First Report of Neutrophil Involvement of Exflagellated Plasmodium vivax Microgametes

No abstract available.

The in vivo antimalarial activity of methylene blue combined with pyrimethamine, chloroquine and quinine

The effectiveness of methylene blue (MB) combined with pyrimethamine (PYR), chloroquine (CQ) or quinine (Q) was examined in a classical four-day suppressive test against a causative agent of rodent malaria, Plasmodium berghei. A marked potentiation was observed when MB was administered at a non-curative dose of 15 mg/kg/day in combination with PYR (0.19 mg/kg/day) or Q (25 mg/kg/day). No synergy was found between MB (15 mg/Kg) and CQ (0.75 mg/Kg). Our results suggest that the combination of MB with PYR or Q may improve the efficacy of these currently used antimalarial drugs.

Immunoglobulin A Nephropathy Associated with Plasmodium falciparum Malaria

Glomerulonephritis occurs as a rare form of renal manifestation in Plasmodium falciparum malaria. Herein, we report a case of falciparum malaria-associated IgA nephropathy for the first time. A 49-yr old male who had been to East Africa was diagnosed with Plasmodium falciparum malaria. Microhematuria and proteinuria along with acute kidney injury developed during the course of the disease. Kidney biopsy showed mesangial proliferation and IgA deposits with tubulointerstitial inflammation. Laboratory tests after recovery from malaria showed disappearance of urinary abnormalities and normalization of kidney function. Our findings suggest that malaria infection might be associated with IgA nephropathy.

Nivel de resistencia a la quinina más doxiciclina en la malaria cloroquina resistente / Resistance level to quinine plus doxiciline in chloroquine-resistant malaria

La elevada incidencia de la resistencia a las drogas antimaláricas ha determinado que las estrategias de tratamiento se fundamenten actualmente en la asociación de por lo menos dos agentes diferentes. Objetivo: determinar la respuesta a la combinación de quinina más doxiciclina en pacientes portadores de malaria cloroquina-resistente en la República de Gambia. Método: se realizó un estudio cuasi experimental en ciento sesenta y cinco pacientes que presentaban formas no complicadas de malaria resistente a la cloroquina, ingresados en el Hospital Royal Victoria de Banjul, Gambia, en el período comprendido entre el 1ro de enero del 2006 al 30 de junio del 2007. Resultados: la mayoría de los pacientes incluidos tenían menos de cuarenta y cinco años (75,15 por ciento). El nivel de resistencia in vivo a la terapéutica analizada fue de 4,85 por ciento. La mayoría de los pacientes presentaron al menos un efecto adverso, los más frecuentes fueron: vértigos, tinnitus e hipoacusia. Conclusiones: el nivel de resistencia a la combinación estudiada resultó notablemente bajo, aunque con un elevado índice de efectos adversos.

The high incidence of the resistance to antimalarial drugs has determined that treatment strategies currently are based in the association of at least two different agents. Objective: to determine the response to the combination of quinine plus doxicicline in patients carriers of chloroquine-resistant malaria in Republic of Gambia. Method: a quasi experimental study in one-hundred sixty five patients that presented non complicated forms of chloroquine-resistant malaria was performed, admitted in the Hospital Royal Victoria of Banjul, Gambia, from January 1st 2006 to June 30 2007. Results: most of the included patients had less than forty five years (75,15 percent). The resistance level in vivo to the analyzed therapy was about 4,85 percent. Most of the patients presented at least one adverse effect, the most frequent were: vertigo, tinnitus and hypoacusis. Conclusions: the resistance level to the studied combination was notably low, although with a high index of adverse effects.

Quinine levels in patients with uncomplicated falciparum malaria in the Amazon region of Brazil

We examined the plasmatic concentrations of quinine in patients with uncomplicated falciparum malaria in an endemic area of the Amazon region in Brazil in a prospective clinical trial, in which a standard three-day course of oral quinine plus doxycycline was used. We measured the quinine in the plasma samples on days 0 and 3by high performance liquid chromatography. The mean concentration of quinine was 6.04 ±2.21 µg/mL in male patients and 5.98 ±1.95 µg/mL in female patients. No significant differences in quinine concentration were observed between these two groups. All samples collected before starting treatment were negative for quinine. This information could help in the development of strategies for the rational use of antimalarial drugs in Brazil.

Rare presentation of a common disease of tropics.

A 19 years male presented with fever, oliguria and purpuric lesions involving both hands. The patient was diagnosed as a case of purpura fulminans with disseminated intravascular coagulation due to complicated falciparum malaria. The case is presented to sensitize the physicians to keep malaria as a differential in cases of fever with purpura fulminans.

Malaria: revisión retrospectiva de 12 casos no autóctonos en Chile / Malaria: Report of 12 non autochthonous cases

Malaria is a protozoan infection caused by four Plasmodia species transmitted by female Anopheles mosquito. Nearly 40% of the world population is at risk of acquiring the disease because of increasing resistance to treatment, climate changes and travels to endemic zones. We report twelve patients with diagnosis of malaria, supported by the identification of parasites on blood smear. All cases had traveled to endemic zones (Peru, Ecuador, Central America, Africa), but only three used chemoprophylaxis. Seven cases were infected with Plasmodium vivax and five cases with P. falciparum. Three of latter required intensive care. All patients were treated with standard drugs according to the severity and Plasmodium specie, with excellent results and no mortality.

In vivo efficacy study of quinine sulphate in the treatment of uncomplicated P. Falciparum malaria in patients from southwestern Cameroon

Objective: To evaluate clinical, parasitological and haematological responses to quinine sulphate therapy in patients with uncomplicated malaria using the 14-day WHO protocol. Design: Longitudinal study.Setting: The Buea Provincial hospital annex located in South Western Cameroon. Subjects: The study participants consisted of children (≥8 months) and adults (≤50 years) with acute malaria attending the outpatient division of health institutions within Fako Division.Results: Quinine sulphate failure was found in 42% of the patients. Of these 10% were resistant at the RI while 32% were at the RII level. Clinically, the overall success rate (ACR) was 94.2% while therapeutic failures (ETF and LTF) were observed in four patients (5.8%). 27.4% and 17.4% of the patients were anaemic at enrolment and day 14 respectively. The mean PCV levels of the patients increased during the follow-up period except on day three when mean PCV levels dropped. The difference in the mean PCV levels during the follow-up was significant (F=60.29; P=0.0001).Conclusion: The relatively high resistance of quinine sulphate observed in this study suggests the need to monitor the spread of resistance to this drug in the study region

Management of severe malaria.

Prompt diagnosis and early institution of therapy is an important determinant of outcome in severe falciparum malaria. Thick smears are the gold standard for diagnosis; in situations where reliable microscopy is not available, tests based on HRP-2 antigen/parasite LDH are useful. As there is widespread resistance to chloroquine in P falciparum in India, the choice for specific antimalarial therapy is between quinine and artermisinin derivatives. Randomized controlled trials have not revealed any significant benefit of the artemisinin derivatives over quinine in quinine sensitive areas. Also, if quinine is administered in the recommended way, the side effects are no greater than artemisinins. However, as the artemisinin derivatives are easier to administer, their use in severe malaria in India is increasing. It is vital that we use these drugs in a rational and judicious manner to prevent development of drug resistance. Supportive care, early diagnosis and management of complications are as essential as antimalarial therapy. The role of exchange blood transfusion in the management of severe malaria is still controversial. It may be considered in the presence of high parasites counts (>10%) with multiorgan dysfunction if adequate quantities of safe blood are available.

A comparative clinical trial of artemether and quinine in children with severe malaria.

OBJECTIVE: To compare the efficacy of artemether and quinine in the treatment of severe malaria in hospitalized children. STUDY DESIGN: Open randomized trial. SETTING: Pediatric ward of a tertiary care center. METHODS: All children admitted with clinical manifestations of severe malaria (as per WHO criteria) and asexual forms of Plasmodium falciparum demonstrated on peripheral smear were randomized to receive either artemether or quinine. Their clinical status and smears for parasite count were assessed every 12 hours until two successive blood films were negative. The primary end point of the study was death in the hospital and residual damage to the organ involved. The secondary end points were clearance of parasites and fever, length of time of recovery from coma and normal functions of the involved system. RESULTS: Forty-six cases completed the study protocol, 23 assigned to each drug group. Cerebral malaria was the commonest manifestation (76.1%). Mean age in artemether versus quinine group (6.6 +/- 3.5 and 5.8 +/- 2.4 years) as well as degree of parasitemia at admission (55,800 and 60,300 per microlitre) were comparable. The overall mortality rate was 23.9% with no significant difference between the two groups. Twenty six cases (56.5%) presented with more than one manifestations of severe malaria. The mortality rate was 100% with four coexisting manifestations of severe malaria. Fever clearance time in artemether and quinine group was 44.5 and 45.9 hours respectively (P >0.05). Parasite clearance time was significantly shorter in artemether group (40.9 vs. 51.9 hours; P<0.001). Recovery from coma was shorter in artemether group (34.8 vs. 38.1 hours; P<0.05). CONCLUSION: Cerebral malaria is the most common manifestation of severe malaria in children. Artemether is a good alternative drug to quinine for P. falciparum malaria. Mortality rate is directly proportional to the number of coexisting manifestations of severe malaria.

Deferiprone (L1) as an adjuvant therapy for Plasmodium falciparum malaria.

BACKGROUND & OBJECTIVES: Mortality due to Plasmodium falciparum infection remains high in India, hence any modality of treatment which can improve the outcome of this disease is worth exploring. The present study was undertaken to see whether addition of an oral iron chelator, deferiprone (L1) to the conventional treatment regime for P. falciparum infection improves the clinical course and final outcome. METHODS: In this prospective, randomised double blind trial, 45 consecutive patients with P. falciparum infection were randomised into two groups. Patients in Group I (control group, 21 patients) received standard quinine and doxycycline therapy along with supportive therapy and placebo capsules for 10 days. Patients in Group II (24 patients) received the same treatment as Group I but in place of placebo capsule received deferiprone capsules 75 mg/kg/day in 12 hourly divided doses. The parameters evaluated included the time taken in resolution of parasitaemia, fever and coma, differences in final outcome i.e., death or other severe complications, and side effects and deferiprone tolerance. RESULTS: Four patients in Group I and two in Group II died (P > 0.05). The resolution of fever and coma was significantly faster in Group II (P < 0.05) and parasitaemia cleared 24 h earlier in this Group. The drug was well tolerated and had no side effects. INTERPRETATION & CONCLUSION: Deferiprone (L1) seems to be a promising agent as an adjuvant in the treatment for severe P. falciparum malaria infection.

Severe acute renal failure in malaria.

BACKGROUND: We have noticed a recent rise in the incidence and severity of acute renal failure (ARF) in malaria. AIM: To study the incidence, severity and outcome of ARF in malaria. SETTING and DESIGN: It is a retrospective analysis of data of one year from a tertiary medical centre in a metropolitan city. MATERIALS AND METHODS: Patients with ARF and smear positive malaria were evaluated. STATISTICAL ANALYSIS: Results were expressed as mean, range and standard deviation. RESULTS: Out of 402 detected smear positive malaria, 24 had ARF. Eighteen were of the age group 21-40 years. Plasmodium falciparum (PF) was detected in 16, Plasmodium vivax in three, and mixed infection in five. Non-oliguric ARF was seen in 14. Eighteen showed severe ARF (Serum creatinine >5 mg%). Twenty-two patients needed dialysis. Prolonged ARF lasting for 2-6 weeks was seen in eight. Seventeen patients recovered completely, while seven showed fatal combination of disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), severe ARF and PF malaria. No response was seen to chloroquine and artesunate given alone and twenty patients required quinine. CONCLUSION: ARF necessitating dialysis was seen in 92% of patients with ARF in malaria. PF infection, severe ARF, DIC and ARDS were poor prognostic factors. Resistance was noted to both chloroquine and artesunate.

Malária grave / Severe malaria

A malária é uma doença parasitária de profundo impacto sanitário mundial, acometendo importante fração da humanidade. Por seu alcance, se faz necessário o conhecimento adequado de suas manifestações clínicas e da terapêutica, para otimização da conduta. Neste âmbito, o presente artigo destina-se à discussão da forma grave da malária, com ênfase no quadro clínico e no tratamento

Guideline in management of severe malaria.

Severe malaria remains a major cause of mortality in the world. Malaria can mimic many diseases and there is no absolute diagnostic clinical features. High index of suspicion is clue for clinical diagnosis. Previous travel history to endemic area should be elicited in all, and in particular, febrile patients. Management of severe malaria needs potent antimalarial drug and intensive care. Artemisinin derivatives can be of altemative use to quinine. Dexamethasone and mannitol have no beneficial value in the management of cerebral malaria. In pulmonary oedema patients whose hydration assessments are difficult to monitor, central venous pressure evaluation may be useful. Acute renal failure patients may need dialysis until uraemic syndrome subsides or patients can void urine. Most severe malaria patients have thrombocytopenia; however, platelet concentrate transfusion is indicated only in patients with systemic bleeding. Morbidity and mortality will be reduced in severe malaria patients with early diagnosis and prompt treatment.

Pulmonary manifestations in malaria.

Malaria, a major killer of mankind, apart from classical ague presentation, may present with respiratory manifestations. This may be misdiagnosed and important time may be lost in instituting antimalarials leading to higher morbidity and mortality. Present work was undertaken to study the clinical presentations of malaria with special reference to respiratory system and to evaluate the effect of antimalarials to such atypical presentation. One hundred slide positive cases of malaria were taken and detailed for respiratory involvement. Response to antimalarials was seen in these cases and associated complications (if any) were looked for. Mean age of the cases was 29.3 years with a male predominance. Positivity of peripheral smear read as: P vivax(53%), P falciparum (36%) and mixed infection (11%). Twenty-six patients had presented with respiratory manifestations-bronchitis (15), pneumonia (4), asthmatic bronchitis (1), adult respiratory distress syndrome (ARDS) (4) and pulmonary tuberculosis (2). Of these 26 cases, presenting symptoms noticed were cough (77%), dyspnoea (32%), expectoration (29%) and chest pain (15%). Twenty-five (96%) of these 26 patients were positive for P falciparum. Response to antimalarials was not significantly different in these 26 patients as compared to the rest (74 cases). All patients developing ARDS expired. The present study concludes that malarial atypical respiratory presentations are far higher in incidence than reported in literature. Peripheral smear examination in all patients of high grade fever with chills and rigors and having respiratory manifestations may unmask malarial infection and warrant early antimalarial treatment resulting in decreased morbidity and mortality.