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Orish V, Afutu L, Ayodele O, Likaj L, Marinkovic A, Sanyaolu A. A 4-Day Incubation Period of Plasmodium falciparum Infection in a Nonimmune Patient in Ghana: A Case Report. Open Forum Infect Dis 2019; 6:ofy169. [PMID: 30680293 PMCID: PMC6335624 DOI: 10.1093/ofid/ofy169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/24/2018] [Indexed: 12/21/2022] Open
Abstract
Plasmodium falciparum can cause severe infection and has the shortest incubation period compared with all the other Plasmodium species. Incubation periods of 9–14 days for the immune and 6–14 days for the nonimmune have been reported for P. falciparum. However, an incubation period of less than 5 days has not been reported, as of yet. This report presents a case of a 23-year-old nonimmune female who presented with signs and symptoms 4 days after being bitten by mosquitoes while visiting Ghana. The patient was successfully treated with a 1-day course of parenteral artesunate, followed by a 3-day course of oral artemisinin combination therapy.
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Affiliation(s)
- Verner Orish
- Department of Microbiology and Immunology, School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Leslie Afutu
- School of Biomedical and Forensic Sciences, University of Cape Coast, Cape Coast, Central Region, Ghana.,Cocoa Clinic, Ghana Cocoa Board, Accra, Ghana
| | | | | | | | - Adekunle Sanyaolu
- Federal Ministry of Health, Abuja, Nigeria.,Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Idi-araba, Lagos, Nigeria
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Wah ST, Hananantachai H, Kerdpin U, Plabplueng C, Prachayasittikul V, Nuchnoi P. Molecular basis of human cerebral malaria development. Trop Med Health 2016; 44:33. [PMID: 27708543 PMCID: PMC5037602 DOI: 10.1186/s41182-016-0033-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/14/2016] [Indexed: 12/18/2022] Open
Abstract
Cerebral malaria is still a deleterious health problem in tropical countries. The wide spread of malarial drug resistance and the lack of an effective vaccine are obstacles for disease management and prevention. Parasite and human genetic factors play important roles in malaria susceptibility and disease severity. The malaria parasite exerted a potent selective signature on the human genome, which is apparent in the genetic polymorphism landscape of genes related to pathogenesis. Currently, much genomic data and a novel body of knowledge, including the identification of microRNAs, are being increasingly accumulated for the development of laboratory testing cassettes for cerebral malaria prevention. Therefore, understanding of the underlying complex molecular basis of cerebral malaria is important for the design of strategy for cerebral malaria treatment and control.
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Affiliation(s)
- Saw Thu Wah
- Department of Clinical Microscopy, Faculty of Medical Technology, Mahidol University, Bangkok, 10700 Thailand
| | | | - Usanee Kerdpin
- Department of Chemistry, Faculty of Science, Naresuan University, Phitsanulok, 65000 Thailand
| | - Chotiros Plabplueng
- Department of Clinical Microscopy, Faculty of Medical Technology, Mahidol University, Bangkok, 10700 Thailand ; Center for Research and Innovation, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand
| | - Virapong Prachayasittikul
- Department of Clinical Microbiology and Applied Technology, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand
| | - Pornlada Nuchnoi
- Department of Clinical Microscopy, Faculty of Medical Technology, Mahidol University, Bangkok, 10700 Thailand ; Center for Research and Innovation, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand
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Quadros Gomes BA, da Silva LFD, Quadros Gomes AR, Moreira DR, Dolabela MF, Santos RS, Green MD, Carvalho EP, Percário S. N-acetyl cysteine and mushroom Agaricus sylvaticus supplementation decreased parasitaemia and pulmonary oxidative stress in a mice model of malaria. Malar J 2015; 14:202. [PMID: 25971771 PMCID: PMC4435846 DOI: 10.1186/s12936-015-0717-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/27/2015] [Indexed: 12/17/2022] Open
Abstract
Background Malaria infection can cause high oxidative stress, which could lead to the development of severe forms of malaria, such as pulmonary malaria. In recent years, the role of reactive oxygen species in the pathogenesis of the disease has been discussed, as well as the potential benefit of antioxidants supplementation. The aim of this study was to investigate the effects of N-acetyl cysteine (NAC) or mushroom Agaricus sylvaticus supplementation on the pulmonary oxidative changes in an experimental model of malaria caused by Plasmodium berghei strain ANKA. Methods Swiss male mice were infected with P. berghei and treated with NAC or AS. Samples of lung tissue and whole blood were collected after one, three, five, seven or ten days of infection for the assessment of thiobarbituric acid reactive substances (TBARS), trolox equivalent antioxidant capacity (TEAC), nitrites and nitrates (NN) and to assess the degree of parasitaemia. Results Although parasitaemia increased progressively with the evolution of the disease in all infected groups, there was a significant decrease from the seventh to the tenth day of infection in both antioxidant-supplemented groups. Results showed significant higher levels of TEAC in both supplemented groups, the highest occurring in the group supplemented with A. sylvaticus. In parallel, TBARS showed similar levels among all groups, while levels of NN were higher in animals supplemented with NAC in relation to the positive control groups and A. sylvaticus, whose levels were similar to the negative control group. Conclusion Oxidative stress arising from plasmodial infection was attenuated by supplementation of both antioxidants, but A. sylvaticus proved to be more effective and has the potential to become an important tool in the adjuvant therapy of malaria. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0717-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruno A Quadros Gomes
- Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém, Pará, Brazil.
| | - Lucio F D da Silva
- Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém, Pará, Brazil.
| | - Antonio R Quadros Gomes
- Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém, Pará, Brazil.
| | - Danilo R Moreira
- Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém, Pará, Brazil.
| | - Maria Fani Dolabela
- Institute of Health Sciences, Federal University of Pará, Belém, Pará, Brazil.
| | - Rogério S Santos
- Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém, Pará, Brazil.
| | - Michael D Green
- Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop G49, Atlanta, GA, USA.
| | - Eliete P Carvalho
- Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém, Pará, Brazil.
| | - Sandro Percário
- Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Belém, Pará, Brazil.
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Zoungrana A, Chou YJ, Pu C. Socioeconomic and environment determinants as predictors of severe malaria in children under 5 years of age admitted in two hospitals in Koudougou district, Burkina Faso: a cross sectional study. Acta Trop 2014; 139:109-14. [PMID: 25076108 DOI: 10.1016/j.actatropica.2014.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 07/17/2014] [Accepted: 07/18/2014] [Indexed: 10/25/2022]
Abstract
Burkina Faso has a high incidence and death rate of severe malaria, especially for children under 5 years of age. Although the malaria elimination program is a high-priority public health project, finding an effective strategy for managing the problem is a major challenge. Understanding the various factors that contribute to the severity of malaria is essential in designing an effective strategy. In this study, parental and environmental factors associated with severe malaria in Burkinabè children were investigated in two hospitals in Koudougou Health District, Burkina Faso. Between July and September 2012, a cross-sectional study was used to test 510 children under 5 years of age (mean age: 23.5 months) admitted with suspected malaria. Each child was screened using a blood smear to identify whether he or she had severe malaria based on the criteria established by the World Health Organization (WHO). When a child was diagnosed with malaria, either severe or not severe, the parents were interviewed by a trained interviewer using a structured questionnaire. A logistic regression was used to identify the determinants of severe malaria and associated deaths. Of the 510 children having malaria, 201 (39.4%) had severe malaria. Most of the patients (54.9%) lived in rural areas. The main factors associated with severe malaria were low education level of the father, low socioeconomic status [odds ratio (OR)=4.11, 95% confidence interval (CI)=1.44-11.75], delayed treatment [OR=4.53, 95% CI=1.76-11.65], treating children at home as a typical practice when the child has a fever [OR=3.24, 95% CI=1.40-7.51], living in rural area [OR=6.66, 95% CI=3.36-13.22], and living beside a water gathering pond (OR=1.67, 95% CI=1.02-2.74]. Parental and environmental context associated with severe malaria for children under 5 years of age remains a serious public health problem that affects malaria outcomes in resource-limited areas. Promotion of early care is urgently required. Parents should be given information on the risks of not consulting a health facility when children exhibit symptoms of malaria.
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Deroost K, Opdenakker G, Van den Steen PE. MalarImDB: an open-access literature-based malaria immunology database. Trends Parasitol 2014; 30:309-16. [DOI: 10.1016/j.pt.2014.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/28/2014] [Accepted: 04/04/2014] [Indexed: 12/23/2022]
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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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Eder M, Farne H, Cargill T, Abbara A, Davidson RN. Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre. Pathog Glob Health 2013; 106:181-7. [PMID: 23265377 DOI: 10.1179/2047773212y.0000000032] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Despite evidence from developing world trials that intravenous (IV) artesunate (AS) is superior to IV quinine (Q) in severe falciparum malaria (FM), IV AS remains unlicensed in the UK with national guidelines listing it as an acceptable alternative to IV Q as the drug of choice. We retrospectively evaluate the safety and effectiveness of IV AS in returning travellers with severe FM. METHODS We identified adults admitted to the Infectious Diseases unit with severe FM and treated with IV Q (1991-2009) or IV AS (2009-2011). Outcomes included adverse events, mortality, length of stay, admission to intensive care and, where data were available, parasite/fever clearance time and hypoglycaemic events. RESULTS Of 167 patients, 24 received IV AS and 143 IV Q. There was one potential AS-associated adverse event, a case of late onset haemolysis. Median length of stay (LOS) was significantly shorter for AS (3·5 versus 5 days, P = 0·017), even after adjusting for African ethnicity (for LOS ≥3 days, mhor = 0·33, P = 0·027; crude OR = 0·29, P = 0·013). In the AS group, there were no fatalities (versus five in Q group, NS) and fewer intensive care unit (ICU) admissions (NS). Median parasite clearance was significantly faster in AS (65 versus 85 hours in Q, P = 0·0045) with no hypoglycaemic episodes (versus five in Q). DISCUSSION We found IV AS to be safe and effective, with shorter LOS, faster parasite and fever clearance, no fatalities or hypoglycaemic events, and fewer ICU admissions versus IV Q. This corroborates both developing world trials and smaller European case series (although these lacked comparison groups). As well as obvious benefits for patients, there are potential resource savings. A case of late-onset haemolysis may represent an adverse event, particularly as it has been documented elsewhere, warranting further investigation. Nonetheless, our experience suggests IV AS should be first-line for treating severe FM in the UK.
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Affiliation(s)
- Marcus Eder
- Department of Infection and Tropical Medicine, Lister Unit, Northwick Park Hospital, Harrow, UK
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Deroost K, Tyberghein A, Lays N, Noppen S, Schwarzer E, Vanstreels E, Komuta M, Prato M, Lin JW, Pamplona A, Janse CJ, Arese P, Roskams T, Daelemans D, Opdenakker G, Van den Steen PE. Hemozoin Induces Lung Inflammation and Correlates with Malaria-Associated Acute Respiratory Distress Syndrome. Am J Respir Cell Mol Biol 2013; 48:589-600. [DOI: 10.1165/rcmb.2012-0450oc] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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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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Miller RS, Li Q, Cantilena LR, Leary KJ, Saviolakis GA, Melendez V, Smith B, Weina PJ. Pharmacokinetic profiles of artesunate following multiple intravenous doses of 2, 4, and 8 mg/kg in healthy volunteers: phase 1b study. Malar J 2012; 11:255. [PMID: 22853818 PMCID: PMC3468400 DOI: 10.1186/1475-2875-11-255] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 07/20/2012] [Indexed: 11/15/2022] Open
Abstract
Background Severe malaria results in over a million deaths every year, most of them in children aged less than five years and living in sub-Saharan Africa. Injectable artesunate (AS) was recommended as initial treatment for severe malaria by WHO in 2006. The Walter Reed Army Institute of Research (WRAIR) has been developing a novel good manufacturing practice (GMP) injection of AS, which was approved by the US FDA for investigational drug use and distribution by the CDC. Methods Tolerability and pharmacokinetics of current GMP intravenous AS, as an anti-malarial agent, were evaluated after ascending multiple doses of 2, 4, and 8 mg/kg daily for three days with 2-minute infusion in 24 healthy subjects (divided into three groups) in the Phase 1 clinical trial study. Results Results showed that there were no dose-dependent increases in any adverse events. Drug concentrations showed no accumulation and no decline of the drug during the three days of treatment. After intravenous injection, parent drug rapidly declined and was converted to dihydroartemisinin (DHA) with overall mean elimination half-lives ranging 0.15-0.23 hr for AS and 1.23-1.63 hr for DHA, but the peak concentration (Cmax) of AS was much higher than that of DHA with a range of 3.08-3.78-folds. In addition, the AUC and Cmax values of AS and DHA were increased proportionally to the AS climbing multiple doses. Discussion The safety of injectable AS, even at the highest dose of 8 mg/kg increases the probability of therapeutic success of the drug even in patients with large variability of parasitaemia.
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Onwujekwe OC, Soremekun RO, Uzochukwu B, Shu E, Onwujekwe O. Patterns of case management and chemoprevention for malaria-in-pregnancy by public and private sector health providers in Enugu state, Nigeria. BMC Res Notes 2012; 5:211. [PMID: 22551039 PMCID: PMC3392746 DOI: 10.1186/1756-0500-5-211] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 05/02/2012] [Indexed: 11/16/2022] Open
Abstract
Background Malaria in pregnancy (MIP) is a major disease burden in Nigeria and has adverse consequences on the health of the mother, the foetus and the newborn. Information is required on how to improve its prevention and treatment from both the providers’ and consumers’ perspectives. Methods The study sites were two public and two private hospitals in Enugu, southeast Nigeria. Data was collected using a pre-tested structured questionnaire. The respondents were healthcare providers (doctors, pharmacists and nurses) providing ante-natal care (ANC) services. They consisted of 32 respondents from the public facilities and 20 from the private facilities. The questionnaire elicited information on their: knowledge about malaria, attitude, chemotherapy and chemoprophylaxis using pyrimethamine, chloroquine proguanil as well as IPTp with sulphadoxine-pyrimethamine (SP). The data was collected from May to June 2010. Results Not many providers recognized maternal and neonatal deaths as potential consequences of MIP. The public sector providers provided more appropriate treatment for the pregnant women, but the private sector providers found IPTp more acceptable and provided it more rationally than public sector providers (p < 0.05). It was found that 50 % of private sector providers and 25 % of public sector providers prescribed chemoprophylaxis using pyrimethamine, chloroquine and proguanil to pregnant women. Conclusions There is sub-optimal level of knowledge about current best practices for treatment and chemoprophylaxis for MIP especially in the private sector. Also, IPTp was hardly used in the public sector. Interventions are required to improve providers’ knowledge and practices with regards to management of MIP.
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Affiliation(s)
- Ogochukwu C Onwujekwe
- Department of Pharmacy, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
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Kopel E, Marhoom E, Sidi Y, Schwartz E. Successful oral therapy for severe falciparum malaria: the World Health Organization criteria revisited. Am J Trop Med Hyg 2012; 86:409-11. [PMID: 22403309 DOI: 10.4269/ajtmh.2012.11-0567] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We report a successful treatment of severe falciparum malaria in a non-immune adult patient with 30% parasitemia treated with the 6-dose oral regimen of artemether plus lumefantrine combination therapy alone. We have also retrospectively searched our tertiary center's database for similar cases and we have found two additional severe malaria cases, resolved uneventfully with oral regimen. These cases might indicate a need to specifically address the definition of severe and complicated malaria in non-immune patients either in designated guidelines or as an explicit addition to the historical World Health Organization criteria.
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Affiliation(s)
- Eran Kopel
- Department of Internal Medicine C, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Akogun O, Adesina A, Njobdi S, Ogundahunsi O. Nomadic Fulani communities manage malaria on the move. Int Health 2012; 4:10-9. [DOI: 10.1016/j.inhe.2011.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Zhu X, Pan Y, Zheng L, Cui L, Cao Y. Polysaccharides from the Chinese medicinal herb Achyranthes bidentata enhance anti-malarial immunity during Plasmodium yoelii 17XL infection in mice. Malar J 2012; 11:49. [PMID: 22348301 PMCID: PMC3312874 DOI: 10.1186/1475-2875-11-49] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 02/20/2012] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Clinical immunity to malaria in human populations is developed after repeated exposure to malaria. Regulation and balance of host immune responses may lead to optimal immunity against malaria parasite infection. Polysaccharides (ABPS) derived from the Chinese herb ox knee Achyranthes bidentata possess immuno-modulatory functions. The aim of this study is to use the rodent malaria model Plasmodium yoelii 17XL (P. y17XL) to examine whether pretreatment with ABPS will modulate host immunity against malaria infection and improve the outcome of the disease. METHODS To determine whether ABPS could modulate immunity against malaria, mice were pretreated with ABPS prior to blood-stage infection by P. y17XL. Host survival and parasitaemia were monitored daily. The effect of pretreatment on host immune responses was studied through the quantitation of cytokines, dendritic cell populations, and natural regulatory T cells (Treg). RESULTS Pretreatment with ABPS prior to infection significantly extended the survival time of mice after P. y17XL infection. At three and five days post-infection, ABPS pretreated mice developed stronger Th1 immune responses against malaria infection with the number of F4/80+CD36+ macrophages and levels of IFN-γ, TNF-α and nitric oxide being significantly higher than in the control group. More importantly, ABPS-treated mice developed more myeloid (CD11c+CD11b+) and plasmacytoid dendritic cells (CD11c+CD45R+/B220+) than control mice. ABPS pretreatment also resulted in modulated expression of MHC-II, CD86, and especially Toll-like receptor 9 by CD11c+ dendritic cells. In comparison, pretreatment with ABPS did not alter the number of natural Treg or the production of the anti-inflammatory cytokine IL-10. CONCLUSION Pretreatment with the immuno-modulatory ABPS selectively enhanced Th1 immune responses to control the proliferation of malaria parasites, and prolonged the survival of mice during subsequent malaria infection.
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Affiliation(s)
- Xiaotong Zhu
- Department of Immunology, College of Basic Medical Sciences, China Medical University, No,92, Bei'er Road, Heping District, Shenyang, Liaoning 110001, China
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Phu NH, Hanson J, Bethell D, Mai NTH, Chau TTH, Chuong LV, Loc PP, Sinh DX, Dondorp A, White N, Hien TT, Day N. A retrospective analysis of the haemodynamic and metabolic effects of fluid resuscitation in Vietnamese adults with severe falciparum malaria. PLoS One 2011; 6:e25523. [PMID: 22022406 PMCID: PMC3191153 DOI: 10.1371/journal.pone.0025523] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 09/06/2011] [Indexed: 01/20/2023] Open
Abstract
Background Optimising the fluid resuscitation of patients with severe malaria is a simple and potentially cost-effective intervention. Current WHO guidelines recommend central venous pressure (CVP) guided, crystalloid based, resuscitation in adults. Methods Prospectively collected haemodynamic data from intervention trials in Vietnamese adults with severe malaria were analysed retrospectively to assess the responses to fluid resuscitation. Results 43 patients were studied of whom 24 received a fluid load. The fluid load resulted in an increase in cardiac index (mean increase: 0.75 L/min/m2 (95% Confidence interval (CI): 0.41 to 1.1)), but no significant change in acid-base status post resuscitation (mean increase base deficit 0.6 mmol/L (95% CI: −0.1 to 1.3). The CVP and PAoP (pulmonary artery occlusion pressure) were highly inter-correlated (rs = 0.7, p<0.0001), but neither were correlated with acid-base status (arterial pH, serum bicarbonate, base deficit) or respiratory status (PaO2/FiO2 ratio). There was no correlation between the oxygen delivery (DO2) and base deficit at the 63 time-points where they were assessed simultaneously (rs = −0.09, p = 0.46). Conclusions In adults with severe falciparum malaria there was no observed improvement in patient outcomes or acid-base status with fluid loading. Neither CVP nor PAoP correlated with markers of end-organ perfusion or respiratory status, suggesting these measures are poor predictors of their fluid resuscitation needs.
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Affiliation(s)
- Nguyen Hoan Phu
- Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
- * E-mail: (NHP); (JH)
| | - Josh Hanson
- Cairns Base Hospital, Cairns, Australia
- * E-mail: (NHP); (JH)
| | - Delia Bethell
- Worldwide Antimalarial Resistance Network, Bangkok, Thailand
| | | | | | - Ly Van Chuong
- Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Pham Phu Loc
- Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Dinh Xuan Sinh
- Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Arjen 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, United Kingdom
| | - Nicholas 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, United Kingdom
| | - Tran Tinh Hien
- Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nicholas 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, United Kingdom
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Marathe SA, Dasgupta I, Gnanadhas DP, Chakravortty D. Multifaceted roles of curcumin: two sides of a coin! Expert Opin Biol Ther 2011; 11:1485-99. [PMID: 21942554 DOI: 10.1517/14712598.2011.623124] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Curcumin has been a front-line topic of mainstream scientific research for a variety of diseases from cancer to Alzheimer's to infectious diseases. Curcumin suppresses the type 1 immune response, which might lead to alleviation of type 1 immune response disorders. However, the inhibition of type 1 immune response might invite infections with opportunistic pathogens. Considering its low bioavailability, several curcumin derivatives have been designed to improve its functionality. AREAS COVERED This is a consolidated review which aims to compare and contrast diverse aspects of curcumin in variety of diseases. The intricate underlying mechanisms and the functional determinants of curcumin are discussed. EXPERT OPINION Curcumin being considered as a spicy panacea, is not a remedy for all diseases. However, its ability to act differentially as an anti-oxidant or pro-oxidant akin to that of a double-edged sword/friend turning foe can be either beneficial or harmful for the host. It exhibits anti-oxidant properties at concentrations achievable in the body, making the host vulnerable to infections due to the suppression of innate immune responses. With the increase in knowledge of its functional groups, production of analogues of curcumin is underway to enhance its bioavailability and hence its therapeutic potency.
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Affiliation(s)
- Sandhya A Marathe
- Indian Institute of Science, Centre for Infectious Disease Research and Biosafety Laboratories, Department of Microbiology and Cell Biology, Bangalore 560012, India
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Zoller T, Junghanss T, Kapaun A, Gjorup I, Richter J, Hugo-Persson M, Mørch K, Foroutan B, Suttorp N, Yürek S, Flick H. Intravenous artesunate for severe malaria in travelers, Europe. Emerg Infect Dis 2011; 17:771-7. [PMID: 21529383 PMCID: PMC3321768 DOI: 10.3201/eid1705.101229] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Multicenter trials in Southeast Asia have shown better survival rates among patients with severe malaria, particularly those with high parasitemia levels, treated with intravenous (IV) artesunate than among those treated with quinine. In Europe, quinine is still the primary treatment for severe malaria. We conducted a retrospective analysis for 25 travelers with severe malaria who returned from malaria-endemic regions and were treated at 7 centers in Europe. All patients survived. Treatment with IV artesunate rapidly reduced parasitemia levels. In 6 patients at 5 treatment centers, a self-limiting episode of unexplained hemolysis occurred after reduction of parasitemia levels. Five patients required a blood transfusion. Patients with posttreatment hemolysis had received higher doses of IV artesunate than patients without hemolysis. IV artesunate was an effective alternative to quinine for treatment of malaria patients in Europe. Patients should be monitored for signs of hemolysis, especially after parasitologic cure.
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Hirji KF, Premji ZG. Pre-referral rectal artesunate in severe malaria: flawed trial. Trials 2011; 12:188. [PMID: 21824389 PMCID: PMC3171715 DOI: 10.1186/1745-6215-12-188] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Accepted: 08/08/2011] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Immediate injectable treatment is essential for severe malaria. Otherwise, the afflicted risk lifelong impairment or death. In rural areas of Africa and Asia, appropriate care is often miles away. In 2009, Melba Gomes and her colleagues published the findings of a randomized, placebo-controlled trial of rectal artesunate for suspected severe malaria in such remote areas. Enrolling nearly 18,000 cases, the aim was to evaluate whether, as patients were in transit to a health facility, a pre-referral artesunate suppository blocked disease progression sufficiently to reduce these risks. The affirmative findings of this, the only trial on the issue thus far, have led the WHO to endorse rectal artesunate as a pre-referral treatment for severe malaria. In the light of its public health importance and because its scientific quality has not been assessed for a systematic review, our paper provides a detailed evaluation of the design, conduct, analysis, reporting, and practical features of this trial. RESULTS We performed a checklist-based and an in-depth evaluation of the trial. The evaluation criteria were based on the CONSORT statement for reporting clinical trials, the clinical trial methodology literature, and practice in malaria research. Our main findings are: The inclusion and exclusion criteria and the sample size justification are not stated. Many clearly ineligible subjects were enrolled. The training of the recruiters does not appear to have been satisfactory. There was excessive between center heterogeneity in design and conduct. Outcome evaluation schedule was not defined, and in practice, became too wide. Large gaps in the collection of key data were evident. Primary endpoints were inconsistently utilized and reported; an overall analysis of the outcomes was not done; analyses of time to event data had major flaws; the stated intent-to-treat analysis excluded a third of the randomized subjects; the design-indicated stratified or multi-variate analysis was not done; many improper subgroups were analyzed in a post-hoc fashion; the analysis and reporting metric was deficient. There are concerns relating to patient welfare at some centers. Exclusion of many cases from data analysis compromised external validity. A bias-controlled reanalysis of available data does not lend support to the conclusions drawn by the authors. CONCLUSIONS This trial has numerous serious deficiencies in design, implementation, and methods of data analysis. Interpretation and manner of reporting are wanting, and the applicability of the findings is unclear. The trial conduct could have been improved to better protect patient welfare. The totality of these problems make it a flawed study whose conclusions remain subject to appreciable doubt.
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Affiliation(s)
- Karim F Hirji
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, United Nations Road, Dar es Salaam, Tanzania
| | - Zulfiqarali G Premji
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, United Nations Road, Da res Salaam, Tanzania
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Coma associated with microscopy-diagnosed Plasmodium vivax: a prospective study in Papua, Indonesia. PLoS Negl Trop Dis 2011; 5:e1032. [PMID: 21666785 PMCID: PMC3110166 DOI: 10.1371/journal.pntd.0001032] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 01/12/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Coma complicates Plasmodium falciparum infection but is uncommonly associated with P. vivax. Most series of vivax coma have been retrospective and have not utilized molecular methods to exclude mixed infections with P. falciparum. METHODS We prospectively enrolled patients hospitalized in Timika, Indonesia, with a Glasgow Coma Score (GCS) ≤10 and P. vivax monoinfection on initial microscopy over a four year period. Hematological, biochemical, serological, radiological and cerebrospinal fluid (CSF) examinations were performed to identify other causes of coma. Repeat microscopy, antigen detection and polymerase chain reaction (PCR) were performed to exclude infections with other Plasmodium species. RESULTS Of 24 patients fulfilling enrolment criteria, 5 had clear evidence for other non-malarial etiologies. PCR demonstrated 10 mixed infections and 3 P. falciparum monoinfections. 6 (25%) patients had vivax monoinfection and no apparent alternative cause, with a median GCS of 9 (range 8-10) and a median coma duration of 42 (range 36-48) hours. CSF leukocyte counts were <10/ul (n=3); 2 of the 3 patients without CSF examination recovered with antimalarial therapy alone. One patient had a tremor on discharge consistent with a post-malarial neurological syndrome. No patient had other organ dysfunction. The only death was associated with pure P. falciparum infection by PCR. Vivax monoinfection-associated risk of coma was estimated at 1 in 29,486 clinical vivax infections with no deaths. In comparison, the risk of falciparum-associated coma was estimated at 1 in 1,276 clinical infections with an 18.5% mortality rate. CONCLUSIONS P. vivax-associated coma is rare, occurring 23 times less frequently than that seen with falciparum malaria, and is associated with a high proportion of non-malarial causes and mixed infections using PCR. The pathogenesis of coma associated with vivax malaria, particularly the role of comorbidities, is uncertain and requires further investigation.
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Lutje V, Gerritsen A, Siegfried N. Randomized controlled trials of malaria intervention trials in Africa, 1948 to 2007: a descriptive analysis. Malar J 2011; 10:61. [PMID: 21406113 PMCID: PMC3064642 DOI: 10.1186/1475-2875-10-61] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 03/15/2011] [Indexed: 12/02/2022] Open
Abstract
Background Nine out of ten deaths from malaria occur in sub-Saharan Africa. Various control measures have achieved some progress in the control of the disease, but malaria is still a major public health problem in Africa. Randomized controlled trials (RCTs) are universally considered the best study type to rigorously assess whether an intervention is effective. The study reported here provides a descriptive analysis of RCTs reporting interventions for the prevention and treatment of malaria conducted in Africa, with the aim of providing detailed information on their main clinical and methodological characteristics, that could be used by researchers and policy makers to help plan future research. Methods Systematic searches for malaria RCTs were conducted using electronic databases (Medline, Embase, the Cochrane Library), and an African geographic search filter to identify RCTs conducted in Africa was applied. Results were exported to the statistical package STATA 8 to obtain a random sample from the overall data set. Final analysis of trial characteristics was done in a double blinded fashion by two authors using a standardized data extraction form. Results A random sample of 92 confirmed RCTs (from a total of 943 reports obtained between 1948 and 2007) was prepared. Most trials investigated drug treatment in children with uncomplicated malaria. Few trials reported on treatment of severe malaria or on interventions in pregnant women. Most trials were of medium size (100-500 participants), individually randomized and based in a single centre. Reporting of trial quality was variable. Although three-quarter of trials provided information on participants' informed consent and ethics approval, more details are needed. Conclusions The majority of malaria RCT conducted in Africa report on drug treatment and prevention in children; there is need for more research done in pregnant women. Sources of funding, informed consent and trial quality were often poorly reported. Overall, clearer reporting of trials is needed.
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Affiliation(s)
- Vittoria Lutje
- International Health Research Group, Liverpool School of Tropical Medicine, Liverpool, UK.
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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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Case management of severe malaria--a forgotten practice: experiences from health facilities in Uganda. PLoS One 2011; 6:e17053. [PMID: 21390301 PMCID: PMC3046961 DOI: 10.1371/journal.pone.0017053] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 01/18/2011] [Indexed: 11/25/2022] Open
Abstract
Introduction Severe malaria is a life-threatening medical emergency and requires prompt and effective treatment to prevent death. There is paucity of published information on current practices of severe malaria case management in sub-Saharan Africa; we evaluated the management practices for severe malaria in Ugandan health facilities Methods and Findings We did a cross sectional survey, using multi-stage sampling methods, of health facilities in 11 districts in the eastern and mid-western parts of Uganda. The study instruments were adapted from the WHO hospital care assessment tools. Between June and August 2009, 105 health facilities were surveyed and 181 health workers and 868 patients/caretakers interviewed. None of the inpatient facilities had all seven components of a basic care package for the management of severe malaria consistently available during the 3 months prior to the survey. Referral practices were appropriate for <10% (18/196) of the patients. Prompt care at any health facility was reported by 29% (247/868) of patients. Severe malaria was correctly diagnosed in 27% of patients (233).Though the quinine dose and regimen was correct in the majority (611/868, 70.4%) of patients, it was administered in the correct volumes of 5% dextrose in only 18% (147/815). Most patients (80.1%) had several doses of quinine administered in one single 500 ml bottle of 5% dextrose. Medications were purchased by 385 (44%) patients and medical supplies by 478 patients (70.6%). Conclusions Management of severe malaria in Ugandan health facilities was sub-optimal. These findings highlight the challenges of correctly managing severe malaria in resource limited settings. Priority areas for improvement include triage and emergency care, referral practises, quality of diagnosis and treatment, availability of medicines and supplies, training and support supervision.
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Affiliation(s)
- Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Department of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand.
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Teja-Isavadharm P, Siriyanonda D, Siripokasupkul R, Apinan R, Chanarat N, Lim A, Wannaying S, Saunders D, Fukuda MM, Miller RS, Weina PJ, Meléndez V. A simplified liquid chromatography-mass spectrometry assay for artesunate and dihydroartemisinin, its metabolite, in human plasma. Molecules 2010; 15:8747-68. [PMID: 21124272 PMCID: PMC6259473 DOI: 10.3390/molecules15128747] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 11/13/2010] [Accepted: 11/27/2010] [Indexed: 11/16/2022] Open
Abstract
Artesunate (AS) is a potent antimalarial that is used worldwide for the treatment of malaria. A simple method with a total run time of 12 min was developed and validated for the quantification of AS and dihydroartemisinin (DHA), its active metabolite, in human (heparinized) plasma based on one-step protein precipitation in acetonitrile using artemisinin (ARN) as an internal standard, followed by liquid chromatography with a single quadrupole mass spectrometry system connected to a C18 column. Peak area ratio responses were fitted to the 2nd-order curve type, polynomial equation with weighting (1/concentration) over a quantification range between 3.20/5.33-3,000/5,000 nM (1.23/1.52-1153/1422 ng/mL) of AS/DHA showing linearity with very good correlation (r2>0.999). Single ion recordings of 5 µL injections of plasma extracts allowed for limits of detection of 1.02 nM (0.39 ng/mL) for AS and 0.44 nM (0.13 ng/mL) for DHA. The inter-assay and intra-assay accuracy and precision of the method was very good with an inaccuracy of ±12.4% and coefficients of variation of ≤10.7% at all tested concentrations. The recovery of the analytes from plasma was ≥95%. Other commonly used antimalarials including mefloquine, quinine, and chloroquine, did not interfere with the analysis. Post-preparative tests over 24 h in an autosampler (10 °C) showed that the DHA response was only 2.1% of AS from auto-hydrolysis, and β-DHA was the major, stable epimer that was used for quantification of DHA. In contrast, α-DHA increased steadily up to 600%. Artesunate and DHA in plasma were stable through three freeze/thaw cycles for up to 6 h at room temperature and up to one year at -80 °C.
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Affiliation(s)
- Paktiya Teja-Isavadharm
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
- Author to whom correspondence should be addressed: ; Tel.: +1-662-6962795; Fax: +1-662-6444784
| | - Duangsuda Siriyanonda
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Raveewan Siripokasupkul
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Roongnapa Apinan
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Nitima Chanarat
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Apassorn Lim
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Srisombat Wannaying
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - David Saunders
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Mark M. Fukuda
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Robert S. Miller
- Department of Pharmacology, Division of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA; (R.S.M.); (P.J.W.)
| | - Peter J. Weina
- Department of Pharmacology, Division of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA; (R.S.M.); (P.J.W.)
| | - Victor Meléndez
- Department of Immunology and Medicine, United States Army Medical Component, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok 10400, Thailand
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Smereck J. Malaria in pregnancy: update on emergency management. J Emerg Med 2010; 40:393-6. [PMID: 20566259 DOI: 10.1016/j.jemermed.2010.04.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 01/12/2010] [Accepted: 04/11/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pregnancy complicates the diagnosis, treatment, and clinical course of malaria. This clinical problem may be encountered in emergency department patients due to international travel. CASE REPORT A primigravida woman at 20 weeks gestation presented to the Emergency Department with episodic fever, chills, headache, and nausea after travel to India and Asia. She had not taken malaria prophylaxis. After hospitalization, she developed acute respiratory distress syndrome and required intensive care management. Although she ultimately recovered from severe infection with Plasmodium vivax, she was not able to sustain her pregnancy and suffered a miscarriage. CONCLUSION This case illustrates the serious nature of malaria in the pregnant patient. For this high-risk group, there is an increased incidence of severe anemia, as well as acute respiratory distress syndrome and pulmonary edema. A guideline is presented for the initial choice of anti-malarial drug treatment for the pregnant patient.
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Affiliation(s)
- Janet Smereck
- Department of Emergency Medicine, Georgetown University Hospital, Washington, DC 20007, USA
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Yeo TW, Lampah DA, Tjitra E, Gitawati R, Darcy CJ, Jones C, Kenangalem E, McNeil YR, Granger DL, Lopansri BK, Weinberg JB, Price RN, Duffull SB, Celermajer DS, Anstey NM. Increased asymmetric dimethylarginine in severe falciparum malaria: association with impaired nitric oxide bioavailability and fatal outcome. PLoS Pathog 2010; 6:e1000868. [PMID: 20421938 PMCID: PMC2858698 DOI: 10.1371/journal.ppat.1000868] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 03/22/2010] [Indexed: 11/18/2022] Open
Abstract
Asymmetrical dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase (NOS), is a predictor of mortality in critical illness. Severe malaria (SM) is associated with decreased NO bioavailability, but the contribution of ADMA to the pathogenesis of impaired NO bioavailability and adverse outcomes in malaria is unknown. In adults with and without falciparum malaria, we tested the hypotheses that plasma ADMA would be: 1) increased in proportion to disease severity, 2) associated with impaired vascular and pulmonary NO bioavailability and 3) independently associated with increased mortality. We assessed plasma dimethylarginines, exhaled NO concentrations and endothelial function in 49 patients with SM, 78 with moderately severe malaria (MSM) and 19 healthy controls (HC). Repeat ADMA and endothelial function measurements were performed in patients with SM. Multivariable regression was used to assess the effect of ADMA on mortality and NO bioavailability. Plasma ADMA was increased in SM patients (0.85 µM; 95% CI 0.74–0.96) compared to those with MSM (0.54 µM; 95%CI 0.5–0.56) and HCs (0.64 µM; 95%CI 0.58–0.70; p<0.001). ADMA was an independent predictor of mortality in SM patients with each micromolar elevation increasing the odds of death 18 fold (95% CI 2.0–181; p = 0.01). ADMA was independently associated with decreased exhaled NO (rs = −0.31) and endothelial function (rs = −0.32) in all malaria patients, and with reduced exhaled NO (rs = −0.72) in those with SM. ADMA is increased in SM and associated with decreased vascular and pulmonary NO bioavailability. Inhibition of NOS by ADMA may contribute to increased mortality in severe malaria. Severe falciparum malaria is associated with impaired microvascular perfusion, lung injury and decreased bioavailability of nitric oxide (NO), but the causes of these processes are not fully understood. Asymmetrical dimethylarginine (ADMA), a competitive endogenous inhibitor of nitric oxide synthase (NOS), is an independent predictor of mortality in other critical illnesses, and can impair vascular function in chronic disease. ADMA can be produced by both the host and malaria parasites. The major novel findings of this study in malaria are that ADMA is an independent predictor of death in falciparum malaria, and is associated with decreased availability of nitric oxide in at least two organ systems affected by malaria parasites, the lining of blood vessels and the lungs. This study contributes to knowledge of regulation and availability of pulmonary and endothelial NO in critical illness and identifies pathogenic processes which may contribute to death in severe malaria. Therapies which increase the availability of NO or which reduce ADMA levels may have potential for adjunctive therapy of severe malaria.
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Affiliation(s)
- Tsin W Yeo
- International Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.
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Barennes H, Srour LM, Pussard E. Is it too soon to eliminate quinine? THE LANCET. INFECTIOUS DISEASES 2010; 10:141-2. [PMID: 20185089 DOI: 10.1016/s1473-3099(10)70009-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Na-Bangchang K, Karbwang J. Current status of malaria chemotherapy and the role of pharmacology in antimalarial drug research and development. Fundam Clin Pharmacol 2009; 23:387-409. [PMID: 19709319 DOI: 10.1111/j.1472-8206.2009.00709.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Antimalarial drugs have played a mainstream role in controlling the spread of malaria through the treatment of patients infected with the plasmodial parasites and controlling its transmissibility. The inadequate armory of drugs in widespread use for the treatment of malaria, development of strains resistant to currently used antimalarials, and the lack of affordable new drugs are the limiting factors in the fight against malaria. In addition, other problems with some existing agents include unfavorable pharmacokinetic properties and adverse effects/toxicity. These factors underscore the continuing need of research for new classes of antimalarial agents, and a re-examination of the existing antimalarial drugs that may be effective against resistant strains. In recent years, major advances have been made in the pharmacology of several antimalarial drugs both in pharmacokinetics and pharmacodynamics aspects. These include the design, development, and optimization of appropriate dosage regimens of antimalarials, basic knowledge in metabolic pathways of key antimalarials, as well as the elucidation of mechanisms of action and resistance of antimalarials. Pharmacologists have been working in close collaboration with scientists in other disciplines of science/biomedical sciences for more understanding on the biology of the parasite, host, in order to exploit rational design of drugs. Multiple general approaches to the identification of new antimalarials are being pursued at this time. All should be implemented in parallel with focus on the rational development of new agents directed against newly identified parasite targets. With major advances in our understanding of malaria parasite biology coupled with the completion of the malaria genome, has presented exciting opportunities for target-based antimalarial drug discovery.
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Affiliation(s)
- Kesara Na-Bangchang
- Graduate Program in Biomedical Sciences, Faculty of Allied Health Sciences, Thammasat University, Pathumtanee, Thailand.
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D'Alessandro U. Existing antimalarial agents and malaria-treatment strategies. Expert Opin Pharmacother 2009; 10:1291-306. [PMID: 19463069 DOI: 10.1517/14656560902942319] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the absence of prompt and efficacious treatment, malaria patients may progress within a few hours from having minor symptoms to severe disease and death. These last years have seen the development of several artemisinin-based combinations, new treatments for severe malaria patients, and new strategies such as intermittent preventive treatment or the home-based/near-home management of malaria. The health sector is now confronted with several treatment options and strategies, in contrast with the period when chloroquine monotherapy was the standard treatment. The major challenge remains the large-scale deployment, in the most efficient way, of the tools available today, including artemisinin-based combination treatments, within health systems that remain extremely weak in malaria endemic countries, particularly in sub-Saharan Africa. Health system research, exploring new potential approaches for the large-scale implementation of these interventions, should be promoted in parallel with that on new therapeutic agents to be used in the unlucky event of the emergence and spread of artemisinin resistance. The prospects of substantially decreasing the malaria burden are brighter today than 20 - 30 years ago, but the efforts and resources committed to this purpose should be maintained over a long period.
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Affiliation(s)
- Umberto D'Alessandro
- Department of Parasitology, Institute of Tropical Medicine, Nationalestraat 10, B-2000 Antwerp, Belgium.
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Picot S, Bienvenu AL, Konate S, Sissoko S, Barry A, Diarra E, Bamba K, Djimdé A, Doumbo OK. Safety of epoietin beta-quinine drug combination in children with cerebral malaria in Mali. Malar J 2009; 8:169. [PMID: 19630971 PMCID: PMC2723129 DOI: 10.1186/1475-2875-8-169] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 07/24/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral malaria carries an unacceptable case fatality rate in children despite timely and adequate chemotherapy. To improve the survival rate, adjunctive therapies previously tested mainly focused on the modulation of the inflammatory response, without definitive effect in humans. In this context, a new adjunctive strategy using a neuroprotective drug: erythropoietin (epoietin-beta, Epo) was proposed. METHODS An open-labelled study including cerebral malaria children (Blantyre coma score below 3) was conducted in Mali. The objective was to assess the short-term safety (seven days) of erythropoietin at high doses (1,500 U/kg/day during three days) combined to quinine. RESULTS 35 patients with unrousable coma were included in the study. None of expected side effects of erythropoietin were observed during the seven days follow-up. No significant increase in the case fatality rate (7/35 patients) was observed compared to other studies with mortality rates ranging from 16 to 22% in similar endemic areas. CONCLUSION These data provide the first evidence of the short-term safety of erythropoietin at high doses combined to quinine. A multicentre study is needed to assess the potential of Epo as an adjunctive therapy to increase the survival during cerebral malaria. CLINICAL REGISTRATION NUMBER: ClinicalTrials.gov ID: NCT00697164.
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Affiliation(s)
- Stéphane Picot
- Malaria Research Unit, EA 4170, University Lyon 1, Faculty of Medicine, Lyon, France.
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The spectrum of retinopathy in adults with Plasmodium falciparum malaria. Trans R Soc Trop Med Hyg 2009; 103:665-71. [PMID: 19344925 PMCID: PMC2700877 DOI: 10.1016/j.trstmh.2009.03.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 03/03/2009] [Accepted: 03/04/2009] [Indexed: 11/29/2022] Open
Abstract
A specific retinopathy has been described in African children with cerebral malaria, but in adults this has not been extensively studied. Since the structure and function of the retinal vasculature greatly resembles the cerebral vasculature, study of retinal changes can reveal insights into the pathophysiology of cerebral malaria. A detailed observational study of malarial retinopathy in Bangladeshi adults was performed using high-definition portable retinal photography. Retinopathy was present in 17/27 adults (63%) with severe malaria and 14/20 adults (70%) with cerebral malaria. Moderate or severe retinopathy was more frequent in cerebral malaria (11/20, 55%) than in uncomplicated malaria (3/15, 20%; P = 0.039), bacterial sepsis (0/5, 0%; P = 0.038) or healthy controls (0/18, 0%; P < 0.001). The spectrum of malarial retinopathy was similar to that previously described in African children, but no vessel discolouration was observed. The severity of retinal whitening correlated with admission venous plasma lactate (P = 0.046), suggesting that retinal ischaemia represents systemic ischaemia. In conclusion, retinal changes related to microvascular obstruction were common in adults with severe falciparum malaria and correlated with disease severity and coma, suggesting that a compromised microcirculation has important pathophysiological significance in severe and cerebral malaria. Portable retinal photography has potential as a valuable tool to study malarial retinopathy.
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Abstract
The artemisinins are the most effective antimalarial drugs known. They possess a remarkably wide therapeutic index. These agents have been used in traditional Chinese herbal medicine for more than 2,000 years but were not subjected to scientific scrutiny until the 1970s. The first formal clinical trials of the artemisinins, and the development of methods for their industrial scale production, followed rapidly. A decade later, Chinese scientists shared their findings with the rest of the world; since then, a significant body of international trial evidence has confirmed these drugs to be far superior to any available alternatives. In particular, they have the ability to rapidly kill a broad range of asexual parasite stages at safe concentrations that are consistently achievable via standard dosing regimens. As their half-life is very short, there was also thought to be a low risk of resistance. These discoveries coincided with the appearance and spread of resistance to all the other major classes of antimalarials. As a result, the artemisinins now form an essential element of recommended first-line antimalarial treatment regimens worldwide. To minimize the risk of artemisinin resistance, they are recommended to be used to treat uncomplicated malaria in combination with other antimalarials as artemisinin combination therapies (ACTs). Their rollout has resulted in documented reductions in malaria prevalence in a number of African and Asian countries. Unfortunately, there are already worrisome early signs of artemisinin resistance appearing in western Cambodia. If this resistance were to spread, it would be disastrous for malaria control efforts worldwide. The enormous challenge for the international community is how to avert this catastrophe and preserve the effectiveness of this antimalarial “magic bullet”. Drug Dev Res 71: 12–19, 2010. © 2009 Wiley-Liss, Inc.
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Affiliation(s)
- Richard J Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University Bangkok 10400, Thailand
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Weinberg JB, Lopansri BK, Mwaikambo E, Granger DL. Arginine, nitric oxide, carbon monoxide, and endothelial function in severe malaria. Curr Opin Infect Dis 2008; 21:468-75. [PMID: 18725795 PMCID: PMC2732119 DOI: 10.1097/qco.0b013e32830ef5cf] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW Parasiticidal therapy of severe falciparum malaria improves outcome, but up to 30% of these patients die despite best therapy. Nitric oxide is protective against severe disease, and both nitric oxide and arginine (the substrate for nitric oxide synthase) are low in clinical malaria. Parasitized red blood cell interactions with endothelium are important in the pathophysiology of malaria. This review describes new information regarding nitric oxide, arginine, carbon monoxide, and endothelial function in malaria. RECENT FINDINGS Low arginine, low nitric oxide production, and endothelial dysfunction are common in severe malaria. The degree of hypoargininemia and endothelial dysfunction (measured by reactive hyperemia-peripheral artery tonometry) is proportional to parasite burden and severity of illness. Plasma arginase (an enzyme that catabolizes arginine) is elevated in severe malaria. Administering arginine intravenously reverses hypoargininemia and endothelial dysfunction. The cause(s) of hypoargininemia in malaria is unknown. Carbon monoxide (which shares certain functional properties with nitric oxide) protects against cerebral malaria in mice. SUMMARY Replenishment of arginine and restoration of nitric oxide production in clinical malaria should diminish parasitized red blood cells adherence to endothelium and reduce the sequelae of these interactions (e.g. cerebral malaria). Arginine therapy given in addition to conventional antimalaria treatment may prove to be beneficial in severe malaria.
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Affiliation(s)
- J Brice Weinberg
- Duke University and VA Medical Centers, Durham, North Carolina 27705, USA.
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Affiliation(s)
- Philip J Rosenthal
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA 94143, USA.
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