Cerebral malaria in adults -- a description of 526 cases admitted to Ispat General Hospital in Rourkela, India.

Although the clinical picture of cerebral malaria in children has been reported extensively, scant information is available about cerebral malaria in adults. This report relates to one of the largest series of adult cases of cerebral malaria patients ever described. At Rourkela, in eastern India, 526 adults (aged >12 years) who each satisfied the World Health Organization's criteria for cerebral malaria were admitted to Ispat General Hospital between 1995 and 2001. These cases represented 18% of the 2994 adult patients who were admitted with Plasmodium falciparum malaria over the same period. Most (76%) of the adult cases of cerebral malaria were male, 48% were aged 21-40 years, and only 4% were older than 60 years. The most common presenting symptoms were fever (97.7%), vomiting (54.6%), headache (30.8%) and seizures (17.1%). Most (62.4%) of the cases had associated severe complications: jaundice (47.5%), acute renal failure (28.9%), and/or severe anaemia (9.7%). Overall, 175 (23%) of the cases were fatal, mortality being particularly high (59%) among those with multi-organ failure. Of the fatal cases, 107 (61%) died within the first 24 h of hospitalization, presumably indicative of late presentation. As the management of multiple complications may be inadequate at primary centres, early referral to higher centres is recommended.

Outcome of parapneumonic empyema.

OBJECTIVE: Empyema thoracis is known to have variable age group affection, causative agents and controversy regarding primary mode of management. To look into current demography, bacteriology and treatment outcome. METHODS: Prospective study made on admitted cases of parapneumonic empyema from July 2001 to June 2003. All cases were treated with chest tube drainage, parenteral antibiotics or thoracotomy in multiloculated or non-improving cases. RESULTS: 0.8% (C.I. 0.6-1.0) of total pediatric admission had empyema, who were more likely to be females (P< 0.05), under-weight (P< 0.05) compared to children admitted for other reasons. Staphylococcus aureus is still the commonest isolate (13.2%). All cases received antibiotics prior to hospitalisation. Majority of cases (90.5%) could be successfully managed with antibiotics and chest tube drainage alone. 9.4% cases needed thoracotomy. 5.8% cases needed salvage thoracotomy following non-improvement with chest tube drainage. Fever remission time and duration of hospital stay were comparable in both groups. Thoracotomy cases required antibiotics for shorter period (P=0.04). Two cases died due to reasons other than mode of management. Radiological and lung function recovery was excellent in most of the cases. CONCLUSION: Chest tube drainage is a safe, efficacious primary method of empyema management.

Indian public health standards (IPHS) for community health centres.

The health care system in India has expanded considerably over the last few decades but the quality of the services is not up to the mark due to various reasons. Hence standards are being introduced in order to improve the quality of services. A task group under the chairmanship of Director General of Health Services, Government of India was constituted to recommend the standards to be called as Indian Public Health Standards. IPHS are a set of standards envisaged to improve the quality of health care delivery in the country under the National Rural Health Mission.

Hepatopathy in complicated falciparum malaria: report from eastern India.

A prospective study done in 216 children with complicated falciparum malaria showed hepatopathy in 33.3% of cases with a higher incidence in children aged above five years. Bilirubin and alanine aminotransferase were moderately raised in most cases. No significant association with other common complications and no higher risk of mortality was observed.

The influence of hyperbilirubinaemia on malaria-related mortality: an analysis of 1103 patients.

The influence of hyperbilirubinaemia on malaria-related mortality was explored among 1103 cases of acute, Plasmodium falciparum malaria at a referral hospital in Orissa, India. Most (64.3%) of the subjects investigated had > 1.2 mg bilirubin/dl serum and were therefore considered hyperbilirubinaemic. Compared with the other patients, those with hyperbilirubinaemia were much more likely to have cerebral malaria (24.1% v. 9.4%; P < 0.0001) or acute renal failure (9.5% v. 2.3%; P < 0.0001), but not severe anaemia (5.9% v. 4.3%; P < 0.22). Mortality was 7.9% among the patients with hyperbilirubinaemia (all the deaths being attributable to cerebral malaria, acute renal failure and/or severe anaemia) but only 1% among the non-hyperbilirubinaemics. There were no deaths, however, among the 506 hyperbilirubinaemics who did not have cerebral malaria, acute renal failure or severe anaemia, even among those with high serum concentrations of bilirubin. It therefore appears that, in acute, Plasmodium falciparum malaria, hyperbilirubinaemia is not in itself a severe complication, and only appears linked with mortality when associated with at least one other complication.

Severe falciparum malaria.

Falciparum malaria affect all ages with multiple-systemic complications which varies in different age group. We studied 242 children with complicated Falciparum malaria with a median age of 6.5 years to look for occurrence of different complications in younger and older age groups and overall mortality picture. Unarousable coma (40.5%), severe anemia (26.03%), repeated seizures (46.2%) and hepatopathy (32.2%) were commonest complications. Under five children had higher risk of development of cerebral malaria (P<0.01), severe anemia (P<0.05) and seizures (P<0.001); whereas above five children had higher risk of acute renal failure (P<0.05) and malarial hepatopathy (P<0.02). Over all mortality was 9.9%, cerebral malaria being the commonest cause (6.6%). Multi-system involvement was seen in 58.4% cases of death. Children having pulmonary edema, shock and cerebral malaria had high case fatality rate.

A multicentric study with arteether in patients of uncomplicated falciparum malaria.

Two hundred and sixty seven patients of uncomplicated P. falciparum malaria completed study in a multicentric phase III clinical trial of Arteether. Arteether was given intramuscularly in a dose of 150 mg daily for three consecutive days. Each patient was followed upto 28 days of alpha, beta arteether therapy. The cure rate was 97% with fever clearance time between 1-7 days (24-168 hours) and parasite clearance time between 1-3 days (24-72 hours). Parasite reappearance rate was found to be 3% and reported at only three of the centres. Following the treatment no adverse effect was observed on haematological, biochemical and vital clinical parameters.

AIDS in India: recent trends in opportunistic infections.

The first case of AIDS in India was reported in 1986. Subsequently, a surveillance system was developed in 1987. The data from this surveillance activity suggest that the HIV infection has now spread to the general population and to all parts of the country, except Arunachal Pradesh in North-eastern India. With the changing scenario of the AIDS epidemic, a host of opportunistic infections add to the present endemic state of some already existing infections like tuberculosis. This report analyses the AIDS cases in India, reported to the National AIDS Control Organization over the years between 1986 to 1997. A total of 3,551 AIDS cases had been reported till 31st May 1997. Tuberculosis (pulmonary and extrapulmonary) is the major opportunistic infection affecting 62% of the cases followed by candidiasis seen in 57% of the patients. In 1997, of the 390 AIDS cases analysed, tuberculosis (pulmonary and extrapulmonary) accounted for 56.5% of the total cases whereas candidiasis was seen in 61% of the cases. An increasing trend was observed with tuberculosis from 58% in 1986-1992 to 68.5% in 1995. No trend could be established in the case of candidiasis, though, a high prevalence of 66% was seen in the cases between 1986 and 1992. An increase was also observed in cases of PCP, cerebral toxoplasmosis and Kaposi sarcoma. In the AIDS cases, chronic diarrhea (76%), weight loss (87%) and fever (85%) appeared to be the major presenting symptoms. But, of the 390 AIDS cases reported in 1997, only 47% of them were suffering from chronic diarrhea. With increase in the number of AIDS cases, India is burdened with a dual epidemic of HIV/AIDS and tuberculosis. The National AIDS Control Organization in India, is involved in training clinicians and laboratory personnel in the diagnosis and management of the AIDS cases. With better diagnosis of the opportunistic infections, especially diarrhea, in AIDS patients, a better picture will emerge regarding the opportunistic infections which would help clinicians and health planners to tackle the AIDS epidemic in a more effective manner.

Status of Plasmodium falciparum resistance to chloroquine in Orissa.

Orissa is known for its contribution of 15-20% of malaria cases to the national total. Deaths due to malaria in the state are also not uncommon. Proportion of P. falciparum cases have reached to 85%. In the recent years over 0.3 million confirmed malaria cases have been reported each year. Annual consumption of chloroquine in the state is over 170 lakh tablets. A 17 year study on monitoring of choloroquine resistance in P. falciparum in Orissa revealed that out of a total of 1165 tests conducted in vivo, in 12% of the cases RI level of resistance was detected. And 4.4% cases were of RII and 1.9% RIII level. 51% of the sample tested in vitro showed P. falciparum resistance to chloroquine. P. falciparum resistance to chloroquine appears to have been developed by the parasite over the length and breadth of the state. Strengthening of the monitoring of drug resistance in P. falciparum in the state is indicated.

alpha, beta-Arteether for the treatment of complicated falciparum malaria.

alpha, beta-Arteether is an ethyl ether derivative of artemisinin which is an efficient schizontocidal drug in mild falciparum malaria. The present study reports the efficacy of the drug in severe falciparum malaria. Fifty patients with severe falciparum malaria were given intramuscular arteether, 150 mg, once daily on 3 consecutive days. The median fever clearance time was 72 h (range 12-120 h) and the median parasite clearance time was 2 d (range 1-4 d). Rapid recovery from coma was observed in cerebral malaria patients (after a median of 18 h, range 6-72 h). The recovery from other complications was also faster and complete. Two patients died; both had cerebral malaria and haemolytic jaundice, one had respiratory distress needing ventilatory support and the other had severe anaemia. Recrudescence within 28 d was observed in 7 patients. Drug toxicity or significant side effects were not noticed in any patient.

Effectiveness of alpha,beta-arteether in acute falciparum malaria.

With the emergence of widespread chloroquine resistance and a world-wide scarcity of quinine, a search for newer antimalarial drugs has become imperative. Different derivatives of qinghaosu have been successfully tried. alpha,beta-Arteether, an ethyl derivative of qinghaosu, was administered to 51 patients with Plasmodium falciparum malaria, in a dose of 150 mg intramuscularly once a day on 3 consecutive days. Complete parasite clearance from the peripheral blood was observed in 80% of the patients at 48 h and in 98% at 72 h. The median parasite clearance time was 2 d (range 1-4 d). 65% of the patients became afebrile within 48 h and 81% by 72 h. The mean fever clearance time was 52.04 h (standard deviation 27.09). No side effect was seen. Patients were followed-up for 4 weeks; 7 were readmitted with P. falciparum infection but it could not be ascertained definitely whether these cases were reinfections or recrudescences. alpha-beta Arteether was a safe, effective and convenient drug for treating P. falciparum malaria. This is the first clinical study with arteether in falciparum malaria.

Vascular clogging, mononuclear cell margination, and enhanced vascular permeability in the pathogenesis of human cerebral malaria.

To document histopathologic evidence on the pathogenic mechanism of human cerebral malaria, we used light microscopy to study brain specimens from 23 patients who died of central nervous system involvement with Plasmodium falciparum. Sequestration of parasitized red blood cells (PRBCs) leading to cerebral capillary clogging was seen. In a few specimens, vascular clogging by PRBCs was associated with margination of mononuclear cells. In others, capillaries were virtually empty and lymphocytes and monocytes were seen in apposition (marginated) to the capillary endothelial surface. The endothelial cells appeared plump, hypertrophied, and prominent. The capillary wall appeared thickened by fibrinous material. Massive intercellular brain edema along with extravasated red blood cells, mononuclear cells, and plasmatic fluid was also noticed. In addition to hypoxia induced by PRBC-mediated vascular clogging, marginating mononuclear cells may contribute to the pathogenesis of cerebral malaria. The precise role played by this phenomenon needs further evaluation.