1
|
Torres-Fernandez D, Dalsuco J, Bramugy J, Bassat Q, Varo R. Innovative strategies for the surveillance, prevention, and management of pediatric infections applied to low-income settings. Expert Rev Anti Infect Ther 2024; 22:413-422. [PMID: 38739471 DOI: 10.1080/14787210.2024.2354839] [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: 06/09/2023] [Accepted: 05/09/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Infectious diseases still cause a significant burden of morbidity and mortality among children in low- and middle-income countries (LMICs). There are ample opportunities for innovation in surveillance, prevention, and management, with the ultimate goal of improving survival. AREAS COVERED This review discusses the current status in the use and development of innovative strategies for pediatric infectious diseases in LMICs by focusing on surveillance, diagnosis, prevention, and management. Topics covered are: Minimally Invasive Tissue Sampling as a technique to accurately ascertain the cause of death; Genetic Surveillance to trace the pathogen genomic diversity and emergence of resistance; Artificial Intelligence as a multidisciplinary tool; Portable noninvasive imaging methods; and Prognostic Biomarkers to triage and risk stratify pediatric patients. EXPERT OPINION To overcome the specific hurdles in child health for LMICs, some innovative strategies appear at the forefront of research. If the development of these next-generation tools remains focused on accessibility, sustainability and capacity building, reshaping epidemiological surveillance, diagnosis, and treatment in LMICs, can become a reality and result in a significant public health impact. Their integration with existing healthcare infrastructures may revolutionize disease detection and surveillance, and improve child health and survival.
Collapse
Affiliation(s)
- David Torres-Fernandez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Jessica Dalsuco
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Justina Bramugy
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ICREA, Pg. Lluís Companys, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| |
Collapse
|
2
|
Mufumba I, Kazinga C, Namazzi R, Opoka RO, Batte A, Bond C, John CC, Conroy AL. sTREM-1: A Biomarker of Mortality in Severe Malaria Impacted by Acute Kidney Injury. J Infect Dis 2024; 229:936-946. [PMID: 38078677 PMCID: PMC11011168 DOI: 10.1093/infdis/jiad561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 12/07/2023] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Malaria is an important cause of mortality in African children. Identification of biomarkers to identify children at risk of mortality has the potential to improve outcomes. METHODS We evaluated 11 biomarkers of host response in 592 children with severe malaria. The primary outcome was biomarker performance for predicting mortality. Biomarkers were evaluated using receiver operating characteristic (ROC) curve analysis comparing the area under the ROC curve (AUROC). RESULTS Mortality was 7.3% among children in the study with 72% of deaths occurring within 24 hours of admission. Among the candidate biomarkers, soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) had the highest AUROC (0.78 [95% confidence interval, .70-.86]), outperforming several other biomarkers including C-reactive protein and procalcitonin. sTREM-1 was the top-performing biomarker across prespecified subgroups (malaria definition, site, sex, nutritional status, age). Using established cutoffs, we evaluated mortality across sTREM-1 risk zones. Among children with acute kidney injury, 39.9% of children with a critical-risk sTREM-1 result had an indication for dialysis. When evaluated relative to a disease severity score, sTREM-1 improved mortality prediction (difference in AUROC, P = .016). CONCLUSIONS sTREM-1 is a promising biomarker to guide rational allocation of clinical resources and should be integrated into clinical decision support algorithms, particularly when acute kidney injury is suspected.
Collapse
Affiliation(s)
- Ivan Mufumba
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
| | | | - Ruth Namazzi
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
- Department of Pediatrics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert O Opoka
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
- Department of Pediatrics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Anthony Batte
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
- Child Health and Development Center, Makerere University College of Health Sciences, Kampala, Uganda
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine
- Center for Global Health, Indiana University, Indianapolis
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine
- Center for Global Health, Indiana University, Indianapolis
| |
Collapse
|
3
|
Baro B, Bassat Q. sTREM-1 to Risk-Stratify Patients With Malaria: A Functional Crystal Ball to Improve Outcomes and Save Lives. J Infect Dis 2024; 229:923-925. [PMID: 38078563 DOI: 10.1093/infdis/jiad565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 04/13/2024] Open
Affiliation(s)
- Bàrbara Baro
- ISGlobal, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Quique Bassat
- ISGlobal, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona
- CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
4
|
Varo R, Crowley VM, Mucasse H, Sitoe A, Bramugy J, Serghides L, Weckman AM, Erice C, Bila R, Vitorino P, Mucasse C, Valente M, Ajanovic S, Balanza N, Zhong K, Derpsch Y, Gladstone M, Mayor A, Bassat Q, Kain KC. Adjunctive rosiglitazone treatment for severe pediatric malaria: A randomized placebo-controlled trial in Mozambican children. Int J Infect Dis 2024; 139:34-40. [PMID: 38013152 DOI: 10.1016/j.ijid.2023.11.031] [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: 08/03/2023] [Revised: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVES We tested the hypothesis that adjunctive rosiglitazone treatment would reduce levels of circulating angiopoietin-2 (Angpt-2) and improve outcomes of Mozambican children with severe malaria. METHODS A randomized, double-blind, placebo-controlled trial of rosiglitazone vs placebo as adjunctive treatment to artesunate in children with severe malaria was conducted. A 0.045 mg/kg/dose of rosiglitazone or matching placebo were administered, in addition to standard of malaria care, twice a day for 4 days. The primary endpoint was the rate of decline of Angpt-2 over 96 hours. Secondary outcomes included the longitudinal dynamics of angiopoietin-1 (Angpt-1) and the Angpt-2/Angpt-1 ratio over 96 hours, parasite clearance kinetics, clinical outcomes, and safety metrics. RESULTS Overall, 180 children were enrolled; 91 were assigned to rosiglitazone and 89 to placebo. Children who received rosiglitazone had a steeper rate of decline of Angpt-2 over the first 96 hours of hospitalization compared to children who received placebo; however, the trend was not significant (P = 0.28). A similar non-significant trend was observed for Angpt-1 (P = 0.65) and the Angpt-2/Angpt-1 ratio (P = 0.34). All other secondary and safety outcomes were similar between groups (P >0.05). CONCLUSION Adjunctive rosiglitazone at this dosage was safe and well tolerated but did not significantly affect the longitudinal kinetics of circulating Angpt-2.
Collapse
Affiliation(s)
- Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Humberto Mucasse
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Justina Bramugy
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Lena Serghides
- Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Canada; Department of Immunology and Institute of Medical Sciences University of Toronto, Toronto, Canada
| | - Andrea M Weckman
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Clara Erice
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Rubao Bila
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Pio Vitorino
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Campos Mucasse
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Marta Valente
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Sara Ajanovic
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Núria Balanza
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Kathleen Zhong
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Yiovanna Derpsch
- Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom; School of Psychology, University of East Anglia, Norwich, United Kingdom
| | - Melissa Gladstone
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Alfredo Mayor
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Department of Physiologic Sciences, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique; Spanish Consortium for Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Medicine, University of Toronto, Toronto, Canada
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Spanish Consortium for Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Medicine, University of Toronto, Toronto, Canada; ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain; Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada; Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada; Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, Canada
| |
Collapse
|
5
|
Knappett M, Nguyen V, Chaudhry M, Trawin J, Kabakyenga J, Kumbakumba E, Jacob ST, Ansermino JM, Kissoon N, Mugisha NK, Wiens MO. Pediatric post-discharge mortality in resource-poor countries: a systematic review and meta-analysis. EClinicalMedicine 2024; 67:102380. [PMID: 38204490 PMCID: PMC10776442 DOI: 10.1016/j.eclinm.2023.102380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
Background Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness. Methods Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975. Findings Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity. Interpretation Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation. Funding No specific funding was received.
Collapse
Affiliation(s)
- Martina Knappett
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Maryum Chaudhry
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jessica Trawin
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jerome Kabakyenga
- Maternal Newborn & Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Dept of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Dept of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Shevin T. Jacob
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - J. Mark Ansermino
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
- Dept of Pediatrics, BC Children’s Hospital, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
| | | | - Matthew O. Wiens
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
| |
Collapse
|
6
|
Biomarkers of Intestinal Injury and Dysfunction: Adding New Possibilities to Current Methods for Risk Stratification of Children with Malaria Disease. mBio 2022; 13:e0222222. [PMID: 36314796 PMCID: PMC9765273 DOI: 10.1128/mbio.02222-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Malaria remains, in 2022, a major cause of pediatric preventable mortality, with its major burden disproportionately circumscribed to sub-Saharan African countries. Although only ~1 to 2% of malaria cases can be considered severe and potentially life threatening, it is often challenging to identify them so as to prioritize adequate health care and resources. In a recent investigation, M. L. Sarangam, R. Namazzi, D. Datta, C. Bond, et al. (mBio 13:e01325-22, 2022, https://journals.asm.org/doi/10.1128/mbio.01325-22) studied intestinal barrier dysfunction and injury in Ugandan children hospitalized with severe malaria and in healthy community controls. By measuring circulating levels of four different and complementary biomarkers of gut barrier dysfunction and microbial translocation, they demonstrated that intestinal injury is common in pediatric severe malaria (18% of all cases) and is associated with increased mortality, acute kidney injury, acidosis, and endothelial activation. This commentary discusses the prognostic implications of these results, knowledge gaps that remain to be filled, and how findings could be potentially translated into effective interventions to improve outcomes in children with malaria.
Collapse
|
7
|
Foko LPK, Narang G, Tamang S, Hawadak J, Jakhan J, Sharma A, Singh V. The spectrum of clinical biomarkers in severe malaria and new avenues for exploration. Virulence 2022; 13:634-653. [PMID: 36036460 PMCID: PMC9427047 DOI: 10.1080/21505594.2022.2056966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Globally, malaria is a public health concern, with severe malaria (SM) contributing a major share of the disease burden in malaria endemic countries. In this context, identification and validation of SM biomarkers are essential in clinical practice. Some biomarkers (C-reactive protein, angiopoietin 2, angiopoietin-2/1 ratio, platelet count, histidine-rich protein 2) have yielded interesting results in the prognosis of Plasmodium falciparum severe malaria, but for severe P. vivax and P. knowlesi malaria, similar evidence is missing. The validation of these biomarkers is hindered by several factors such as low sample size, paucity of evidence-evaluating studies, suboptimal values of sensitivity/specificity, poor clinical practicality of measurement methods, mixed Plasmodium infections, and good clinical value of the biomarkers for concurrent infections (pneumonia and current COVID-19 pandemic). Most of these biomarkers are non-specific to pathogens as they are related to host response and hence should be regarded as prognostic/predictive biomarkers that complement but do not replace pathogen biomarkers for clinical evaluation of SM patients. This review highlights the importance of research on diagnostic/predictive/therapeutic biomarkers, neglected malaria species, and clinical practicality of measurement methods in future studies. Finally, the importance of omics technologies for faster identification/validation of SM biomarkers is also included.
Collapse
Affiliation(s)
- Loick Pradel Kojom Foko
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Geetika Narang
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Suman Tamang
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Joseph Hawadak
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Jahnvi Jakhan
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Amit Sharma
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India.,Molecular Medicine Group, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Vineeta Singh
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| |
Collapse
|
8
|
McDonald CR, Weckman AM, Richardson E, Hawkes MT, Leligdowicz A, Namasopo S, Opoka RO, Conroy AL, Kain KC. Sex as a determinant of disease severity and clinical outcome in febrile children under five presenting to a regional referral hospital in Uganda. PLoS One 2022; 17:e0276234. [PMID: 36269702 PMCID: PMC9586386 DOI: 10.1371/journal.pone.0276234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 10/03/2022] [Indexed: 11/20/2022] Open
Abstract
Sex and gender are well-established determinants of health in adult and adolescent populations in low resource settings. There are limited data on sex as a determinant of host response to disease and clinical outcome in febrile children in sub-Saharan Africa, where the risk of infection-related mortality is greatest. We examined sex differences and gender biases in health-seeking behavior, clinical care, biological response to infection, or outcome in a prospective observational cohort of febrile children under 5 years of age presenting to a regional referral hospital in Jinja, Uganda. Main outcomes (stratified by sex) were disease severity at presentation measured by clinical and biological parameters, clinical management (e.g., time to see a physician, treatment by diagnosis), and disease outcome (e.g., mortality). Clinical measures of disease severity included Lambaréné Organ Dysfunction Score (LODS), Signs of Inflammation in Children that Kill (SICK), and the Pediatric Early Death Index for Africa (PEDIA). Biological measures of disease severity were assessed using circulating markers of immune and endothelial activation associated with severe and fatal infections. Differences in outcome by sex were analyzed using bivariate analyses with Bonferroni correction for multiple comparisons. In this cohort of febrile patients admitted to hospital (n = 2049), malaria infection was common (59.2%). 15.9% of children presented with severe disease (LODS score ≥ 2). 97 children (4.7%) died, and most deaths (n = 83) occurred within 48 hours of hospital admission. Clinical measures of disease severity at presentation, clinical management, and outcome (e.g., mortality) did not differ by sex in children under five years of age. Host response to infection, as determined by endothelial and inflammatory mediators (e.g., sTREM1, Ang-2) quantified at hospital presentation, did not differ by sex. In this cohort of children under the age of five, sex was not a principal determinant of disease severity at hospital presentation, clinical management, disease outcome, or biological response to infection (p-values not significant for all comparisons, after Bonferroni correction). The results suggest that health seeking behavior by caregivers and clinical care in the hospital setting did not reflect a gender bias in this cohort.
Collapse
Affiliation(s)
- Chloe R. McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Andrea M. Weckman
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Emma Richardson
- Clinical Epidemiology & Biostatistics Department, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Michael T. Hawkes
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada
| | - Aleksandra Leligdowicz
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada,Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Sophie Namasopo
- Department of Paediatrics, Kabale Regional Referral Hospital, Kabale, Uganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kawempe, Kampala, Uganda
| | - Andrea L. Conroy
- Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, Indiana, United States of America
| | - Kevin C. Kain
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada,Toronto General Hospital Research Institute, University Health Network, Toronto, Canada,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada,* E-mail:
| |
Collapse
|
9
|
de Jesus MCS, Barbosa JHR, Menezes RADO, Gomes MDSM, Bomfim LGS, Pimenta TS, Baptista ARDS, Machado RLD, de Moura TR, Storti-Melo LM. Soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and other inflammatory mediators in malaria by Plasmodium vivax during enteroparasites coinfection. PLoS One 2022; 17:e0270007. [PMID: 35749690 PMCID: PMC9232225 DOI: 10.1371/journal.pone.0270007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/01/2022] [Indexed: 11/19/2022] Open
Abstract
Malaria is a major health issue with more than 200 million cases occurring annually. Moreover, in Malaria endemic area are frequently observed Malaria-enteroparasite co-infections associated with the modulation of inflammatory response. In this aspect, biomarkers play an important role in the disease prognosis. This study aimed to evaluate inflammatory mediators in malaria during coinfection with enteroparasites. A subset of serum samples already collected was analyzed and divided into four groups: Malaria (n = 34), Co-infected (n = 116), Enteroparasite (n = 120) and Control (n = 95). The serum levels of sTREM-1 and IL-6 were measured by ELISA. TNF-α, and IL-10 levels were previously carried out by flow cytometry. Higher serum levels of sTREM-1 and IL-6 were showed in malaria patients compared to healthy controls. In co-infected malarial patients sTREM-1 serum levels were similar to control group. Interestingly, co-infected malaria patients showed IL-6 serum levels decreased compared to individuals only infected with P. vivax. However, in Malaria patients and co-infected there was a positive correlation between the IL-6 and IL-10 levels (P < 0.0001). This is the first report of sTREM-1 levels in P. vivax infected. Moreover, the results revealing a divergent effect of co-infection with the increased balance between pro-and anti-inflammatory cytokines and reduced IL-6 levels but increases the anemia occurrence. The results also highlight the potential use of IL-6 as a biomarker for P. vivax and enteroparasites coinfection.
Collapse
Affiliation(s)
- Myrela Conceição Santos de Jesus
- Programa de Pós-Graduação em Microbiologia e Parasitologia Aplicadas, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brasil
| | - José Hugo Romão Barbosa
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brasil
| | | | | | | | - Tamirys Simão Pimenta
- Instituto Evandro Chagas / Secretaria de Vigilância em Saúde / Ministério da Saúde, Ananindeua, Pará, Brasil
| | - Andrea Regina de Souza Baptista
- Programa de Pós-Graduação em Microbiologia e Parasitologia Aplicadas, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brasil
| | - Ricardo Luiz Dantas Machado
- Programa de Pós-Graduação em Microbiologia e Parasitologia Aplicadas, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brasil
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brasil
| | - Tatiana Rodrigues de Moura
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brasil
- Health Sciences Graduate Program, Federal University of Sergipe, São Cristóvão, Brazil
- Departamento de Morfologia, Centro de Ciências Biológicas e da Saúde, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brasil
- * E-mail:
| | - Luciane Moreno Storti-Melo
- Programa de Pós-Graduação em Biologia Parasitária, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brasil
- Departamento de Biologia, Centro de Ciências Biológicas e da Saúde, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brasil
| |
Collapse
|
10
|
Pathophysiology of Acute Kidney Injury in Malaria and Non-Malarial Febrile Illness: A Prospective Cohort Study. Pathogens 2022; 11:pathogens11040436. [PMID: 35456111 PMCID: PMC9031196 DOI: 10.3390/pathogens11040436] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 01/06/2023] Open
Abstract
Acute kidney injury (AKI) is a life-threatening complication. Malaria and sepsis are leading causes of AKI in low-and-middle-income countries, but its etiology and pathogenesis are poorly understood. A prospective observational cohort study was conducted to evaluate pathways of immune and endothelial activation in children hospitalized with an acute febrile illness in Uganda. The relationship between clinical outcome and AKI, defined using the Kidney Disease: Improving Global Outcomes criteria, was investigated. The study included 967 participants (mean age 1.67 years, 44.7% female) with 687 (71.0%) positive for malaria by rapid diagnostic test and 280 (29.1%) children had a non-malarial febrile illness (NMFI). The frequency of AKI was higher in children with NMFI compared to malaria (AKI, 55.0% vs. 46.7%, p = 0.02). However, the frequency of severe AKI (stage 2 or 3 AKI) was comparable (12.1% vs. 10.5%, p = 0.45). Circulating markers of both immune and endothelial activation were associated with severe AKI. Children who had malaria and AKI had increased mortality (no AKI, 0.8% vs. AKI, 4.1%, p = 0.005), while there was no difference in mortality among children with NMFI (no AKI, 4.0% vs. AKI, 4.6%, p = 0.81). AKI is a common complication in children hospitalized with acute infections. Immune and endothelial activation appear to play central roles in the pathogenesis of AKI.
Collapse
|
11
|
Jain V, Thomas T, Basak S, Sharma RK, Singh N. Sequential dysregulated plasma levels of angiopoietins (ANG-2 and ratios of ANG-2/ANG-1) are associated with malaria severity and mortality among hospital admitted cases in South Bastar Region of Chhattisgarh, Central India. Pathog Glob Health 2022; 116:47-58. [PMID: 34308785 PMCID: PMC8812749 DOI: 10.1080/20477724.2021.1953685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Cerebral malaria (CM) is one of the most severe forms of P. falciparum infection, with an associated high case-fatality rate. Angiopoietins (ANG-1 and ANG-2) are important biomarkers of endothelial activation and dysfunction. This study was carried out in Maharani Hospital and associated Medical College, Jagdalpur, CG, Central India from 2010 to 2014. Based on the treatment recovery patterns, cases (n = 65) were classified as mild malaria with rapid recovery (MM-RR), n= 14; non-cerebral severe malaria with moderately fast recovery (NCSM-MFR), n= 9; CM survivors with slow recovery (CMS-SR), n= 36 and deteriorated CM non-survivors (Det-CMNS), n= 6. Plasma levels (pg/ml) of ANG-1 and ANG-2 were measured by ELISA in all the samples at the time of hospital admission and 48 hours of treatment. Levels were also measured in available samples at the third time point (time of discharge for survivors or 72 hours post-treatment in fatal cases). Data analysis was done by appropriate statistical tests using Stata 11.0 and SPSS 25.0 software. At the time of admission, ANG-2 and ratios of ANG-2/ANG-1 significantly distinguished Det-CMNS cases from MM-RR and NCSM-MFR cases with good AUC scores (0.8-0.9). Further, Det-CMNS cases could also be distinguished from MM-RR, NCSM-MFR, and CMS-SR cases by ANG-2 (AUC scores 0.9) and ratios of ANG-2/ANG-1 (AUC: 0.8-0.9) at 48 hours of treatment. Paired analysis of sequential measurement of angiopoietins revealed that compared to admission levels, the ratios of ANG-2/ANG-1 significantly declined 48 hours after treatment in MM-RR (p= 0.041), NCSM-MFR (p= 0.050), and CMS-SR (p= 0.0002) cases but not in cases of Det-CMNS (p= 0.916). In conclusion, plasma levels of ANG-2 and ratios of ANG-2/ANG-1 may serve as good biomarkers to distinguish the malaria severity at the time of hospital admission and recovery patterns upon treatment in Central India.
Collapse
Affiliation(s)
- Vidhan Jain
- Department of Virology and Zoonotic Diseases, ICMR-National Institute of Research in Tribal Health, Jabalpur, MP, India
| | - Trilok Thomas
- Department of Virology and Zoonotic Diseases, ICMR-National Institute of Research in Tribal Health, Jabalpur, MP, India
| | - Sanjay Basak
- Former District Malaria Officer, Maharani Hospital and Associated Medical College Jagdalpur, Chhattisgarh, India
| | - Ravendra Kumar Sharma
- Department of Statistics, ICMR-National Institute of Medical Statistics, ICMR Campus, New Delhi, India
| | - Neeru Singh
- Department of Virology and Zoonotic Diseases, ICMR-National Institute of Research in Tribal Health, Jabalpur, MP, India
| |
Collapse
|
12
|
Decreased parasite burden and altered host response in children with sickle cell anemia and severe anemia with malaria. Blood Adv 2021; 5:4710-4720. [PMID: 34470050 PMCID: PMC8759120 DOI: 10.1182/bloodadvances.2021004704] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/21/2021] [Indexed: 11/20/2022] Open
Abstract
Plasmodium falciparum malaria causes morbidity and mortality in African children with sickle cell anemia (SCA), but comparisons of host responses to P falciparum between children with SCA (homozygous sickle cell disease/hemoglobin SS [HbSS]) and normal hemoglobin genotype/hemoglobin AA (HbAA) are limited. We assessed parasite biomass and plasma markers of inflammation and endothelial activation in children with HbAA (n = 208) or HbSS (n = 22) who presented with severe anemia and P falciparum parasitemia to Mulago Hospital in Kampala, Uganda. Genotyping was performed at study completion. No child had known SCA at enrollment. Children with HbSS did not differ from children with HbAA in peripheral parasite density, but had significantly lower sequestered parasite biomass. Children with HbSS had greater leukocytosis but significantly lower concentrations of several plasma inflammatory cytokines, including tumor necrosis factor α (TNF-α). In contrast, children with HbSS had threefold greater concentrations of angiopoietin-2 (Angpt-2), a marker of endothelial dysregulation associated with mortality in severe malaria. Lower TNF-α concentrations were associated with increased risk of postdischarge mortality or readmission, whereas higher Angpt-2 concentrations were associated with increased risk of recurrent clinical malaria. Children with SCA have decreased parasite sequestration and inflammation but increased endothelial dysregulation during severe anemia with P falciparum parasitemia, which may ameliorate acute infectious complications but predispose to harmful long-term sequelae.
Collapse
|
13
|
Chandna A, Osborn J, Bassat Q, Bell D, Burza S, D'Acremont V, Fernandez-Carballo BL, Kain KC, Mayxay M, Wiens M, Dittrich S. Anticipating the future: prognostic tools as a complementary strategy to improve care for patients with febrile illnesses in resource-limited settings. BMJ Glob Health 2021; 6:bmjgh-2021-006057. [PMID: 34330761 PMCID: PMC8327814 DOI: 10.1136/bmjgh-2021-006057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022] Open
Abstract
In low-income and middle-income countries, most patients with febrile illnesses present to peripheral levels of the health system where diagnostic capacity is very limited. In these contexts, accurate risk stratification can be particularly impactful, helping to guide allocation of scarce resources to ensure timely and tailored care. However, reporting of prognostic research is often imprecise and few prognostic tests or algorithms are translated into clinical practice. Here, we review the often-conflated concepts of prognosis and diagnosis, with a focus on patients with febrile illnesses. Drawing on a recent global stakeholder consultation, we apply these concepts to propose three use-cases for prognostic tools in the management of febrile illnesses in resource-limited settings: (1) guiding referrals from the community to higher-level care; (2) informing resource allocation for patients admitted to hospital and (3) identifying patients who may benefit from closer follow-up post-hospital discharge. We explore the practical implications for new technologies and reflect on the challenges and knowledge gaps that must be addressed before this approach could be incorporated into routine care settings. Our intention is that these use-cases, alongside other recent initiatives, will help to promote a harmonised yet contextualised approach for prognostic research in febrile illness. We argue that this is especially important given the heterogeneous settings in which care is often provided for patients with febrile illnesses living in low-income and middle-income countries.
Collapse
Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia .,Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
| | - Jennifer Osborn
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ICREA, Pg. Lluís Companys 23, Barcelona, Spain.,Pediatrics Department, Hospital Sant Joan de Dé, Universitat de Barcelona, Esplugues, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - David Bell
- Independent Consultant, Issaquah, Washington, USA
| | | | - Valérie D'Acremont
- Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Kevin C Kain
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Mayfong Mayxay
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK.,Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao People's Democratic Republic.,Institute of Research and Education Development (IRED), University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Matthew Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada.,Mbarara University of Science and Technology, Mbarara, Uganda.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.,Walimu, Kampala, Uganda
| | - Sabine Dittrich
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK.,Foundation for Innovative New Diagnostics, Geneva, Switzerland
| |
Collapse
|
14
|
Chandna A, Aderie EM, Ahmad R, Arguni E, Ashley EA, Cope T, Dat VQ, Day NPJ, Dondorp AM, Illanes V, De Jesus J, Jimenez C, Kain K, Suy K, Koshiaris C, Lasry E, Mayxay M, Mondal D, Perera R, Pongvongsa T, Rattanavong S, Rekart M, Richard-Greenblatt M, Shomik M, Souvannasing P, Tallo V, Turner C, Turner P, Waithira N, Watson JA, Yosia M, Burza S, Lubell Y. Prediction of disease severity in young children presenting with acute febrile illness in resource-limited settings: a protocol for a prospective observational study. BMJ Open 2021; 11:e045826. [PMID: 33495264 PMCID: PMC7839891 DOI: 10.1136/bmjopen-2020-045826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In rural and difficult-to-access settings, early and accurate recognition of febrile children at risk of progressing to serious illness could contribute to improved patient outcomes and better resource allocation. This study aims to develop a prognostic clinical prediction tool to assist community healthcare providers identify febrile children who might benefit from referral or admission for facility-based medical care. METHODS AND ANALYSIS This prospective observational study will recruit at least 4900 paediatric inpatients and outpatients under the age of 5 years presenting with an acute febrile illness to seven hospitals in six countries across Asia. A venous blood sample and nasopharyngeal swab is collected from each participant and detailed clinical data recorded at presentation, and each day for the first 48 hours of admission for inpatients. Multianalyte assays are performed at reference laboratories to measure a panel of host biomarkers, as well as targeted aetiological investigations for common bacterial and viral pathogens. Clinical outcome is ascertained on day 2 and day 28.Presenting syndromes, clinical outcomes and aetiology of acute febrile illness will be described and compared across sites. Following the latest guidance in prediction model building, a prognostic clinical prediction model, combining simple clinical features and measurements of host biomarkers, will be derived and geographically externally validated. The performance of the model will be evaluated in specific presenting clinical syndromes and fever aetiologies. ETHICS AND DISSEMINATION The study has received approval from all relevant international, national and institutional ethics committees. Written informed consent is provided by the caretaker of all participants. Results will be shared with local and national stakeholders, and disseminated via peer-reviewed open-access journals and scientific meetings. TRIAL REGISTRATION NUMBER NCT04285021.
Collapse
Affiliation(s)
- Arjun Chandna
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Endashaw M Aderie
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Riris Ahmad
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Eggi Arguni
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Tanya Cope
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Victor Illanes
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Joanne De Jesus
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Carolina Jimenez
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Kevin Kain
- Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Keang Suy
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | | | - Estrella Lasry
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Mayfong Mayxay
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Dinesh Mondal
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | - Rafael Perera
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tiengkham Pongvongsa
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Savannakhet Provincial Health Department, Savannakhet, Lao People's Democratic Republic
| | - Sayaphet Rattanavong
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Michael Rekart
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | | | - Mohammad Shomik
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | | | - Veronica Tallo
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Claudia Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | - Paul Turner
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Naomi Waithira
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - James A Watson
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Mikhael Yosia
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Sakib Burza
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| |
Collapse
|
15
|
Richard-Greenblatt M, Boillat-Blanco N, Zhong K, Mbarack Z, Samaka J, Mlaganile T, Kazimoto T, D'acremont V, Kain KC. Prognostic Accuracy of Soluble Triggering Receptor Expressed on Myeloid Cells (sTREM-1)-based Algorithms in Febrile Adults Presenting to Tanzanian Outpatient Clinics. Clin Infect Dis 2021; 70:1304-1312. [PMID: 31102510 DOI: 10.1093/cid/ciz419] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/17/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The inability to identify individuals with acute fever at risk of death is a barrier to effective triage and management of severe infections, especially in low-resource settings. Since endothelial and immune activation contribute to the pathogenesis of various distinct life-threatening infections, we hypothesized that measuring mediators of these pathways at clinical presentation would identify febrile adults at risk of death. METHODS Plasma concentrations of markers of endothelial (angiopoetin-1/2, soluble fms-like tyrosine kinase-1, soluble vascular cell adhesion molecule-1, soluble intercellular adhesion molecule-1) and immune (soluble triggering receptor expressed on myeloid cells [sTREM-1], interleukin-6, interleukin-8, chitinase-3-like protein-1, soluble tumor necrosis factor receptor-1, procalcitonin [PCT], C-reactive protein [CRP]) activation pathways were determined in consecutive adults with acute fever (≥38°C) at presentation to outpatient clinics in Dar es Salaam, Tanzania. We evaluated the accuracy of these mediators in predicting all-cause mortality and examined whether markers could improve the prognostic accuracy of clinical scoring systems, including the quick sequential organ failure assessment (qSOFA) and Glasgow coma scale (GCS). RESULTS Of 507 febrile adults, 32 died (6.3%) within 28 days of presentation. We found that sTREM-1 was the best prognostic marker for 28-day mortality (area under the receiver operating characteristic [AUROC] 0.87, 95% confidence interval [CI] 0.81-0.92) and was significantly better than CRP (P < .0001) and PCT (P = .0001). The prognostic accuracy of qSOFA and the GCS were significantly enhanced when sTREM-1 was added (0.80 [95% CI 0.76-0.83] to 0.91 [95% CI 0.88-0.94; P < .05] and 0.72 [95% CI 0.63-0.80] to 0.94 [95% CI 0.91-0.97; P < .05], respectively). CONCLUSIONS Measuring sTREM-1 at clinical presentation can identify febrile individuals at risk of all-cause febrile mortality. Adding severity markers such as sTREM-1 to simple clinical scores could improve the recognition and triage of patients with life-threatening infections in resource-limited settings.
Collapse
Affiliation(s)
| | | | - Kathleen Zhong
- Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada
| | - Zainab Mbarack
- Mwananyamala Hospita, Dar es Salaam, United Republic of Tanzanial
| | - Josephine Samaka
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Tarsis Mlaganile
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Thekla Kazimoto
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Valerie D'acremont
- Swiss Tropical and Public Health Institute, Basel.,University Centre of General Medicine and Public Health, Lausanne, Switzerland
| | - Kevin C Kain
- Tropical Disease Unit, Department of Medicine, University of Toronto, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada
| |
Collapse
|
16
|
Ouma BJ, Bangirana P, Ssenkusu JM, Datta D, Opoka RO, Idro R, Kain KC, John CC, Conroy AL. Plasma angiopoietin-2 is associated with age-related deficits in cognitive sub-scales in Ugandan children following severe malaria. Malar J 2021; 20:17. [PMID: 33407493 PMCID: PMC7789657 DOI: 10.1186/s12936-020-03545-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/11/2020] [Indexed: 12/27/2022] Open
Abstract
Background Elevated angiopoietin-2 (Angpt-2) concentrations are associated with worse overall neurocognitive function in severe malaria survivors, but the specific domains affected have not been elucidated. Methods Ugandan children with severe malaria underwent neurocognitive evaluation a week after hospital discharge and at 6, 12 and 24 months follow-up. The relationship between Angpt-2 concentrations and age-adjusted, cognitive sub-scale z-scores over time were evaluated using linear mixed effects models, adjusting for disease severity (coma, acute kidney injury, number of seizures in hospital) and sociodemographic factors (age, gender, height-for-age z-score, socio-economic status, enrichment in the home environment, parental education, and any preschool education of the child). The Mullen Scales of Early Learning was used in children < 5 years and the Kaufman Assessment Battery for Children 2nd edition was used in children ≥ 5 years of age. Angpt-2 levels were measured on admission plasma samples by enzyme-linked immunosorbent assay. Adjustment for multiple comparisons was conducted using the Benjamini–Hochberg Procedure of False Discovery Rate. Results Increased admission Angpt-2 concentration was associated with worse outcomes in all domains (fine and gross motor, visual reception, receptive and expressive language) in children < 5 years of age at the time of severe malaria episode, and worse simultaneous processing and learning in children < 5 years of age at the time of severe malaria who were tested when ≥ 5 years of age. No association was seen between Angpt-2 levels and cognitive outcomes in children ≥ 5 years at the time of severe malaria episode, but numbers of children and testing time points were lower for children ≥ 5 years at the time of severe malaria episode. Conclusion Elevated Angpt-2 concentration in children with severe malaria is associated with worse outcomes in multiple neurocognitive domains. The relationship between Angpt-2 and worse cognition is evident in children < 5 years of age at the time of severe malaria presentation and in selected domains in older years.
Collapse
Affiliation(s)
- Benson J Ouma
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda.,Centre of Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Kevin C Kain
- Department of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA.
| |
Collapse
|
17
|
Bassat Q. The Perks of Prognostic Biomarkers: A Paradigm Shift in the Triage of Sick Febrile Patients. Clin Infect Dis 2020; 70:1313-1315. [PMID: 31102517 DOI: 10.1093/cid/ciz420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/17/2019] [Indexed: 01/12/2023] Open
Affiliation(s)
- Quique Bassat
- Barcelona Institute for Global Health, Hospital Clínic-Universitat de Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,Institució Catalana de Recerca i Estudis Avançats.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Spain
| |
Collapse
|
18
|
Patel H, Dunican C, Cunnington AJ. Predictors of outcome in childhood Plasmodium falciparum malaria. Virulence 2020; 11:199-221. [PMID: 32063099 PMCID: PMC7051137 DOI: 10.1080/21505594.2020.1726570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 12/16/2022] Open
Abstract
Plasmodium falciparum malaria is classified as either uncomplicated or severe, determining clinical management and providing a framework for understanding pathogenesis. Severe malaria in children is defined by the presence of one or more features associated with adverse outcome, but there is wide variation in the predictive value of these features. Here we review the evidence for the usefulness of these features, alone and in combination, to predict death and other adverse outcomes, and we consider the role that molecular biomarkers may play in augmenting this prediction. We also examine whether a more personalized approach to predicting outcome for specific presenting syndromes of severe malaria, particularly cerebral malaria, has the potential to be more accurate. We note a general need for better external validation in studies of outcome predictors and for the demonstration that predictors can be used to guide clinical management in a way that improves survival and long-term health.
Collapse
Affiliation(s)
- Harsita Patel
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, UK
| | - Claire Dunican
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, UK
| | - Aubrey J. Cunnington
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, UK
| |
Collapse
|
19
|
Erice C, Kain KC. New insights into microvascular injury to inform enhanced diagnostics and therapeutics for severe malaria. Virulence 2020; 10:1034-1046. [PMID: 31775570 PMCID: PMC6930010 DOI: 10.1080/21505594.2019.1696621] [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] [Indexed: 12/25/2022] Open
Abstract
Severe malaria (SM) has high mortality and morbidity rates despite treatment with potent antimalarials. Disease onset and outcome is dependent upon both parasite and host factors. Infected erythrocytes bind to host endothelium contributing to microvascular occlusion and dysregulated inflammatory and immune host responses, resulting in endothelial activation and microvascular damage. This review focuses on the mechanisms of host endothelial and microvascular injury. Only a small percentage of malaria infections (≤1%) progress to SM. Early recognition and treatment of SM can improve outcome, but we lack triage tools to identify SM early in the course of infection. Current point-of-care pathogen-based rapid diagnostic tests do not address this critical barrier. Immune and endothelial activation have been implicated in the pathobiology of SM. We hypothesize that measuring circulating mediators of these pathways at first clinical presentation will enable early triage and treatment of SM. Moreover, that host-based interventions that modulate these pathways will stabilize the microvasculature and improve clinical outcome over that of antimalarial therapy alone.
Collapse
Affiliation(s)
- Clara Erice
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Kevin C Kain
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
20
|
Varo R, Erice C, Johnson S, Bassat Q, Kain KC. Clinical trials to assess adjuvant therapeutics for severe malaria. Malar J 2020; 19:268. [PMID: 32709257 PMCID: PMC7382078 DOI: 10.1186/s12936-020-03340-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/17/2020] [Indexed: 01/07/2023] Open
Abstract
Despite potent anti-malarial treatment, mortality rates associated with severe falciparum malaria remain high. To attempt to improve outcome, several trials have assessed a variety of potential adjunctive therapeutics, however none to date has been shown to be beneficial. This may be due, at least partly, to the therapeutics chosen and clinical trial design used. Here, we highlight three themes that could facilitate the choice and evaluation of putative adjuvant interventions for severe malaria, paving the way for their assessment in randomized controlled trials. Most clinical trials of adjunctive therapeutics to date have been underpowered due to the large number of participants required to reach mortality endpoints, rendering these study designs challenging and expensive to conduct. These limitations may be mitigated by the use of risk-stratification of participants and application of surrogate endpoints. Appropriate surrogate endpoints include direct measures of pathways causally involved in the pathobiology of severe and fatal malaria, including markers of host immune and endothelial activation and microcirculatory dysfunction. We propose using circulating markers of these pathways to identify high-risk participants that would be most likely to benefit from adjunctive therapy, and further by adopting these biomarkers as surrogate endpoints; moreover, choosing interventions that target deleterious host immune responses that directly contribute to microcirculatory dysfunction, multi-organ dysfunction and death; and, finally, prioritizing where possible, drugs that act on these pathways that are already approved by the FDA, or other regulators, for other indications, and are known to be safe in target populations, including children. An emerging understanding of the critical role of the host response in severe malaria pathogenesis may facilitate both clinical trial design and the search of effective adjunctive therapeutics.
Collapse
Affiliation(s)
- Rosauro Varo
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Clara Erice
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | | | - Quique Bassat
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique.,ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Kevin C Kain
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada. .,Department of Medicine, Division of Infectious Diseases, Tropical Disease Unit, University of Toronto, Toronto, Canada.
| |
Collapse
|
21
|
Balanza N, Erice C, Ngai M, Varo R, Kain KC, Bassat Q. Host-Based Prognostic Biomarkers to Improve Risk Stratification and Outcome of Febrile Children in Low- and Middle-Income Countries. Front Pediatr 2020; 8:552083. [PMID: 33072673 PMCID: PMC7530621 DOI: 10.3389/fped.2020.552083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Fever is one of the leading causes for pediatric medical consultation and the most common symptom at clinical presentation in low- and middle-income countries (LMICs). Most febrile episodes are due to self-limited infections, but a small proportion of children will develop life-threatening infections. The early recognition of children who have or are progressing to a critical illness among all febrile cases is challenging, and there are currently no objective and quantitative tools to do so. This results in increased morbidity and mortality among children with impending life-threatening infections, whilst contributing to the unnecessary prescription of antibiotics, overwhelming health care facilities, and harm to patients receiving avoidable antimicrobial treatment. Specific fever origin is difficult to ascertain and co-infections in LMICs are common. However, many severe infections share common pathways of host injury irrespective of etiology, including immune and endothelial activation that contribute to the pathobiology of sepsis (i.e., pathogen "agnostic" mechanisms of disease). Importantly, mediators of these pathways are independent markers of disease severity and outcome. We propose that measuring circulating levels of these factors can provide quantitative and objective evidence to: enable early recognition of severe infection; guide patient triage and management; enhance post-discharge risk stratification and follow up; and mitigate potential gender bias in clinical decisions. Here, we review the clinical and biological evidence supporting the clinical utility of host immune and endothelial activation biomarkers as components of novel rapid triage tests, and discuss the challenges and needs for developing and implementing such tools.
Collapse
Affiliation(s)
- Núria Balanza
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Clara Erice
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle Ngai
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Kevin C Kain
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique.,ICREA, Barcelona, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| |
Collapse
|
22
|
Evaluating Immunopathogenic Biomarkers During Severe Malaria Illness as Modifiers of the Neuropsychologic Benefits of Computer Cognitive Games Rehabilitation in Ugandan Children. Pediatr Infect Dis J 2019; 38:840-848. [PMID: 31232898 PMCID: PMC6629482 DOI: 10.1097/inf.0000000000002367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We explored 3 immunopathogenic biomarkers collected during acute malaria illness as potential moderators of gains from a computerized cognitive rehabilitation training (CCRT) intervention. METHOD Von Willebrand Factor (vWF), tumor necrosis factor (TNF) and Regulated on Activation, Normal T Expressed and Secreted (RANTES) were assayed from plasma and cerebral spinal fluid (CSF) of children during acute severe malaria anemia or cerebral malaria. Two years after acute malaria illness, 150 surviving children and 150 nonmalaria community controls (CCs) from their households 6-12 years old entered a 3-arm randomized controlled trial of titrating and nontitrating CCRT against no CCRT. Tests of cognition [Kaufman Assessment Battery for Children (KABC)], Tests of Variables of Attention and Achenbach Child Behavior Checklist (CBCL) were administered before and after 24 CCRT sessions over a 3-month period, and at 1-year follow-up. Differences in outcomes by trial arms and biomarker levels were evaluated using linear mixed effects models. RESULTS Severe malaria survivors with lower levels of vWF, lower CSF levels of TNF and higher levels of plasma and CSF RANTES had better KABC cognitive performance after both titrating and nontitrating CCRT compared with no CCRT. For the CBCL, high plasma RANTES was associated with no benefit from either the titrating and nontitrating CCRT, whereas high TNF plasma was predictive of the benefit for both interventions. These biomarker moderating effects were not evident for CC children. CONCLUSIONS Severe malaria immunopathogenic biomarkers may be related to poorer long-term brain/behavior function as evidenced by diminished benefit from a computerized cognitive rehabilitation intervention.
Collapse
|
23
|
Systemic inflammation is associated with malaria and preterm birth in women living with HIV on antiretrovirals and co-trimoxazole. Sci Rep 2019; 9:6758. [PMID: 31043691 PMCID: PMC6494863 DOI: 10.1038/s41598-019-43191-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/12/2019] [Indexed: 02/06/2023] Open
Abstract
Women living with HIV (WLHIV) have an increased risk of malaria in pregnancy (MiP). It is unclear if MiP in WLHIV causes a systemic inflammatory response and increases the risk of adverse birth outcomes, especially for women receiving antiretroviral therapy (ART) and daily trimethoprim-sulfamethoxazole (TMP/SXT). We analyzed repeated plasma samples in a cohort of malaria-exposed Ugandan WLHIV receiving ART and daily TMP/SXT to examine changes in inflammatory markers across pregnancy and their association with birth outcomes. Concentrations of CHI3L1, CRP, IL-18BP, IL-6, sICAM-1, and sTNFR2 were quantified by ELISA in 1115 plasma samples collected over pregnancy from 326 women. MiP was associated with increased sTNFR2, sICAM-1 and IL-18BP concentrations across pregnancy. Women who delivered preterm had elevated concentrations of sTNFR2 and altered levels of IL-6 during pregnancy. Women with sTNFR2 concentrations in the highest quartile within 6 weeks of delivery had an increased relative risk of preterm birth. Our results indicate that despite daily TMP/SXT, MiP in WLHIV induced a systemic inflammatory response that was associated with an increased risk of preterm birth. These findings highlight the need for additional strategies to protect WLHIV from malaria infection in pregnancy to promote healthy outcomes for mother and child.
Collapse
|
24
|
Leligdowicz A, Richard-Greenblatt M, Wright J, Crowley VM, Kain KC. Endothelial Activation: The Ang/Tie Axis in Sepsis. Front Immunol 2018; 9:838. [PMID: 29740443 PMCID: PMC5928262 DOI: 10.3389/fimmu.2018.00838] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/05/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis, a dysregulated host response to infection that causes life-threatening organ dysfunction, is a highly heterogeneous syndrome with no specific treatment. Although sepsis can be caused by a wide variety of pathogenic organisms, endothelial dysfunction leading to vascular leak is a common mechanism of injury that contributes to the morbidity and mortality associated with the syndrome. Perturbations to the angiopoietin (Ang)/Tie2 axis cause endothelial cell activation and contribute to the pathogenesis of sepsis. In this review, we summarize how the Ang/Tie2 pathway is implicated in sepsis and describe its prognostic as well as therapeutic utility in life-threatening infections.
Collapse
Affiliation(s)
- Aleksandra Leligdowicz
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Melissa Richard-Greenblatt
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Julie Wright
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Valerie M Crowley
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| |
Collapse
|
25
|
Conroy AL, Hawkes MT, Elphinstone R, Opoka RO, Namasopo S, Miller C, John CC, Kain KC. Chitinase-3-like 1 is a biomarker of acute kidney injury and mortality in paediatric severe malaria. Malar J 2018; 17:82. [PMID: 29448936 PMCID: PMC5815237 DOI: 10.1186/s12936-018-2225-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/07/2018] [Indexed: 12/16/2022] Open
Abstract
Background Chitinase-3-like 1 (CHI3L1) is a glycoprotein elevated in paediatric severe malaria, and an emerging urinary biomarker of acute kidney injury (AKI). Based on the hypothesis that elevated CHI3L1 levels in malaria are associated with disease severity, the relationship between plasma CHI3L1 levels, AKI and mortality was investigated in Ugandan children enrolled in a clinical trial evaluating inhaled nitric oxide (iNO) as an adjunctive therapy for severe malaria. Methods Plasma CHI3L1 levels were measured daily for 4 days in children admitted to hospital with severe malaria and at day 14 follow up. AKI was defined using the Kidney Disease: Improving Global Outcomes consensus criteria. This is a secondary analysis of a randomized double-blind placebo-controlled trial of iNO versus placebo as an adjunctive therapy for severe malaria. Inclusion criteria were: age 1–10 years, and selected criteria for severe malaria. Exclusion criteria included suspected bacterial meningitis, known chronic illness including renal disease, haemoglobinopathy, or severe malnutrition. iNO was administered by non-rebreather mask for up to 72 h at 80 ppm. Results CHI3L1 was elevated in patients with AKI and remained higher over hospitalization (p < 0.0001). Admission CHI3L1 levels were elevated in children who died. By multivariable analysis logCHI3L1 levels were associated with increased risk of in-hospital death (relative risk, 95% CI 4.10, 1.32–12.75, p = 0.015) and all-cause 6 month mortality (3.21, 1.47–6.98, p = 0.003) following correction for iNO and AKI. Treatment with iNO was associated with delayed CHI3L1 recovery with a daily decline of 34% in the placebo group versus 29% in the iNO group (p = 0.012). CHI3L1 levels correlated with markers of inflammation (CRP, sTREM-1, CXCL10), endothelial activation (Ang-2, sICAM-1) and intravascular haemolysis (LDH, haem, haemopexin). Conclusions CHI3L1 is a novel biomarker of malaria-associated AKI and an independent risk factor for mortality that is associated with well-established pathways of severe malaria pathogenesis including inflammation, endothelial activation, and haemolysis. Trial registration Clinicaltrials.gov, NCT01255215. Registered December 7th 2010 Electronic supplementary material The online version of this article (10.1186/s12936-018-2225-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA. .,Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada. .,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Michael T Hawkes
- Division of Pediatric Infectious Diseases, 3-593 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, T6G1C9, Canada
| | - Robyn Elphinstone
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada
| | - Robert O Opoka
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Sophie Namasopo
- Department of Pediatrics, Jinja Regional Referral Hospital, P.O. Box 43, Jinja, Uganda
| | | | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
26
|
Crowley VM, Ayi K, Lu Z, Liby KT, Sporn M, Kain KC. Synthetic oleanane triterpenoids enhance blood brain barrier integrity and improve survival in experimental cerebral malaria. Malar J 2017; 16:463. [PMID: 29137631 PMCID: PMC5686938 DOI: 10.1186/s12936-017-2109-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/04/2017] [Indexed: 12/31/2022] Open
Abstract
Background Cerebral malaria (CM) is a severe complication of Plasmodium falciparum infection associated with high mortality and neurocognitive impairment in survivors. New anti-malarials and host-based adjunctive therapy may improve clinical outcome in CM. Synthetic oleanane triterpenoid (SO) compounds have shown efficacy in the treatment of diseases where inflammation and oxidative stress contribute to pathogenesis. Methods A derivative of the SO 2-cyano-3,12-dioxooleana-1,9-dien-28-oic acid (CDDO), CDDO-ethyl amide (CDDO-EA) was investigated for the treatment of severe malaria in a pre-clinical model. CDDO-EA was evaluated in vivo as a monotherapy as well as adjunctive therapy with parenteral artesunate in the Plasmodium berghei strain ANKA experimental cerebral malaria (ECM) model. Results CDDO-EA alone improved outcome in ECM and, given as adjunctive therapy in combination with artesunate, it significantly improved outcome over artesunate alone (p = 0.009). Improved survival was associated with reduced inflammation, enhanced endothelial stability and blood–brain barrier integrity. Survival was improved even when administered late in the disease course after the onset of neurological symptoms. Conclusions These results indicate that SO are a new class of immunomodulatory drugs and support further studies investigating this class of agents as potential adjunctive therapy for severe malaria.
Collapse
Affiliation(s)
- Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Kodjo Ayi
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Ziyue Lu
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Karen T Liby
- Department of Pharmacology, Dartmouth Medical School, Hanover, NH, USA
| | - Michael Sporn
- Department of Pharmacology, Dartmouth Medical School, Hanover, NH, USA
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada. .,Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, ON, Canada.
| |
Collapse
|