Predictors of mortality in severe malaria: a two year experience in a non-endemic area

Mouse Models for Unravelling Immunology of Blood Stage Malaria

Malaria comprises a spectrum of disease syndromes and the immune system is a major participant in malarial disease. This is particularly true in relation to the immune responses elicited against blood stages of Plasmodium-parasites that are responsible for the pathogenesis of infection. Mouse models of malaria are commonly used to dissect the immune mechanisms underlying disease. While no single mouse model of Plasmodium infection completely recapitulates all the features of malaria in humans, collectively the existing models are invaluable for defining the events that lead to the immunopathogenesis of malaria. Here we review the different mouse models of Plasmodium infection that are available, and highlight some of the main contributions these models have made with regards to identifying immune mechanisms of parasite control and the immunopathogenesis of malaria.

Prevention and Therapy of AKI in Asia: A Big Challenge

Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.

Is Malaria an Important Cause of Death among Adults?

A long-held assumption has been that nearly all malaria deaths in high-transmission areas are of children younger than 5 years and pregnant women. Most global malaria mortality estimates incorporate this assumption in their calculations. In 2010, the Indian Million Death Study, which assigns cause of death by verbal autopsy (VA), challenged the reigning perception, producing a U-shaped mortality age curve, with rates rising after age 45 years in areas of India with substantial malaria transmission. Similar patterns are seen in Africa in the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) network, also relying on VA. Whether these results are accurate or are misidentified deaths can be resolved by improving the evidence for assigning causes for adult acute infectious deaths in high malaria transmission areas. The options for doing so include improving the accuracy of VA and adding postmortem biological evidence, steps we believe should be initiated without delay.

Artesunate compared with quinine for the treatment of severe malaria in adult patients managed in an intensive care unit: A retrospective observational study

Background

There are limited South African data on the outcomes of patients with severe malaria treated with quinine compared with those treated with artesunate in the intensive care unit (ICU).

Objectives

To compare the outcomes of adult patients treated with artesunate against those treated with quinine in the ICU. Primary outcome variables are length of stay (LOS) in the ICU and mortality. Secondary outcomes include the incidence of hypoglycaemic episodes and neurological outcomes.

Methods

This was a retrospective cohort study of patients with severe malaria treated at a multidisciplinary ICU with artesunate or quinine from 1 January 2008 to 31 December 2012.

Results

Of the 92 patients included in the study, 63 (69.2%) were male. The mean age in the quinine and artesunate groups was 36.2 years and 40.5 years, respectively (p=0.071). Most (98.6%) of the patients with a positive travel history had visited a malaria-endemic region. Of the 53 patients tested for HIV infection, 71.7% tested positive (p=0.520). The average CD4+ cell count of HIV-positive patients treated with quinine was 200 cells/µL compared with 217.17 cells/µL for those treated with artesunate (p=0.875). The mean APACHE II score at admission was 20.85 and 19.62 in the quinine group and artesunate group, respectively (p=0.380). The median LOS was 5 days (range 1 - 27). Mortality was 15.4% in the quinine group and 7.7% in the artesunate group (p=0.246).

Conclusion

A statistically insignificant mortality difference was observed in outcomes of the two treatment groups in this retrospective, single-centre cohort study.

Contributions of the study

Intravenous artesunate is currently the preferred treatment in the management of patients with severe malaria. However, there are limited local data on the outcomes of artesunate v. quinine therapy for the management of severe malaria in highly monitored clinical environments in non-endemic regions of South Africa.We describe clinical characteristics, management and outcomes of patients with severe malaria treated with quinine and those treated with artesunate in the ICU in a non-endemic region.

Acute Kidney Injury of Infectious Etiology in Monsoon Season: A Prospective Study Using Acute Kidney Injury Network Criteria

The epidemiological pattern of acute kidney injury (AKI) in tropical countries during monsoon reflects infectious disease as the most important cause. AKI is a confounding factor and may be overlooked by primary health-care providers and underreported in health statistics. The present study prospectively helps estimate the burden of disease and analyze etiology, clinical profile, and outcome in a tertiary care hospital of a metropolitan city in a tropical country. The study period included monsoon season of 2012 and 2013, a total of 8 months. AKI staging was done as per the AKI Network (AKIN) criteria. Patients were treated for primary disease. Renal replacement therapy (RRT) was given as required. Patients were followed up during hospitalization till recovery/death. Out of a total of 9930 admissions during this period, 1740 (17.52%) were for infections and 230 (2.31%) had AKI secondary to infectious diseases during monsoon. The incidence of AKI (230/1740) in infectious diseases during monsoon was 13.21%. The study population (n = 230) comprised 79.5% of males and the mean age was 40.95 ± 16.55 years. Severe AKI: AKIN Stage III was seen in 48.26% of patients and AKIN Stage I in 41.74%. The most common etiology of AKI was malaria (28.3%) followed by acute gastroenteritis (23%), dengue (16.5%), leptospirosis (13%), undifferentiated fever (10.4%), more than one etiology (5.4%), and enteric fever (3.5%). RRT was required in 44.78% of patients. Requirement for RRT was maximum in patients with more than one etiology followed by leptospirosis, malaria, dengue, and least in typhoid. The overall mortality was 12.17%. In multivariate analysis, vasopressor support and assisted ventilation were risk factors for mortality.

Factors associated with severe malaria among children below ten years in Mutasa and Nyanga districts, Zimbabwe, 2014-2015

INTRODUCTION

Severe malaria is a rare life threatening illness. Only a small proportion of patients with clinical malaria progress to this medical emergency. On reviewing 61 malaria death investigation forms submitted to the provincial office in 2014, 22(36%) were children below ten years who succumbed to severe malaria. Mutasa and Nyanga Districts reported 73% of these deaths. This study was conducted to determine factors associated with severe malaria so as to come up with evidence based interventions to prevent severe malaria and associated mortality.

METHODS

A 1:2 unmatched case control study was conducted. A case was defined as a child 10 years and below, who was admitted at Hauna (Mutasa) or Nyanga District Hospitals between September 2014 and May 2015 with a primary diagnosis of severe malaria. Controls were children of similar age with uncomplicated malaria. Permission to conduct the study was sought and granted by the Medical Research Council of Zimbabwe (Approval number B/874), Joint Research Ethics Committee, Health Studies Office and the Manicaland Directorate Institutional Review Board. Written informed consent was sought from all caregivers of enrolled children. Interviewer administered questionnaires were used to ascertain exposures.

RESULTS

A total of 52 cases and 104 controls were enrolled into the study. The median age of cases was 4 years (Q₁=3, Q₃=9) and 6 years for controls (Q₁=3, Q₃=8). The Case Fatality Rate among cases was 28.8%. The independent risk factors for severe malaria were; distance >10km to the nearest health facility [Adjusted Odds Ratio (aOR)=14.35, 95% CI=1.30, 158.81], duration of symptoms before seeking medical care >2 days [aOR=9.03, 95% CI=2.21, 36.93], having comorbidities [aOR=5.38, 95% CI=1.90, 15.19], staying in a house under construction [aOR=4.51, 95%CI=1.80, 11.32] and duration of illness before receiving antimalarial medicines >24 hours [aOR=3.82, 95% CI=1.44, 10.12]. Owning at least one ITN in the household [aOR=0.32, 95% CI=0.11, 0.95] and having a mother as a caregiver [aOR=0.23, 95% CI=0.09, 0.76] were independently protective of severe malaria. Being undernourished [Odds Ratio (OR)=10.13, 95% CI=1.04, 98.49] and being female [OR=0.27, 95% CI=0.08, 0.96] were associated with mortality owing to severe malaria.

CONCLUSION

Factors associated with severe malaria and mortality owing to severe malaria identified in this study are consistent with other studies. Caregiver healthcare seeking behaviours, patient related factors and health system related factors are important determinants of severe malaria among children. There is need for regular health education campaigns emphasizing on malaria prevention, signs and symptoms and benefits of seeking medical care immediately for sick children.

The fluid management of adults with severe malaria

Fluid resuscitation has long been considered a key intervention in the treatment of adults with severe falciparum malaria. Profound hypovolemia is common in these patients and has the potential to exacerbate the acidosis and acute kidney injury that are independent predictors of death. However, new microvascular imaging techniques have shown that disease severity correlates more strongly with obstruction of the microcirculation by parasitized erythrocytes - a process termed sequestration. Fluid loading has little effect on sequestration and increases the risk of complications, particularly pulmonary edema, a condition that can develop suddenly and unpredictably and that is frequently fatal in this population. Accordingly, even if a patient is clinically hypovolemic, if there is an adequate blood pressure and urine output, there may be little advantage in infusing intravenous fluid beyond a maintenance rate of 1 to 2 mL/kg per hour. The optimal agent for fluid resuscitation remains uncertain; significant anemia requires blood transfusion, but colloid solutions may be associated with harm and should be avoided. The preferred crystalloid is unclear, although the use of balanced solutions requires investigation. There are fewer data to guide the fluid management of severe vivax and knowlesi malaria, although a similar conservative strategy would appear prudent.

Managing malaria in the intensive care unit

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.

Imported falciparum malaria among adults requiring intensive care: analysis of the literature

Background

Malaria is the most important imported tropical disease. Infection with Plasmodium falciparum is responsible for most of the morbidity and mortality. There are differences in both the epidemiology of imported malaria and in the facilities available to treat travellers with severe malaria between different parts of the world. There are limited data to guide clinicians caring for adults with imported malaria in an intensive care unit (ICU). Available data from the English-speaking literature concerning such patients was reviewed.

Methods

PubMed was searched for studies on adults with imported malaria treated in an ICU. Data were extracted on the epidemiology, management, rates of concomitant community-acquired bacterial infection and outcomes.

Results

Thirteen studies were identified, which between them included 1,001 patients over more than 40 years. Forty-one per cent were born and often still resident in an endemic country and were assumed to have at least partial immunity to the disease. Acute kidney injury (AKI) (36%), acute respiratory distress syndrome (ARDS) (31%) and impaired consciousness (25%) were common. Hyperparasitaemia (more than 2%) was seen in 57%. Thirty-four per cent required mechanical ventilation and 22% required renal replacement therapy. Community-acquired bacterial co-infection was seen in 8%; 2% had gram-negative bacteraemia at admission. Overall the case fatality rate was 9%.

Conclusions

Many patients who require admission to ICU were originally from malaria-endemic countries and many did not have hyperparasitaemia. Gram-negative bacteraemia was uncommon among adults with severe malaria. The case fatality rate remains high; however, improvements in ICU care and increasing use of artemisinins may reduce this in the future.

Reducing the delay in initiation of treatment improved clinical outcomes in patients with imported malaria

Although imported malaria poses a grave public health threat in Japan, diagnostic methods and disease management among patients and primary care providers has rarely been reported. Here, we retrospectively reviewed medical records of patients diagnosed with imported malaria in our hospital from 1991 to 2010. Thirty-four malaria cases were identified, corresponding to approximately 2% of the total number of cases in Japan. Falciparum malaria has become predominant in the last 2 decades, and compared with patients in the earlier decade (1991-2000), patients in the latter decade (2001-2010) showed significantly shorter delays in consulting medical facilities. The overall hospital delay also tended to be shorter in the latter decade, although delayed referral of patients by a week or more was still observed in more than one-third of the cases. The prevalence of risk factors for severe malaria among patients on the day of the referral visit was also lower in the latter decade. Further, the number of WHO-defined cases of severe malaria was smaller, and the length of the hospital stay was not prolonged during that decade. These findings indicated that a shorter delay in seeking medical treatment could reduce the risks of severe malaria.

Extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome in severe malaria

Background

Severe malaria may be complicated by the acute respiratory distress syndrome (ARDS), which is associated with a high mortality. In the present report, a series of three cases of imported malaria complicated by refractory severe ARDS supported with extracorporeal membrane oxygenation (ECMO) is presented.

Methods

One female and two male adult patients (ages 39 to 53) were included. Two patients had Plasmodium falciparum infection and one patient had Plasmodium vivax and Plasmodium ovale co-infection. Anti-malarial therapy consisted in intravenous quinine (in two patients) and intravenous quinidine (in one patient), plus clindamycin or doxycycline.

Results

Despite lung protective ventilation, a conservative strategy of fluid management, corticosteroids (two patients), prone position (two patients) and inhaled nitric oxide (one patient), refractory severe ARDS supervened (PaO₂ to FiO₂ ratio 68) and venovenous ECMO was then initiated. In one patient, a bicaval dual-lumen cannula was inserted; in the two other patients, a two-site configuration was used. Two patients survived to hospital-discharge (duration of ECMO support: 8.5 days) and one patient died from nosocomial sepsis and multi-organ failure after 40 days of ECMO support.

Conclusions

ECMO support allowed adequate oxygenation and correction of hypercapnia under lung protective ventilation, therefore reducing ventilator-induced lung injury. ECMO referral should be considered early in malaria complicated by severe ARDS refractory to conventional treatment.

Changing epidemiology of community-acquired acute kidney injury in developing countries: analysis of 2405 cases in 26 years from eastern India

Background

The epidemiology of acute kidney injury (AKI) differs from country to country and varies from center to center within a country. Owing to the absence of a central registry, data on overall epidemiology of AKI are scanty from India.

Methods

This study aimed at describing changes in epidemiology of community-acquired AKI (CAAKI) over a time span of 26 years in two study periods, namely, 1983–95 and 1996–2008.

Results

We studied 2405 (1375 male and 1030 female) cases of AKI in the age range 1–95 (mean: 40.32) years. The incidence of CAAKI in 1983–95 and 1996–2008 was 1.95 and 4.14 per 1000 admission, respectively (P < 0.01). Obstetrical AKI has decreased because of the declining number of post-abortal AKI. Surgical AKI decreased from 13.8% in 1983–95 to 9.17% in 1996–2008(P < 0.01). Malarial AKI increased significantly from 4.7% in the first half of the study to 17% in the later period (P < 0.01). Diarrhea-associated AKI had significantly decreased from 36.83% in 1983–95 to 19% in 1996–2008 (P < 0.01). Sepsis-related AKI had increased from 1.57% in 1983–95 to 11.43% in 1996–2008 (P < 0.01). Nephrotoxic AKI showed an increasing trend in recent years (P < 0.01) and mainly caused by rifampicin and NSAIDs. Liver disease-related AKI increased from 1.73% in 1983–95 to 3.17% in 1996–2008 (P < 0.01). Myeloma-associated acute renal failure (ARF) accounted for 1.25% of the total number of ARF cases in the period 1996–2008. HIV infection contributed to 1.65% of ARF of the total number of AKI cases in the second period (1996–2008). Incidence of renal cortical necrosis (RCN) decreased significantly from 5.8% in 1983–95 to 1.3% in 1996–2008 of the total number of ARF cases (P < 0.01). However, during the same period ARF due to acute tubular necrosis, acute glomerulonephritis and acute interstitial nephritis remained unchanged. The mortality rate from AKI decreased significantly from 20% in 1983–95 to 10.98% in 1996–2008 (P < 0.01).

Conclusions

The epidemiological characteristics of CAAKI have changed over the past three decades. There has been an increase in the overall incidence of ARF with the changing etiology of AKI in recent years. Incidences of obstetrical, surgical and diarrheal AKI have decreased significantly, whereas those of AKI associated with malaria, sepsis, nephrotoxic drugs and liver disease have increased. RCN has decreased significantly. In contrast to developed nations, community-acquired AKI is more common in developing countries. It often affects younger individuals and is caused by single and preventable diseases.

Respiratory manifestations of malaria

Respiratory distress develops in up to 25% of adults and 40% of children with severe falciparum malaria. Its diverse causes include respiratory compensation of metabolic acidosis, noncardiogenic pulmonary edema, concomitant pneumonia, and severe anemia. Patients with severe falciparum, vivax, and knowlesi malaria may develop acute lung injury (ALI) and ARDS, often several days after antimalarial drug treatment. ARDS rates, best characterized for severe Plasmodium falciparum, are 5% to 25% in adults and up to 29% in pregnant women; ARDS is rare in young children. ARDS pathophysiology centers on inflammatory-mediated increased capillary permeability or endothelial damage leading to diffuse alveolar damage that can continue after parasite clearance. The role of parasite sequestration in the pulmonary microvasculature is unclear, because sequestration occurs intensely in P falciparum, less so in P knowlesi, and has not been shown convincingly in P vivax. Because early markers of ALI/ARDS are lacking, fluid resuscitation in severe malaria should follow the old adage to "keep them dry." Bacteremia and hospital-acquired pneumonia can complicate severe malaria and may contribute to ALI/ARDS. Mechanical ventilation can save life in ALI/ARDS. Basic critical care facilities are increasingly available in tropical countries. The use of lung-protective ventilation has helped to reduce mortality from malaria-induced ALI/ARDS, but permissive hypercapnia in unconscious patients is not recommended because increased intracranial pressure and cerebral swelling may occur in cerebral malaria. The best antimalarial treatment of severe malaria is IV artesunate.

The use of Drotrecogin Alfa in Severe Falciparum Malaria

We report the case of a 55-year-old male European who became septic after he returned from a four-week holiday to Uganda. Soon after, he was diagnosed with severe falciparum malaria and developed multi-organ failure. Due to the worsening condition of the patient, drotrecogin alfa (activated) was started, soon after which the patient's condition significantly improved. He returned home on day 36 after admission, without neurologic sequelae.

Looking at those few cases of severe forms of malaria where drotrecogin alfa (activated) was successfully used, it should at least be considered for administration in patients with severe falciparum malaria with disseminated intravascular coagulation and cerebral involvement who do not respond to or deteriorate during standard treatment.

Ursodeoxycholic acid and artesunate in the treatment of severe falciparum malaria patients with jaundice

BACKGROUND AND AIMS

Plasmodium falciparum (PF) infection can lead to severe complications. Ursodeoxycholic acid (UDCA) is increasingly used for the treatment of cholestatic liver diseases. The present study aims to determine the effects of combined UDCA and artesunate compared to placebo and artesunate on the improvement of liver tests in severe PF jaundiced patients.

METHODS

All severe PF jaundiced patients, aged > or = 15 years and diagnosed as having severe malaria according to WHO 2000 criteria, were enrolled. Patients with evidence of biliary obstruction, other cholestatic liver diseases and those who were pregnant were excluded. Patients were randomized to receive either oral UDCA or placebo for 2 weeks in additional to artesunate. All patients were admitted for at least 14 days to monitor the result of the treatment.

RESULTS

Seventy-four severe PF malaria patients with jaundice were enrolled. Both groups had similar demographic and laboratory tests, with the exception being more males in the UDCA group than in the placebo group (P = 0.04). The median of percentage change of total bilirubin and aminotransferase levels at the end of weeks 1, 2, 3 and 4 showed no difference between the two groups. Only the median of percentage change of alkaline phosphatase at the end of week one compared with the baseline values showed less increment in the UDCA group than in the placebo group (P = 0.04). No serious adverse events were seen during the 4 weeks of follow up.

CONCLUSIONS

In severe PF malaria patients with jaundice, combined therapy with UDCA and artesunate is safe, but does not significantly improve liver tests compared to placebo and artesunate.

Drotrecogin alfa (activated) in severe falciparum malaria

Drotrecogin alfa (activated) is a drug licensed for the treatment of severe sepsis. We describe the care of a 61-year-old man who developed multi-organ failure secondary to severe falciparum malaria infection with parasitaemia levels of 40%. Included in his care were an exchange blood transfusion and an infusion of Drotrecogin alfa (activated). Within hours of starting the infusion of Drotrecogin alfa (activated), the patient's clinical condition stopped deteriorating. Steady improvement followed with weaning from ventilatory assistance on day 14 post admission. The patient made a full recovery and was discharged home following rehabilitation. The indications for Drotrecogin alfa (activated) and the appropriateness of its use in severe malaria with multi-organ failure are discussed. Drotrecogin alfa (activated) may be a useful treatment in patients with multi-organ failure resulting from severe malaria.

Severe imported malaria: Clinical presentation at the time of hospital admission and outcome in 42 cases diagnosed from 1996 to 2002

The objectives of this retrospective study were to describe initial clinical profiles and subsequent outcome of adult patients in France who were diagnosed with severe imported malaria, as defined by the World Health Organization (WHO). Forty-two patients diagnosed from 1996 to 2002 were included (median age: 30 years, men: 78%, non-immune persons: 74%, return from Africa: 100%, inappropriate antimalarial chemoprophylaxis: 95%). At the time of hospital admission, jaundice (62%), hyperparasitemia (56%), and prostration (52%) were the most frequent findings, followed by acute renal failure (31%). Other findings, as described by the WHO criteria, were less common. Twenty-three patients presented only with jaundice, hyperparasitemia, or prostration in isolation, or in combination. Of these 23, five non-immune persons subsequently developed coma, shock, acute respiratory distress syndrome or acute renal failure; this led to death in 2 of these cases. This suggests that non-immune persons with imported malaria who present with jaundice, hyperparasitemia, or prostration should be admitted to the intensive care unit for close monitoring.

Increased prevalence of severe malaria in HIV-infected adults in South Africa

BACKGROUND

Conflicting reports exist regarding the impact of human immunodeficiency virus (HIV) infection on the risk of severe malaria. We aimed to assess the effect of HIV infection status, advancing immunosuppression, and antimalarial immunity on the severity of malaria.

METHODS

A prospective cohort study was conducted. Consecutive hospitalized adult patients with falciparum malaria were tested for HIV antibodies and to determine CD4+ T cell count. Immunity to malaria was assessed by obtaining a history of childhood residence in an area where malaria is endemic. Patients were assessed for features of severe malaria.

RESULTS

Three hundred thirty-six patients were enrolled in the study, of whom 32 (10%) had severe malaria. The prevalence of HIV infection was 33%, and 111 patients (33%) were nonimmune to malaria. HIV-infected patients complained more frequently about respiratory and abdominal symptoms and less frequently about rigors and headache. Risk factors for severe malaria determined by multivariate analysis included being nonimmune to malaria, having a positive HIV serostatus, having an elevated parasite count, and having an increased white blood cell count. Risk of severe malaria was increased in HIV-infected patients with a CD4+ T cell count of < 200 x 10(6) cells/L (P < or = .001). Nonimmune HIV-infected patients were significantly more likely to have severe malaria (13 [36%] of 36 patients) than were nonimmune non-HIV-infected patients (9 [12%] of 75 patients; odds ratio, 4.15 [95% confidence interval, 1.57-10.97]; P = .003). HIV serostatus did not affect risk of severe malaria in the group from an area with endemicity (5 [7%] of 74 HIV-infected patients had severe malaria, and 5 [3%] of 151 non-HIV-infected patients had malaria; P = .248).

CONCLUSIONS

HIV-infected nonimmune adults are at increased risk of severe malaria. This risk is associated with a low CD4+ T cell count. This interaction is of great public health importance.

Clinical review: Severe malaria

Malaria represents a medical emergency because it may rapidly progress to complications and death without prompt and appropriate treatment. Severe malaria is almost exclusively caused by Plasmodium falciparum. The incidence of imported malaria is increasing and the case fatality rate remains high despite progress in intensive care and antimalarial treatment. Clinical deterioration usually appears 3-7 days after onset of fever. Complications involve the nervous, respiratory, renal, and/or hematopoietic systems. Metabolic acidosis and hypoglycemia are common systemic complications. Intravenous quinine and quinidine are the most widely used drugs in the initial treatment of severe falciparum malaria, whereas artemisinin derivatives are currently recommended for quinine-resistant cases. As soon as the patient is clinically stable and able to swallow, oral treatment should be given. The intravascular volume should be maintained at the lowest level sufficient for adequate systemic perfusion to prevent development of acute respiratory distress syndrome. Renal replacement therapy should be initiated early. Exchange blood transfusion has been suggested for the treatment of patients with severe malaria and high parasitemia. For early diagnosis, it is paramount to consider malaria in every febrile patient with a history of travel in an area endemic for malaria.

Renal dysfunction in children with uncomplicated, Plasmodium falciparum malaria in Tamale, Ghana

In a study performed in Tamale, in the Northern region of Ghana, cystatin C, a new and sensitive indicator of the glomerular filtration rate (GFR), was used to estimate the frequency of renal dysfunction in 78 children with uncomplicated, Plasmodium falciparum malaria. The excretion in urine of albumin, immunoglobulin G and alpha1-microglobulin was also investigated. Plasma concentrations of cystatin C were found to be elevated in 17% of the children, indicating subclinical impairment of renal function. As most (85%) of the children had glomerular as well as tubular patterns of proteinuria, it appears that both glomerulonephritis and damage to tubular cells often occur in P. falciparum malaria.

The clinical spectrum of severe imported falciparum malaria in the intensive care unit: report of 188 cases in adults

Little is known about severe imported malaria in nonendemic industrialized countries. The purpose of this retrospective study was to describe the clinical spectrum of severe imported malaria in adults and to determine factors that were present at admission and were associated with in-intensive care unit mortality. This retrospective study evaluated the 188 patients who were admitted to our intensive care unit in 1988-1999 with severe and/or complicated imported malaria. Among them, 93 had strictly defined severe malaria, and 95 had less severe malaria. The mean age was 38 years, 51% of patients were nonimmune whites, 94% acquired Plasmodium falciparum in sub-Saharan Africa, and 96% had taken inadequate antimalarial chemoprophylaxis. Mortality was 11% (10 patients) in the severe malaria group, whereas no patients died in the less severe malaria group (p = 0.002). In the bivariable analysis, the main factors associated with death in the severe malaria group were the Simplified Acute Physiology Score, shock, acidosis, coma, pulmonary edema (p < 0.001 for each), and coagulation disorders (p = 0.002). Bacterial coinfection is not infrequent and may contribute to death. Severe imported malaria remains a major threat to travelers. In our population, the most relevant World Health Organization major defining criteria were coma, shock, pulmonary edema, and acidosis.

Renal dysfunction in falciparum--malaria is detected more often when assessed by serum concentration of cystatin C instead of creatinine

OBJECTIVES

To estimate the frequency of renal dysfunction in falciparum malaria by serum concentration of cystatin C, a new sensitive indicator of the glomerular filtration rate (GFR).

METHODS

Retrospective study of stored sera and patient files. Assessment of renal function by serum concentration of creatinine and cystatin C and comparison of the results from both indicators of GFR.

RESULTS

A total of 108 adult patients with falciparum malaria were included in the study. Concentration of creatinine and cystatin C correlated well (r = 0.706; P < 0.001). Elevated cystatin C was more frequent than elevated creatinine (54.6%vs. 20.4%; P < 0.001). Patients older than 50 years developed renal dysfunction more often (P < 0.05) than younger ones. Results from cystatin C and creatinine were concordant in 63 (58.3%) and contradictory in 45 (41.6%) cases. Four (3.7%) patients had elevated creatinine but normal cystatin C levels, hence 63 patients (58.3%) showed elevation of at least one indicator of GFR. The frequency of elevated cystatin C and elevated creatinine was unrelated to body weight, gender or bilirubin level.

CONCLUSIONS

The prevalence of impaired renal function in patients with falciparum malaria seems to have been underestimated in the past. Using a sensitive marker, 55% of the patients have a reduced GFR.

Adult respiratory distress syndrome in the tropics

Today ARDS is more frequently recognized and managed in tropical countries, although published data from most locations is meager. The spectrum of disorders causing ARDS in tropical countries includes virtually all conditions encountered in the West. Additionally, tropical infections and other disorders are seen far more commonly. In particular, malaria and TB are important infections that predispose patients to ARDS in the tropics. Both of these illnesses give lead to severe forms of disease, such as falciparum malaria, acute miliary TB or TB bronchopneumonia, and may cause ARDS. Awareness of the complications helps in early recognition and differential diagnosis from several similar manifestations. Although earlier reports painted a gloomy picture of the outcome of these patients in general--mainly due to financial and logistic constraints--the scenario is improving quickly with better and wider availability of newer diagnostic and management tools.

Malaria and the lung

Pulmonary edema that results from increased pulmonary capillary permeability is the most important pulmonary manifestation of malaria. It is a common feature of severe malaria but also occurs rarely in milder disease. Mortality rate is high. The pathophysiologic basis is unclear. In the field, there is much clinical overlap between malaria and pneumonia in children. For physicians in nonmalarial areas, malaria always should be considered in the differential diagnosis of a sick patient who has traveled to a malaria-endemic area. More research is needed to better define and tailor treatments for malarial and nonmalarial ALI and ARDS.

[Severe malaria in expatriates in an intensive care unit in Abidjan (Ivory Coast)]

OBJECTIVE

To analyse clinical and prognosis aspects of severe malaria in expatriates hospitalized between 1990 and 1999 in the intensive care unit in Abidjan.

STUDY DESIGN

Retrospective survey.

METHODS

According to the World Health Organization's criteria, the retrospective study of severe cases of malaria who received treatment and care at the intensive care unit. Epidemiological, clinical manifestations and evolution were analysed on each patients.

RESULTS

66 upon 927 expatriates hospitalised in the period of the study, had severe malaria with falciparum Plasmodium (7.12%). The average age was 42 years. Eleven patients took prophylactic treatment (17%). The clinical aspects were neurological (83%) followed by renal failure (48%), haemoglobinuria (48%) and hyperparasitemia (59%). During the hospitalisation we recorded 12 deaths (18%). The criteria that were associated with mortality in pejorative order were: coma (RR = 8.04), respiratory distress (RR = 5.06), metabolic acidosis (RR = 5.06), shock (RR = 3.67) and convulsions (RR = 2.86).

CONCLUSION

Severe malaria was frequent and associated with high mortality in expatriates who are living in Africa. This study reinsists the necessity of prophylactic treatment to be reinforced in informing the travellers. This study showed frequency and mortality rate of survey of malaria and the criteria associated with high mortality rate.

Severe falciparum malaria in five soldiers from East Timor: a case series and literature review

Despite chemoprophylaxis, malaria remains a serious threat for large numbers of non-immune soldiers deployed in endemic areas. Five adult cases of severe falciparum malaria are reported. Three cases were complicated by multiorgan failure and one of these patients died from cerebral malaria. These cases serve to highlight issues, in an Australian intensive care unit, associated with the management of severe malaria, an uncommon disease in our country. The need for rapid diagnosis and commencement of appropriate treatment is paramount in preventing further morbidity and mortality. Understanding and management of malaria continues to evolve rapidly. The pathophysiology of acute lung injury, shock and brain injury associated with malaria are examined in light of recent research. This article discusses the current controversies of exchange blood transfusion and the use of the new artemisinin derivatives.

Fulminant tracheobronchial and pulmonary aspergillosis complicating imported Plasmodium falciparum malaria in an apparently immunocompetent woman

We describe an unusual case of fulminant tracheobronchial and pulmonary aspergillosis presenting as acute respiratory distress syndrome. The patient, who was apparently immunocompetent, was admitted with severe Plasmodium falciparum malaria but died from aspergillosis.

Critical care in Africa. North to south and the future with special reference to southern Africa

The medical fraternity in Africa needs to ration resource allocation and aptly apply distributive justice. At present, pockets of Intensive Care Units are held together largely by individuals. Unless the correct assistance and support is provided to develop its vast potential, African Intensive Care will degenerate into primary health care.