Evolución satisfactoria de un paciente adulto con malaria grave y complicada por Plasmodium falciparum / Satisfactory course of an adult patient with severe complicated Plasmodium falciparum malaria

Introducción: La malaria continúa siendo un importante problema de salud a nivel mundial, su diagnóstico temprano y tratamiento inmediato son fundamentales para prevenir las complicaciones y la muerte. Objetivo: Reportar el caso de un paciente cubano procedente de República de Guinea, que presentó malaria complicada por Plasmodium falciparum, el cual fue hospitalizado en el Instituto de Medicina Tropical Pedro Kourí (IPK). Caso clínico: Paciente masculino, cubano, de piel negra, 63 años de edad, profesión marinero mercante. Sin antecedentes patológicos personales. Llegó al IPK en camilla, con cierto deterioro de la conciencia, debilidad generalizada, dificultad respiratoria y compromiso del ritmo diurético. Ingresó en la Unidad de Cuidados Intensivos donde recibió tratamiento con los antipalúdicos artesunato y primaquina. La parasitemia fue descendiendo en el decursar de los días. El paciente sobrevivió y egresó satisfactoriamente a los 16 días posteriores a su ingreso. Fue debidamente notificado a las autoridades del Ministerio de Salud Pública de Cuba, lo que constituye un procedimiento obligatorio del Sistema Nacional de Vigilancia de Enfermedades Transmisibles en Cuba. Conclusión: La rapidez en el diagnóstico, así como el tratamiento integral, eficaz y oportuno, fue de importancia vital y condujo a un buen desenlace de la enfermedad.

Introduction: Malaria continues to be a major health problem worldwide, its early diagnosis and prompt treatment are critical to prevent complications and death. Objective: To report the case of a Cuban patient from the Republic of Guinea, who presented with complicated Plasmodium falciparum malaria, who was hospitalized at the Institute of Tropical Medicine Pedro Kourí (IPK). Clinical case: Male patient, Cuban, black-skinned, 63 years old, occupation: merchant seaman. No personal pathological history. He arrived at the IPK on a stretcher, with some deterioration of consciousness, generalized weakness, respiratory distress and diuretic rhythm compromise. He was admitted to the Intensive Care Unit where he received treatment with the antimalarial drugs artesunate and primaquine. Parasitemia decreased over the days. The patient survived and was discharged satisfactorily 16 days after admission. This case was duly notified to the authorities of the Ministry of Public Health of Cuba, which is a mandatory procedure of the National Surveillance System of Communicable Diseases in Cuba. Conclusion: Prompt diagnosis, as well as a comprehensive, effective, and timely treatment was vital and led to a good disease outcome.

Malaria y coinfecciones en una región endémica de Venezuela

Introducción: La malaria continúa siendo un importante problema de salud pública en todo el mundo. Las coinfecciones son un factor de riesgo que incrementa la mortalidad de esta enfermedad. En Venezuela no existen estudios que describan la presencia de coinfecciones en pacientes con malaria. Nosotros determinamos las características clínicas y epidemiológicas de los pacientes con malaria y la presencia de coinfecciones en Ciudad Bolívar, Estado Bolívar, Venezuela. Metodología: Se realizó un estudio descriptivo, correlacional y transversal, que incluyó pacientes diagnosticados con malaria por prueba rápida y/o gota gruesa y extendido de sangre periférica que consultaron en tres centros médicos de Ciudad Bolívar, estado Bolívar, entre junio y noviembre de 2018. Se realizó una evaluación clínica y de laboratorio de cada paciente, las coinfecciones con Dengue (VD), Hepatitis viral (HV) (A, B y C), Leptospirosis (LP), y Chikungunya (VCHIK) fueron evaluadas mediante la técnica de ELISA. Resultados: Un total de 161 pacientes fueron estudiados, 106 (65,8 %) presentaron infección por P. vivax, 43 (26,7 %) por P. falciparum y 12 (7,4 %) tenían malaria mixta (Pf/Pv). La media de edad fue 33,8 (±13,43) años; 103 (63,9 %) fueron hombres, la raza más frecuente fue mestiza (94,4 %); la mayoría de los pacientes (37,3 %) practicaban la minería ilegal. Los síntomas más frecuentes fueron fiebre, escalofríos y cefalea. Anemia leve, trombocitopenia moderada, y compromiso de la función hepática fueron los hallazgos de laboratorio más relevantes en todas las especies parasitarias. Se encontró coinfección en 55/161 (34,2 %) pacientes, siendo más frecuente entre los pacientes con P. falciparum (48,8 %). La coinfección más frecuente fue con VD (14,9 %), seguida de VHA (11,8 %)VHB (6,2 %), VCHIK (5,5 %) y LP (3,7 %). En el grupo de coinfectados fue más frecuente la malaria complicada (56,36 %) que la no complicada (43,63 %) con una diferencia estadísticamente significativa (P=0,018). Conclusión: Se encontró una alta prevalencia de coinfecciones en los pacientes con malaria, y su asociación con la severidad de la Malaria, estos datos epidemiológicos influyen de manera directa en el curso clínico, así como en la mortalidad de la enfermedad. Estos hallazgos deben darse a conocer al personal de salud para la identificación oportuna de coinfecciones en estos pacientes.

Introduction: Malaria continues to be a major public health problem worldwide. Co-infections are a risk factor that increases the mortality of this disease. In Venezuela there are no studies describing the presence of coinfections in patients with malaria. We determine the clinical and epidemiological characteristics of patients with malaria and the presence of coinfections in Ciudad Bolívar, Bolívar state, Venezuela. Methodology: A descriptive, correlational and cross-sectional study was carried out, which included patients diagnosed with malaria by rapid test and / or thick and extended peripheral blood drop that they consulted in three medical centers in Ciudad Bolívar, Bolívar state, between June and November 2018 A clinical and laboratory evaluation of each patient was performed, coinfections with Dengue (DV), viral hepatitis (HV) (A, B and C), Leptospirosis (LP), and Chikungunya (VCHIK) were evaluated using the technique of ELISA Results: A total of 161 patients were studied, 106 (65.8 %) had P. vivax infection, 43 (26.7 %) due to P. falciparum and 12 (7.4 %) had mixed malaria (Pf / Pv ). The mean age was 33.8 (± 13.43) years; 103 (63.9 %) were men, the most frequent race was mestizo (94.4 %); the majority of patients (37.3 %) practiced illegal mining. The most frequent symptoms were fever, chills and headache. Mild anemia, moderate thrombocytopenia, and hepatic function impairment were the most relevant laboratory findings in all parasitic species. Coinfection was found in 55/161 (34.2 %) patients, being more frequent among patients with P. falciparum (48.8 %). The most frequent coinfection was with RV (14.9 %), followed by HAV (11.8 %) HBV (6.2 %), HCV (5.5 %) and LP (3.7 %). Complicated malaria (56.36 %) was more frequent than uncomplicated (43.63 %) with a statistically significant difference (P = 0.018). Conclusion: A high prevalence of coinfections was found in patients with malaria, and its association with the severity of Malaria, these epidemiological data directly influence the clinical course, as well as the mortality of the disease. These findings should be made known to health personnel for the timely identification of coinfections in these patients.

Complicated malaria: relationship of complications and parasite load to outcome

Background: The pregnant women are more commonly affected with asymptomatic bacteriuria (ASB) than non-pregnant women and its progression could lead to adverse maternal and perinatal outcomes. The study was designed with an aim to know the prevalence of ASB and its effects on maternal and perinatal outcome.Methods: In this prospective study, 300 antenatal women attending Anil Neerukonda Hospital were screened for ASB. Urine culture was performed using standardized Kirby-Bauer disc diffusion method on blood agar, Mac Conkey抯 agar for antibiotic sensitivity testing. The screened antenatal women were divided into two subgroups viz. asymptomatic bacteriuria positive (Group I) and asymptomatic bacteriuria negative (Group II) depending on the culture study and were followed till delivery for maternal and perinatal outcomes.Results: The prevalence of ASB was 11.33%. Out of 34 cases of ASB positive, 8 cases (23.5%) were delivered with birth weight <2500 grams as compared to 11 cases (4.1%) in unexposed cases (RR 5.68, 95% CI; 2.46-13.15; p<0.05). Preterm low birth was noticed in 5 (14.7%) cases of ASB positive pregnant women with compared to unexposed cases (RR 1.5, 95% CI; 0.61-3.65, p=0.36). Regarding maternal outcomes, premature labour was observed in 8 cases (23.5%) of ASB exposed women whereas 22 (8.3%) in non-exposed cases (RR 2.84, 95% CI; 1.37-5.88, p=0.004). A significant number of women have developed hypertension (17.6%) and preeclampsia (8.8%) in ASB positive cases as compared to ASB negative cases (4.9% and 2.3% respectively).Conclusions: The prevalence of ASB was 11.33% in the present study. As one third of the cases were identified in early and late trimesters, regular and trimester wise screening need to be incorporated in routine antenatal screening for safe motherhood and new born health.

A complicated case of Plasmodium falciparum malaria with symmetrical peripheral gangrene with a review of literature.

Malaria causes nearly one million deaths each year and with its recent re-emergence, several fatal complications are seen such as cerebral malaria, hypotension or shock, renal failure, pulmonary oedema/adult respiratory distress syndrome, and hypoglycaemia. Symmetric peripheral gangrene (SPG) is a severe but extremely rare complication of malaria. It has a rapid and sudden onset leading to necrosis which cannot be reversed. A 26 year old male was admitted and treated for complicated malaria and developed SPG. He was given intravenous artesunate, doxycyline, clopidogrel and acetyl salicyclic acid for the gangrene; however, he went into multiple organ dysfunction syndrome and septic shock and thus could not be resuscitated. We report this case to highlight that physicians treating malaria should always look for these signs for timely correction and to improve the patient outcome.

Plasma glutathione and oxidized glutathione level, glutathione/oxidized glutathione ratio, and albumin concentration in complicated and uncomplicated falciparum malaria

Objective: To compare the level of glutathione (GSH) and oxidized glutathione (GSSG), the ratio of GSH/GSSG and the concentration of albumin in plasma of patients with complicated and un-complicated falciparum malaria. Methods: This research was a cross sectional study using comparison analysis with the plasma GSH and GSSG, the ratio of plasma GSH/GSSG and the concentration of plasma albumin as variables. The complicated malaria patients were obtained from Dr. Saiful Anwar Hospital Malang, whereas uncomplicated malaria patients were obtained from the Regency of Pleihari South Kalimantan. Plasma GSH and GSSG levels were determined by the spectrophotometer at the wave length of 412 nm, whereas the concentration of albumin was determined by bromocresol green method in the pH of 4.1. Results: There were no significant differences between the level of plasma GSH and GSSG in complicated and uncomplicated malaria patients, as well as the ratio of plasma GSH/GSSG in the two groups (P=0.373;P=0.538;and P=0.615, respectively, independent t-test). In contrast, the plasma albumin concentration in complicated malaria patients were significantly higher than uncomplicated malaria patients (P=0.000, Mann Whitney U test). Conclusions: It can be concluded that the average of plasma GSH and GSSG level, also plasma GSH/GSSG ratio in complicated malaria are not different from uncomplicated ma-laria. Although plasma concentration of albumin in both groups is below the normal range, there is an increase in complicated malaria that might be as compensation of oxidative stress.

Plasma glutathione and oxidized glutathione level, glutathione/oxidized glutathione ratio, and albumin concentration in complicated and uncomplicated falciparum malaria

Objective To compare the level of glutathione (GSH) and oxidized glutathione (GSSG), the ratio of GSH/GSSG and the concentration of albumin in plasma of patients with complicated and un-complicated falciparum malaria. Methods This research was a cross sectional study using comparison analysis with the plasma GSH and GSSG, the ratio of plasma GSH/GSSG and the concentration of plasma albumin as variables. The complicated malaria patients were obtained from Dr. Saiful Anwar Hospital Malang, whereas uncomplicated malaria patients were obtained from the Regency of Pleihari South Kalimantan. Plasma GSH and GSSG levels were determined by the spectrophotometer at the wave length of 412 nm, whereas the concentration of albumin was determined by bromocresol green method in the pH of 4.1. Results There were no significant differences between the level of plasma GSH and GSSG in complicated and uncomplicated malaria patients, as well as the ratio of plasma GSH/GSSG in the two groups (P = 0.373; P = 0.538; and P = 0.615, respectively, independent t-test). In contrast, the plasma albumin concentration in complicated malaria patients were significantly higher than uncomplicated malaria patients (P = 0.000, Mann Whitney U test). Conclusions It can be concluded that the average of plasma GSH and GSSG level, also plasma GSH/GSSG ratio in complicated malaria are not different from uncomplicated malaria. Although plasma concentration of albumin in both groups is below the normal range, there is an increase in complicated malaria that might be as compensation of oxidative stress.

Incidence, severity, prognostic significance of thrombocytopenia in malaria.

Background: Malaria is an infectious disease caused by plasmodium parasite. P. falciparum account for majority of morbidity and mortality. Thrombocytopenia and anaemia are the most frequently associated hematological complications in malaria. The low platelet count together with acute febrile syndrome emerged as the strongest predictor of malaria a finding that is frequent and present even before anemia and splenomegaly sets in. Severe thrombocytopenia is a good predictor of poor prognosis than mild and moderate thrombocytopenia. The aim is to study the incidence, severity, prognostic significance of thrombocytopenia in malaria. Methods: This was an observational and prospective study. The study enrolled 100 patients with thrombocytopenia and fever who were proven to have malaria either by peripheral smear or Quantitative Buffy Coat (QBC) test or malarial antigen assay were included in the study and patients with thrombocytopenia due to other causes were excluded from the study. Platelet count was estimated on a fully automated quantitative analyzer. All the 100 patients were followed during the hospital stay and upto discharge or till the outcome. Results: The incidence of thrombocytopenia was 73% indicating a common association in malaria. Complicated malaria was observed in 58.80% of P. falciparum infection whereas 66% of P. vivax infection was associated with uncomplicated malaria. Severe thrombocytopenia showed positive correlation with severity of malaria. Thrombocytopenic patients with effective anti-malarial treatment showed 95.90% recovery and 3 patients 4.10% had mortality. Patients with severe thrombocytopenia were 8.5 times more likely to have complicated malaria with P <0.001 according to student „t‟ test. Conclusion: Thrombocytopenia is the most common hematological finding in malaria. Severe thrombocytopenia showed positive correlation with complicated malaria and a good predictor of poor prognosis. Patients with classical malarial fever and thrombocytopenia who were negative for malaria parasite were not included in the study.

Complicated congenital malaria due to Plasmodium vivax / Paludismo congénito complicado debido a Plasmodium vivax

La malaria congénita es una enfermedad que aparece en el período neonatal y que, si no se trata oportunamente, puede tener consecuencias fatales para el recién nacido. Según las estadísticas publicadas en el Informe del Estado Mundial de la Infancia 2009, actualmente mueren 3.7 millones de niños menores de 28 días en todo el mundo. El 8% de los casos corresponden a niños menores de 5 años con malaria (1). De manera similar, los estudios en áreas endémicas han reportado incidencias de malaria congénita de entre 0.83 y 5.93% (2). Aquí, presentamos un caso de malaria congénita en un lactante de un mes de edad cuya madre recibió tratamiento para la malaria por Plasmodium vivax (P. vivax) durante la gestación pero sufrió una recaída con el consiguiente compromiso del bebé en el útero. Es necesario reconocer la alta prevalencia de esta enfermedad en nuestro contexto y saber cómo vigilar y tratar la enfermedad en casos especiales como los de las madres gestantes y los recién nacidos con infecciones congénitas.

Congenital malaria is a disease that appears in the neonatal period and that, if not treated in a timely manner, may have fatal consequences for the newborn. According to statistics published in The State of the World Children 2009 Report, 3.7 million children under the age of 28 days die annually around the world at present. 8% of cases correspond to children under 5 years of age with malaria (1). Similarly, studies in endemic areas have reported incidences of congenital malaria of between 0.83 and 5.93% (2). Here, we present a case of congenital malaria in a one-month-old nursing infant whose mother received treatment for malaria from Plasmodium vivax (P. vivax) during gestation but suffered a relapse with a consequent compromise of the infant in utero. There is a need to recognize the high prevalence of this disease in our context and to know how to monitor and treat the disease in special cases like those of gestating mothers and newborn infants with congenital infections.

Ictericia y hepatopatía en el paciente con malaria / Jaundice and hepatopathy in patients with malaria

La ictericia es un hallazgo frecuente en el paciente con malaria. Según la Organización Mundial de la Salud, se considera un signo de peligro cuando se acompaña de aumento importante de las bilirrubinas y comúnmente se relaciona con disfunción hepática y lesión de otros sistemas. La lesión hepática en estos pacientes es frecuente, está asociada a otras complicaciones, y es reversible si se identifica y se trata a tiempo. Con este trabajo se pretende revisar el valor semiológico de la ictericia como indicador de malaria complicada, explicar su patogénesis y los mecanismos de daño hepático; además, hacer un enfoque del paciente con hepatopatía palúdica, diferenciando la disfunción hepática de la falla y la encefalopatía hepáticas.

Jaundice is a common finding in malaria patients. According to the World Health Organization, it is considered a sign of danger when accompanied by an important increase of bilirubin and it is frequently related to hepatic dysfunction and injury to other organs. Liver injury in these patients is common and it is associated with other complications. If it is identified and treated early, it is reversible. This paper reviews the semiological value of jaundice as an indicator of complicated malaria; it explains its pathogenesis and the mechanisms of liver damage. It also focuses on the patient with hepathopathy, distinguishing hepatic dysfunction, hepatic failure and hepatic encephalopathy.

Methemoglobinemia minies complicated malaria.

Methemoglobinemia is an uncommon condition seen in clinical practice. It is generally cussed by exposure to drugs, chemicals or solvents. Many drugs are implicated in the causation of Methernoglobinemia one of which is chloroquine. We present here a case of Methemoglobinemia following Chloroquine which was given for the treatment of fever. The clinical presentation resembled closely to that of complicated Malaria. This case is presented with the objective of increasing awareness that uncommon illnesses can sometimes resemble closely to a very commonly seen condition and hence can be missed.

Clínica de la malaria complicada debida a Plasmodiun falciparum: Estudio de casos y controles en Tumaco y Turbo (Colombia) / Clinical presentation of severe malaria due Plasmodiun falciparum: Case control study in Tumaco and Turbo (Colombia)

ANTECEDENTES Y PROBLEMA : son muy pocos los estudios latinoamericanos sobre malaria por Plasmodium falciparum (P falciparum) complicada y se requiere estudiarla para identificar un patrón propio. OBJETIVOS : Identificar las complicaciones presentes en pacientes de Tumaco (Nariño) y Turbo (Antioquia) en Colombia, con malaria por P falciparum. MÉTODOS : Diseño de casos y controles. Se aplicaron los criterios diagnósticos de complicación OMS-2000 (Organización Mundial de la Salud). RESULTADOS : Se captaron 64 casos (con malaria por P. falciparum complicada) y 135 controles (con malaria por P. falciparum no complicada). El tiempo de evolución de la enfermedad (promedio 5,6 días en los casos y 5,9 en los controles) y la frecuencia de síntomas fueron similares en ambos grupos (p>0,05), pero la dificultad respiratoria y la ictericia fueron más frecuentes en los casos que en los controles (p<0,05). Los valores promedio de glicemia y creatinina fueron similares en ambos grupos, pero los casos tuvieron hemoglobina y recuento de plaquetas menores que los controles (p<0,05) y mayores niveles de nitrógeno ureico, aspartatoaminotransferasa y bilirrubinas total y directa (p<0,05). Las complicaciones encontradas fueron hiperparasitemia en 48%, disfunción hepática en 44%, síndrome de dificultad respiratoria aguda en 9%, falla renal en 6%, trombocitopenia grave en 5%, anemia grave en 3%, malaria cerebral en 3% e hipoglicemia grave en 2%. Los criterios de complicación malárica de OMS se comparan con otros y se discuten las implicaciones.

BACKGROUND : Latin American studies on severe falciparum malaria are scarce, therefore, the pattern of complications of the region is uknown. OBJECTIVES : To identify characterize severe malaria in patients from Tumaco (Nariño) and Turbo (Antioquia) in Colombia . METHODS : The 2000 World Health Organization criteria for complicated malaria were applied in a cases and controls study. RESULTS : 64 cases ( P falciparum complicated malaria) and 135 controls ( P falciparum uncomplicated malaria) were included. The time of evolution of the disease (mean 5.6 days in cases and 5.9 in the controls) and the frequency of most symptoms were similar in both groups (p>0.05). However, respiratory distress and jaundice was more frequent in the cases (p<0.05). The mean glycemia and creatinina values were similar in both groups; hemoglobin and platelet count were lower in the cases (p<0.05) when compared to controls. On the other hand, blood ureic nitrogen, aspartatoaminotransferase, and total and direct bilirrubin were lower in controls (p<0.05). The frequency of complications in the cases was as follows: hyperparasitaemia 48%, liver dysfunction 44%, acute; respiratory distress syndrome 9%, kidney failure 6%, severe thrombocytopenia 5%, severe anemia 3%, cerebral malaria 3% and severe hipoglycemia 2%. The WHO criteria for severe malaria were compared with others and the implications are discussed.

Comparative Efficacy of Quinine and Artesunate in the Treatment of Severe Malaria:A Randomized Controlled Trial

There is a paucity of head to head studies of quinine and artesunate in Indian patients. A consensus on the best treatment for severe malaria is lacking. To compare the efficacy of quinine and artesunate in severe falciparum malaria. This is a prospective randomized controlled, opened-labeled trial, conducted in a tertiary care center in western India. Thiry-five patients above the age of 18 years, with asexual forms of plasmodium falciparum in the peripheral smear and satisfying the WHO criteria for severe malaria, formed the study population. On randomization 18 received quinine and 17 artesunate. The end points of the study were parasite clearance time (PCT), fever clearance time (FCT), coma resolution time (CRT), adverse effects of the drugs and death. The FCT (p 0.023) and PCT (p=0.04) were lower with artesunate. The CRT was lower with quinine (p 0.03). One patient in each arm succumbed to the illness (p 0.96). There was no side effect warranting a crossover to the other arm. Thus, quinine is as good as artesunate in the treatment of severe falciparum malaria.