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Royo J, Vianou B, Accrombessi M, Kinkpé E, Ayédadjou L, Dossou-Dagba I, Ladipo Y, Alao MJ, Bertin GI, Cot M, Boumédiène F, Houzé S, Faucher JF, Aubouy A. Elevated plasma interleukin-8 as a risk factor for mortality in children presenting with cerebral malaria. Infect Dis Poverty 2023; 12:8. [PMID: 36759905 PMCID: PMC9909955 DOI: 10.1186/s40249-023-01059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Cerebral malaria (CM) is a neuropathology which remains one of the deadliest forms of malaria among African children. The kinetics of the pathophysiological mechanisms leading to neuroinflammation and the death or survival of patients during CM are still poorly understood. The increasing production of cytokines, chemokines and other actors of the inflammatory and oxidative response by various local actors in response to neuroinflammation plays a major role during CM, participating in both the amplification of the neuroinflammation phenomenon and its resolution. In this study, we aimed to identify risk factors for CM death among specific variables of inflammatory and oxidative responses to improve our understanding of CM pathogenesis. METHODS Children presenting with CM (n = 70) due to P. falciparum infection were included in southern Benin and divided according to the clinical outcome into 50 children who survived and 20 who died. Clinical examination was complemented by fundoscopic examination and extensive blood biochemical analysis associated with molecular diagnosis by multiplex PCR targeting 14 pathogens in the patients' cerebrospinal fluid to rule out coinfections. Luminex technology and enzyme immunoassay kits were used to measure 17 plasma and 7 urinary biomarker levels, respectively. Data were analysed by univariate analysis using the nonparametric Mann‒Whitney U test and Pearson's Chi2 test. Adjusted and multivariate analyses were conducted separately for plasma and urinary biomarkers to identify CM mortality risk factors. RESULTS Univariate analysis revealed higher plasma levels of tumour necrosis factor (TNF), interleukin-1beta (IL-1β), IL-10, IL-8, C-X-C motif chemokine ligand 9 (CXCL9), granzyme B, and angiopoietin-2 and lower urinary levels of prostanglandine E2 metabolite (PGEM) in children who died compared to those who survived CM (Mann-Whitney U-test, P-values between 0.03 and < 0.0001). The multivariate logistic analysis highlighted elevated plasma levels of IL-8 as the main risk factor for death during CM (adjusted odd ratio = 14.2, P-value = 0.002). Values obtained during follow-up at D3 and D30 revealed immune factors associated with disease resolution, including plasma CXCL5, C-C motif chemokine ligand 17 (CCL17), CCL22, and urinary 15-F2t-isoprostane. CONCLUSIONS The main risk factor of death during CM was thus elevated plasma levels of IL-8 at inclusion. Follow-up of patients until D30 revealed marker profiles of disease aggravation and resolution for markers implicated in neutrophil activation, endothelium activation and damage, inflammatory and oxidative response. These results provide important insight into our understanding of CM pathogenesis and clinical outcome and may have important therapeutic implications.
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Affiliation(s)
- Jade Royo
- grid.508721.9UMR152 PHARMADEV, IRD, UPS, Toulouse University, 35 Chemin Des Maraichers, 31400 Toulouse, France
| | - Bertin Vianou
- grid.508721.9UMR152 PHARMADEV, IRD, UPS, Toulouse University, 35 Chemin Des Maraichers, 31400 Toulouse, France ,Clinical Research Institute of Benin (IRCB), Abomey Calavi, Benin
| | - Manfred Accrombessi
- Clinical Research Institute of Benin (IRCB), Abomey Calavi, Benin ,grid.8991.90000 0004 0425 469XFaculty of Infectious and Tropical Diseases, Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Elisée Kinkpé
- Paediatric Department, Calavi Hospital, Calavi, Benin
| | - Linda Ayédadjou
- Paediatric Department, Mother and Child University and Hospital Center (CHU-MEL), Cotonou, Benin
| | | | - Yélé Ladipo
- Paediatric Department, Mother and Child University and Hospital Center (CHU-MEL), Cotonou, Benin
| | - Maroufou Jules Alao
- Paediatric Department, Mother and Child University and Hospital Center (CHU-MEL), Cotonou, Benin
| | | | - Michel Cot
- grid.462420.6UMR261 MERIT, IRD, Paris University, Paris, France
| | - Farid Boumédiène
- grid.9966.00000 0001 2165 4861UMR 1094 EpiMaCT, Inserm, Limoges University Hospital, Limoges University, Limoges, France
| | - Sandrine Houzé
- grid.462420.6UMR261 MERIT, IRD, Paris University, Paris, France ,grid.411119.d0000 0000 8588 831XFrench Malaria Reference Center, APHP, Bichat Hospital, Paris, France ,grid.411119.d0000 0000 8588 831XParasitology Laboratory, APHP, Bichat-Claude-Bernard Hospital, Paris, France
| | - Jean François Faucher
- grid.9966.00000 0001 2165 4861UMR 1094 EpiMaCT, Inserm, Limoges University Hospital, Limoges University, Limoges, France ,grid.411178.a0000 0001 1486 4131Infectious Diseases and Tropical Medicine Department, Limoges University Hospital, Limoges, France
| | - Agnès Aubouy
- UMR152 PHARMADEV, IRD, UPS, Toulouse University, 35 Chemin Des Maraichers, 31400, Toulouse, France. .,Clinical Research Institute of Benin (IRCB), Abomey Calavi, Benin.
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Blatt DB, Hanisch B, Co K, Datta D, Bond C, Opoka RO, Cusick SE, Michelow IC, John CC. Impact of Oxidative Stress on Risk of Death and Readmission in African Children With Severe Malaria: A Prospective Observational Study. J Infect Dis 2022; 226:714-722. [PMID: 35678643 PMCID: PMC9890907 DOI: 10.1093/infdis/jiac234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/07/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We hypothesized that oxidative stress in Ugandan children with severe malaria is associated with mortality. METHODS We evaluated biomarkers of oxidative stress in children with cerebral malaria (CM, n = 77) or severe malarial anemia (SMA, n = 79), who were enrolled in a randomized clinical trial of immediate vs delayed iron therapy, compared with community children (CC, n = 83). Associations between admission biomarkers and risk of death during hospitalization or risk of readmission within 6 months were analyzed. RESULTS Nine children with CM and none with SMA died during hospitalization. Children with CM or SMA had higher levels of heme oxygenase-1 (HO-1) (P < .001) and lower superoxide dismutase (SOD) activity than CC (P < .02). Children with CM had a higher risk of death with increasing HO-1 concentration (odds ratio [OR], 6.07 [95% confidence interval {CI}, 1.17-31.31]; P = .03) but a lower risk of death with increasing SOD activity (OR, 0.02 [95% CI, .001-.70]; P = .03). There were no associations between oxidative stress biomarkers on admission and risk of readmission within 6 months of enrollment. CONCLUSIONS Children with CM or SMA develop oxidative stress in response to severe malaria. Oxidative stress is associated with higher mortality in children with CM but not with SMA. CLINICAL TRIALS REGISTRATION NCT01093989.
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Affiliation(s)
| | | | - Katrina Co
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dibyadyuti Datta
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitlin Bond
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Sarah E Cusick
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ian C Michelow
- Correspondence: Ian C. Michelow, MD, DTM&H, Department of Pediatrics, Division of Infectious Diseases, Connecticut Children’s Medical Center, 85 Seymour St, Hartford, CT 06106, USA ()
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3
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Mala W, Wilairatana P, Samerjai C, Masangkay FR, Kotepui KU, Kotepui M. Prevalence of Signs of Severity Identified in the Thai Population with Malaria: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031196. [PMID: 35162229 PMCID: PMC8834971 DOI: 10.3390/ijerph19031196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 02/05/2023]
Abstract
Understanding the prevalence of signs of severity identified in the Thai population with malaria could aid clinical management and disease control efforts, decrease mortality, and promote malaria elimination in Thailand. This systematic review aimed to collate the evidence regarding signs of severity identified in the Thai population with malaria. MEDLINE, Web of Science, and Scopus were searched for potentially relevant studies. The quality of the included studies was assessed using the Joanna Briggs Institute critical appraisal tools. The pooled prevalence of signs of severity among patients with severe malaria and the pooled proportion of each sign of severity among all signs of severity were estimated using random-effects models. Heterogeneity among included studies was assessed using Cochran’s Q test. A subgroup analysis was performed to evaluate whether differences in pooled estimates between different study sites. Publication bias was assessed by visualizing funnel plot asymmetry and using Egger’s test. Among 741 studies identified by literature searching, 12 studies of a total of 2900 patients with severe malaria, in 7 Thai hospitals, met the eligibility criteria. Results of meta-analyses showed that the signs of the severity of malaria with the highest prevalence in Thailand were jaundice (54%), hyperparasitemia (47%), impaired consciousness/coma (21%), acidosis (18%), renal impairment (13%), shock (10%), convulsions (9%), severe anemia (8%), pulmonary edema/acute respiratory distress syndrome (ARDS) (8%), hypoglycemia (4%), and bleeding/disseminated intravascular coagulation (DIC) (2%). The signs of the severity of malaria that made up the highest proportion of all signs of severity identified in the Thai population with malaria were hyperparasitemia (33%), jaundice (33%), impaired consciousness/coma (12%), acidosis (9%), renal impairment (7%), severe anemia (6%), convulsions (5%), shock (5%), pulmonary edema/ARDS (3%), bleeding/DIC (1%), and hypoglycemia (1%). The present study revealed the prevalence of signs of severity identified in the Thai population with malaria. Jaundice, hyperparasitemia, and impaired consciousness/coma were the most common signs of severity identified. These results may inform the management of patients with severe malaria and promote malaria-elimination efforts in Thailand.
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Affiliation(s)
- Wanida Mala
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Chutharat Samerjai
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | | | - Kwuntida Uthaisar Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Manas Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
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Vasquez M, Zuniga M, Rodriguez A. Oxidative Stress and Pathogenesis in Malaria. Front Cell Infect Microbiol 2021; 11:768182. [PMID: 34917519 PMCID: PMC8669614 DOI: 10.3389/fcimb.2021.768182] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/16/2021] [Indexed: 02/05/2023] Open
Abstract
Malaria is a highly inflammatory and oxidative disease. The production of reactive oxygen species by host phagocytes is an essential component of the host response to Plasmodium infection. Moreover, host oxidative enzymes, such as xanthine oxidase, are upregulated in malaria patients. Although increased production of reactive oxygen species contributes to the clearance of the parasite, excessive amounts of these free radicals can mediate inflammation and cause extensive damage to host cells and tissues, probably contributing to severe pathologies. Plasmodium has a variety of antioxidant enzymes that allow it to survive amidst this oxidative onslaught. However, parasitic degradation of hemoglobin within the infected red blood cell generates free heme, which is released at the end of the replication cycle, further aggravating the oxidative burden on the host and possibly contributing to the severity of life-threatening malarial complications. Additionally, the highly inflammatory response to malaria contributes to exacerbate the oxidative response. In this review, we discuss host and parasite-derived sources of oxidative stress that may promote severe disease in P. falciparum infection. Therapeutics that restore and maintain oxidative balance in malaria patients may be useful in preventing lethal complications of this disease.
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Affiliation(s)
| | | | - Ana Rodriguez
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY, United States
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Duan H, Zhao S, Xiang J, Ju C, Chen X, Gramaglia I, Yan X. Targeting the CD146/Galectin-9 axis protects the integrity of the blood-brain barrier in experimental cerebral malaria. Cell Mol Immunol 2021; 18:2443-2454. [PMID: 33203936 PMCID: PMC8484550 DOI: 10.1038/s41423-020-00582-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023] Open
Abstract
Cerebral malaria (CM) is a life-threatening diffuse encephalopathy caused by Plasmodium falciparum, in which the destruction of the blood-brain barrier (BBB) is the main cause of death. However, increasing evidence has shown that antimalarial drugs, the current treatment for CM, do little to protect against CM-induced BBB damage. Therefore, a means to alleviate BBB dysfunction would be a promising adjuvant therapy for CM. The adhesion molecule CD146 has been reported to be expressed in both endothelial cells and proinflammatory immune cells and mediates neuroinflammation. Here, we demonstrate that CD146 expressed on BBB endothelial cells but not immune cells is a novel therapeutic target in a mouse model of experimental cerebral malaria (eCM). Endothelial CD146 is upregulated during eCM development and facilitates the sequestration of infected red blood cells (RBCs) and/or proinflammatory lymphocytes in CNS blood vessels, thereby promoting the disruption of BBB integrity. Mechanistic studies showed that the interaction of CD146 and Galectin-9 contributes to the aggregation of infected RBCs and lymphocytes. Deletion of endothelial CD146 or treatment with the anti-CD146 antibody AA98 prevents severe signs of eCM, such as limb paralysis, brain vascular leakage, and death. In addition, AA98 combined with the antiparasitic drug artemether improved the cognition and memory of mice with eCM. Taken together, our findings suggest that endothelial CD146 is a novel and promising target in combination with antiparasitic drugs for future CM therapies.
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Affiliation(s)
- Hongxia Duan
- Key Laboratory of Protein and Peptide Pharmaceutical, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China.
| | - Shuai Zhao
- Key Laboratory of Protein and Peptide Pharmaceutical, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China
| | - Jianquan Xiang
- Key Laboratory of Protein and Peptide Pharmaceutical, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China
- Laboratory of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Chenhui Ju
- Key Laboratory of Protein and Peptide Pharmaceutical, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China
| | - Xuehui Chen
- Key Laboratory of Protein and Peptide Pharmaceutical, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China
| | | | - Xiyun Yan
- Key Laboratory of Protein and Peptide Pharmaceutical, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China.
- Laboratory of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, Sichuan, China.
- Joint Laboratory of Nanozymes in Zhengzhou University, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, China.
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6
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Sinha S, Gautam CS, Sehgal R. L-cysteine whether a nutritional booster or a radical scavenger for Plasmodium. Trop Parasitol 2021; 11:19-24. [PMID: 34195056 PMCID: PMC8213117 DOI: 10.4103/tp.tp_20_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 10/13/2020] [Accepted: 10/24/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Plasmodium falciparum is the most noxious species among other Plasmodium species that cause malaria. Attention is required to understand more about the pathophysiology and parasite biology to obscure this disease. The fact is, very little is known about the nutritional requirement in sense of carbohydrate, lipid, nucleic acid, and amino acid metabolism that regulate the growth of parasite and out of this, studies related to the metabolism of amino acid are exceptionally limited. Out of several amino acids, L-cysteine is essential for the continuous erythrocytic growth of Plasmodium. However, the exact role of L-cysteine in regulating the growth of Plasmodium is unknown. Here, we tried to investigate how does L-cysteine affects the growth of Plasmodium in in vitro culture, and also the study was aimed to find whether there is a synergism with chloroquine on the Plasmodium growth in vitro. Materials and Methods: Parasite inhibition assay based on schizont maturation inhibition following WHO protocol on P. falciparum chloroquine-sensitive strain (MRC-2) was employed to determine IC50 value and drug interaction pattern was shown through fractional inhibitory concentration index. Results: Inhibitory effect of L-cysteine hydrochloride on Plasmodium growth was depicted with IC50 1.152 ± 0.287 μg/mL and the most synergistic pattern of interaction was shown with chloroquine. Conclusions: The present study anticipates two important findings, firstly inconsistent results from previous findings and secondly, synergistic effect with chloroquine suggests its potency that may be used as an add-on therapy along with chloroquine. However, further study is needed to validate the above findings in vivo models.
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Affiliation(s)
- Shweta Sinha
- Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - C S Gautam
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, India
| | - Rakesh Sehgal
- Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Zou Y, Tuo F, Zhang Z, Guo J, Yuan Y, Zhang H, Xu Z, Pan Z, Tang Y, Deng C, Julie N, Wu W, Guo W, Li C, Huang X, Xu Q, Song J, Wang Q. Safety and Efficacy of Adjunctive Therapy With Artesunate in the Treatment of Severe Malaria: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:596697. [PMID: 33343367 PMCID: PMC7748123 DOI: 10.3389/fphar.2020.596697] [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] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/02/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: The purpose of this meta-analysis of longitudinal studies is to determine the safety and efficacy of artesunate combined with other forms of adjunctive therapies for severe malaria. Methods: Following the PRISMA guidelines, we searched multiple databases with the search terms "artesunate" and "adjunctive therapy" and "severe malaria" in July 2020. If the search showed a randomized controlled trial, the study was included in this meta-analysis. The random-effects model was used to calculate the combined incidence rate and relative risk or risk difference. Results: This meta-analysis included nine longitudinal studies with 724 participants. We found that the mortality rates in the artesunate monotherapy group and the artesunate + adjuvant therapy group are similar (RD = -0.02, 95% confidence interval: -0.06-0.02). The incidence of adverse reactions in the artesunate monotherapy group and the artesunate + adjuvant therapy group was also similar. Conclusion: No significant differences in safety and efficacy were observed between the artesunate monotherapy group and the artesunate + adjuvant therapy group. Higher quality and rigorously designed randomized controlled studies are needed to validate our findings.
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Affiliation(s)
- Yuanyuan Zou
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fei Tuo
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiqi Zhang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiawen Guo
- Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yueming Yuan
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China.,Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hongying Zhang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiyong Xu
- Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ziyi Pan
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yexiao Tang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Changsheng Deng
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nadia Julie
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wanting Wu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenfeng Guo
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Changqing Li
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xinan Huang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qin Xu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianping Song
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qi Wang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
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8
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Schiess N, Villabona-Rueda A, Cottier KE, Huether K, Chipeta J, Stins MF. Pathophysiology and neurologic sequelae of cerebral malaria. Malar J 2020; 19:266. [PMID: 32703204 PMCID: PMC7376930 DOI: 10.1186/s12936-020-03336-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 07/13/2020] [Indexed: 12/14/2022] Open
Abstract
Cerebral malaria (CM), results from Plasmodium falciparum infection, and has a high mortality rate. CM survivors can retain life-long post CM sequelae, including seizures and neurocognitive deficits profoundly affecting their quality of life. As the Plasmodium parasite does not enter the brain, but resides inside erythrocytes and are confined to the lumen of the brain's vasculature, the neuropathogenesis leading to these neurologic sequelae is unclear and under-investigated. Interestingly, postmortem CM pathology differs in brain regions, such as the appearance of haemorragic punctae in white versus gray matter. Various host and parasite factors contribute to the risk of CM, including exposure at a young age, parasite- and host-related genetics, parasite sequestration and the extent of host inflammatory responses. Thus far, several proposed adjunctive treatments have not been successful in the treatment of CM but are highly needed. The region-specific CM neuro-pathogenesis leading to neurologic sequelae is intriguing, but not sufficiently addressed in research. More attention to this may lead to the development of effective adjunctive treatments to address CM neurologic sequelae.
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Affiliation(s)
- Nicoline Schiess
- Department of Neurology, Johns Hopkins School of Medicine, 600 N. Wolfe St., Meyer 6-113, Baltimore, MD, 21287, USA
| | - Andres Villabona-Rueda
- Malaria Research Institute, Dept Molecular Microbiology Immunology, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
| | - Karissa E Cottier
- Malaria Research Institute, Dept Molecular Microbiology Immunology, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.,BioIVT, 1450 South Rolling Road, Baltimore, MD, USA
| | | | - James Chipeta
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Monique F Stins
- Malaria Research Institute, Dept Molecular Microbiology Immunology, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
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L-arginine supplementation and thromboxane synthase inhibition increases cerebral blood flow in experimental cerebral malaria. Sci Rep 2019; 9:13621. [PMID: 31541129 PMCID: PMC6754365 DOI: 10.1038/s41598-019-49855-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 12/14/2022] Open
Abstract
Cerebral malaria pathogenesis involves vascular dysfunction with low nitric oxide (NO) bioavailability, vasoconstriction and impaired vasodilation, leading to ischemia, tissue hypoxia and ultimately death. Cerebral blood flow (CBF) involves NO and other pathways, including arachidonic acid (AA)-derived metabolites. Here we show that mice with experimental cerebral malaria (ECM) by P. berghei ANKA showed marked decreases in CBF (as assessed by laser speckle contrast imaging - LSCI) and that administration of L-arginine supplementation (50 mg/kg) and/or of the thromboxane synthase inhibitor Ozagrel (100 mg/kg) induced immediate increases in CBF. L-arginine in combination with artesunate (32 mg/kg) induced immediate reversal of brain ischemia in the short-term (1 hour), but the effect subsided after 3 and 6 hours. Neither L-arginine nor Ozagrel reversed blood brain barrier breakdown. Mice with ECM showed brain levels of selected AA-derived metabolites with a vasoconstrictor profile, with increased levels of 8-isoprostanes, 20-HETE and 14,15-DHET, whereas mice infected with a non-ECM-inducing strain of P. berghei (NK65) showed a vasodilator profile, with normal levels of 20-HETE and 14,15-DHET and increased levels of PGE2. L-arginine is capable of partially reversing cerebral ischemia and AA metabolites may play a role in the cerebrovascular dysfunction in ECM.
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Leopold SJ, Watson JA, Jeeyapant A, Simpson JA, Phu NH, Hien TT, Day NPJ, Dondorp AM, White NJ. Investigating causal pathways in severe falciparum malaria: A pooled retrospective analysis of clinical studies. PLoS Med 2019; 16:e1002858. [PMID: 31442221 PMCID: PMC6707545 DOI: 10.1371/journal.pmed.1002858] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 07/25/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Severe falciparum malaria is a medical emergency characterised by potentially lethal vital organ dysfunction. Patient fatality rates even with parenteral artesunate treatment remain high. Despite considerable research into adjuvant therapies targeting organ and tissue dysfunction, none have shown efficacy apart from renal replacement therapy. Understanding the causal contributions of clinical and laboratory abnormalities to mortality is essential for the design and evaluation of novel therapeutic interventions. METHODS AND FINDINGS We used a structural model causal inference approach to investigate causal relationships between epidemiological, laboratory, and clinical variables in patients with severe falciparum malaria enrolled in clinical trials and their in-hospital mortality. Under this causal model, we analysed records from 9,040 hospitalised children (0-12 years, n = 5,635) and adults (n = 3,405, 12-87 years) with severe falciparum malaria from 15 countries in Africa and Asia who were studied prospectively over the past 35 years. On admission, patient covariates associated with increased in-hospital mortality were severity of acidosis (odds ratio [OR] 2.10 for a 7-mEq/L increase in base deficit [95% CI 1.93-2.28]), renal impairment (OR 1.71 for a 2-fold increase in blood urea nitrogen [95% CI 1.58, 1.86]), coma (OR 3.59 [95% CI 3.07-4.21]), seizures (OR 1.40 [95% CI 1.16-1.68]), shock (OR 1.51 [95% CI 1.14-1.99]), and presumed pulmonary oedema (OR 1.58 [95% CI 1.04-2.39]). Lower in-hospital mortality was associated with moderate anaemia (OR 0.87 for a decrease of 10 percentage points in haematocrit [95% CI 0.80-0.95]). Circulating parasite density was not associated with mortality (OR 1.02 for a 6-fold increase [95% CI 0.94-1.11]), so the pathological effects of parasitaemia appear to be mediated entirely by the downstream effects of sequestration. Treatment with an artemisinin derivative decreased mortality compared with quinine (OR 0.64 [95% CI 0.56-0.74]). These estimates were consistent across children and adults (mainly representing African and Asian patients, respectively). Using inverse probability weighting, transfusion was not estimated to be beneficial in children with admission haematocrit values between 15% and 25% (OR 0.99 [95% CI 0.97-1.02]). Except for the effects of artemisinin treatment and transfusion, causal interpretations of these estimates could be biased by unmeasured confounding from severe bacterial sepsis, immunity, and duration of illness. CONCLUSION These data suggest that moderate anaemia is associated with a reduced risk of death in severe falciparum malaria. This is possibly a direct causal association. The severe anaemia threshold criteria for a definition of severe falciparum malaria should be reconsidered.
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Affiliation(s)
- Stije J. Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - James A. Watson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Atthanee Jeeyapant
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nguyen H. Phu
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Tran T. Hien
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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11
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Gramaglia I, Velez J, Chang YS, Caparros-Wanderley W, Combes V, Grau G, Stins MF, van der Heyde HC. Citrulline protects mice from experimental cerebral malaria by ameliorating hypoargininemia, urea cycle changes and vascular leak. PLoS One 2019; 14:e0213428. [PMID: 30849122 PMCID: PMC6407779 DOI: 10.1371/journal.pone.0213428] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 02/21/2019] [Indexed: 12/18/2022] Open
Abstract
Clinical and model studies indicate that low nitric oxide (NO) bioavailability due in part to profound hypoargininemia contributes to cerebral malaria (CM) pathogenesis. Protection against CM pathogenesis may be achieved by altering the diet before infection with Plasmodium falciparum infection (nutraceutical) or by administering adjunctive therapy that decreases CM mortality (adjunctive therapy). This hypothesis was tested by administering citrulline or arginine in experimental CM (eCM). We report that citrulline injected as prophylaxis immediately post infection (PI) protected virtually all mice by ameliorating (i) hypoargininemia, (ii) urea cycle impairment, and (iii) disruption of blood brain barrier. Citrulline prophylaxis inhibited plasma arginase activity. Parasitemia was similar in citrulline- and vehicle control-groups, indicating that protection from pathogenesis was not due to decreased parasitemia. Both citrulline and arginine administered from day 1 PI in the drinking water significantly protected mice from eCM. These observations collectively indicate that increasing dietary citrulline or arginine decreases eCM mortality. Citrulline injected ip on day 4 PI with quinine-injected ip on day 6 PI partially protected mice from eCM; citrulline plus scavenging of superoxide with pegylated superoxide dismutase and pegylated catalase protected all recipients from eCM. These findings indicate that ameliorating hypoargininemia with citrulline plus superoxide scavenging decreases eCM mortality.
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Affiliation(s)
- Irene Gramaglia
- La Jolla Infectious Disease Institute, San Diego, CA, United States of America
- * E-mail:
| | - Joyce Velez
- La Jolla Infectious Disease Institute, San Diego, CA, United States of America
| | | | | | - Valery Combes
- La Jolla Infectious Disease Institute, San Diego, CA, United States of America
- School of Life Sciences, University of Technology Sydney, Sydney, Australia
| | - Georges Grau
- La Jolla Infectious Disease Institute, San Diego, CA, United States of America
- Vascular Immunology Unit, University of Sydney, Sydney, Australia
| | - Monique F. Stins
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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12
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Cooper DJ, Plewes K, Grigg MJ, Rajahram GS, Piera KA, William T, Chatfield MD, Yeo TW, Dondorp AM, Anstey NM, Barber BE. The effect of regularly dosed paracetamol versus no paracetamol on renal function in Plasmodium knowlesi malaria (PACKNOW): study protocol for a randomised controlled trial. Trials 2018; 19:250. [PMID: 29690924 PMCID: PMC5926539 DOI: 10.1186/s13063-018-2600-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/19/2018] [Indexed: 11/27/2022] Open
Abstract
Background Plasmodium knowlesi is the most common cause of human malaria in Malaysia. Acute kidney injury (AKI) is a frequent complication. AKI of any cause can have long-term consequences, including increased risk of chronic kidney disease, adverse cardiovascular events and increased mortality. Additional management strategies are therefore needed to reduce the frequency and severity of AKI in malaria. In falciparum malaria, cell-free haemoglobin (CFHb)-mediated oxidative damage contributes to AKI. The inexpensive and widely available drug paracetamol inhibits CFHb-induced lipid peroxidation via reduction of ferryl haem to the less toxic Fe3+ state, and has been shown to reduce oxidative damage and improve renal function in patients with sepsis complicated by haemolysis as well as in falciparum malaria. This study aims to assess the ability of regularly dosed paracetamol to reduce the incidence and severity of AKI in knowlesi malaria by attenuating haemolysis-induced oxidative damage. Methods PACKNOW is a two-arm, open-label randomised controlled trial of adjunctive paracetamol versus no paracetamol in patients aged ≥ 5 years with knowlesi malaria, conducted over a 2-year period at four hospital sites in Sabah, Malaysia. The primary endpoint of change in creatinine from enrolment to 72 h will be evaluated by analysis of covariance (ANCOVA) using enrolment creatinine as a covariate. Secondary endpoints include longitudinal changes in markers of oxidative stress (plasma F2-isoprostanes and isofurans) and markers of endothelial activation/Weibel–Palade body release (angiopoietin-2, von Willebrand Factor, P-selectin, osteoprotegerin) over 72 h, as well as blood and urine biomarkers of AKI. This study will be powered to detect a difference between the two treatment arms in a clinically relevant population including adults and children with knowlesi malaria of any severity. Discussion Paracetamol is widely available and has an excellent safety profile; if a renoprotective effect is demonstrated, this trial will support the administration of regularly dosed paracetamol to all patients with knowlesi malaria. The secondary outcomes in this study will provide further insights into the pathophysiology of haemolysis-induced oxidative damage and acute kidney injury in knowlesi malaria and other haemolytic diseases. Trial registration Clinicaltrials.gov, NCT03056391. Registered on 12 October 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2600-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel J Cooper
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia. .,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Matthew J Grigg
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Giri S Rajahram
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Infectious Diseases Unit, Clinical Research Centre, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia.,Sabah Department of Health, Kota Kinabalu, Sabah, Malaysia
| | - Kim A Piera
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Jesselton Medical Centre, Kota Kinabalu, Sabah, Malaysia
| | - Mark D Chatfield
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Queensland Institute of Medical Research, Brisbane, Australia
| | - Tsin Wen Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Bridget E Barber
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Queensland Institute of Medical Research, Brisbane, Australia
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13
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Sriboonvorakul N, Ghose A, Hassan MMU, Hossain MA, Faiz MA, Pukrittayakamee S, Chotivanich K, Sukthana Y, Leopold SJ, Plewes K, Day NPJ, White NJ, Tarning J, Dondorp AM. Acidosis and acute kidney injury in severe malaria. Malar J 2018; 17:128. [PMID: 29566677 PMCID: PMC5865348 DOI: 10.1186/s12936-018-2274-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/14/2018] [Indexed: 12/31/2022] Open
Abstract
Background In severe falciparum malaria metabolic acidosis and acute kidney injury (AKI) are independent predictors of a fatal outcome in all age groups. The relationship between plasma acids, urine acids and renal function was investigated in adult patients with acute falciparum malaria. Methods Plasma and urinary acids which previously showed increased concentrations in proportion to disease severity in patients with severe falciparum malaria were quantified. Patients with uncomplicated malaria, sepsis and healthy volunteers served as comparator groups. Multiple regression and multivariate analysis were used to assess the relationship between organic acid concentrations and clinical syndromes, in particular AKI. Results Patients with severe malaria (n = 90), uncomplicated malaria (n = 94), non-malaria sepsis (n = 19), and healthy volunteers (n = 61) were included. Univariate analysis showed that both plasma and creatinine-adjusted urine concentrations of p-hydroxyphenyllactic acid (pHPLA) were higher in severe malaria patients with AKI (p < 0.001). Multiple regression analysis, including plasma or creatinine-adjusted urinary acids, and PfHRP2 as parasite biomass marker as independent variables, showed that pHPLA was independently associated with plasma creatinine (β = 0.827) and urine creatinine (β = 0.226). Principal component analysis, including four plasma acids and seven urinary acids separated a group of patients with AKI, which was mainly driven by pHPLA concentrations. Conclusions Both plasma and urine concentrations of pHPLA closely correlate with AKI in patients with severe falciparum malaria. Further studies will need to assess the potential nephrotoxic properties of pHPLA. Electronic supplementary material The online version of this article (10.1186/s12936-018-2274-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Natthida Sriboonvorakul
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | | | - M Abul Faiz
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Sasithon Pukrittayakamee
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kesinee Chotivanich
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yaowalark Sukthana
- Department of Protozoology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stije J Leopold
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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14
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Varo R, Crowley VM, Sitoe A, Madrid L, Serghides L, Kain KC, Bassat Q. Adjunctive therapy for severe malaria: a review and critical appraisal. Malar J 2018; 17:47. [PMID: 29361945 PMCID: PMC5781278 DOI: 10.1186/s12936-018-2195-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite recent efforts and successes in reducing the malaria burden globally, this infection still accounts for an estimated 212 million clinical cases, 2 million severe malaria cases, and approximately 429,000 deaths annually. Even with the routine use of effective anti-malarial drugs, the case fatality rate for severe malaria remains unacceptably high, with cerebral malaria being one of the most life-threatening complications. Up to one-third of cerebral malaria survivors are left with long-term cognitive and neurological deficits. From a population point of view, the decrease of malaria transmission may jeopardize the development of naturally acquired immunity against the infection, leading to fewer total cases, but potentially an increase in severe cases. The pathophysiology of severe and cerebral malaria is not completely understood, but both parasite and host determinants contribute to its onset and outcomes. Adjunctive therapy, based on modulating the host response to infection, could help to improve the outcomes achieved with specific anti-malarial therapy. RESULTS AND CONCLUSIONS In the last decades, several interventions targeting different pathways have been tested. However, none of these strategies have demonstrated clear beneficial effects, and some have shown deleterious outcomes. This review aims to summarize evidence from clinical trials testing different adjunctive therapy for severe and cerebral malaria in humans. It also highlights some preclinical studies which have evaluated novel strategies and other candidate therapeutics that may be evaluated in future clinical trials.
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Affiliation(s)
- Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
| | - Lola Madrid
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain
| | - 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
| | - 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
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.
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15
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Plewes K, Kingston HWF, Ghose A, Maude RJ, Herdman MT, Leopold SJ, Ishioka H, Hasan MMU, Haider MS, Alam S, Piera KA, Charunwatthana P, Silamut K, Yeo TW, Faiz MA, Lee SJ, Mukaka M, Turner GDH, Anstey NM, Jackson Roberts L, White NJ, Day NPJ, Hossain MA, Dondorp AM. Cell-free hemoglobin mediated oxidative stress is associated with acute kidney injury and renal replacement therapy in severe falciparum malaria: an observational study. BMC Infect Dis 2017; 17:313. [PMID: 28449641 PMCID: PMC5408414 DOI: 10.1186/s12879-017-2373-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/30/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intravascular hemolysis is an intrinsic feature of severe malaria pathophysiology but the pathogenic role of cell-free hemoglobin-mediated oxidative stress in severe malaria associated acute kidney injury (AKI) is unknown. METHODS As part of a prospective observational study, enrolment plasma cell-free hemoglobin (CFH), lipid peroxidation markers (F2-isoprostanes (F2-IsoPs) and isofurans (IsoFs)), red cell deformability, and serum creatinine were quantified in Bangladeshi patients with severe falciparum malaria (n = 107), uncomplicated malaria (n = 80) and sepsis (n = 28). The relationships between these indices and kidney function and clinical outcomes were examined. RESULTS AKI was diagnosed at enrolment in 58% (62/107) of consecutive patients with severe malaria, defined by an increase in creatinine ≥1.5 times expected baseline. Severe malaria patients with AKI had significantly higher plasma cell-free hemoglobin (geometric mean CFH: 8.8 μM; 95% CI, 6.2-12.3 μM), F2-isoprostane (56.7 pg/ml; 95% CI, 45.3-71.0 pg/ml) and isofuran (109.2 pg/ml; 95% CI, 85.1-140.1 pg/ml) concentrations on enrolment compared to those without AKI (CFH: 5.1 μM; 95% CI, 4.0-6.6 μM; P = 0.018; F2-IsoPs: 27.8 pg/ml; 95% CI, 23.7-32.7 pg/ml; P < 0.001; IsoFs: 41.7 pg/ml; 95% CI, 30.2-57.6 pg/ml; P < 0.001). Cell-free hemoglobin correlated with markers of hemolysis, parasite burden (P. falciparum histidine rich protein 2 (PfHRP2)), and F2-IsoPs. Plasma F2-IsoPs and IsoFs inversely correlated with pH, positively correlated with creatinine, PfHRP2 and fractional excretion of sodium, and were higher in patients later requiring hemodialysis. Plasma F2-IsoP concentrations also inversely correlated with red cell deformability and were higher in fatal cases. Mixed effects modeling including an interaction term for CFH and time showed that F2-IsoPs, IsoFs, PfHRP2, CFH, and red cell rigidity were independently associated with increasing creatinine over 72 h. Multivariable logistic regression showed that admission F2-IsoPs, IsoFs and red cell deformability were associated with the need for subsequent hemodialysis. CONCLUSIONS Cell-free hemoglobin and lipid peroxidation are associated with acute kidney injury and disease severity in falciparum malaria, suggesting a pathophysiological role in renal tubular injury. Evaluation of adjunctive therapies targeting cell-free hemoglobin-mediated oxidative stress is warranted.
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Affiliation(s)
- Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Medicine and Vancouver Coastal Health, University of British Columbia Clinical Investigator program, Vancouver, Canada
| | - Hugh W F Kingston
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M Trent Herdman
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stije J Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Haruhiko Ishioka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Md Mahtab Uddin Hasan
- Department of Medicine, Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | - Md Shafiul Haider
- Department of Nephrology, Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | - Shamsul Alam
- Department of Anesthesiology, Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | - Kim A Piera
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Prakaykaew Charunwatthana
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kamolrat Silamut
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tsin W Yeo
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | | | - Sue J Lee
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gareth D H Turner
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas M Anstey
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - L Jackson Roberts
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Md Amir Hossain
- Department of Medicine, Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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16
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Aggarwal HK, Jain D, Rao A, Kalra R. Role of Coma Acidosis Malaria Score in Patients with Severe Malaria among Indian Population: a Tertiary Care Center Experience. Eurasian J Med 2017; 49:30-35. [PMID: 28416929 DOI: 10.5152/eurasianjmed.2017.16069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Malaria is a prime public health threat in developing countries like India. There is an unmet need of a simplified methodology for the purpose of triage and provision of intensive care to the severely infected patients in these areas. MATERIALS AND METHODS We did a prospective study in patients (n=60) admitted with severe malaria in a single tertiary care center in the state of Haryana, India. We assessed the role of coma acidosis malaria (CAM) score in these patients when predicting mortality and morbidity events. Stepwise logistic regression analysis was applied to identify patients requiring intensive care based on the CAM score, and the prediction value of the scoring system was assessed among these patients. RESULTS Cerebral malaria (measured using the Glasgow coma scale) and acidosis (base deficit) were the major determinants of the CAM score. Serum bicarbonate levels and respiratory rates were assessed as the proxy markers of the base deficit as it is not always available. Morbidity increased steadily as the CAM scores increased. Sensitivity and negative predictive value of 100% depicted that the scoring system was able to identify patients who needed intensive care and accurately exclude the patients who could be conservatively managed in the ward. Positive predictive values of 73.9%, 68%, and 80.9% indicated that CAM, bicarbonate-based CAM (BCAM), and respiratory rate-based CAM (RCAM) scores, respectively, could precisely predict the morbidity and mortality events among patients with CAM scores ≥2. CONCLUSION CAM scores have precise predictive values in assessing patients with severe malaria. The scoring system helps in accurate and systemic triage of patients, irrespective of species, and directs the treating physicians toward vigilant treatment and emergency care.
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Affiliation(s)
- Hari Krishan Aggarwal
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Deepak Jain
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Avinash Rao
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Rajinish Kalra
- Department of Pathology, Pt B.D. Sharma University of Health Sciences, Haryana, India
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17
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Wezena CA, Krafczyk J, Staudacher V, Deponte M. Growth inhibitory effects of standard pro- and antioxidants on the human malaria parasite Plasmodium falciparum. Exp Parasitol 2017; 180:64-70. [PMID: 28242353 DOI: 10.1016/j.exppara.2017.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/10/2017] [Accepted: 02/23/2017] [Indexed: 01/13/2023]
Abstract
The redox metabolism of the malaria parasite Plasmodium falciparum and its human host has been suggested to play a central role for parasite survival and clearance. A common approach to test hypotheses in redox research is to challenge or rescue cells with pro- and antioxidants. However, quantitative data on the susceptibility of infected erythrocytes towards standard redox agents is surprisingly scarce. Here we determined the IC50 values of P. falciparum strains 3D7 and Dd2 for a set of redox agents using a SYBR green-based growth assay. Parasite killing in this assay required extremely high concentrations of hydrogen peroxide with a millimolar IC50 value, whereas IC50 values for tert-butyl hydroperoxide and diamide were between 67 and 121 μM. Thus, in contrast to tert-butyl hydroperoxide and the disulfide-inducing agent diamide, the host-parasite unit appears to be very robust against challenges with hydrogen peroxide with implications for host defense mechanisms. N-acetylcysteine, ascorbate, and dithiothreitol also had antiproliferative instead of growth-promoting effects with IC50 values around 12, 3 and 0.4 mM, respectively. So-called antioxidants can therefore also inhibit parasite growth with implications for clinical trials and studies on 'oxidative stress'. Furthermore, the addition of reductants to parasite cultures resulted in the gelation of albumin, the formation of methemoglobin and hemolysis. These effects can alter the fluorescence in SYBR green assays and have to be taken into account for the determination of IC50 values. In summary, standard oxidants and reductants both inhibit the growth of P. falciparum with IC50 values differing by three orders of magnitude.
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Affiliation(s)
- Cletus A Wezena
- Department of Parasitology, Ruprecht-Karls University, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany
| | - Johannes Krafczyk
- Department of Parasitology, Ruprecht-Karls University, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany
| | - Verena Staudacher
- Department of Parasitology, Ruprecht-Karls University, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany
| | - Marcel Deponte
- Department of Parasitology, Ruprecht-Karls University, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany.
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18
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Jeeyapant A, Kingston HW, Plewes K, Maude RJ, Hanson J, Herdman MT, Leopold SJ, Ngernseng T, Charunwatthana P, Phu NH, Ghose A, Hasan MMU, Fanello CI, Faiz MA, Hien TT, Day NPJ, White NJ, Dondorp AM. Defining Surrogate Endpoints for Clinical Trials in Severe Falciparum Malaria. PLoS One 2017; 12:e0169307. [PMID: 28052109 PMCID: PMC5215574 DOI: 10.1371/journal.pone.0169307] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 12/14/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical trials in severe falciparum malaria require a large sample size to detect clinically meaningful differences in mortality. This means few interventions can be evaluated at any time. Using a validated surrogate endpoint for mortality would provide a useful alternative allowing a smaller sample size. Here we evaluate changes in coma score and plasma lactate as surrogate endpoints for mortality in severe falciparum malaria. METHODS Three datasets of clinical studies in severe malaria were re-evaluated: studies from Chittagong, Bangladesh (adults), the African 'AQUAMAT' trial comparing artesunate and quinine (children), and the Vietnamese 'AQ' study (adults) comparing artemether with quinine. The absolute change, relative change, slope of the normalization over time, and time to normalization were derived from sequential measurements of plasma lactate and coma score, and validated for their use as surrogate endpoint, including the proportion of treatment effect on mortality explained (PTE) by these surrogate measures. RESULTS Improvements in lactate concentration or coma scores over the first 24 hours of admission, were strongly prognostic for survival in all datasets. In hyperlactataemic patients in the AQ study (n = 173), lower mortality with artemether compared to quinine closely correlated with faster reduction in plasma lactate concentration, with a high PTE of the relative change in plasma lactate at 8 and 12 hours of 0.81 and 0.75, respectively. In paediatric patients enrolled in the 'AQUAMAT' study with cerebral malaria (n = 785), mortality was lower with artesunate compared to quinine, but this was not associated with faster coma recovery. CONCLUSIONS The relative changes in plasma lactate concentration assessed at 8 or 12 hours after admission are valid surrogate endpoints for severe malaria studies on antimalarial drugs or adjuvant treatments aiming at improving the microcirculation. Measures of coma recovery are not valid surrogate endpoints for mortality.
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Affiliation(s)
- Atthanee Jeeyapant
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Hugh W. Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Richard J. Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Josh Hanson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Global Health Division, Menzies School of Health Research, Darwin, Australia
| | - M. Trent Herdman
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- University College, Oxford, United Kingdom
| | - Stije J. Leopold
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thatsanun Ngernseng
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol Unversity,Bangkok,Thailand
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit. Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | | | - Caterina I. Fanello
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Md Abul Faiz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Malaria Research Group, Dev Care Foundation, Dhaka, Bangladesh
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit. Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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19
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Conroy AL, Hawkes M, Hayford K, Hermann L, McDonald CR, Sharma S, Namasopo S, Opoka RO, John CC, Liles WC, Miller C, Kain KC. Methemoglobin and nitric oxide therapy in Ugandan children hospitalized for febrile illness: results from a prospective cohort study and randomized double-blind placebo-controlled trial. BMC Pediatr 2016; 16:177. [PMID: 27814710 PMCID: PMC5097382 DOI: 10.1186/s12887-016-0719-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/25/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Exposure of red blood cells to oxidants increases production of methemoglobin (MHb) resulting in impaired oxygen delivery to tissues. There are no reliable estimates of methemoglobinemia in low resource clinical settings. Our objectives were to: i) evaluate risk factors for methemoglobinemia in Ugandan children hospitalized with fever (study 1); and ii) investigate MHb responses in critically ill Ugandan children with severe malaria treated with inhaled nitric oxide (iNO), an oxidant that induces MHb in a dose-dependent manner (study 2). METHODS Two prospective studies were conducted at Jinja Regional Referral Hospital in Uganda between 2011 and 2013. Study 1, a prospective cohort study of children admitted to hospital with fever (fever cohort, n = 2089 children 2 months to 5 years). Study 2, a randomized double-blind placebo-controlled parallel arm trial of room air placebo vs. 80 ppm iNO as an adjunctive therapy for children with severe malaria (RCT, n = 180 children 1-10 years receiving intravenous artesunate and 72 h of study gas). The primary outcomes were: i) masimo pulse co-oximetry elevated MHb levels at admission (>2 %, fever cohort); ii) four hourly MHb levels in the RCT. RESULTS In the fever cohort, 34 % of children admitted with fever had elevated MHb at admission. Children with a history of vomiting, delayed capillary refill, elevated lactate, severe anemia, malaria, or hemoglobinopathies had increased odds of methemoglobinemia (p < 0.05 in a multivariate model). MHb levels at admission were higher in children who died (n = 89) compared to those who survived (n = 1964), p = 0.008. Among children enrolled in the iNO RCT, MHb levels typically plateaued within 12-24 h of starting study gas. MHb levels were higher in children receiving iNO compared to placebo, and MHb > 10 % occurred in 5.7 % of children receiving iNO. There were no differences in rates of study gas discontinuation between trial arms. CONCLUSIONS Hospitalized children with evidence of impaired oxygen delivery, metabolic acidosis, anemia, or malaria were at risk of methemoglobinemia. However, we demonstrated high-dose iNO could be safely administered to critically ill children with severe malaria with appropriate MHb monitoring. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01255215 (Date registered: December 5, 2010).
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Affiliation(s)
- Andrea L Conroy
- Depatment of Medicine, University of Toronto, Toronto, Canada.,Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Michael Hawkes
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada
| | - Kyla Hayford
- Depatment of Medicine, University of Toronto, Toronto, Canada.,Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Laura Hermann
- Depatment of Medicine, University of Toronto, Toronto, Canada
| | - Chloe R McDonald
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Suparna Sharma
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Sophie Namasopo
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - W Conrad Liles
- Department of Medicine, University of Washington, Seattle, WA, 98195, USA
| | - Christopher Miller
- Department of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Kevin C Kain
- Depatment of Medicine, University of Toronto, Toronto, Canada. .,Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada. .,Institute of Medical Sciences, University of Toronto, Toronto, Canada. .,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada. .,MaRS Centre, TMDT, 10th floor 10-351, Toronto, ON, M5G1L7, Canada.
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20
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DellaValle B, Hempel C, Staalsoe T, Johansen FF, Kurtzhals JAL. Glucagon-like peptide-1 analogue, liraglutide, in experimental cerebral malaria: implications for the role of oxidative stress in cerebral malaria. Malar J 2016; 15:427. [PMID: 27554094 PMCID: PMC4995661 DOI: 10.1186/s12936-016-1486-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/11/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cerebral malaria from Plasmodium falciparum infection is major cause of death in the tropics. The pathogenesis of the disease is complex and the contribution of reactive oxygen and nitrogen species (ROS/RNS) in the brain is incompletely understood. Insulinotropic glucagon-like peptide-1 (GLP-1) mimetics have potent neuroprotective effects in animal models of neuropathology associated with ROS/RNS dysfunction. This study investigates the effect of the GLP-1 analogue, liraglutide against the clinical outcome of experimental cerebral malaria (ECM) and Plasmodium falciparum growth. Furthermore the role of oxidative stress on ECM pathogenesis is evaluated. METHODS ECM was induced in Plasmodium berghei ANKA-infected C57Bl/6j mice. Infected Balb/c (non-cerebral malaria) and uninfected C57Bl/6j mice were included as controls. Mice were treated twice-daily with vehicle or liraglutide (200 μg/kg). ROS/RNS were quantified with in vivo imaging and further analyzed ex vivo. Brains were assayed for cAMP, activation of cAMP response element binding protein (CREB) and nitrate/nitrite. Plasmodium falciparum was cultivated in vitro with increasing doses of liraglutide and growth and metabolism were quantified. RESULTS The development and progression of ECM was not affected by liraglutide. Indeed, although ROS/RNS were increased in peripheral organs, ROS/RNS generation was not present in the brain. Interestingly, CREB was activated in the ECM brain and may protect against ROS/RNS stress. Parasite growth was not adversely affected by liraglutide in mice or in P. falciparum cultures indicating safety should not be a concern in type-II diabetics in endemic regions. CONCLUSIONS Despite the breadth of models where GLP-1 is neuroprotective, ECM was not affected by liraglutide providing important insight into the pathogenesis of ECM. Furthermore, ECM does not induce excess ROS/RNS in the brain potentially associated with activation of the CREB system.
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Affiliation(s)
- Brian DellaValle
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark. .,Department of Biomedical Sciences, Biotech Research and Innovation Center, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark. .,Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Casper Hempel
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trine Staalsoe
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Flemming Fryd Johansen
- Department of Biomedical Sciences, Biotech Research and Innovation Center, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen Anders Lindholm Kurtzhals
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
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21
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Lalloo DG, Shingadia D, Bell DJ, Beeching NJ, Whitty CJM, Chiodini PL. UK malaria treatment guidelines 2016. J Infect 2016; 72:635-649. [PMID: 26880088 PMCID: PMC7132403 DOI: 10.1016/j.jinf.2016.02.001] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 12/15/2022]
Abstract
1.Malaria is the tropical disease most commonly imported into the UK, with 1300-1800 cases reported each year, and 2-11 deaths. 2. Approximately three quarters of reported malaria cases in the UK are caused by Plasmodium falciparum, which is capable of invading a high proportion of red blood cells and rapidly leading to severe or life-threatening multi-organ disease. 3. Most non-falciparum malaria cases are caused by Plasmodium vivax; a few cases are caused by the other species of plasmodium: Plasmodium ovale, Plasmodium malariae or Plasmodium knowlesi. 4. Mixed infections with more than one species of parasite can occur; they commonly involve P. falciparum with the attendant risks of severe malaria. 5. There are no typical clinical features of malaria; even fever is not invariably present. Malaria in children (and sometimes in adults) may present with misleading symptoms such as gastrointestinal features, sore throat or lower respiratory complaints. 6. A diagnosis of malaria must always be sought in a feverish or sick child or adult who has visited malaria-endemic areas. Specific country information on malaria can be found at http://travelhealthpro.org.uk/. P. falciparum infection rarely presents more than six months after exposure but presentation of other species can occur more than a year after exposure. 7. Management of malaria depends on awareness of the diagnosis and on performing the correct diagnostic tests: the diagnosis cannot be excluded until more than one blood specimen has been examined. Other travel related infections, especially viral haemorrhagic fevers, should also be considered. 8. The optimum diagnostic procedure is examination of thick and thin blood films by an expert to detect and speciate the malarial parasites. P. falciparum and P. vivax (depending upon the product) malaria can be diagnosed almost as accurately using rapid diagnostic tests (RDTs) which detect plasmodial antigens. RDTs for other Plasmodium species are not as reliable. 9. Most patients treated for P. falciparum malaria should be admitted to hospital for at least 24 h as patients can deteriorate suddenly, especially early in the course of treatment. In specialised units seeing large numbers of patients, outpatient treatment may be considered if specific protocols for patient selection and follow up are in place. 10. Uncomplicated P. falciparum malaria should be treated with an artemisinin combination therapy (Grade 1A). Artemether-lumefantrine (Riamet(®)) is the drug of choice (Grade 2C) and dihydroartemisinin-piperaquine (Eurartesim(®)) is an alternative. Quinine or atovaquone-proguanil (Malarone(®)) can be used if an ACT is not available. Quinine is highly effective but poorly-tolerated in prolonged treatment and should be used in combination with an additional drug, usually oral doxycycline. 11. Severe falciparum malaria, or infections complicated by a relatively high parasite count (more than 2% of red blood cells parasitized) should be treated with intravenous therapy until the patient is well enough to continue with oral treatment. Severe malaria is a rare complication of P. vivax or P. knowlesi infection and also requires parenteral therapy. 12. The treatment of choice for severe or complicated malaria in adults and children is intravenous artesunate (Grade 1A). Intravenous artesunate is unlicensed in the EU but is available in many centres. The alternative is intravenous quinine, which should be started immediately if artesunate is not available (Grade 1A). Patients treated with intravenous quinine require careful monitoring for hypoglycemia. 13. Patients with severe or complicated malaria should be managed in a high-dependency or intensive care environment. They may require haemodynamic support and management of: acute respiratory distress syndrome, disseminated intravascular coagulation, acute kidney injury, seizures, and severe intercurrent infections including Gram-negative bacteraemia/septicaemia. 14. Children with severe malaria should also be treated with empirical broad spectrum antibiotics until bacterial infection can be excluded (Grade 1B). 15. Haemolysis occurs in approximately 10-15% patients following intravenous artesunate treatment. Haemoglobin concentrations should be checked approximately 14 days following treatment in those treated with IV artemisinins (Grade 2C). 16. Falciparum malaria in pregnancy is more likely to be complicated: the placenta contains high levels of parasites, stillbirth or early delivery may occur and diagnosis can be difficult if parasites are concentrated in the placenta and scanty in the blood. 17. Uncomplicated falciparum malaria in the second and third trimester of pregnancy should be treated with artemether-lumefantrine (Grade 2B). Uncomplicated falciparum malaria in the first trimester of pregnancy should usually be treated with quinine and clindamycin but specialist advice should be sought. Severe malaria in any trimester of pregnancy should be treated as for any other patient with artesunate preferred over quinine (Grade 1C). 18. Children with uncomplicated malaria should be treated with an ACT (artemether-lumefantrine or dihydroartemisinin-piperaquine) as first line treatment (Grade 1A). Quinine with doxycycline or clindamycin, or atovaquone-proguanil at appropriate doses for weight can also be used. Doxycycline should not be given to children under 12 years. 19. Either an oral ACT or chloroquine can be used for the treatment of non-falciparum malaria. An oral ACT is preferred for a mixed infection, if there is uncertainty about the infecting species, or for P. vivax infection from areas where chloroquine resistance is common (Grade 1B). 20. Dormant parasites (hypnozoites) persist in the liver after treatment of P. vivax or P. ovale infection: the only currently effective drug for eradication of hypnozoites is primaquine (1A). Primaquine is more effective at preventing relapse if taken at the same time as chloroquine (Grade 1C). 21. Primaquine should be avoided or given with caution under expert supervision in patients with Glucose-6-phosphate dehydrogenase deficiency (G6PD), in whom it may cause severe haemolysis. 22. Primaquine (for eradication of P. vivax or P. ovale hypnozoites) is contraindicated in pregnancy and when breastfeeding (until the G6PD status of child is known); after initial treatment for these infections a pregnant woman should take weekly chloroquine prophylaxis until after delivery or cessation of breastfeeding when hypnozoite eradication can be considered. 23. An acute attack of malaria does not confer protection from future attacks: individuals who have had malaria should take effective anti-mosquito precautions and chemoprophylaxis during future visits to endemic areas.
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Affiliation(s)
- David G Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK.
| | - Delane Shingadia
- Department of Infectious Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK
| | - David J Bell
- Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Nicholas J Beeching
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Christopher J M Whitty
- Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street off Tottenham Court Road, London WC1E 6AU, UK
| | - Peter L Chiodini
- Malaria Reference Laboratory, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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22
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Hora R, Kapoor P, Thind KK, Mishra PC. Cerebral malaria--clinical manifestations and pathogenesis. Metab Brain Dis 2016; 31:225-37. [PMID: 26746434 DOI: 10.1007/s11011-015-9787-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 12/22/2015] [Indexed: 01/28/2023]
Abstract
One of the most common central nervous system diseases in tropical countries is cerebral malaria (CM). Malaria is a common protozoan infection that is responsible for enormous worldwide mortality and economic burden on the society. Episodes of Plasmodium falciparum (Pf) caused CM may be lethal, while survivors are likely to suffer from persistent debilitating neurological deficits, especially common in children. In this review article, we have summarized the various symptoms and manifestations of CM in children and adults, and entailed the molecular basis of the disease. We have also emphasized how pathogenesis of the disease is effected by the parasite and host responses including blood brain barrier (BBB) disruption, endothelial cell activation and apoptosis, nitric oxide bioavailability, platelet activation and apoptosis, and neuroinflammation. Based on a few recent studies carried out in experimental mouse malaria models, we propose a basis for the neurological deficits and sequelae observed in human cerebral malaria, and summarize how existing drugs may improve prognosis in affected individuals.
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Affiliation(s)
- Rachna Hora
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, 143005, India.
| | - Payal Kapoor
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, 143005, India
| | - Kirandeep Kaur Thind
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, 143005, India
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23
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Deroost K, Pham TT, Opdenakker G, Van den Steen PE. The immunological balance between host and parasite in malaria. FEMS Microbiol Rev 2015; 40:208-57. [PMID: 26657789 DOI: 10.1093/femsre/fuv046] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2015] [Indexed: 12/16/2022] Open
Abstract
Coevolution of humans and malaria parasites has generated an intricate balance between the immune system of the host and virulence factors of the parasite, equilibrating maximal parasite transmission with limited host damage. Focusing on the blood stage of the disease, we discuss how the balance between anti-parasite immunity versus immunomodulatory and evasion mechanisms of the parasite may result in parasite clearance or chronic infection without major symptoms, whereas imbalances characterized by excessive parasite growth, exaggerated immune reactions or a combination of both cause severe pathology and death, which is detrimental for both parasite and host. A thorough understanding of the immunological balance of malaria and its relation to other physiological balances in the body is of crucial importance for developing effective interventions to reduce malaria-related morbidity and to diminish fatal outcomes due to severe complications. Therefore, we discuss in this review the detailed mechanisms of anti-malarial immunity, parasite virulence factors including immune evasion mechanisms and pathogenesis. Furthermore, we propose a comprehensive classification of malaria complications according to the different types of imbalances.
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Affiliation(s)
- Katrien Deroost
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium The Francis Crick Institute, Mill Hill Laboratory, London, NW71AA, UK
| | - Thao-Thy Pham
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium
| | - Ghislain Opdenakker
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium
| | - Philippe E Van den Steen
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium
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The role of previously unmeasured organic acids in the pathogenesis of severe malaria. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:317. [PMID: 26343146 PMCID: PMC4561438 DOI: 10.1186/s13054-015-1023-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 08/11/2015] [Indexed: 12/16/2022]
Abstract
Introduction Severe falciparum malaria is commonly complicated by metabolic acidosis. Together with lactic acid (LA), other previously unmeasured acids have been implicated in the pathogenesis of falciparum malaria. Methods In this prospective study, we characterised organic acids in adults with severe falciparum malaria in India and Bangladesh. Liquid chromatography-mass spectrometry was used to measure organic acids in plasma and urine. Patients were followed until recovery or death. Results Patients with severe malaria (n=138), uncomplicated malaria (n=102), sepsis (n=32) and febrile encephalopathy (n=35) were included. Strong ion gap (mean±SD) was elevated in severe malaria (8.2 mEq/L±4.5) and severe sepsis (8.6 mEq/L±7.7) compared with uncomplicated malaria (6.0 mEq/L±5.1) and encephalopathy (6.6 mEq/L±4.7). Compared with uncomplicated malaria, severe malaria was characterised by elevated plasma LA, hydroxyphenyllactic acid (HPLA), α-hydroxybutyric acid and β-hydroxybutyric acid (all P<0.05). In urine, concentrations of methylmalonic, ethylmalonic and α-ketoglutaric acids were also elevated. Multivariate logistic regression showed that plasma HPLA was a strong independent predictor of death (odds ratio [OR] 3.5, 95 % confidence interval [CI] 1.6–7.5, P=0.001), comparable to LA (OR 3.5, 95 % CI 1.5–7.8, P=0.003) (combined area under the receiver operating characteristic curve 0.81). Conclusions Newly identified acids, in addition to LA, are elevated in patients with severe malaria and are highly predictive of fatal outcome. Further characterisation of their sources and metabolic pathways is now needed. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1023-5) contains supplementary material, which is available to authorized users.
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Abstract
Over 90% of the world's severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the publication of the AQUAMAT trial in 2010, involving 5,425 children at 11 centres across 9 African countries, showing that in artesunate-treated children, the relative risk of death was 22.5% (95% confidence interval (CI) 8.1 to 36.9) lower than in those receiving quinine. Human trials of supportive therapies carried out on the basis of pathophysiology studies, have so far made little progress on reducing mortality; despite appearing to reduce morbidity endpoints, more often than not they have led to an excess of adverse outcomes. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.
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Yeo TW, Lampah DA, Kenangalem E, Tjitra E, Price RN, Weinberg JB, Hyland K, Granger DL, Anstey NM. Impaired systemic tetrahydrobiopterin bioavailability and increased dihydrobiopterin in adult falciparum malaria: association with disease severity, impaired microvascular function and increased endothelial activation. PLoS Pathog 2015; 11:e1004667. [PMID: 25764397 PMCID: PMC4357386 DOI: 10.1371/journal.ppat.1004667] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/07/2015] [Indexed: 12/22/2022] Open
Abstract
Tetrahydrobiopterin (BH₄) is a co-factor required for catalytic activity of nitric oxide synthase (NOS) and amino acid-monooxygenases, including phenylalanine hydroxylase. BH4 is unstable: during oxidative stress it is non-enzymatically oxidized to dihydrobiopterin (BH₂), which inhibits NOS. Depending on BH₄ availability, NOS oscillates between NO synthase and NADPH oxidase: as the BH₄/BH₂ ratio decreases, NO production falls and is replaced by superoxide. In African children and Asian adults with severe malaria, NO bioavailability decreases and plasma phenylalanine increases, together suggesting possible BH₄ deficiency. The primary three biopterin metabolites (BH₄, BH₂ and B₀ [biopterin]) and their association with disease severity have not been assessed in falciparum malaria. We measured pterin metabolites in urine of adults with severe falciparum malaria (SM; n=12), moderately-severe malaria (MSM, n=17), severe sepsis (SS; n=5) and healthy subjects (HC; n=20) as controls. In SM, urinary BH₄ was decreased (median 0.16 ¼mol/mmol creatinine) compared to MSM (median 0.27), SS (median 0.54), and HC (median 0.34)]; p<0.001. Conversely, BH₂ was increased in SM (median 0.91 ¼mol/mmol creatinine), compared to MSM (median 0.67), SS (median 0.39), and HC (median 0.52); p<0.001, suggesting increased oxidative stress and insufficient recycling of BH2 back to BH4 in severe malaria. Overall, the median BH₄/BH₂ ratio was lowest in SM [0.18 (IQR: 0.04-0.32)] compared to MSM (0.45, IQR 0.27-61), SS (1.03; IQR 0.54-2.38) and controls (0.66; IQR 0.43-1.07); p<0.001. In malaria, a lower BH₄/BH₂ ratio correlated with decreased microvascular reactivity (r=0.41; p=0.03) and increased ICAM-1 (r=-0.52; p=0.005). Decreased BH4 and increased BH₂ in severe malaria (but not in severe sepsis) uncouples NOS, leading to impaired NO bioavailability and potentially increased oxidative stress. Adjunctive therapy to regenerate BH4 may have a role in improving NO bioavailability and microvascular perfusion in severe falciparum malaria.
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Affiliation(s)
- Tsin W. Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Daniel A. Lampah
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, and District Ministry of Health, Timika, Papua, Indonesia
| | - Enny Kenangalem
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, and District Ministry of Health, Timika, Papua, Indonesia
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Jakarta, Indonesia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - J. Brice Weinberg
- Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Keith Hyland
- Medical Neurogenetics LLC, Atlanta, Georgia, United States of America
| | - Donald L. Granger
- Division of Infectious Diseases, University of Utah and Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Marks M, Gupta-Wright A, Doherty JF, Singer M, Walker D. Managing malaria in the intensive care unit. Br J Anaesth 2014; 113:910-21. [PMID: 24946778 PMCID: PMC4235570 DOI: 10.1093/bja/aeu157] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The number of people travelling to malaria-endemic countries continues to increase, and malaria remains the commonest cause of serious imported infection in non-endemic areas. Severe malaria, mostly caused by Plasmodium falciparum, often requires intensive care unit (ICU) admission and can be complicated by cerebral malaria, respiratory distress, acute kidney injury, bleeding complications, and co-infection. The mortality from imported malaria remains significant. This article reviews the manifestations, complications and principles of management of severe malaria as relevant to critical care clinicians, incorporating recent studies of anti-malarial and adjunctive treatment. Effective management of severe malaria includes prompt diagnosis and early institution of effective anti-malarial therapy, recognition of complications, and appropriate supportive management in an ICU. All cases should be discussed with a specialist unit and transfer of the patient considered.
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Affiliation(s)
- M Marks
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - A Gupta-Wright
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - J F Doherty
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK
| | - M Singer
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
| | - D Walker
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
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Plewes K, Royakkers AA, Hanson J, Hasan MMU, Alam S, Ghose A, Maude RJ, Stassen PM, Charunwatthana P, Lee SJ, Turner GDH, Dondorp AM, Schultz MJ. Correlation of biomarkers for parasite burden and immune activation with acute kidney injury in severe falciparum malaria. Malar J 2014; 13:91. [PMID: 24618154 PMCID: PMC3995633 DOI: 10.1186/1475-2875-13-91] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/26/2014] [Indexed: 11/24/2022] Open
Abstract
Background Acute kidney injury (AKI) complicating severe Plasmodium falciparum malaria occurs in up to 40% of adult patients. The case fatality rate reaches 75% in the absence of renal replacement therapy (RRT). The precise pathophysiology of AKI in falciparum malaria remains unclear. Histopathology shows acute tubular necrosis with localization of host monocytes and parasitized red blood cells in the microvasculature. This study explored the relationship of plasma soluble urokinase-type plasminogen activator receptor (suPAR), as a proxy-measure of mononuclear cell activation, and plasma P. falciparum histidine rich protein 2 (PfHRP2), as a measure of sequestered parasite burden, with AKI in severe malaria. Methods Admission plasma suPAR and PfHRP2 concentrations were assessed in Bangladeshi adults with severe falciparum malaria (n = 137). Patients were stratified according to AKI severity based on admission creatinine clearance. Results A total of 106 (77%) patients had AKI; 32 (23%), 42 (31%) and 32 (23%) were classified into ‘mild, ‘moderate’ and ‘severe’ AKI groups, respectively. Plasma suPAR and PfHRP2 concentrations increased with AKI severity (test-for-trend P <0.0001) and correlated with other markers of renal dysfunction. Admission plasma suPAR and PfHRP2 concentrations were higher in patients who later required RRT (P <0.0001 and P = 0.0004, respectively). In a multivariate analysis, both increasing suPAR and PfHRP2 were independently associated with increasing urine neutrophil gelatinase-associated lipocalin concentration, a marker of acute tubular necrosis (β = 16.54 (95% CI 6.36-26.71) and β = 0.07 (0.02-0.11), respectively). Conclusions Both sequestered parasite burden and immune activation contribute to the pathogenesis of AKI in severe falciparum malaria.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Francischetti IMB, Gordon E, Bizzarro B, Gera N, Andrade BB, Oliveira F, Ma D, Assumpção TCF, Ribeiro JMC, Pena M, Qi CF, Diouf A, Moretz SE, Long CA, Ackerman HC, Pierce SK, Sá-Nunes A, Waisberg M. Tempol, an intracellular antioxidant, inhibits tissue factor expression, attenuates dendritic cell function, and is partially protective in a murine model of cerebral malaria. PLoS One 2014; 9:e87140. [PMID: 24586264 PMCID: PMC3938406 DOI: 10.1371/journal.pone.0087140] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/18/2013] [Indexed: 01/19/2023] Open
Abstract
Background The role of intracellular radical oxygen species (ROS) in pathogenesis of cerebral malaria (CM) remains incompletely understood. Methods and Findings We undertook testing Tempol—a superoxide dismutase (SOD) mimetic and pleiotropic intracellular antioxidant—in cells relevant to malaria pathogenesis in the context of coagulation and inflammation. Tempol was also tested in a murine model of CM induced by Plasmodium berghei Anka infection. Tempol was found to prevent transcription and functional expression of procoagulant tissue factor in endothelial cells (ECs) stimulated by lipopolysaccharide (LPS). This effect was accompanied by inhibition of IL-6, IL-8, and monocyte chemoattractant protein (MCP-1) production. Tempol also attenuated platelet aggregation and human promyelocytic leukemia HL60 cells oxidative burst. In dendritic cells, Tempol inhibited LPS-induced production of TNF-α, IL-6, and IL-12p70, downregulated expression of co-stimulatory molecules, and prevented antigen-dependent lymphocyte proliferation. Notably, Tempol (20 mg/kg) partially increased the survival of mice with CM. Mechanistically, treated mice had lowered plasma levels of MCP-1, suggesting that Tempol downmodulates EC function and vascular inflammation. Tempol also diminished blood brain barrier permeability associated with CM when started at day 4 post infection but not at day 1, suggesting that ROS production is tightly regulated. Other antioxidants—such as α-phenyl N-tertiary-butyl nitrone (PBN; a spin trap), MnTe-2-PyP and MnTBAP (Mn-phorphyrin), Mitoquinone (MitoQ) and Mitotempo (mitochondrial antioxidants), M30 (an iron chelator), and epigallocatechin gallate (EGCG; polyphenol from green tea) did not improve survival. By contrast, these compounds (except PBN) inhibited Plasmodium falciparum growth in culture with different IC50s. Knockout mice for SOD1 or phagocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (gp91phox–/–) or mice treated with inhibitors of SOD (diethyldithiocarbamate) or NADPH oxidase (diphenyleneiodonium) did not show protection or exacerbation for CM. Conclusion Results with Tempol suggest that intracellular ROS contribute, in part, to CM pathogenesis. Therapeutic targeting of intracellular ROS in CM is discussed.
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Affiliation(s)
- Ivo M. B. Francischetti
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
- * E-mail: (IMBF); (MW)
| | - Emile Gordon
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Bruna Bizzarro
- Laboratory of Experimental Immunology, Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil
| | - Nidhi Gera
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Bruno B. Andrade
- Laboratory of Parasitic Diseases, NIAID/NIH, Bethesda, Maryland, United States of America
| | - Fabiano Oliveira
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Dongying Ma
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Teresa C. F. Assumpção
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - José M. C. Ribeiro
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Mirna Pena
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Chen-Feng Qi
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Ababacar Diouf
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Samuel E. Moretz
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Carole A. Long
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Hans C. Ackerman
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Susan K. Pierce
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Anderson Sá-Nunes
- Laboratory of Experimental Immunology, Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil
| | - Michael Waisberg
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
- University of Virginia, Department of Pathology, Charlottesville, Virginia, United States of America
- * E-mail: (IMBF); (MW)
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Isah MB, Ibrahim MA. The role of antioxidants treatment on the pathogenesis of malarial infections: a review. Parasitol Res 2014; 113:801-9. [PMID: 24525759 DOI: 10.1007/s00436-014-3804-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/28/2014] [Indexed: 11/28/2022]
Abstract
Oxidative damage is one of the most important pathological consequences of malarial infections. It affects vital organs of the body manifesting in changes such as splenomegaly, hepatomegaly, endothelial and cognitive damages. The currently used antimalarials often leave traces of these damages after therapy, as evident in memory impairment after cerebral malaria. Hence, some research investigations have focused attention on the use of antioxidants, alone or in combination with antimalarials, as a viable therapeutic strategy aimed at alleviating plasmodium-induced oxidative stress and its associated complications. However, the practical application of this approach often yields conflicting outcomes because some antimalarials specifically act via induction of oxidative stress. This article critically reviews most of the studies conducted on the potential role of antioxidant therapy in malarial infections. The most frequently investigated antioxidants are vitamins C and E, N-acetylcystein, folate and desferroxamine. Some of the investigations measured the effects of direct administration of the antioxidants on the plasmodium parasites while others performed an adjunctive therapy with standard antimalarials. The therapeutic application of each of the antioxidants in malaria management depends on the targeted aspect of malarial pathology. It is hoped that this article will provide an informed basis for future research activities on the therapeutic role of antioxidants on malarial pathogenesis.
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31
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Hanson J, Lee SJ, Mohanty S, Faiz MA, Anstey NM, Price RN, Charunwatthana P, Yunus EB, Mishra SK, Tjitra E, Rahman R, Nosten F, Htut Y, Maude RJ, Thi Hong Chau T, Phu NH, Hien TT, White NJ, Day NPJ, Dondorp AM. Rapid clinical assessment to facilitate the triage of adults with falciparum malaria, a retrospective analysis. PLoS One 2014; 9:e87020. [PMID: 24489828 PMCID: PMC3906099 DOI: 10.1371/journal.pone.0087020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/15/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Most adults dying from falciparum malaria will die within 48 hours of their hospitalisation. An essential component of early supportive care is the rapid identification of patients at greatest risk. In resource-poor settings, where most patients with falciparum malaria are managed, decisions regarding patient care must frequently be made using clinical evaluation alone. METHODS We retrospectively analysed 4 studies of 1801 adults with severe falciparum malaria to determine whether the presence of simple clinical findings might assist patient triage. RESULTS If present on admission, shock, oligo-anuria, hypo- or hyperglycaemia, an increased respiratory rate, a decreased Glasgow Coma Score and an absence of fever were independently predictive of death. The variables were used to construct a simple clinical algorithm. When applied to the 1801 patients, this algorithm's positive predictive value for survival to 48 hours was 99.4 (95% confidence interval (CI) 97.8-99.9) and for survival to discharge 96.9% (95% CI 94.3-98.5). In the 712 patients receiving artesunate, the algorithm's positive predictive value for survival to 48 hours was 100% (95% CI 97.3-100) and to discharge was 98.5% (95% CI 94.8-99.8). CONCLUSIONS Simple clinical findings are closely linked to the pathophysiology of severe falciparum malaria in adults. A basic algorithm employing these indices can facilitate the triage of patients in settings where intensive care services are limited. Patients classified as low-risk by this algorithm can be safely managed initially on a general ward whilst awaiting senior clinical review and laboratory data.
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Global Health Division, Menzies School of Health Research, Darwin, Australia
- * E-mail:
| | - Sue J. Lee
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Sanjib Mohanty
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India
| | - M. Abul Faiz
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Dev Care Foundation, Dhaka, Bangladesh
| | - Nicholas M. Anstey
- Global Health Division, Menzies School of Health Research, Darwin, Australia
| | - Ric N. Price
- Global Health Division, Menzies School of Health Research, Darwin, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | | | - Saroj K. Mishra
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | | | - Francois Nosten
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mae Sot, Thailand
| | - Ye Htut
- Department of Medical Research, Lower Myanmar, Ministry of Health, Yangon, Myanmar
| | - Richard J. Maude
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Tran Thi Hong Chau
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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32
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Maude RJ, Silamut K, Plewes K, Charunwatthana P, Ho M, Abul Faiz M, Rahman R, Hossain MA, Hassan MU, Bin Yunus E, Hoque G, Islam F, Ghose A, Hanson J, Schlatter J, Lacey R, Eastaugh A, Tarning J, Lee SJ, White NJ, Chotivanich K, Day NPJ, Dondorp AM. Randomized controlled trial of levamisole hydrochloride as adjunctive therapy in severe falciparum malaria with high parasitemia. J Infect Dis 2014; 209:120-9. [PMID: 23943850 PMCID: PMC3864382 DOI: 10.1093/infdis/jit410] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 07/08/2013] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cytoadherence and sequestration of erythrocytes containing mature stages of Plasmodium falciparum are central to the pathogenesis of severe malaria. The oral anthelminthic drug levamisole inhibits cytoadherence in vitro and reduces sequestration of late-stage parasites in uncomplicated falciparum malaria treated with quinine. METHODS Fifty-six adult patients with severe malaria and high parasitemia admitted to a referral hospital in Bangladesh were randomized to receive a single dose of levamisole hydrochloride (150 mg) or no adjuvant to antimalarial treatment with intravenous artesunate. RESULTS Circulating late-stage parasites measured as the median area under the parasite clearance curves were 2150 (interquartile range [IQR], 0-28 025) parasites/µL × hour in patients treated with levamisole and 5489 (IQR, 192-25 848) parasites/µL × hour in controls (P = .25). The "sequestration ratios" at 6 and 12 hours for all parasite stages and changes in microvascular blood flow did not differ between treatment groups (all P > .40). The median time to normalization of plasma lactate (<2 mmol/L) was 24 (IQR, 12-30) hours with levamisole vs 28 (IQR, 12-36) hours without levamisole (P = .15). CONCLUSIONS There was no benefit of a single-dose of levamisole hydrochloride as adjuvant to intravenous artesunate in the treatment of adults with severe falciparum malaria. Rapid parasite killing by intravenous artesunate might obscure the effects of levamisole.
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Affiliation(s)
- Richard J. Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Kamolrat Silamut
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - May Ho
- Department of Microbiology and Infectious Disease, University of Calgary, Alberta, Canada
| | - M. Abul Faiz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Specialized Care and Research, Chittagong
- Dev Care Foundation, Dhaka
| | | | - Md Amir Hossain
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Mahtab U. Hassan
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Emran Bin Yunus
- Centre for Specialized Care and Research, Chittagong
- Dev Care Foundation, Dhaka
| | - Gofranul Hoque
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Faridul Islam
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Josh Hanson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Joel Schlatter
- Department of Pharmacy and Toxicology, University Hospital of Jean Verdier, Bondy, France
| | - Rachel Lacey
- Worcestershire Royal Hospital, Worcester, United Kingdom
| | | | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Sue J. Lee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Kesinee Chotivanich
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
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Abstract
Severe malaria is a medical emergency requiring early intervention to prevent death. This article highlights key aspects of the management of severe malaria syndromes in the intensive care unit, with a focus on individual case management of imported malaria. Key differences in the presentation, management, and outcomes of severe malaria by endemicity and by age group are emphasized. In all groups with severe malaria, intravenous artesunate is the antimalarial agent of choice. This article discusses specific antimalarial therapies, optimal supportive management strategies, differences from strategies for bacterial sepsis, and trials of adjunctive therapy for severe malaria in humans.
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Martins YC, Daniel-Ribeiro CT. A new hypothesis on the manifestation of cerebral malaria: the secret is in the liver. Med Hypotheses 2013; 81:777-83. [PMID: 23978689 DOI: 10.1016/j.mehy.2013.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
Abstract
Despite the abundance of information on cerebral malaria (CM), the pathogenesis of this disease is not completely understood. At present, two nonexclusive dominant hypotheses exist to explain how the neurological syndrome manifests: the sequestration (or mechanical) hypothesis and the inflammatory hypothesis. The sequestration hypothesis states that sequestration of Plasmodium falciparum-parasitized red blood cells (pRBCs) to brain capillary endothelia causes obstruction of capillary blood flow followed by brain tissue anoxia and coma. The inflammatory hypothesis postulates that P. falciparum infection releases toxic molecules in the circulation, inducing an imbalanced systemic inflammatory response that leads to coagulopathy, brain endothelial cell dysfunction, accumulation of leukocytes in the brain microcirculation, blood brain barrier (BBB) leakage, cerebral vasoconstriction, edema, and coma. However, both hypotheses, even when considered together, are not sufficient to fully explain the pathogenesis of CM. Here, we propose that the development of acute liver failure (ALF) together with BBB breakdown are the necessary and sufficient conditions for the genesis of CM. ALF is characterized by coagulopathy and hepatic encephalopathy (HE) in a patient without pre-existing liver disease. Signs of hepatic dysfunction have been shown to occur in 2.5-40% of CM patients. In addition, recent studies with murine models demonstrated that mice presenting experimental cerebral malaria (ECM) had hepatic damage and brain metabolic changes characteristic of HE. However, the occurrence of CM in patients with mild or without apparent hepatocellular liver damage and the presence of liver damage in non-CM murine models indicate that the development of ALF during malaria infection is not the single factor responsible for neuropathology. To solve this problem, we also propose that BBB breakdown contributes to the pathogenesis of CM and synergizes with hepatic failure to cause neurological signs and symptoms. BBB dysfunction would thus occur in CM by a mechanism similar to the one occurring in sepsis and is in agreement with the inflammatory hypothesis. Nevertheless, differently from in the inflammatory hypothesis, BBB leakage would facilitate the penetration of ammonia and other toxins into the brain parenchyma, but would not be sufficient to cause CM when occurring alone. We believe our hypothesis better explains the pathogenesis of CM, does not have problems to deal with the exception data not explained by the previous hypotheses, and reveals new targets for adjunctive therapy.
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Affiliation(s)
- Yuri Chaves Martins
- Laboratório de Pesquisas em Malária, Instituto Oswaldo Cruz and Centro de Pesquisa Diagnóstico e Treinamento em Malária, Fiocruz, Rio de Janeiro, RJ, Brazil; Department of Pathology, Albert Einstein College of Medicine, The Bronx, NY, USA.
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Lipoxin A₄ and 15-epi-lipoxin A₄ protect against experimental cerebral malaria by inhibiting IL-12/IFN-γ in the brain. PLoS One 2013; 8:e61882. [PMID: 23613965 PMCID: PMC3628580 DOI: 10.1371/journal.pone.0061882] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 03/17/2013] [Indexed: 12/12/2022] Open
Abstract
Cerebral malaria is caused by infection with Plasmodium falciparum and can lead to severe neurological manifestations and predominantly affects sub-Saharan African children. The pathogenesis of this disease involves unbalanced over-production of pro-inflammatory cytokines. It is clear that signaling though IL-12 receptor is a critical step for development of cerebral malaria, IL-12 genetic deficiency failed to show the same effect, suggesting that there is redundancy among the soluble mediators which leads to immunopathology and death. Consequently, counter-regulatory mediators might protect the host during cerebral malaria. We have previously showed that endogenously produced lipoxins, which are anti-inflammatory mediators generated by 5-lipoxygenase (5-LO)-dependent metabolism of arachidonic acid, limit host damage in a model of mouse toxoplasmosis. We postulated here that lipoxins might also play a counter-regulatory role during cerebral malaria. To test this hypothesis, we infected 5-LO-deficient hosts with P. berghei ANKA strain, which induces a mouse model of cerebral malaria (ECM). Our results show accelerated mortality concomitant with exuberant IL-12 and IFN-γ production in the absence of 5-lipoxygenase. Moreover, in vivo administration of lipoxin to 5-LO-deficient hosts prevented early mortality and reduced the accumulation of CD8+IFN-γ+ cells in the brain. Surprisingly, WT animals treated with lipoxin either at the time of infection or 3 days post-inoculum also showed prolonged survival and diminished brain inflammation, indicating that although protective, endogenous lipoxin production is not sufficient to optimally protect the host from brain damage in cerebral malaria. These observations establish 5-LO/LXA4 as a host protective pathway and suggest a new therapeutic approach against human cerebral malaria (HCM). (255 words).
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36
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DellaValle B, Staalsoe T, Kurtzhals JAL, Hempel C. Investigation of hydrogen sulfide gas as a treatment against P. falciparum, murine cerebral malaria, and the importance of thiolation state in the development of cerebral malaria. PLoS One 2013; 8:e59271. [PMID: 23555646 PMCID: PMC3608628 DOI: 10.1371/journal.pone.0059271] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/12/2013] [Indexed: 01/16/2023] Open
Abstract
Introduction Cerebral malaria (CM) is a potentially fatal cerebrovascular disease of complex pathogenesis caused by Plasmodium falciparum. Hydrogen sulfide (HS) is a physiological gas, similar to nitric oxide and carbon monoxide, involved in cellular metabolism, vascular tension, inflammation, and cell death. HS treatment has shown promising results as a therapy for cardio- and neuro- pathology. This study investigates the effects of fast (NaHS) and slow (GYY4137) HS-releasing drugs on the growth and metabolism of P. falciparum and the development of P. berghei ANKA CM. Moreover, we investigate the role of free plasma thiols and cell surface thiols in the pathogenesis of CM. Methods P. falciparum was cultured in vitro with varying doses of HS releasing drugs compared with artesunate. Growth and metabolism were quantified. C57Bl/6 mice were infected with P. berghei ANKA and were treated with varying doses and regimes of HS-releasing drugs. Free plasma thiols and cell surface thiols were quantified in CM mice and age-matched healthy controls. Results HS-releasing drugs significantly and dose-dependently inhibited P. falciparum growth and metabolism. Treatment of CM did not affect P. berghei growth, or development of CM. Interestingly, CM was associated with lower free plasma thiols, reduced leukocyte+erythrocyte cell surface thiols (infection day 3), and markedly (5-fold) increased platelet cell surface thiols (infection day 7). Conclusions HS inhibits P. falciparum growth and metabolism in vitro. Reduction in free plasma thiols, cell surface thiols and a marked increase in platelet cell surface thiols are associated with development of CM. HS drugs were not effective in vivo against murine CM.
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Affiliation(s)
- Brian DellaValle
- Centre for Medical Parasitology, Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark.
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Islam N, Bonovas S, Nikolopoulos GK. An epidemiological overview of malaria in Bangladesh. Travel Med Infect Dis 2013; 11:29-36. [PMID: 23434288 DOI: 10.1016/j.tmaid.2013.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 12/17/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
Abstract
Bangladesh is one of the four major malaria-endemic countries in South-East Asia having approximately 34% of its population at risk of malaria. This paper aims at providing an overview of the malaria situation in this country. Relevant information was retrieved from published articles and reports in PubMed and Google Scholar. Malaria in Bangladesh is concentrated in 13 districts with a prevalence ranging between 3.1% and 36%, and is mostly caused by Plasmodium falciparum. Geographical conditions pose a potential risk for Plasmodium knowlesi malaria. Resistance to a number of drugs previously recommended for treatment has been reported. Low socio-economic status, poor schooling and close proximity to water bodies and forest areas comprise important risk factors. Despite the significant steps in Long Lasting Insecticide Net (LLIN)/Insecticide Treated Net (ITN) coverage in Bangladesh, there are still many challenges including the extension of malaria support to the remote areas of Bangladesh, where malaria prevalence is higher, and further improvements in the field of referral system and treatment.
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Affiliation(s)
- Nazrul Islam
- Cyprus International Institute for Environmental and Public Health, Limassol, Cyprus
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38
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Balaji SN, Trivedi V. Extracellular methemoglobin primes red blood cell aggregation in malaria: an in vitro mechanistic study. FEBS Lett 2013; 587:350-7. [PMID: 23313944 DOI: 10.1016/j.febslet.2012.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 12/02/2012] [Accepted: 12/17/2012] [Indexed: 11/28/2022]
Abstract
Toxic byproducts from infected RBC cause rheological alteration and RBC aggregation. Malaria culture supernatant has the ability to exhibit RBC aggregation. Ammonium sulfate fractionation and immunodepletion of methemoglobin from culture supernatant confirms methemoglobin as a major aggregant. In vitro treatment of RBC with methemoglobin induces irreversible high order RBC aggregates, resistant to shear stress and physical forces. Methemoglobin-mediated ROS generation in the external micro-environment to develop oxidative stress close to RBC membrane seems to be responsible for initiating and forming high order RBC aggregates through phosphatidyl-serine externalization. Removal of oxidative stress through antioxidant treatment abolishes high order RBC aggregate formation. In conclusion, we discovered a novel pathway of methemoglobin-mediated RBC aggregation and its potential role in patho-physiological effects during malaria.
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Affiliation(s)
- S N Balaji
- Malaria Research Group, Department of Biotechnology, Indian Institute of Technology-Guwahati, Guwahati 781039, Assam, India
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39
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Abstract
PURPOSE OF REVIEW Artesunate treatment reduces mortality in severe malaria when compared with quinine. Nevertheless, severe malaria is associated with mortality rates between 1.4 and 9.5% after hospitalization. This review puts into context the recent developments in understanding the pathophysiology of malaria and how these may be reflected in renewed attempts at improving adjunct therapies. Identifying new adjunct approaches has been particularly difficult for severe malaria because most interventions have either caused harm or failed to confer benefit. RECENT FINDINGS Imaging and postmortem findings in children with severe and cerebral malaria have given impetus to study new interventions that could be added to antimalarial treatment. Some pilot studies have (re)tested different approaches to improve complications of cerebral malaria such as the use of N-acetyl cysteine or mannitol. Fluids administration, blood transfusions and red cell exchanges in severe malaria are controversial and important areas that are also reviewed with new evidence. Other interventions such as measures to increase nitric oxide, manage acute renal failure or optimize artesunate dosing are discussed. SUMMARY Outcomes with adjunct therapies for severe malaria have been poor, but as insights into pathophysiological processes are deepened it may be possible eventually to reduce mortality further.
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40
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Szakmany T, Hauser B, Radermacher P. N-acetylcysteine for sepsis and systemic inflammatory response in adults. Cochrane Database Syst Rev 2012; 2012:CD006616. [PMID: 22972094 PMCID: PMC6517277 DOI: 10.1002/14651858.cd006616.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Death is common in systemic inflammatory response syndrome (SIRS) or sepsis-induced multisystem organ failure and it has been thought that antioxidants such as N-acetylcysteine could be beneficial. OBJECTIVES We assessed the clinical effectiveness of intravenous N-acetylcysteine for the treatment of patients with SIRS or sepsis. SEARCH METHODS We searched the following databases: Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library 2011, Issue 12); MEDLINE (January 1950 to January 2012); EMBASE (January 1980 to January 2012); CINAHL (1982 to January 2012); the NHS Trusts Clinical Trials Register and Current Controlled Trials (www.controlled-trials.com); LILACS; KoreaMED; MEDCARIB; INDMED; PANTELEIMON; Ingenta; ISI Web of Knowledge and the National Trials Register to identify all relevant randomized controlled trials available for review. SELECTION CRITERIA We included only randomized controlled trials (RCTs) in the meta-analysis. DATA COLLECTION AND ANALYSIS We independently performed study selection, quality assessment and data extraction. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. MAIN RESULTS We included 41 fully published studies (2768 patients). Mortality was similar in the N-acetylcysteine group and the placebo group (RR 1.06, 95% CI 0.79 to 1.42; I(2) = 0%). Neither did N-acetylcysteine show any significant effect on length of stay, duration of mechanical ventilation or incidence of new organ failure. Early application of N-acetylcysteine to prevent the development of an oxidato-inflammatory response did not affect the outcome, nor did late application that is after 24 hours of developing symptoms. Late application was associated with cardiovascular instability. AUTHORS' CONCLUSIONS Overall, this meta-analysis puts doubt on the safety and utility of intravenous N-acetylcysteine as an adjuvant therapy in SIRS and sepsis. At best, N-acetylcysteine is ineffective in reducing mortality and complications in this patient population. At worst, it can be harmful, especially when administered later than 24 hours after the onset of symptoms, by causing cardiovascular depression. Unless future RCTs provide evidence of treatment effect, clinicians should not routinely use intravenous N-acetylcysteine in SIRS or sepsis and academics should not promote its use.
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Affiliation(s)
- Tamas Szakmany
- Department of Anaesthesia, Cwm Taf NHS Trust, Royal Glamorgan Hospital, Llantrisant, UK.
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41
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Anthony MP, Burrows JN, Duparc S, JMoehrle J, Wells TNC. The global pipeline of new medicines for the control and elimination of malaria. Malar J 2012; 11:316. [PMID: 22958514 PMCID: PMC3472257 DOI: 10.1186/1475-2875-11-316] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/21/2012] [Indexed: 12/03/2022] Open
Abstract
Over the past decade, there has been a transformation in the portfolio of medicines to combat malaria. New fixed-dose artemisinin combination therapy is available, with four different types having received approval from Stringent Regulatory Authorities or the World Health Organization (WHO). However, there is still scope for improvement. The Malaria Eradication Research agenda identified several gaps in the current portfolio. Simpler regimens, such as a single-dose cure are needed, compared with the current three-day treatment. In addition, new medicines that prevent transmission and also relapse are needed, but with better safety profiles than current medicines. There is also a big opportunity for new medicines to prevent reinfection and to provide chemoprotection. This study reviews the global portfolio of new medicines in development against malaria, as of the summer of 2012. Cell-based phenotypic screening, and 'fast followers' of clinically validated classes, mean that there are now many new classes of molecules starting in clinical development, especially for the blood stages of malaria. There remain significant gaps for medicines blocking transmission, preventing relapse, and long-duration molecules for chemoprotection. The nascent pipeline of new medicines is significantly stronger than five years ago. However, there are still risks ahead in clinical development and sustainable funding of clinical studies is vital if this early promise is going to be delivered.
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Affiliation(s)
- Melinda P Anthony
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Jeremy N Burrows
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Stephan Duparc
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Joerg JMoehrle
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Timothy NC Wells
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
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42
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Kolyva C, Kingston H, Tachtsidis I, Mohanty S, Mishra S, Patnaik R, Maude RJ, Dondorp AM, Elwell CE. Oscillations in cerebral haemodynamics in patients with falciparum malaria. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 765:101-107. [PMID: 22879021 PMCID: PMC4038006 DOI: 10.1007/978-1-4614-4989-8_15] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Spontaneous oscillations in cerebral haemodynamics studied with near-infrared spectroscopy (NIRS), become impaired in several pathological conditions. We assessed the spectral characteristics of these oscillations in 20 patients with falciparum malaria admitted to Ispat General Hospital, Rourkela, India. Monitoring included continuous frontal lobe NIRS recordings within 24 h of admission (Day 0), together with single measurements of a number of clinical and chemical markers recorded on admission. Seven patients returned for follow-up measurements on recovery (FU). A 2,048 sampling-point segment of oxygenated haemoglobin concentration ([ΔHbO(2)]) data was subjected to Fourier analysis per patient, and power spectral density was derived over the very low frequency (VLF: 0.02-0.04 Hz), low frequency (LF: 0.04-0.15 Hz) and high frequency (HF: 0.15-0.4 Hz) bands. At Day 0, VLF spectral power was 21.1 ± 16.4, LF power 7.2 ± 4.6 and HF power 2.6 ± 5.0, with VLF power being statistically significantly higher than LF and HF (P < 0.005). VLF power tended to decrease in the severely ill patients and correlated negatively with heart rate (r = 0.57, P < 0.01), while LF power correlated positively with aural body temperature (r = 0.49, P < 0.05). In all but one of the patients who returned for FU measurements, VLF power increased after recovery. This may be related to autonomic dysfunction in severe malaria, a topic of little research to date. The present study demonstrated that application of NIRS in a resource-poor setting is feasible and has potential as a research tool.
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Affiliation(s)
- Christina Kolyva
- grid.83440.3b0000000121901201Department of Medical Physics and Bioengineering, University College London, Malet Place Engineering Building, Gower Street, London, WC1E 6BT UK
| | - Hugh Kingston
- grid.10223.320000 0004 1937 0490Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Ilias Tachtsidis
- grid.83440.3b0000000121901201Department of Medical Physics and Bioengineering, University College London, Malet Place Engineering Building, Gower Street, London, WC1E 6BT UK
| | - Sanjib Mohanty
- grid.440315.7Department of Internal Medicine, Ispat General Hospital, Rourkela, India
| | - Saroj Mishra
- grid.440315.7Department of Internal Medicine, Ispat General Hospital, Rourkela, India
| | - Rajya Patnaik
- grid.440315.7Department of Internal Medicine, Ispat General Hospital, Rourkela, India
| | - Richard J. Maude
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Arjen M. Dondorp
- grid.10223.320000 0004 1937 0490Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Clare E. Elwell
- grid.83440.3b0000000121901201Department of Medical Physics and Bioengineering, University College London, Malet Place Engineering Building, Gower Street, London, WC1E 6BT UK
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Alister GC, Mohd Fadzli Mustaffa K. Cytoadherence and severe malaria. Malays J Med Sci 2012; 19:5-18. [PMID: 22973133 PMCID: PMC3431742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 11/15/2011] [Indexed: 06/01/2023] Open
Abstract
Malaria is a disease that causes enormous human morbidity and mortality. One feature of mature Plasmodium falciparum-infected erythrocytes leading to the development of severe malaria is thought to be cytoadherence and blockage of the microvasculature. Therefore, an understanding of mechanisms that mediate parasite adhesion leading to malaria pathology is needed to yield new treatments for malaria. However, to date, cytoadherence-associated pathology is still under debate. Is cytoadherence needed to develop severe malaria? This review will discuss the available information on associations of cytoadherence with the development of severe malaria.
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Affiliation(s)
- G Craig Alister
- Department of Molecular and Biochemical
Parasitology, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA
Liverpool, United Kingdom
| | - Khairul Mohd Fadzli Mustaffa
- Department of Molecular and Biochemical
Parasitology, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA
Liverpool, United Kingdom
- Institute for Research in Molecular
Medicine, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan,
Malaysia
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44
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Oxidative and Nitrosative Stress on Phagocytes’ Function: from Effective Defense to Immunity Evasion Mechanisms. Arch Immunol Ther Exp (Warsz) 2011; 59:441-8. [DOI: 10.1007/s00005-011-0144-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 06/27/2011] [Indexed: 12/12/2022]
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Hanson J, Hasan MMU, Royakkers AA, Alam S, Charunwatthana P, Maude RJ, Douthwaite ST, Yunus EB, Mantha ML, Schultz MJ, Faiz MA, White NJ, Day NP, Dondorp AM. Laboratory prediction of the requirement for renal replacement in acute falciparum malaria. Malar J 2011; 10:217. [PMID: 21813009 PMCID: PMC3199906 DOI: 10.1186/1475-2875-10-217] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 08/03/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute renal failure is a common complication of severe malaria in adults, and without renal replacement therapy (RRT), it carries a poor prognosis. Even when RRT is available, delaying its initiation may increase mortality. Earlier identification of patients who will need RRT may improve outcomes. METHOD Prospectively collected data from two intervention studies in adults with severe malaria were analysed focusing on laboratory features on presentation and their association with a later requirement for RRT. In particular, laboratory indices of acute tubular necrosis (ATN) and acute kidney injury (AKI) that are used in other settings were examined. RESULTS Data from 163 patients were available for analysis. Whether or not the patients should have received RRT (a retrospective assessment determined by three independent reviewers) was used as the reference. Forty-three (26.4%) patients met criteria for dialysis, but only 19 (44.2%) were able to receive this intervention due to the limited availability of RRT. Patients with impaired renal function on admission (creatinine clearance < 60 ml/min) (n = 84) had their laboratory indices of ATN/AKI analysed. The plasma creatinine level had the greatest area under the ROC curve (AUC): 0.83 (95% confidence interval 0.74-0.92), significantly better than the AUCs for, urinary sodium level, the urea to creatinine ratio (UCR), the fractional excretion of urea (FeUN) and the urinary neutrophil gelatinase-associated lipocalcin (NGAL) level. The AUC for plasma creatinine was also greater than the AUC for blood urea nitrogen level, the fractional excretion of sodium (FeNa), the renal failure index (RFI), the urinary osmolality, the urine to plasma creatinine ratio (UPCR) and the creatinine clearance, although the difference for these variables did not reach statistical significance. CONCLUSIONS In adult patients with severe malaria and impaired renal function on admission, none of the evaluated laboratory indices was superior to the plasma creatinine level when used to predict a later requirement for renal replacement therapy.
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Zimmerman GA, Castro-Faria-Neto H. Persistent cognitive impairment after cerebral malaria: models, mechanisms and adjunctive therapies. Expert Rev Anti Infect Ther 2011; 8:1209-12. [PMID: 21073283 DOI: 10.1586/eri.10.117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mimche PN, Taramelli D, Vivas L. The plant-based immunomodulator curcumin as a potential candidate for the development of an adjunctive therapy for cerebral malaria. Malar J 2011; 10 Suppl 1:S10. [PMID: 21411011 PMCID: PMC3059458 DOI: 10.1186/1475-2875-10-s1-s10] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The clinical manifestations of cerebral malaria (CM) are well correlated with underlying major pathophysiological events occurring during an acute malaria infection, the most important of which, is the adherence of parasitized erythrocytes to endothelial cells ultimately leading to sequestration and obstruction of brain capillaries. The consequent reduction in blood flow, leads to cerebral hypoxia, localized inflammation and release of neurotoxic molecules and inflammatory cytokines by the endothelium. The pharmacological regulation of these immunopathological processes by immunomodulatory molecules may potentially benefit the management of this severe complication. Adjunctive therapy of CM patients with an appropriate immunomodulatory compound possessing even moderate anti-malarial activity with the capacity to down regulate excess production of proinflammatory cytokines and expression of adhesion molecules, could potentially reverse cytoadherence, improve survival and prevent neurological sequelae. Current major drug discovery programmes are mainly focused on novel parasite targets and mechanisms of action. However, the discovery of compounds targeting the host remains a largely unexplored but attractive area of drug discovery research for the treatment of CM. This review discusses the properties of the plant immune-modifier curcumin and its potential as an adjunctive therapy for the management of this complication.
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Affiliation(s)
- Patrice N Mimche
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK.
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John CC, Kutamba E, Mugarura K, Opoka RO. Adjunctive therapy for cerebral malaria and other severe forms of Plasmodium falciparum malaria. Expert Rev Anti Infect Ther 2011; 8:997-1008. [PMID: 20818944 DOI: 10.1586/eri.10.90] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe malaria due to Plasmodium falciparum causes more than 800,000 deaths every year. Primary therapy with quinine or artesunate is generally effective in controlling P. falciparum parasitemia, but mortality from cerebral malaria and other forms of severe malaria remains unacceptably high. Long-term cognitive impairment is also common in children with cerebral malaria. Of the numerous adjunctive therapies for cerebral malaria and severe malaria studied over the past five decades, only one (albumin) was associated with a reduction in mortality. In this article, we review past and ongoing studies of adjunctive therapy, and examine the evidence of efficacy for newer therapies, including inhibitors of cytoadherence (e.g., levamisole), immune modulators (e.g., rosiglitazone), agents that increase nitric oxide levels (e.g., arginine) and neuroprotective agents (e.g., erythropoietin).
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Affiliation(s)
- Chandy C John
- Center for Global Pediatrics, 717 Delaware Street SE, Room 363, Minneapolis, MN 55455, USA.
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49
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Waknine-Grinberg JH, McQuillan JA, Hunt N, Ginsburg H, Golenser J. Modulation of cerebral malaria by fasudil and other immune-modifying compounds. Exp Parasitol 2010; 125:141-6. [DOI: 10.1016/j.exppara.2010.01.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 11/12/2009] [Accepted: 01/12/2010] [Indexed: 01/10/2023]
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Maude RJ, Yunus EB, Hoque G, Hassan MU, Hossain A, Samad R, Rahman R, Ghose A, Day NP, White NJ, Dondorp AM, Faiz MA. CMCH and MORU: a Highly Successful Collaboration. JOURNAL OF CHITTAGONG MEDICAL COLLEGE TEACHERS' ASSOCIATION 2010; 20:2-5. [PMID: 34916892 PMCID: PMC7612102 DOI: 10.3329/jcmcta.v20i1.4926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Chittagong Medical College and Hospital (CMCH) in Chittagong, Bangladesh, and Mahidol-Oxford Tropical Medicine Research Unit (MORU) of Bangkok, Thailand, are partners in a highly successful and productive research collaboration that is now heading into its tenth year. It produced arguably one of the most important clinical trials in tropical medicine this decade, the South-East-Asia-Quinine-Artesuante-Malaria-Trial (SEAQUAMAT) study, and has continued to evolve and grow ever since. The collaboration has successfully completed a number of significant clinical studies which have given important new insights into the management and pathogenesis of malaria and, to date, generated 14 peer-reviewed international journal publications. With each passing year, the size of the collaboration continues to increase along with the number and complexity of research studies undertaken. It has also helped to provide valuable postgraduate training to develop clinical services and increase capacity for high quality research in Bangladesh. The partners have complementary knowledge, skills and expertise and share common goals and it is hoped that this will remain a highly successful collaboration long into the future.
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Affiliation(s)
- Richard J. Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | | | | | - Amir Hossain
- Chittagong Medical College, Chittagong, Bangladesh
| | | | | | | | - Nicholas P Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - M. Abul Faiz
- Sir Salimullah Medical College, Dhaka, Bangladesh
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