Imported malaria at an inner-city hospital in the United States

A Systematic Review and Meta-Analysis of the Proportion Estimates of Disseminated Intravascular Coagulation (DIC) in Malaria

Disseminated intravascular coagulation (DIC) is a potentially life-threatening condition that causes systemic coagulation to be turned on and coagulation factors to be used up. However, the evidence for DIC in malaria patients is still not clear, and small case series and retrospective studies have shown varying results. This meta-analysis was intended for the evaluation of the evidence of DIC among malaria patients using a meta-analysis approach. The protocol for the systematic review was registered at PROSPERO as CRD42023392194. Studies that investigated DIC in patients with malaria were searched in Ovid, Scopus, Embase, PubMed, and MEDLINE. The pooled proportion with 95% confidence intervals (CI) of DIC among malaria patients was estimated using a random-effects model. A total of 1837 articles were identified, and 38 articles were included in the meta-analysis. The overall proportion of DIC in malaria was 11.6% (95% CI: 8.9%-14.3%, I²: 93.2%, 38 studies). DIC in severe falciparum malaria and fatal malaria was 14.6% (95% CI: 5.0-24.3%, I²: 95.5%, 11 studies) and 82.2% (95% CI: 56.2-100%, I²: 87.3, 4 studies). The estimates of DIC among severe malaria patients who had multi-organ dysfunction with bleeding, cerebral malaria, acute renal failure, and ≥2 complications were 79.6% (95% CI: 67.1-88.2%, one study), 11.9% (95% CI: 7.9-17.6%, one study), 16.7% (95% CI: 10.2-23.3%, ten studies), and 4.8% (95% CI: 1.9-7.7%, nine studies), respectively. The proportion estimates of DIC among the patients with malaria depended on the Plasmodium species, clinical severity, and types of severe complications. The information from this study provided useful information to guide the management of malaria patients. Future studies are needed to investigate the association between Plasmodium infection and DIC and to understand the mechanism of malaria-induced DIC.

Prevalence, anti-malarial chemoprophylaxis and causes of deaths for severe imported malaria: A systematic review and meta-analysis

BACKGROUND

There are limited data regarding prevalence, anti-malarial chemoprophylaxis, and causes of death for severe imported malaria. Thus, we conducted a systematic review and meta-analysis to characterise these variables.

METHODS

We searched studies reporting deaths attributable to severe imported malaria. The following pooled prevalence rates were determined: 1) the pooled prevalence of severe malaria among patients with imported malaria, 2) the pooled prevalence of deaths among patients with severe imported malaria, 3) the pooled prevalence of anti-malarial chemoprophylaxis among patients with severe imported malaria, and 4) the causes of death among patients with severe imported malaria.

RESULTS

The search identified 52 studies that were mainly conducted in Europe (25, 48.1%), North America (16, 30.8%) and Asia (7, 13.5%). The pooled prevalence of severe imported malaria was 12.5% (95% confidence interval [CI] = 10.3%-14.6%, I² = 99.32%, 12393 severe cases/118325 imported cases). The pooled prevalence of deaths attributable to severe imported malaria was 5.1% (95% CI = 4.0%-6.2%, I² = 91.72%, 721 deaths/16310 severe cases). The pooled prevalence of adequate anti-malarial chemoprophylaxis among patients with severe imported malaria was 9.7% (95% CI = 6.5%-13.0%, I² = 89.9%, 203/2049 cases). The most common cause of death was multi-organ failure (12.3%).

CONCLUSION

The results highlighted the need for education and preventative measures for travellers, immigrants, or workers who plan to visit malaria-endemic areas to minimize the risk of severe disease or death.

Rapid Discrimination of Malaria- and Dengue-Infected Patients Sera Using Raman Spectroscopy

Malaria and dengue have overlapping clinical symptoms and are prevalent in the same geographic region (tropical and subtropical), hence precise diagnosis is challenging. The high mortality rate associated with both malaria and dengue could be attributed to "false", "delayed", or "missed" diagnosis. The present study thus aims to stratify malaria and dengue using Raman spectroscopy (RS). In total, 130 human sera were analyzed for model development and double-blinded testing. Principal components linear discriminant analysis (PC-LDA) of acquired RS-spectra could classify malaria and dengue with a minor overlap of 16.7%. Receiver operating characteristic (ROC) analysis of test samples showed sensitivity/specificity of 0.9529 for malaria vs healthy controls (HC) and 0.9584 for dengue vs HC. The Raman findings were complemented by mass spectroscopy (MS)-based metabolite analysis of 8 individuals, each from malaria, dengue, and HC. Several of the metabolites, including amino acids, cell-free DNA, creatinine, and bilirubin, assigned for the predominant RS-bands were also identified by MS and showed similar trends. Our data clearly indicates that RS-based serum analysis using a microprobe has immense potential for early, accurate, and automated detection and discrimination of malaria and dengue, and in the future, it could be extrapolated in field-settings combined with hand-held RS. Further, this approach might be extended to diagnose other closely related infections with similar clinical manifestations.

Economic impact of malaria-related hospitalizations in the United States, 2000-2014

BACKGROUND

Despite its elimination in the early 1950s, about 1700 cases of malaria are reported in the US every year. Few studies have quantified the direct and indirect costs of imported malaria in the US.

METHODS

Disparities in the mean and total hospital days, hospital charges, and hospital costs for malaria-related hospitalizations in the US by demographic, clinical, species, financial, geographic, and institutional characteristics were examined using the 2000-2014 Nationwide Inpatient Sample (NIS). Trends and potential predictors for length of stay and hospital charges and costs were identified using negative binomial regression and linear regression, respectively.

RESULTS

From 2000 to 2014, 22,029 malaria cases resulted in 95,948 hospital days for malaria-related hospitalizations, $176,391,466 in total hospital costs, and $555,435,849 in total charges. Mean charges increased significantly over the study period. Males, Blacks, and patients aged 25-44years accounted for the highest direct and indirect costs. Older age and having severe malaria was associated with a longer length of stay. Older age, severe malaria, HIV infection, and longer lengths of stay were associated with higher charges and costs.

CONCLUSIONS

Malaria resulted in substantial direct and indirect costs in the US. Primary and secondary prevention measures should be prioritized among high-risk groups to reduce the economic burden.

Knowledge gaps in the diagnosis and management of patients with tropical diseases presenting to Canadian emergency departments: are the gaps being met?

OBJECTIVE

We conducted a needs assessment to identify knowledge gaps in the management of tropical diseases by Canadian emergency physicians and identify available, related continuing medical education (CME) resources.

METHODS

A literature review was conducted to summarize challenges in the management of commonly encountered tropical diseases. An anonymous online survey was administered to Canadian emergency physicians using the Canadian Association of Emergency Physicians survey deployment service in July and August 2012. The survey identified self-reported gaps in knowledge and assessed knowledge using case-based vignettes. A list of CME resources was generated from a review of major academic emergency medicine journals, online cases, and conference topics from emergency medicine associations during 2010-2011. Two independent reviewers assessed the relevance of the resources; differences were resolved by consensus.

RESULTS

From 635 citations, 47 articles were selected for full review; the majority (66%) were retrospective chart reviews, few (10.6%) had an emergency medicine focus, and fewer still were Canadian (8.5%). In total, 1,128 surveys were distributed, and 296 (27%) participants were included in the study. Most respondents reported "no" (52.4%) or "some" (45.9%) training in tropical medicine. Most (69.9%) rated their comfort in managing patients with tropical diseases as "low." Few (11.1%) respondents reported a tropical disease being misdiagnosed or mismanaged; 44.1% indicated malaria. The perceived need for further training was high (76.7%). Conference workshops were the most highly requested CME modality, followed by case studies and podcasts. Correct answers to case vignettes ranged from 30.7 to 58.4%. Although 2,038 CME titles were extracted from extensive searches, only 6 were deemed relevant.

CONCLUSIONS

Most Canadian emergency physicians have had minimal training in tropical diseases, reported a low comfort level in their management, and identified a high need for CME opportunities, which are lacking.

Ligation of Glycophorin A Generates Reactive Oxygen Species Leading to Decreased Red Blood Cell Function

Acute, inflammatory conditions associated with dysregulated complement activation are characterized by significant increases in blood concentration of reactive oxygen species (ROS) and ATP. The mechanisms by which these molecules arise are not fully understood. In this study, using luminometric- and fluorescence-based methods, we show that ligation of glycophorin A (GPA) on human red blood cells (RBCs) results in a 2.1-fold, NADPH-oxidase-dependent increase in intracellular ROS that, in turn, trigger multiple downstream cascades leading to caspase-3 activation, ATP release, and increased band 3 phosphorylation. Functionally, using 2D microchannels to assess membrane deformability, GPS-ligated RBCs travel 33% slower than control RBCs, and lipid mobility was hindered by 10% using fluorescence recovery after photobleaching (FRAP). These outcomes were preventable by pretreating RBCs with cell-permeable ROS scavenger glutathione monoethyl ester (GSH-ME). Our results obtained in vitro using anti-GPA antibodies were validated using complement-altered RBCs isolated from control and septic patients. Our results suggest that during inflammatory conditions, circulating RBCs significantly contribute to capillary flow dysfunctions, and constitute an important but overlooked source of intravascular ROS and ATP, both critical mediators responsible for endothelial cell activation, microcirculation impairment, platelet activation, as well as long-term dysregulated adaptive and innate immune responses.

Acute kidney injury in imported Plasmodium falciparum malaria

BACKGROUND

Acute kidney injury (AKI) is a known complication of malaria, and is reported to occur in up to 40% of adult patients with a severe Plasmodium falciparum infection in endemic regions. To gain insight in the incidence and risk factors of AKI in imported P. falciparum malaria, a retrospective analysis was performed on a large cohort of mostly non-immune patients with imported P. falciparum malaria. Aiming to include not only severe but also milder forms of renal failure, the KDIGO criteria were used to define AKI.

METHODS

Clinical and laboratory data from 485 consecutive cases of imported P. falciparum malaria were extracted from the Rotterdam Malaria Cohort database. Acute kidney injury (AKI) was defined using the KDIGO criteria. Univariate and multivariate logistic regression analyses were used to identify risk factors for AKI.

RESULTS

AKI was seen in 39 (8%) of all patients and in 23 (38%) of the 61 patients with severe malaria. Eight patients eventually needed renal replacement therapy (RRT); seven of them already had AKI at presentation. Higher age, higher leucocyte count and thrombocytopaenia were independently-associated with AKI but their positive predictive values were relatively poor.

CONCLUSION

AKI was found to be a common complication in adults with imported P. falciparum necessitating RRT in only a small minority of patients. The use of the KDIGO staging allows early recognition of a decline in renal function.

Severe falciparum malaria in iran: a very rare case from an endemic region

Introduction:

Malaria is a protozoal disease, transmitted to humans by female Anopheles mosquito bite. Plasmodium falciparum, compared to other kinds of Plasmodium, causes more severe malaria and is associated with a higher mortality rate. Annually, one to three million deaths occur due to malaria, especially by P. falciparum.

Case Presentation:

In this report, we introduce an Iranian patient suffering from P. falciparum. Peripheral blood smear for malaria parasites showed severe infection of P. falciparum, with 75 to 85 percent of red blood cells containing one to five parasites per cell. However, the patient revealed a fast response to treatment and a good prognosis, suggesting a high level of relative immunity in the patient. To confirm this hypothesis, we conducted a comparative study by comparing the rate of clinical response to treatment as well as the level of prognosis of our patient with similar patients from different regions around the world. These included some malaria cases (caused by P. falciparum) chosen from endemic and nonendemic regions, such as Africa, South Europe and Canada.

Discussion:

The findings revealed that generally, patients from endemic regions significantly show a greater response to treatment and also a better prognosis in comparison to the patients from nonendemic regions. These differences can plausibly be attributed to a high level of relative immunity in endemic regions. Consequently, we would strongly support the hypothesis that response to treatment and prognosis of malaria is a matter of patients’ living environment circumstances. In other words, people who live in endemic regions acquire a high relative immunity leading to a greater response to treatment and a better prognosis.

Malaria: a haematological disease

Plasmodium falciparum malaria remains a major cause of mortality throughout the tropical world. Haematological abnormalities are considered a hallmark of malaria, bearing an impact on final outcome and representing indices of prognostic and follow-up value. These include severe anaemia, coagulation disturbances, leukocyte numerical or functional changes and spleen involvement. Anaemia involves red blood cell lysis due to parasite invasion, as well as mechanisms of intravascular haemolysis and decreased erythropoiesis. Exchange or blood transfusion is mainly recommended in the management of these patients. Haemorrhagic complications in severe malaria are relatively rare despite prominent thrombocytopenia and dysfunction in the coagulation pathway. Numerical, as well as functional changes in the white blood cell are less dramatic than other blood cell series, but still, remain a significant index of disease progression and ultimate prognosis. Finally, the role of the spleen in severe malaria is multifactorial. Care and vigilance should be taken against splenic rupture which is fatal and can occur despite appropriate antimalarial prophylaxis and treatment.

[Imported malaria in adults. Clinical, epidemiological and analytical features]

INTRODUCTION

Up to now, the epidemiological and clinical features of imported malaria in Spain have been described in small series from general hospitals. Almost all diagnosis had been made based on symptomatic patients. The aim of this study has been to determine the epidemiological, clinical and laboratorial characteristics of imported malaria in a Reference Unit for Tropical Diseases.

PATIENTS AND METHODS

We performed a cross-sectional, observational and retrospective study. The series consisted of patients diagnosed of malaria who had been attended at the Hospital Carlos III from January 1, 2002 to December 31, 2007.

RESULTS

We identified 484 episodes of malaria, of which 398 cases were included in the analysis. Almost 50% of the patients were natives of endemic areas, while the rest were native-travelers or travelers. Most cases (88-98% according to the group) had not taken malaria chemoprophylaxis correctly when indicated. At the time of diagnosis, 30.4% of patients were asymptomatic and 28.1% of asymptomatic patients had anemia, 19.8% thrombocytopenia, 14% leukopenia, 5% hypocholesterolemia, 5% renal failure and 4.1% hypoglycemia. Low parasitemia was present in 97.5% of asymptomatic individuals compared to 80.5% of the symptomatic patients (P<0.001).

DISCUSSION

Absence of chemoprophylaxis (or poor compliance) is the main reason for malaria in individuals traveling to endemic areas. Malaria must be ruled out in individuals coming from tropical countries with compatible symptoms, and it also should be suspected in certain groups of asymptomatic individuals with abnormal laboratorial parameters.

Imported malaria: an update

Evidence suggests that imported malaria is a diagnostic challenge with initial misdiagnosis rates of 40% or greater. Given that prompt diagnosis and appropriate treatment are the only intervention proven to prevent progression to severe malaria and death, these figures are concerning. The purpose of this clinical review is to provide the most up-to-date and practical information on the diagnosis and treatment of imported malaria for the emergency health care provider. We highlight common pitfalls, errors, and mistakes in arriving at the correct diagnosis. We also emphasize the 3 key aspects to avoid progression to severe disease: rapid diagnosis, prompt initiation of treatment, and appropriate choice of antimalarial treatment.

Pediatric malaria: 8-year case series in Atlanta, Georgia, and review of the literature

BACKGROUND

Although malaria is frequent in travelers, it is often misdiagnosed on initial presentation, especially in children. The objective of this study is to describe epidemiology, clinical and laboratory presentation, and treatment of children with malaria in the United States.

METHODS

We performed a retrospective review of 50 confirmed cases of malaria from two pediatric metropolitan hospitals in Atlanta, GA, from 2000 to 2008.

RESULTS

Malarial smears were performed in 385 unique patients; 50 (12.6%) were positive. American children who had visited family and friends in malaria-endemic countries comprised 62% of our cases. Most cases visited Nigeria or Cameroon; all but three traveled to Africa. Three patients presented 8 to 12 months following travel. Plasmodium falciparum was diagnosed most frequently (72%). Most patients had low-level parasitemia (<1%). Gametocytes were rarely identified. Treatment was primarily with quinine and either doxycycline or clindamycin, and transfusion was rare. All patients responded rapidly to treatment. Although seven (14%) had hyperparasitemia (> 5%), no fatalities or long-term sequelae were seen.

CONCLUSIONS

Malarial diagnosis can be difficult in children because parasitemia is usually below 1%. A high index of suspicion is required in patients who have traveled to Africa.

Determining utility values related to malaria and malaria chemoprophylaxis

BACKGROUND

Chemoprophylaxis for travellers' malaria is problematic. Decision modeling may help determine optimal prevention strategies for travellers' malaria. Such models can fully assess effect of drug use and disease on quality of life, and help travellers make informed values based decisions. Such models require utility values reflecting societal preferences over different health states of relevance. To date, there are no published utility values relating to clinical malaria or chemoprophylaxis adverse events.

METHODS

Utility estimates for health states related to falciparum malaria, sequelae and drug-related adverse events were obtained using a self-administered visual analogue scale in 20 individuals. Utility values for health states related to clinical malaria were obtained from a survey of 11 malaria experts questioned about length of hospital stay or equivalent disability with simple and severe travellers' malaria.

RESULTS

The general public (potential travellers), were more tolerant of taking prophylaxis if associated with no or mild AEs and least tolerant of mild sequelae from malaria and severe drug related events. The rating value reported for taking no prophylaxis was quite variable. Tropical medicine specialists estimated a mean hospital stay 3.23 days (range 0.5-4.5 days) for simple and 6.36 days (range 4.5-7 days) for severe malaria.

CONCLUSIONS

This study provides a benchmark for important utility value estimates for modeling malaria and drug-related outcomes in non-immune travellers.

The persistent problem of malaria: addressing the fundamental causes of a global killer

Despite decades of global eradication and control efforts and explosive global economic development, malaria is the most important vector-borne disease of our day, killing more people today than 40 years ago and affecting millions worldwide, particularly poor residents of tropical regions. Global eradication efforts from the 1950s through the 1980s largely failed, leaving vector and parasite resistance in their wake. The persistence of malaria and the magnitude of its effects call for an action paradigm that links the traditional proximal arenas of intervention with malaria's fundamental causes by addressing the environmental, economic, and political dimensions of risk. We explore the more distal determinants of malaria burden that create underlying vulnerabilities, evaluating malaria risk as a function of socioeconomic context, environmental conditions, global inequality, systems of health care provision, and research. We recommend that future action to combat malaria be directed by a broad-spectrum approach that meaningfully addresses both the proximal and fundamental causes of this disease.

Fever of unknown origin in the returning traveler

The returning traveler with fever presents a diagnostic challenge for the health care provider. When evaluating such a patient, the highest priority should be given to diseases that are potentially fatal or may represent public health threats. A good history is paramount and needs to include destination, time and duration of travel, type of activity, onset of fever in relation to travel, associated comorbidities, and any associated symptoms. Pretravel immunizations and chemoprophylaxis may alter the natural course of disease and should be inquired about specifically. The fever pattern, presence of a rash or eschar, organomegaly, or neurologic findings are helpful physical findings. Laboratory abnormalities are nonspecific but when corroborated with clinical and epidemiologic data may offer a clue to diagnosis.

Imported malaria in Jakarta, Indonesia: passive surveillance of returned travelers and military members postdeployment

BACKGROUND

Autochthonous malaria does not currently occur in Jakarta, the most populous city in Indonesia. Military, forestry, mining, and tourist activities draw Jakarta residents to distant parts of the archipelago with high rates of malaria. Although malaria is a reportable disease in Jakarta, little has been published.

METHODS

We collected demographic and travel information from patients in Jakarta with microscopically confirmed malaria from January 2004 to February 2005, using a standardized data collection form. These results were compared to regional rainfall statistics and transit patterns of Jakarta residents to and from rural areas.

RESULTS

Data from 240 patients were collected. Aceh Province was the travel destination most commonly recorded for military members, while Papua and Bangka Island were the most frequently cited by civilians. Plasmodium falciparum accounted for 53% of cases, of which 15% had detectable gametocytemia. The most common admission diagnoses were malaria (39%), febrile illness not otherwise specified (23%), viral hepatitis (19%), and dengue (11%). The median time from admission to microscopic diagnosis was 2 days for civilian patients and 2.5 days for military patients. The highest number of cases occurred in May, July, and December with the nadir in October.

CONCLUSIONS

The diagnosis of malaria may be overlooked and therefore delayed, in nonendemic areas such as Jakarta. Travel destinations associated with contracting malaria vary significantly for civilian and military populations. The factors affecting the peak months of importation likely include rainfall, holiday transit, military flight availability, and referral center locations.

Problem pathogens: prevention of malaria in travellers

Human infection with Plasmodium spp leading to clinical episodes of malaria probably began very early in the history of humankind and has persistently inflicted disease among human populations. Malaria is currently considered the world's most important parasitic infection. The global impact of malaria is incalculable and appears to be worsening over the past decades. Although most of this burden of disease is carried by developing tropical countries, cases of imported malaria acquired by international travel are increasingly reported. These numbers are growing because of increased travel to malaria-endemic areas and also due to increased risk of transmission in these areas. Indeed, travel has contributed to the global spread of malaria during the history of humankind. Travellers visiting malaria risk areas should use both personal protective measures and chemoprophylaxis. Non-adherence to chemoprophylactic regimens is frequently secondary to drug side-effects. Therefore, a careful risk-benefit analysis on the use of antimalarial prophylaxis should be carried out in every individual travelling to malaria risk areas. Standby malaria self-treatment represents an alternative in some travellers. However, carefully selected and geographically specific antimalarial drug regimens should be recommended to non-immune people travelling to high-risk areas.