tuberculous meningitis (N = 3, 0.6% of admissions), or herpes encephalitis (N = 1, 0.21% of admissions). Febrile convulsions, traumatic brain injury, and epilepsy contributed less significantly to overall hospital prevalence of ANI (3.19/1,000, 1.37/1,000, and 1.06/1,000, respectively). Overall mortality for the cohort was 21% (97/471). Neurologic sequelae were seen in another 31% of participants, with only 45% completing the study with a normal neurologic examination. This type of data is imperative to help plan effective strategies for illness and injury prevention and control, and to allow optimal use of limited resources in terms of provision of acute care and rehabilitation for these children.
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Affiliation(s)
- Taty Tshimangani
- Hopital Pediatrique de Kalembe Lembe, Cliniques Universitaires de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jean Pongo
- Department of Pediatrics, Universite des Sciences et des Technologie de Lodja, Lodja, Democratic Republic of the Congo
| | - Joseph Bodi Mabiala
- Department of Pediatrics, Cliniques Universitaires de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Nicole F O'Brien
- The Ohio State University, Columbus, Ohio.,Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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12
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Small DS, Taylor TE, Postels DG, Beare NA, Cheng J, MacCormick IJ, Seydel KB. Evidence from a natural experiment that malaria parasitemia is pathogenic in retinopathy-negative cerebral malaria. eLife 2017; 6. [PMID: 28590246 PMCID: PMC5462542 DOI: 10.7554/elife.23699] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 11/21/2022] Open
Abstract
Cerebral malaria (CM) can be classified as retinopathy-positive or retinopathy-negative, based on the presence or absence of characteristic retinal features. While malaria parasites are considered central to the pathogenesis of retinopathy-positive CM, their contribution to retinopathy-negative CM is largely unknown. One theory is that malaria parasites are innocent bystanders in retinopathy-negative CM and the etiology of the coma is entirely non-malarial. Because hospitals in malaria-endemic areas often lack diagnostic facilities to identify non-malarial causes of coma, it has not been possible to evaluate the contribution of malaria infection to retinopathy-negative CM. To overcome this barrier, we studied a natural experiment involving genetically inherited traits, and find evidence that malaria parasitemia does contribute to the pathogenesis of retinopathy-negative CM. A lower bound for the fraction of retinopathy-negative CM that would be prevented if malaria parasitemia were to be eliminated is estimated to be 0.93 (95% confidence interval: 0.68, 1). DOI:http://dx.doi.org/10.7554/eLife.23699.001 Malaria is a life-threatening disease caused by a parasite that is transferred between people by infected mosquitoes. Most infected individuals suffer flu-like symptoms, but in rare cases malaria can affect the brain, resulting in brain damage, coma or death. The World Health Organization defines a person as suffering from cerebral malaria if the person is in a coma, has malaria parasites in his or her blood, and has no known alternative cause of the coma. Patients suffering from cerebral malaria are categorized based on whether they have damage to the back of the eyes known as retinopathy. It had previously been found that children who died of “retinopathy-positive” cerebral malaria (i.e. those who had retinopathy) had malaria parasites stuck in small vessels in their brains, which likely caused the coma. By contrast, children who died of “retinopathy-negative” cerebral malaria lacked this parasitic condition, and often also had other infections that can cause a coma, such as meningitis or sepsis. Because hospitals in many of the areas most affected by malaria often lack the ability to identify what – other than malaria – caused a coma, it was not clear whether malaria parasites influence how retinopathy-negative cerebral malaria develops. People with certain genetic variants – such as those that underlie sickle cell disease – are protected against the symptoms of malaria infections, and so these variants should also protect against cerebral malaria cases caused by the parasites. Small et al. therefore looked through data that had been collected over several years from people who had been admitted to a hospital in Malawi for cerebral malaria. This revealed that the genetically inherited sickle cell trait is highly protective against retinopathy-negative (as well as retinopathy-positive) cerebral malaria. Therefore, malaria parasites do play a role in a substantial proportion of cases of retinopathy-negative cerebral malaria. Although Small et al. provide evidence that malaria parasites play a role in retinopathy-negative cerebral malaria, they may not be the only cause of the coma. In the future, the absence of retinopathy could be used as a sign to look for additional factors that contribute to the coma. Currently, all cerebral malaria patients are treated in the same way. Understanding how malaria parasites interact with other illnesses to produce a coma could lead to the development of targeted treatment plans for retinopathy-negative patients. DOI:http://dx.doi.org/10.7554/eLife.23699.002
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Affiliation(s)
- Dylan S Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, United States
| | - Terrie E Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, United States.,Blantyre Malaria Project, Blantyre, Malawi
| | - Douglas G Postels
- Department of Neurology and Ophthalmology, College of Osteopathic Medicine, Michigan State University, East Lansing, United States
| | - Nicholas Av Beare
- Department of Eye and Vision Science, University of Liverpool, Liverpool, United Kingdom.,St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco, San Francisco, United States
| | - Ian Jc MacCormick
- Department of Eye and Vision Science, University of Liverpool, Liverpool, United Kingdom.,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, United States.,Blantyre Malaria Project, Blantyre, Malawi
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13
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14
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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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15
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Carlton JM, Volkman SK, Uplekar S, Hupalo DN, Alves JMP, Cui L, Donnelly M, Roos DS, Harb OS, Acosta M, Read A, Ribolla PEM, Singh OP, Valecha N, Wassmer SC, Ferreira M, Escalante AA. Population Genetics, Evolutionary Genomics, and Genome-Wide Studies of Malaria: A View Across the International Centers of Excellence for Malaria Research. Am J Trop Med Hyg 2015; 93:87-98. [PMID: 26259940 PMCID: PMC4574278 DOI: 10.4269/ajtmh.15-0049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/13/2015] [Indexed: 12/21/2022] Open
Abstract
The study of the three protagonists in malaria-the Plasmodium parasite, the Anopheles mosquito, and the human host-is key to developing methods to control and eventually eliminate the disease. Genomic technologies, including the recent development of next-generation sequencing, enable interrogation of this triangle to an unprecedented level of scrutiny, and promise exciting progress toward real-time epidemiology studies and the study of evolutionary adaptation. We discuss the use of genomics by the International Centers of Excellence for Malaria Research, a network of field sites and laboratories in malaria-endemic countries that undertake cutting-edge research, training, and technology transfer in malarious countries of the world.
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Affiliation(s)
- Jane M. Carlton
- *Address correspondence to Jane M. Carlton, Center for Genomics and Systems Biology, New York University, 12 Waverly Place, New York, NY 10003. E-mail:
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Greiner J, Dorovini-Zis K, Taylor TE, Molyneux ME, Beare NAV, Kamiza S, White VA. Correlation of hemorrhage, axonal damage, and blood-tissue barrier disruption in brain and retina of Malawian children with fatal cerebral malaria. Front Cell Infect Microbiol 2015; 5:18. [PMID: 25853095 PMCID: PMC4360761 DOI: 10.3389/fcimb.2015.00018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 02/16/2015] [Indexed: 11/17/2022] Open
Abstract
Background: The retinal and brain histopathological findings in children who died from cerebral malaria (CM) have been recently described. Similar changes occur in both structures, but the findings have not been directly compared in the same patients. In this study, we compared clinical retinal findings and retinal and cerebral histopathological changes in a series of patients in Blantyre, Malawi, who died of CM. Methods: The features systematically compared in the same patient were: (1) clinical, gross and microscopic retinal hemorrhages with microscopic cerebral hemorrhages, (2) retinal and cerebral hemorrhage-associated and -unassociated axonal damage, and fibrinogen leakage, and (3) differences in the above features between the pathological categories of CM without microvascular pathology (CM1) and CM with microvascular pathology (CM2) in retina and brain. Results: Forty-seven patients were included: seven CM1, 28 CM2, and 12 controls. In the 35 malaria cases retinal and cerebral pathology correlated in all features except for non-hemorrhage associated fibrinogen leakage. Regarding CM1 and CM2 cases, the only differences were in the proportion of patients with hemorrhage-associated cerebral pathology, and this was expected, based on the definitions of CM1 and CM2. The retina did not show this difference. Non-hemorrhage associated pathology was similar for the two groups. Comment: As postulated, histopathological features of hemorrhages, axonal damage and non-hemorrhage associated fibrinogen leakage correlated in the retina and brain of individual patients, although the difference in hemorrhages between the CM1 and CM2 groups was not consistently observed in the retina. These results help to underpin the utility of ophthalmoscopic examination and fundus findings to help in diagnosis and assessment of cerebral malaria patients, but may not help in distinguishing between CM1 and CM2 patients during life.
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Affiliation(s)
- Jesse Greiner
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital and University of British Columbia Vancouver, BC, Canada
| | - Katerina Dorovini-Zis
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital and University of British Columbia Vancouver, BC, Canada
| | - Terrie E Taylor
- College of Medicine, University of Malawi Blantyre, Malawi ; Blantyre Malaria Project Blantyre, Malawi ; Department of Osteopathic Medical Specialities, Michigan State University East Lansing, MI, USA
| | - Malcolm E Molyneux
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme Blantyre, Malawi ; Department of Pathology, Malawi College of Medicine Blantyre, Malawi ; Liverpool School of Tropical Medicine Liverpool, 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 Liverpool, UK
| | - Steve Kamiza
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme Blantyre, Malawi ; Department of Pathology, Malawi College of Medicine Blantyre, Malawi
| | - Valerie A White
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital and University of British Columbia Vancouver, BC, Canada ; Department of Ophthalmology and Visual Science, Vancouver General Hospital and University of British Columbia Vancouver, BC, Canada
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17
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Abstract
Over 90% of the world's severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the publication of the AQUAMAT trial in 2010, involving 5,425 children at 11 centres across 9 African countries, showing that in artesunate-treated children, the relative risk of death was 22.5% (95% confidence interval (CI) 8.1 to 36.9) lower than in those receiving quinine. Human trials of supportive therapies carried out on the basis of pathophysiology studies, have so far made little progress on reducing mortality; despite appearing to reduce morbidity endpoints, more often than not they have led to an excess of adverse outcomes. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.
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19
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Milner DA, Whitten RO, Kamiza S, Carr R, Liomba G, Dzamalala C, Seydel KB, Molyneux ME, Taylor TE. The systemic pathology of cerebral malaria in African children. Front Cell Infect Microbiol 2014; 4:104. [PMID: 25191643 PMCID: PMC4139913 DOI: 10.3389/fcimb.2014.00104] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/14/2014] [Indexed: 11/23/2022] Open
Abstract
Pediatric cerebral malaria carries a high mortality rate in sub-Saharan Africa. We present our systematic analysis of the descriptive and quantitative histopathology of all organs sampled from a series of 103 autopsies performed between 1996 and 2010 in Blantyre, Malawi on pediatric cerebral malaria patients and control patients (without coma, or without malaria infection) who were clinically well characterized prior to death. We found brain swelling in all cerebral malaria patients and the majority of controls. The histopathology in patients with sequestration of parasites in the brain demonstrated two patterns: (a) the “classic” appearance (i.e., ring hemorrhages, dense sequestration, and extra-erythrocytic pigment) which was associated with evidence of systemic activation of coagulation and (b) the “sequestration only” appearance associated with shorter duration of illness and higher total burden of parasites in all organs including the spleen. Sequestration of parasites was most intense in the gastrointestinal tract in all parasitemic patients (those with cerebral malarial and those without).
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Affiliation(s)
- Danny A Milner
- Department of Pathology, Brigham and Women's Hospital Boston, MA, USA ; Department of Immunology and Infectious Disease, Harvard School of Public Health Boston, MA, USA ; The Blantyre Malaria Project, College of Medicine, University of Malawi Blantyre, Malawi
| | | | - Steve Kamiza
- Department of Histopathology, College of Medicine, University of Malawi Blantyre, Malawi
| | - Richard Carr
- Department of Histopathology, South Warwickshire General Hospitals Warwick, UK
| | - George Liomba
- Department of Histopathology, College of Medicine, University of Malawi Blantyre, Malawi
| | - Charles Dzamalala
- Department of Histopathology, College of Medicine, University of Malawi Blantyre, Malawi
| | - Karl B Seydel
- The Blantyre Malaria Project, College of Medicine, University of Malawi Blantyre, Malawi ; Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University East Lansing, MI, USA
| | - Malcolm E Molyneux
- Department of Histopathology, College of Medicine, University of Malawi Blantyre, Malawi ; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine Blantyre, Malawi ; Liverpool School of Tropical Medicine, University of Liverpool Liverpool, UK
| | - Terrie E Taylor
- The Blantyre Malaria Project, College of Medicine, University of Malawi Blantyre, Malawi ; Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University East Lansing, MI, USA
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20
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Mohanty S, Taylor TE, Kampondeni S, Potchen MJ, Panda P, Majhi M, Mishra SK, Wassmer SC. Magnetic resonance imaging during life: the key to unlock cerebral malaria pathogenesis? Malar J 2014; 13:276. [PMID: 25038815 PMCID: PMC4114090 DOI: 10.1186/1475-2875-13-276] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 07/14/2014] [Indexed: 12/22/2022] Open
Abstract
Understanding the mechanisms underlying the pathophysiology of cerebral malaria in patients with Plasmodium falciparum infection is necessary to implement new curative interventions. While autopsy-based studies shed some light on several pathological events that are believed to be crucial in the development of this neurologic syndrome, their investigative potential is limited and has not allowed the identification of causes of death in patients who succumb to it. This can only be achieved by comparing features between patients who die from cerebral malaria and those who survive. In this review, several alternative approaches recently developed to facilitate the comparison of specific parameters between fatal, non-fatal cerebral malaria and uncomplicated malaria patients are described, as well as their limitations. The emergence of neuroimaging as a revolutionary tool in identifying critical structural and functional modifications of the brain during cerebral malaria is discussed and highly promising areas of clinical research using magnetic resonance imaging are highlighted.
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Affiliation(s)
| | | | | | | | | | | | | | - Samuel C Wassmer
- Department of Microbiology, Division of Parasitology, New York University School of Medicine, 341 East 25th Street, New York NY 10010, USA.
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21
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Abdali N, Malik AM, Shamim MD, Rizvi SWA. Bilateral subhyaloid haemorrhage in a conscious patient: a new spectrum of ocular involvement by Plasmodium falciparum. BMJ Case Rep 2014; 2014:bcr-2013-202811. [PMID: 24862605 DOI: 10.1136/bcr-2013-202811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 24-year-old woman presented with a history of high-grade fever with rigours since 3 days and bilateral sudden loss of vision since 6 h. She was conscious, oriented and her vitals were stable. She had a temperature of 101°F, anaemia, thrombocytopaenia, normal white cell count and moderate splenomegaly. On testing visual activity, she could only perceive hand movements although her pupils were bilaterally equal, and normal in size and reaction. On indirect ophthalmoscopy, optic discs were normal bilaterally; however, fovea of both eyes was masked by subhyaloid haemorrhage. Peripheral smear showed gametocytes of Plasmodium falciparum. The patient was started on arteminsinin-combined therapy and advised to be in propped-up position to help resolution of the haemorrhage. The patient was afebrile in 4 days and follow-up fundus examination showed gradual resolution of the haemorrhage. After two months, the patient regained normal visual acuity in both eyes; however, it took nearly 3 months for complete resolution of the haemorrhage.
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Affiliation(s)
- Nasar Abdali
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
| | | | - Md Dilawez Shamim
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
| | - Syed Wajahat Ali Rizvi
- Department of Ophthalmology, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
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Mallewa M, Wilmshurst JM. Overview of the effect and epidemiology of parasitic central nervous system infections in African children. Semin Pediatr Neurol 2014; 21:19-25. [PMID: 24655400 PMCID: PMC3989118 DOI: 10.1016/j.spen.2014.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Infections of the central nervous system are a significant cause of neurologic dysfunction in resource-limited countries, especially in Africa. The prevalence is not known and is most likely underestimated because of the lack of access to accurate diagnostic screens. For children, the legacy of subsequent neurodisability, which affects those who survive, is a major cause of the burden of disease in Africa. Of the parasitic infections with unique effect in Africa, cerebral malaria, neurocysticercosis, human African trypanosomiasis, toxoplasmosis, and schistosomiasis are largely preventable conditions, which are rarely seen in resource-equipped settings. This article reviews the current understandings of these parasitic and other rarer infections, highlighting the specific challenges in relation to prevention, diagnosis, treatment, and the complications of coinfection.
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Affiliation(s)
- Macpherson Mallewa
- Department of Paediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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23
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MacCormick IJC, Beare NAV, Taylor TE, Barrera V, White VA, Hiscott P, Molyneux ME, Dhillon B, Harding SP. Cerebral malaria in children: using the retina to study the brain. ACTA ACUST UNITED AC 2014; 137:2119-42. [PMID: 24578549 PMCID: PMC4107732 DOI: 10.1093/brain/awu001] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cerebral malaria is a dangerous complication of Plasmodium falciparum infection, which takes a devastating toll on children in sub-Saharan Africa. Although autopsy studies have improved understanding of cerebral malaria pathology in fatal cases, information about in vivo neurovascular pathogenesis is scarce because brain tissue is inaccessible in life. Surrogate markers may provide insight into pathogenesis and thereby facilitate clinical studies with the ultimate aim of improving the treatment and prognosis of cerebral malaria. The retina is an attractive source of potential surrogate markers for paediatric cerebral malaria because, in this condition, the retina seems to sustain microvascular damage similar to that of the brain. In paediatric cerebral malaria a combination of retinal signs correlates, in fatal cases, with the severity of brain pathology, and has diagnostic and prognostic significance. Unlike the brain, the retina is accessible to high-resolution, non-invasive imaging. We aimed to determine the extent to which paediatric malarial retinopathy reflects cerebrovascular damage by reviewing the literature to compare retinal and cerebral manifestations of retinopathy-positive paediatric cerebral malaria. We then compared retina and brain in terms of anatomical and physiological features that could help to account for similarities and differences in vascular pathology. These comparisons address the question of whether it is biologically plausible to draw conclusions about unseen cerebral vascular pathogenesis from the visible retinal vasculature in retinopathy-positive paediatric cerebral malaria. Our work addresses an important cause of death and neurodisability in sub-Saharan Africa. We critically appraise evidence for associations between retina and brain neurovasculature in health and disease, and in the process we develop new hypotheses about why these vascular beds are susceptible to sequestration of parasitized erythrocytes.
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Affiliation(s)
- Ian J C MacCormick
- 1 Malawi-Liverpool-Wellcome Trust Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - Nicholas A V Beare
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK3 Royal Liverpool University Hospital, St. Paul's Eye Unit, Prescot St, Liverpool, Merseyside L7 8XP, UK
| | - Terrie E Taylor
- 5 Blantyre Malaria Project, Blantyre, Malawi6 Michigan State University, Department of Osteopathic Medical Specialities, West Fee Hall, 909 Fee Road, Room B305, East Lansing, MI 48824, USA
| | - Valentina Barrera
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - Valerie A White
- 7 Vancouver General Hospital, Department of Pathology and Laboratory Medicine, Vancouver, B.C. V5Z1M9, Canada
| | - Paul Hiscott
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - Malcolm E Molyneux
- 1 Malawi-Liverpool-Wellcome Trust Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi4 University of Malawi College of Medicine, College of Medicine, P/Bag 360 Chichiri, Blantyre 3 Malawi8 Liverpool School of Tropical Medicine, Liverpool School of Tropical Medicine, Pembroke Place , Liverpool, L3 5QA , UK
| | - Baljean Dhillon
- 9 University of Edinburgh, Department of Ophthalmology, Edinburgh, UK10 Princess Alexandra Eye Pavilion, Edinburgh, UK
| | - Simon P Harding
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK3 Royal Liverpool University Hospital, St. Paul's Eye Unit, Prescot St, Liverpool, Merseyside L7 8XP, UK
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Noval S, Cabrejas L, Jarrín E, Ruiz-Guerrero M, Ciancas E. [Pediatric case series in an ophthalmic camp in Turkana (Kenya)]. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2013; 88:466-472. [PMID: 24257256 DOI: 10.1016/j.oftal.2013.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 04/29/2013] [Accepted: 06/11/2013] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Turkana is the largest district in Kenya, situated in the Northwest of the country. It features a semi-nomadic population of 850,000. Around 60% of population lives below the poverty threshold. The ratio of doctors is 1:75,000 inhabitants. Five ophthalmologists took part in the last deployment in November. Local staff had previously selected the patients from the rural areas, as well as in Lodwar, the capital of the district. Of the 371 patients who attended the clinic, 128 required surgery. OBJETIVE To describe the pediatric population attended to in the last «Turkana Eye Project» Camp. METHODS Description of the ophthalmic pathologies of the children seen in the clinic in this surgical camp, and the diagnostic and therapeutic options according to the limitations of the environment. RESULTS Of the 371 patients, 54 were younger than 15 years old (14.5%). Four children had surgery (3.25% of the 128 patients). In 2 more cases surgery was the indicated but not performed. Therefore, of the total of 54 cases, 6 could be considered as surgical (11.1%), and 17 suffered ophthalmic problems other than refraction defects, or mild ocular surface pathologies: traumatic cataracts, neuropathies, impetigo, exophthalmos, retinal dystrophies, dermoid cysts, or nyctalopia. The etiology was traumatic in four of the 17 children (23.5%). CONCLUSION Surgical camps are increasing in the developing countries. They are usually focused on particular pathologies, such as cataracts or trachoma. Our case series shows the importance of pediatric teams and the need to be prepared to face complex pediatric pathologies.
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Affiliation(s)
- S Noval
- Servicio de Oftalmología, Hospital Infantil La Paz, Madrid. España.
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Nimir AR, Saliem A, Ibrahim IAA. Ophthalmic parasitosis: a review article. Interdiscip Perspect Infect Dis 2012; 2012:587402. [PMID: 23024652 PMCID: PMC3457613 DOI: 10.1155/2012/587402] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 08/10/2012] [Accepted: 08/15/2012] [Indexed: 12/03/2022] Open
Abstract
Ocular parasitosis in human is more prevalent in geographical areas where environmental factors and poor sanitary conditions favor the parasitism between man and animals. Lesions in the eye can be due to damage directly caused by the infectious pathogen, indirect pathology caused by toxic products, or the immune response incited by infections or ectopic parasitism. The epidemiology of parasitic ocular diseases reflects the habitat of the causative parasites as well as the habits and health status of the patient. An ocular examination may provide clues to the underlying disease/infection, and an awareness of the possibilities of travel-related pathology may shed light on an ocular presentation. This paper is a comprehensive review of the parasitic diseases of the eye. The majority of the clinically important species of parasites involved in eye infection are reviewed in this paper. Parasites are discussed by the disease or infection they cause.
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Affiliation(s)
- Amal R. Nimir
- Division of Basic Medical Sciences, Faculty of Medicine, Cyberjaya University College of Medical Sciences, 63000 Selangor, Malaysia
| | - Ahmed Saliem
- Division of Basic Medical Sciences, Faculty of Medicine, Cyberjaya University College of Medical Sciences, 63000 Selangor, Malaysia
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Milner DA, Pochet N, Krupka M, Williams C, Seydel K, Taylor TE, Van de Peer Y, Regev A, Wirth D, Daily JP, Mesirov JP. Transcriptional profiling of Plasmodium falciparum parasites from patients with severe malaria identifies distinct low vs. high parasitemic clusters. PLoS One 2012; 7:e40739. [PMID: 22815802 PMCID: PMC3399889 DOI: 10.1371/journal.pone.0040739] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 06/12/2012] [Indexed: 01/30/2023] Open
Abstract
Background In the past decade, estimates of malaria infections have dropped from 500 million to 225 million per year; likewise, mortality rates have dropped from 3 million to 791,000 per year. However, approximately 90% of these deaths continue to occur in sub-Saharan Africa, and 85% involve children less than 5 years of age. Malaria mortality in children generally results from one or more of the following clinical syndromes: severe anemia, acidosis, and cerebral malaria. Although much is known about the clinical and pathological manifestations of CM, insights into the biology of the malaria parasite, specifically transcription during this manifestation of severe infection, are lacking. Methods and Findings We collected peripheral blood from children meeting the clinical case definition of cerebral malaria from a cohort in Malawi, examined the patients for the presence or absence of malaria retinopathy, and performed whole genome transcriptional profiling for Plasmodium falciparum using a custom designed Affymetrix array. We identified two distinct physiological states that showed highly significant association with the level of parasitemia. We compared both groups of Malawi expression profiles with our previously acquired ex vivo expression profiles of parasites derived from infected patients with mild disease; a large collection of in vitro Plasmodium falciparum life cycle gene expression profiles; and an extensively annotated compendium of expression data from Saccharomyces cerevisiae. The high parasitemia patient group demonstrated a unique biology with elevated expression of Hrd1, a member of endoplasmic reticulum-associated protein degradation system. Conclusions The presence of a unique high parasitemia state may be indicative of the parasite biology of the clinically recognized hyperparasitemic severe disease syndrome.
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Affiliation(s)
- Danny A Milner
- The Brigham and Women's Hospital, Department of Pathology, Boston, Massachusetts, United States of America.
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Clinical aspects of uncomplicated and severe malaria. Mediterr J Hematol Infect Dis 2012; 4:e2012026. [PMID: 22708041 PMCID: PMC3375727 DOI: 10.4084/mjhid.2012.026] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 03/23/2012] [Indexed: 11/08/2022] Open
Abstract
The first symptoms of malaria, common to all the different malaria species, are nonspecific and mimic a flu-like syndrome. Although fever represents the cardinal feature, clinical findings in malaria are extremely diverse and may range in severity from mild headache to serious complications leading to death, particularly in falciparum malaria. As the progression to these complications can be rapid, any malaria patient must be assessed and treated rapidly, and frequent observations are needed to look for early signs of systemic complications. In fact, severe malaria is a life threatening but treatable disease. The protean and nonspecific clinical findings occurring in malaria (fever, malaise, headache, myalgias, jaundice and sometimes gastrointestinal symptoms of nausea, vomiting and diarrhoea) may lead physicians who see malaria infrequently to a wrong diagnosis, such as influenza (particularly during the seasonal epidemic flu), dengue, gastroenteritis, typhoid fever, viral hepatitis, encephalitis. Physicians should be aware that malaria is not a clinical diagnosis but must be diagnosed, or excluded, by performing microscopic examination of blood films. Prompt diagnosis and appropriate treatment are then crucial to prevent morbidity and fatal outcomes. Although Plasmodium falciparum malaria is the major cause of severe malaria and death, increasing evidence has recently emerged that Plasmodium vivax and Plasmodium knowlesi can also be severe and even fatal.
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Potchen MJ, Kampondeni SD, Seydel KB, Birbeck GL, Hammond CA, Bradley WG, DeMarco JK, Glover SJ, Ugorji JO, Latourette MT, Siebert JE, Molyneux ME, Taylor TE. Acute brain MRI findings in 120 Malawian children with cerebral malaria: new insights into an ancient disease. AJNR Am J Neuroradiol 2012; 33:1740-6. [PMID: 22517285 DOI: 10.3174/ajnr.a3035] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE There have been few neuroimaging studies of pediatric CM, a common often fatal tropical condition. We undertook a prospective study of pediatric CM to better characterize the MRI features of this syndrome, comparing findings in children meeting a stringent definition of CM with those in a control group who were infected with malaria but who were likely to have a nonmalarial cause of coma. MATERIALS AND METHODS Consecutive children admitted with traditionally defined CM (parasitemia, coma, and no other coma etiology evident) were eligible for this study. The presence or absence of malaria retinopathy was determined. MRI findings in children with ret+ CM (patients) were compared with those with ret- CM (controls). Two radiologists blinded to retinopathy status jointly developed a scoring procedure for image interpretation and provided independent reviews. MRI findings were compared between patients with and without retinopathy, to assess the specificity of changes for patients with very strictly defined CM. RESULTS Of 152 children with clinically defined CM, 120 were ret+, and 32 were ret-. Abnormalities much more common in the patients with ret+ CM were markedly increased brain volume; abnormal T2 signal intensity; and DWI abnormalities in the cortical, deep gray, and white matter structures. Focal abnormalities rarely respected arterial vascular distributions. Most of the findings in the more clinically heterogeneous ret- group were normal, and none of the abnormalities noted were more prevalent in controls. CONCLUSIONS Distinctive MRI findings present in patients meeting a stringent definition of CM may offer insights into disease pathogenesis and treatment.
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Affiliation(s)
- M J Potchen
- Department of Radiology, Michigan State University, East Lansing, Michigan, USA
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von Seidlein L, Olaosebikan R, Hendriksen ICE, Lee SJ, Adedoyin OT, Agbenyega T, Nguah SB, Bojang K, Deen JL, Evans J, Fanello CI, Gomes E, Pedro AJ, Kahabuka C, Karema C, Kivaya E, Maitland K, Mokuolu OA, Mtove G, Mwanga-Amumpaire J, Nadjm B, Nansumba M, Ngum WP, Onyamboko MA, Reyburn H, Sakulthaew T, Silamut K, Tshefu AK, Umulisa N, Gesase S, Day NPJ, White NJ, Dondorp AM. Predicting the clinical outcome of severe falciparum malaria in african children: findings from a large randomized trial. Clin Infect Dis 2012; 54:1080-90. [PMID: 22412067 PMCID: PMC3309889 DOI: 10.1093/cid/cis034] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Four predictors were independently associated with an increased risk of death: acidosis, cerebral manifestations of malaria, elevated blood urea nitrogen, or signs of chronic illness. The standard base deficit was found to be the single most relevant predictor of death. Background. Data from the largest randomized, controlled trial for the treatment of children hospitalized with severe malaria were used to identify such predictors of a poor outcome from severe malaria. Methods. African children (<15 years) with severe malaria participated in a randomized comparison of parenteral artesunate and parenteral quinine in 9 African countries. Detailed clinical assessment was performed on admission. Parasite densities were assessed in a reference laboratory. Predictors of death were examined using a multivariate logistic regression model. Results. Twenty indicators of disease severity were assessed, out of which 5 (base deficit, impaired consciousness, convulsions, elevated blood urea, and underlying chronic illness) were associated independently with death. Tachypnea, respiratory distress, deep breathing, shock, prostration, low pH, hyperparasitemia, severe anemia, and jaundice were statistically significant indicators of death in the univariate analysis but not in the multivariate model. Age, glucose levels, axillary temperature, parasite density, heart rate, blood pressure, and blackwater fever were not related to death in univariate models. Conclusions. Acidosis, cerebral involvement, renal impairment, and chronic illness are key independent predictors for a poor outcome in African children with severe malaria. Mortality is markedly increased in cerebral malaria combined with acidosis. Clinical Trial Registration. ISRCTN50258054.
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Affiliation(s)
- Lorenz von Seidlein
- Department of Global Health, Menzies School of Health Research, Casuarina, Northern Territory, Australia.
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Conroy AL, Glover SJ, Hawkes M, Erdman LK, Seydel KB, Taylor TE, Molyneux ME, Kain KC. Angiopoietin-2 levels are associated with retinopathy and predict mortality in Malawian children with cerebral malaria: a retrospective case-control study*. Crit Care Med 2012; 40:952-9. [PMID: 22343839 PMCID: PMC3284252 DOI: 10.1097/ccm.0b013e3182373157] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To investigate the relationship among the angiopoietin-Tie-2 system, retinopathy, and mortality in children with cerebral malaria. DESIGN A case-control study of retinopathy-positive vs. retinopathy-negative children with clinically defined cerebral malaria. SETTING Queen Elizabeth Central Hospital in Blantyre, Malawi. SUBJECTS One hundred fifty-five children presenting with severe malaria and meeting a strict definition of clinical cerebral malaria (Blantyre Coma Score ≤ 2, Plasmodium falciparum parasitemia, no other identifiable cause for coma) were included in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and laboratory parameters were recorded at admission and funduscopic examinations were performed. Admission levels of angiopoietin-1, angiopoietin-2, and a soluble version of their cognate receptor were measured by enzyme-linked immunosorbent assay. We show that angiopoietin-1 levels are decreased and angiopoietin-2 and soluble Tie-2 levels are increased in children with cerebral malaria who had retinopathy compared with those who did not. Angiopoietin-2 and soluble Tie-2 were independent predictors of retinopathy (adjusted odds ratio [95% CI], angiopoietin-2, 4.3 [1.3-14.6], p = .019; soluble Tie-2, 9.7 [2.1-45.8], p = .004). Angiopoietin-2 and soluble Tie-2 were positively correlated with the number of hemorrhages, the severity or retinal whitening, and the extent of capillary whitening observed on funduscopic examination (p < .05 after adjustment for multiple comparisons). Angiopoietin-2 and soluble Tie-2 levels were elevated in children with cerebral malaria who subsequently died and angiopoetin-2 was an independent predictor of death (adjusted odds ratio: 3.9 [1.2-12.7], p = .024). When combined with clinical parameters, angiopoetin-2 improved prediction of mortality using logistic regression models and classification trees. CONCLUSIONS These results provide insights into mechanisms of endothelial activation in cerebral malaria and indicate that the angiopoietin-Tie-2 axis is associated with retinopathy and mortality in pediatric cerebral malaria.
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Affiliation(s)
- Andrea L Conroy
- Sandra A Rotman Laboratories, McLaughlin-Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada
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Lacerda MVG, Mourão MPG, Alexandre MAA, Siqueira AM, Magalhães BML, Martinez-Espinosa FE, Filho FSS, Brasil P, Ventura AMRS, Tada MS, Couto VSCD, Silva AR, Silva RSU, Alecrim MGC. Understanding the clinical spectrum of complicated Plasmodium vivax malaria: a systematic review on the contributions of the Brazilian literature. Malar J 2012; 11:12. [PMID: 22230294 PMCID: PMC3268102 DOI: 10.1186/1475-2875-11-12] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 01/09/2012] [Indexed: 12/12/2022] Open
Abstract
The resurgence of the malaria eradication agenda and the increasing number of severe manifestation reports has contributed to a renewed interested in the Plasmodium vivax infection. It is the most geographically widespread parasite causing human malaria, with around 2.85 billion people living under risk of infection. The Brazilian Amazon region reports more than 50% of the malaria cases in Latin America and since 1990 there is a marked predominance of this species, responsible for 85% of cases in 2009. However, only a few complicated cases of P. vivax have been reported from this region. A systematic review of the Brazilian indexed and non-indexed literature on complicated cases of vivax malaria was performed including published articles, masters' dissertations, doctoral theses and national congresses' abstracts. The following information was retrieved: patient characteristics (demographic, presence of co-morbidities and, whenever possible, associated genetic disorders); description of each major clinical manifestation. As a result, 27 articles, 28 abstracts from scientific events' annals and 13 theses/dissertations were found, only after 1987. Most of the reported information was described in small case series and case reports of patients from all the Amazonian states, and also in travellers from Brazilian non-endemic areas. The more relevant clinical complications were anaemia, thrombocytopaenia, jaundice and acute respiratory distress syndrome, present in all age groups, in addition to other more rare clinical pictures. Complications in pregnant women were also reported. Acute and chronic co-morbidities were frequent, however death was occasional. Clinical atypical cases of malaria are more frequent than published in the indexed literature, probably due to a publication bias. In the Brazilian Amazon (considered to be a low to moderate intensity area of transmission), clinical data are in accordance with the recent findings of severity described in diverse P. vivax endemic areas (especially anaemia in Southeast Asia), however in this region both children and adults are affected. Finally, gaps of knowledge and areas for future research are opportunely pointed out.
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Affiliation(s)
- Marcus V G Lacerda
- Fundação de Medicina Tropical Dr, Heitor Vieira Dourado, Av, Pedro Teixeira, 25, 69040-000, Manaus Amazonas, Brazil.
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Beare NAV, Lewallen S, Taylor TE, Molyneux ME. Redefining cerebral malaria by including malaria retinopathy. Future Microbiol 2011; 6:349-55. [PMID: 21449844 DOI: 10.2217/fmb.11.3] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Accurate diagnosis of cerebral malaria (CM) is important for patient management, epidemiological and end point surveillance, and enrolling patients with CM in studies of pathogenesis or therapeutic trials. In malaria-endemic areas, where asymptomatic Plasmodium falciparum parasitemia is common, a positive blood film in a comatose individual does not prove that the coma is due to malaria. A retinopathy consisting of two unique features - patchy retinal whitening and focal changes of vessel color - is highly specific for encephalopathy of malarial etiology. White-centered retinal hemorrhages are a common but less specific feature. Either indirect or direct ophthalmoscopy can be used to identify the changes, and both procedures can be learned and practiced by nonspecialist clinicians. In view of its important contributions to both clinical care and research, examination of the retina should become a routine component of the assessment of a comatose child or adult when CM is a possible diagnosis.
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Affiliation(s)
- Nicholas A V Beare
- Kilimanjaro Centre for Community Ophthalmology, KCM College, Tumaini University, Moshi, Tanzania.
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White VA. Malaria in Malawi: inside a research autopsy study of pediatric cerebral malaria. Arch Pathol Lab Med 2011; 135:220-6. [PMID: 21284442 DOI: 10.5858/135.2.220] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Malaria is still a major cause of death in sub-Saharan Africa. OBJECTIVES To describe my participation as a pathologist in a research autopsy study in Malawi and to examine retinal pathologic findings in cerebral malaria and correlate them with those in the brain. To describe the challenges of conducting a research study in sub-Saharan Africa and the personal and scientific benefits resulting from this. DESIGN Children with coma are admitted to the pediatric research ward, classified according to the clinical definition of severe malaria or another cause of coma, evaluated, and treated systematically. The eyes are examined by indirect ophthalmoscopy after dilatation. If a child dies and permission is given, a standardized autopsy is carried out. The patients' condition is then reclassified pathologically. RESULTS Ninety autopsies have been completed, with the cause of death confirmed as cerebral malaria in 64 cases (71.1%). These patients showed heavy parasite sequestration and often extravascular pathologic findings in the brain, retina, gastrointestinal tract, and subcutaneous fat. Clinical and pathologic findings in the retina correlated with those in the brain, and ophthalmoscopy has become a useful tool in the diagnosis and prognosis of children with cerebral malaria. Twenty-eight percent of patients clinically classified as having cerebral malaria showed another cause of death and no malarial pathologic process or retinopathy. CONCLUSIONS The human, financial, and transportation resources and organization required for this autopsy project are substantial. The scientific benefits are now becoming evident after sufficient autopsies have been completed for detailed comparisons. Personal benefits include the opportunity to work and travel in an African setting and to develop collaborations world-wide.
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Affiliation(s)
- Valerie A White
- Department of Pathology, Vancouver General Hospital, British Columbia, Canada.
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Liver pathology in Malawian children with fatal encephalopathy. Hum Pathol 2011; 42:1230-9. [PMID: 21396681 DOI: 10.1016/j.humpath.2010.11.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 11/17/2010] [Accepted: 11/19/2010] [Indexed: 01/22/2023]
Abstract
A common clinical presentation of Plasmodium falciparum is parasitemia, complicated by an encephalopathy for which other explanations cannot be found, termed cerebral malaria-an important cause of death in young children in endemic areas. Our objective was to study hepatic histopathology in Malawian children with fatal encephalopathy, with and without P falciparum parasitemia, to assess the contributions of severe malaria. We report autopsy results from a series of 87 Malawian children who died between 1996 and 2008. Among 75 cases with P falciparum parasitemia, 51 had intracerebral sequestered parasites, whereas 24 without sequestered parasites had other causes of death revealed by autopsy including 4 patients with clinicopathologic findings which may represent Reye syndrome. Hepatic histology in parasitemic cases revealed very limited sequestration of parasites in hepatic sinusoids, even in cases with extensive sequestration elsewhere, but increased numbers of hemozoin-laden Kupffer cells were invariably present with a strong association with histologic evidence of cerebral malaria by quantitative analysis. Of 12 patients who were consistently aparasitemic during their fatal illness, 5 had clinicopathologic findings which may represent Reye syndrome. Hepatic sequestration of parasitized erythrocytes is not a feature of fatal malaria in Malawian children, and there is no structural damage in the liver. Reye syndrome may be an important cause of fatal encephalopathy in children in Malawi with and without peripheral parasitemia and warrants close scrutiny of aspirin use in malaria-endemic areas.
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Abstract
PURPOSE OF REVIEW Intense interventions are ongoing to combat malaria. Malaria mortality investigation remains as an intense area of study with controversies, competing models of pathogenesis, and a few carefully proceeding clinical trials. This review suggests a reframing of the question of cerebral malaria pathology in light of recent findings to focus on dissection of pathogenesis that will lead to effective treatments. RECENT FINDINGS Pediatric and adult manifestations of cerebral malaria within the retina allows for intense study of the clinical defined patients including the advent of multiple imaging modalities in endemic regions. Basic pathogenesis in mouse models and human studies, focused on cytokines, inflammation, cytoadherence, and endothelial activation, continues to be elucidated molecule by molecule. Coagulation is variably important and may serve as one of several unifying principles of current pathogenesis models. Parasite-derived molecules - surface or soluble - remain necessary but not sufficient to explain pathologic manifestations. SUMMARY As we close the gaps in the fight against global malaria, the question of cerebral malaria mortality remains a source of great concern. We currently have no effective means of reversal of coma or impacting mortality in the comatose patient. As transmission is broken, cerebral malaria will spread to older age groups in Africa where we expect mortality will be higher. Continued directed study of pathogenesis with the primary goal of efficacious interventions in the comatose is a necessity.
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Affiliation(s)
- Danny A Milner
- The Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Essuman VA, Ntim-Amponsah CT, Astrup BS, Adjei GO, Kurtzhals JAL, Ndanu TA, Goka B. Retinopathy in severe malaria in Ghanaian children--overlap between fundus changes in cerebral and non-cerebral malaria. Malar J 2010; 9:232. [PMID: 20704742 PMCID: PMC2927612 DOI: 10.1186/1475-2875-9-232] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 08/12/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In malaria-endemic areas, reliably establishing parasitaemia for diagnosis of malaria can be difficult. A retinopathy with some features unique to severe malaria with a predictive value on prognosis, has been described. Detection of this retinopathy could be a useful diagnostic tool. This study was designed to determine the diagnostic usefulness of retinopathy on ophthalmoscopy in severe malaria syndromes: Cerebral malaria (CM) and non-cerebral severe malaria (non-CM), i.e. malaria with respiratory distress (RD) and malaria with severe anaemia (SA), in Ghanaian children. Secondly, to determine any association between retinopathy and the occurrence of convulsions in patients with CM. METHODS AND SUBJECTS A cross-sectional study of consecutive patients on admission with severe malaria who were assessed for retinal signs, at the Department of Child Health, Korle-Bu Teaching Hospital, Accra, from July to August 2002 was done. All children had dilated-fundus examination by direct and indirect ophthalmoscopy. RESULTS Fifty-eight children aged between six months and nine years were recruited. Twenty six(45%) had CM, 22 with convulsion; 26(45%) had SA and six(10%) had RD.Any retinopathy was seen in: CM 19(73%), SA 14(54%), RD 3(50.0%), CM with convulsion 15(68%) and CM without convulsion 4(100%). Comparison between CM versus non-CM groups showed a significant risk relationship between retinal whitening and CM(OR = 11.0, CI = 2.2- 56.1, p = 0.001). There was no significant association with papilloedema(OR = 0.9, CI = 0.3 - 3.0, p = 0.9), macular whitening(OR = 1.6, CI = 0.5 - 4.8, p = 0.4), macular haemorrhage(OR = 0.28, CI = 0.03 - 2.7 p = 0.2), retinal haemorrhage(OR = 1.9, CI = 0.6 - 5.6, p = 0.3), vessel abnormality(OR = 1.9, CI = 0.6 - 6.1, p = 0.3) and cotton wool spots(OR not calculated, p = 0.08).Tortuous and engorged retinal veins, not previously described as a feature of CM, was the most common vascular abnormality(15/58 = 26%) and was detected even in the absence of papilloedema. CONCLUSION Retinal whitening, a sign suggestive of retinal ischaemia, was significantly more common in CM than in non-CM syndromes. However, the high prevalence of any retinopathy in the latter suggests that the brain and the retina may be suffering from ischaemia in both CM and non-CM.
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Affiliation(s)
- Vera A Essuman
- University of Ghana Medical School, College of Health Sciences-University of Ghana, Accra, Ghana.
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Potchen MJ, Birbeck GL, Demarco JK, Kampondeni SD, Beare N, Molyneux ME, Taylor TE. Neuroimaging findings in children with retinopathy-confirmed cerebral malaria. Eur J Radiol 2010; 74:262-8. [PMID: 19345538 PMCID: PMC3786197 DOI: 10.1016/j.ejrad.2009.02.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 02/23/2009] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe brain CT findings in retinopathy-confirmed, paediatric cerebral malaria. MATERIALS AND METHODS In this outcomes study of paediatric cerebral malaria, a subset of children with protracted coma during initial presentation was scanned acutely. Survivors experiencing adverse neurological outcomes also underwent a head CT. All children had ophthalmological examination to confirm the presence of the retinopathy specific for cerebral malaria. Independent interpretation of CT images was provided by two neuroradiologists. RESULTS Acute brain CT findings in three children included diffuse oedema with obstructive hydrocephalus (2), acute cerebral infarctions in multiple large vessel distributions with secondary oedema and herniation (1), and oedema of thalamic grey matter (1). One child who was reportedly normal prior to admission had parenchymal atrophy suggestive of pre-existing CNS injury. Among 56 survivors (9-84 months old), 15 had adverse neurologic outcomes-11/15 had a follow-up head CT, 3/15 died and 1/15 refused CT. Follow-up head CTs obtained 7-18 months after the acute infection revealed focal and multifocal lobar atrophy correlating to regions affected by focal seizures during the acute infection (5/11). Other findings were communicating hydrocephalus (2/11), vermian atrophy (1/11) and normal studies (3/11). CONCLUSIONS The identification of pre-existing imaging abnormalities in acute cerebral malaria suggests that population-based studies are required to establish the rate and nature of incidental imaging abnormalities in Malawi. Children with focal seizures during acute cerebral malaria developed focal cortical atrophy in these regions at follow-up. Longitudinal studies are needed to further elucidate mechanisms of CNS injury and death in this common fatal disease.
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Affiliation(s)
- Michael J Potchen
- Michigan State University, Department of Radiology, 184 Radiology Building, East Lansing, MI 48824-1303, USA.
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Birbeck GL, Beare N, Lewallen S, Glover SJ, Molyneux ME, Kaplan PW, Taylor TE. Identification of malaria retinopathy improves the specificity of the clinical diagnosis of cerebral malaria: findings from a prospective cohort study. Am J Trop Med Hyg 2010; 82:231-4. [PMID: 20133998 DOI: 10.4269/ajtmh.2010.09-0532] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The diagnosis of cerebral malaria (CM) is difficult to confirm in endemic regions with limited neurodiagnostics. Accurate diagnoses are critical for trials and outcomes studies. Findings from an autopsy-based study suggest that identifying malaria retinopathy in children satisfying the standard clinical case definition of CM improves our ability to accurately diagnose CM in vivo. In a post hoc analysis of a prospective exposure-control study to evaluate CM as a risk factor for epilepsy, we stratified children meeting the standard case definition by their retinopathy status (presence versus absence) and compared these groups for pre-existing risk factors for epilepsy. We also compared them to the concurrently enrolled, non-comatose controls. Children meeting the standard case definition of CM who lacked malaria retinopathy had a higher prevalence of pre-existing developmental problems and family history of epilepsy. This subset of patients may represent children with a pre-existing propensity to adverse neurologic symptoms and outcomes.
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Affiliation(s)
- Gretchen L Birbeck
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, East Lansing, Michigan, USA.
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Pediatric Eye Disease in Tanzania. Clin Ophthalmol 2010; 50:137-48. [DOI: 10.1097/iio.0b013e3181f0f24c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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41
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Mohammed I, Ibrahim UY, Mukhtar M, Farouq Z, Obiagwu PN, Yashua AH. Malarial retinopathy in northern Nigerian children. Trop Doct 2009; 40:50-2. [PMID: 20008061 DOI: 10.1258/td.2009.080420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This is a prospective study involving two centres. Children younger than 16 years old who had severe malaria underwent funduscopy. In one centre, direct ophthalmoscopy was performed by both an ophthalmologist and a non-ophthalmologist physician. At the other, two ophthalmologists performed a funduscopy on each patient using different methods (one using direct and the other indirect ophthalmoscopy). The objective was to determine the frequency of retinopathy and evaluate the effectiveness of direct ophthalmoscopy in detecting retinopathy in constantly dilated eyes. Of 62 children seen at both centres, 37% were found to have malarial retinopathy. Macula whitening was the most common finding. There was substantial agreement between the ophthalmologists using either the direct or indirect ophthalmoscopy techniques (Kappa value 0.604). However, at the centre using only direct ophthalmoscopy, there was poor agreement between the ophthalmologist and the non-ophthalmologist (kappa value -0.244). Direct ophthalmoscopy seemed to be effective in detecting malarial retinopathy, but only when performed by experienced personnel.
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Affiliation(s)
- I Mohammed
- Department of Ophthalmology, Aminu Kano Teaching Hospital, PMB 3452, Kano, Nigeria.
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42
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Mehta SA, Ansari AS, Jiandani P. Opthalmoscopic Findings in Adult Patients with Severe Falciparum Malaria. Ocul Immunol Inflamm 2009; 16:239-41. [DOI: 10.1080/09273940802409977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Salil A. Mehta
- Department of Ophthalmology, Lilavati Hospital and Research Center, Mumbai, India
| | - Abdul Samad Ansari
- Department of Critical Care Medicine, Lilavati Hospital and Research Center, Mumbai, India
| | - Prakash Jiandani
- Department of Critical Care Medicine, Lilavati Hospital and Research Center, Mumbai, India
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Maude RJ, Dondorp AM, Abu Sayeed A, Day NPJ, White NJ, Beare NAV. The eye in cerebral malaria: what can it teach us? Trans R Soc Trop Med Hyg 2009; 103:661-4. [PMID: 19100590 PMCID: PMC2700878 DOI: 10.1016/j.trstmh.2008.11.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Revised: 11/04/2008] [Accepted: 11/04/2008] [Indexed: 11/24/2022] Open
Abstract
The pathophysiology of coma in cerebral malaria (CM) is not well understood. Obstruction of microcirculatory flow is thought to play a central role, but other hypotheses include roles for parasite- and host-derived factors such as immune mediators, and for increased blood-brain barrier permeability leading to raised intracranial pressure. The retinal vasculature is a direct extension of the cerebral vasculature. It is the only vascular bed easily accessible for visualisation and provides a unique opportunity to observe vascular pathology and its effect on neurological tissue. A specific retinopathy has been well described in African children with CM and its severity correlates with outcome. This retinopathy has been less well described in adults. The central mechanism causing malarial retinopathy appears to be microvascular obstruction, which has been demonstrated in affected retinas by fluorescein angiography. The presence in a central nervous system tissue of microvascular obstruction strongly supports the hypothesis that the sequestration of erythrocytes in small blood vessels and consequent obstruction of microcirculatory flow is an important mechanism causing coma and death in CM. Despite advances in the antimalarial treatment of severe malaria, its mortality remains approximately 15-20%. Adjunctive treatment targeting sequestration is a promising strategy to further lower mortality.
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Affiliation(s)
- Richard J Maude
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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44
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The spectrum of retinopathy in adults with Plasmodium falciparum malaria. Trans R Soc Trop Med Hyg 2009; 103:665-71. [PMID: 19344925 PMCID: PMC2700877 DOI: 10.1016/j.trstmh.2009.03.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 03/03/2009] [Accepted: 03/04/2009] [Indexed: 11/29/2022] Open
Abstract
A specific retinopathy has been described in African children with cerebral malaria, but in adults this has not been extensively studied. Since the structure and function of the retinal vasculature greatly resembles the cerebral vasculature, study of retinal changes can reveal insights into the pathophysiology of cerebral malaria. A detailed observational study of malarial retinopathy in Bangladeshi adults was performed using high-definition portable retinal photography. Retinopathy was present in 17/27 adults (63%) with severe malaria and 14/20 adults (70%) with cerebral malaria. Moderate or severe retinopathy was more frequent in cerebral malaria (11/20, 55%) than in uncomplicated malaria (3/15, 20%; P = 0.039), bacterial sepsis (0/5, 0%; P = 0.038) or healthy controls (0/18, 0%; P < 0.001). The spectrum of malarial retinopathy was similar to that previously described in African children, but no vessel discolouration was observed. The severity of retinal whitening correlated with admission venous plasma lactate (P = 0.046), suggesting that retinal ischaemia represents systemic ischaemia. In conclusion, retinal changes related to microvascular obstruction were common in adults with severe falciparum malaria and correlated with disease severity and coma, suggesting that a compromised microcirculation has important pathophysiological significance in severe and cerebral malaria. Portable retinal photography has potential as a valuable tool to study malarial retinopathy.
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Moxon CA, Heyderman RS, Wassmer SC. Dysregulation of coagulation in cerebral malaria. Mol Biochem Parasitol 2009; 166:99-108. [PMID: 19450727 PMCID: PMC2724037 DOI: 10.1016/j.molbiopara.2009.03.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 03/12/2009] [Accepted: 03/13/2009] [Indexed: 12/27/2022]
Abstract
Cerebral malaria (CM) is a life-threatening complication of Plasmodium falciparum infection and represents a major cause of morbidity and mortality worldwide. The nature of the pathogenetic processes leading to the cerebral complications remains poorly understood. It has recently emerged that in addition to their conventional role in the regulation of haemostasis, coagulation factors have an inflammatory role that is pivotal in the pathogenesis of a number of acute and chronic conditions, including CM. This new insight offers important therapeutic potential. This review explores the clinical, histological and molecular evidence for the dysregulation of the coagulation system in CM, looking at possible underlying mechanisms. We discuss areas for future research to improve understanding of CM pathogenesis and for the development of new therapeutic approaches.
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Affiliation(s)
- Christopher Alan Moxon
- Malawi Liverpool Wellcome Trust Clinical Research Programme, College of Medicine, Chichiri, PO Box 30096, Blantyre 3, Malawi.
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Beare NAV, Harding SP, Taylor TE, Lewallen S, Molyneux ME. Perfusion abnormalities in children with cerebral malaria and malarial retinopathy. J Infect Dis 2009; 199:263-71. [PMID: 18999956 DOI: 10.1086/595735] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In patients with cerebral malaria (CM), retinal angiography allows the study of infected central nervous system microvasculature in vivo. We aimed to examine retinal perfusion in children with CM by use of fluorescein angiography to investigate the pathophysiology of CM. METHODS We performed fluorescein angiography on children with CM admitted to Queen Elizabeth Central Hospital, Malawi. We related angiograms to funduscopic findings. RESULTS Fluorescein angiography was performed for 34 patients with CM, and impaired perfusion was identified in 28 (82%). Areas of capillary nonperfusion (CNP) were seen in 26 patients (76%). Multiple, scattered areas of CNP were typical and topographically matched to retinal whitening. Larger retinal vessels were occluded in 9 patients (26%) who had associated ischemia. These vessels appeared white on ophthalmoscopy. Intravascular abnormalities were seen in 9 patients (26%), including filling defects and mottling of the blood column. Limited fluorescein leakage occurred in 15 patients (44%) and was not related to angiographic intravascular abnormalities or visible vessel discoloration. CONCLUSIONS Impaired perfusion occurs in the retinal microvasculature of most children with CM. This is evidence for hypoxia and ischemia as important components in the pathogenesis of CM. Vessel occlusion and filling defects are likely to be due to sequestration of infected erythrocytes. Interventions which improve perfusion or limit hypoxic injury may be beneficial in CM.
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Affiliation(s)
- Nicholas A V Beare
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom.
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White VA, Lewallen S, Beare NAV, Molyneux ME, Taylor TE. Retinal pathology of pediatric cerebral malaria in Malawi. PLoS One 2009; 4:e4317. [PMID: 19177166 PMCID: PMC2627904 DOI: 10.1371/journal.pone.0004317] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 12/22/2008] [Indexed: 11/19/2022] Open
Abstract
Introduction The causes of coma and death in cerebral malaria remain unknown. Malarial retinopathy has been identified as an important clinical sign in the diagnosis and prognosis of cerebral malaria. As part of a larger autopsy study to determine causes of death in children with coma presenting to hospital in Blantyre, Malawi, who were fully evaluated clinically prior to death, we examined the histopathology of eyes of patients who died and underwent autopsy. Methodology/Principal Findings Children with coma were admitted to the pediatric research ward, classified according to clinical definitions as having cerebral malaria or another cause of coma, evaluated and treated. The eyes were examined by direct and indirect ophthalmoscopy. If a child died and permission was given, a standardized autopsy was carried out. The patient was then assigned an actual cause of death according to the autopsy findings. The eyes were examined pathologically for hemorrhages, cystoid macular edema, parasite sequestration and thrombi. They were stained immunohistochemically for fibrin and CD61 to identify the components of thrombi, β-amyloid precursor protein to detect axonal damage, for fibrinogen to identify vascular leakage and for glial fibrillary acidic protein to detect gliosis. Sixty-four eyes from 64 patients were examined: 35 with cerebral malaria and 29 with comas of other causes. Cerebral malaria was distinguished by sequestration of parasitized erythrocytes, the presence and severity of retinal hemorrhages, the presence of cystoid macular edema, the occurrence and number of fibrin-platelet thrombi, the presence and amount of axonal damage and vascular leakage. Conclusions/Significance We found significant differences in retinal histopathology between patients who died of cerebral malaria and those with other diagnoses. These histopathological findings offer insights into the etiology of malarial retinopathy and provide a pathological basis for recently described retinal capillary non-perfusion in children with malarial retinopathy. Because of the similarities between the retina and the brain it also suggests mechanisms that may contribute to coma and death in cerebral malaria.
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Affiliation(s)
- Valerie A White
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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48
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Smith A, Beare NA, Musumba CO, Lochhead J, Newton CR, Harding SP. New classification of acute papilledema in children with severe malaria. JOURNAL OF PEDIATRIC NEUROLOGY 2009; 7:381-388. [PMID: 23750109 PMCID: PMC3672988 DOI: 10.3233/jpn-2009-0317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Raised intracranial pressure is a feature of cerebral malaria in children living in Africa. We investigated specific clinical optic disc features of papilledema to establish their prognostic significance in this encephalopathy. We developed a classification of acute papilledema and tested it against disease outcome. Kenyan children admitted with severe falciparum malaria (cerebral or impaired consciousness) underwent dilated fundal examination using direct and indirect ophthalmoscopy. Clinical features of the optic disc were systematically recorded and compared to the child's outcome. Poor outcome defined as death or neurological impairment on discharge was used to construct and test a clinical classification of papilledema. Forty-five children were examined (26 cerebral malaria, 17 severe malaria with an impaired conscious level or prostration) of whom seven had a poor outcome (three died, four had residual neurological impairment). Loss of the optic disc cup and marked optic disc elevation were significantly correlated with a poor outcome (P < 0.05). Increasing severity in the proposed classification of acute papilledema was positively correlated with a poor outcome (P < 0.05, chi-square test for trend). Loss of the optic disc cup and marked elevation of the optic disc head appear to be correlated with poor outcome in children with severe malaria whereas the presence of dilated veins suggests a good outcome. The proposed classification of acute papilledema is useful as a prognostic indicator and may be applicable to other encephalopathies with raised intracranial pressure.
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Affiliation(s)
- Amy Smith
- St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Crispin O. Musumba
- Kenya Medical Research Institute (KEMRI), Kilifi District Hospital, Kilifi, Kenya
| | - Jonathan Lochhead
- St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Charles R.J.C. Newton
- Kenya Medical Research Institute (KEMRI), Kilifi District Hospital, Kilifi, Kenya
- Neurosciences Unit, Institute of Child Health, University College London, London, UK
| | - Simon P. Harding
- St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
- Ophthalmology Research Unit, School of Clinical Sciences, University of Liverpool, Liverpool, UK
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Lewallen S, Bronzan RN, Beare NA, Harding SP, Molyneux ME, Taylor TE. Using malarial retinopathy to improve the classification of children with cerebral malaria. Trans R Soc Trop Med Hyg 2008; 102:1089-94. [PMID: 18760435 PMCID: PMC3804549 DOI: 10.1016/j.trstmh.2008.06.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 06/24/2008] [Accepted: 06/24/2008] [Indexed: 11/16/2022] Open
Abstract
The mechanisms leading to death in cerebral malaria (CM) remain unclear. We compared clinical and laboratory data among children with CM, categorized by ocular fundus findings, to elucidate differences that suggest different underlying pathological processes. From 1999-2005, standard examinations, treatment and record keeping were used for children with a clinical diagnosis of CM. Children were divided into ocular subgroups: normal fundus (N), malarial retinopathy (R), or papilloedema alone (P) and appropriate statistical tests were used to compare clinical and laboratory findings among groups. Eight hundred and eighty children who had eye examinations within 6 h of admission were included in the analysis. The groups differed significantly in case-fatality rates: Group P, 44.4% (95% CI 25.3-63.2), Group R, 18.0% (95% CI 15.6-22.3) and Group N, 7.0% (95% CI 4.2-9.8). There were also significant differences among the groups in blood pressure, prevalence of deep breathing, haematocrit, parasite density, platelet concentration and, among survivors, hours taken to recover from coma. Differences among groups suggest that different underlying pathophysiological processes are operating in children with CM defined by existing criteria. Our proposed classification, by improving the specificity of diagnosis, would enhance consistency among different study sites and prove useful in future research studies.
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Affiliation(s)
- Susan Lewallen
- Kilimanjaro Centre for Community Ophthalmology, Tumaini University/KCMC, Moshi, Tanzania.
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50
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Haldar K, Murphy SC, Milner DA, Taylor TE. Malaria: mechanisms of erythrocytic infection and pathological correlates of severe disease. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2008; 2:217-49. [PMID: 18039099 DOI: 10.1146/annurev.pathol.2.010506.091913] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Malaria is an ancient disease that continues to cause enormous human morbidity and mortality. The life cycle of the causative parasite involves multiple tissues in two distinct host organisms, mosquitoes and humans. However, all the clinical symptoms of malaria are a consequence of infection of human erythrocytes. An understanding of the basic mechanisms that govern parasite invasion, remodeling, growth, and reinvasion of erythrocytes and the complex events leading to tissue pathology may yield new diagnostics and treatments for malaria. This approach is revealing a more complete picture of the most serious syndrome associated with this infection-cerebral malaria. We focus on the most recent understanding of the molecular basis of infection, summarize our finding from an ongoing pediatric cerebral malaria autopsy study in Malawi, and integrate these insights to malarial pathology.
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Affiliation(s)
- Kasturi Haldar
- Department of Pathology and Microbiology-Immunology, Northwestern University, Chicago, Illinois 60611, USA.
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