Not all severe malaria cases are severe: Is it time to redefine severity criteria for malaria in non-endemic regions?

BACKGROUND: The current definition of severe malaria in non-endemic areas follows WHO criteria, which mainly target children in malaria-endemic areas, potentially misclassifying cases in non-endemic regions. We assessed the performance of a modified severe malaria classification criteria within our patient cohort. METHODS: A cohort study of patients managed for malaria in a non-endemic setting (2005-2023) was analyzed. We classified patients into severe malaria (SM) using WHO 2013 criteria except for hyperparasitemia, where 2 % threshold was applied. Patients with SM were distinguished as very severe malaria (VSM) when presenting at least one of the following conditions: parasitemia >10 %, pulmonary edema, impaired consciousness, seizures, renal failure, metabolic acidosis or hyperlactatemia, shock or hypoglycemia. In patients with SM and no criteria for VSM, less severe malaria (LSM) was defined by: 2-10 % parasitemia, hyperbilirubinemia, prostration, anemia or minor bleeding. The primary composite outcome was death or the need for a life-saving intervention, as analyzed in the three comparative groups. Secondary outcome was the prevalence of co-infections. RESULTS: Among 506 patients with malaria, 176 (34.8 %) presented with SM. A total of 37 (7.3 %) patients developed a life-threatening condition, namely death (n = 4) and/or the need for life-saving interventions (n = 34). All fatalities and 33 out of the 34 life-saving interventions occurred in the VSM group. Patients in LSM group did not develop any life-threatening conditions. As to co-infections, 28 (5.5 %) patients had a community-acquired co-infection, with no differences between groups (p = 0.763). CONCLUSIONS: Severity criteria definitions would benefit from a review when assessing patients with malaria in non-endemic areas. Within the spectrum of SM, patients reclassified as LSM have a low risk of developing a life-threatening condition and present low co-infection incidence and could benefit from management out of intensive care units and a restrictive use of empirical antibiotics.

Host biomarkers for early identification of severe imported Plasmodium falciparum malaria.

BACKGROUND: Severe imported P. falciparum malaria is a source of morbi-mortality in non-endemic regions. WHO criteria don't accurately classify patients at risk of complications. There is a need to evaluate new tools such as biomarkers to better identify patients with severe imported malaria. METHODS: A case-control study was conducted in Barcelona, from January 2011-January 2021. Adult patients with microbiologically confirmed P. falciparum malaria were classified according to WHO criteria. Patients with imported non-malarial fevers were included as controls. In each group, angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), soluble triggering receptor expressed on myeloid cells (sTREM-1), C-reactive protein (CRP) and platelets were measured and their concentrations were compared between groups. New groups were made with a modified WHO severity classification and biomarkers' performance was evaluated using multiple imputation models. RESULTS: 131 participants were included: 52 severe malaria, 30 uncomplicated malaria and 49 non-malarial fever cases. All biomarkers except sTREM-1 showed significant differences between groups. Using the modified WHO severity classification, Ang-2 and CRP presented the best AUROC; 0.79 (95%CI 0.64-0.94) and 0.80(95%CI 0.67-0.93). A model combining CRP and Ang-2 showed the best AUROC, of 0.84(95%CI 0.68-0.99), with the highest sensitivity and specificity: 84.6%(95%CI 58.9-98.1) and 77.4% (95%CI 65.9-87.7), respectively. CONCLUSIONS: The combination of Ang-2 and CRP may be a reliable tool for the early identification of severe imported malaria. The use of a rapid prognostic test including the mentioned biomarkers could optimize imported malaria management, with the potential to decrease the rate of complications and hospitalizations in patients with imported malaria.

Improved diagnosis of gastrointestinal infections using a semi-automated multiplex real-time PCR for detection of enteropathogens.

Introduction. The identification of enteropathogens is critical for the clinical management of patients with suspected gastrointestinal infection. The FLOW multiplex PCR system (FMPS) is a semi-automated platform (FLOW System, Roche) for multiplex real-time PCR analysis.Hypothesis/Gap Statement. FMPS has greater sensitivity for the detection of enteric pathogens than standard methods such as culture, biochemical identification, immunochromatography or microscopic examination.Aim.The diagnostic performance of the FMPS was evaluated and compared to that of traditional microbiological procedures.Methodology. A total of 10 659 samples were collected and analysed over a period of 7 years. From 2013 to 2018 (every July to September), samples were processed using standard microbiological culture methods. In 2019, the FMPS was implemented using real-time PCR to detect the following enteropathogens: Shigella spp., Salmonella spp., Campylobacter spp., Giardia intestinalis, Entamoeba histolytica, Blastocystis hominis, Cryptosporidum spp., Dientamoeba fragilis, adenovirus, norovirus and rotavirus. Standard microbiological culture methods (2013-2018) included stool culture, microscopy and immunochromatography.Results. A total of 1078 stool samples were analysed prospectively using the FMPS from July to September (2019): bacterial, parasitic and viral pathogens were identified in 15.3, 9.71 and 5.29 % of cases, respectively. During the same period of 6 years (2013-2018), the proportion of positive identifications using standard microbiological methods from 2013 to 2018 was significantly lower. A major significant recovery improvement was observed for all bacteria species tested: Shigella spp./enteroinvasive Escherichia coli (EIEC) (P <0.05), Salmonella spp. (P <0.05) and Campylobacter spp. (P <0.05). Marked differences were also observed for the parasites G. intestinalis, Cryptosporidium spp. and D. fragilis.Conclusion. These results support the value of multiplex real-time PCR analysis for the detection of enteric pathogens in laboratory diagnosis with outstanding performance in identifying labile micro-organisms. The identification of unsuspected micro-organisms for less specific clinical presentations may also impact on clinical practice and help optimize patient management.

Clinical and epidemiological features of 33 imported Strongyloides stercoralis infections.

Strongyloides stercoralis has a unique ability to replicate in the human host and lead to chronic infection that can persist for several decades. Thirty-three patients (10 travellers and 23 immigrants) with imported S. stercoralis infection were studied and clinical and epidemiological characteristics described. Only 16 patients (48.5%) reported symptoms, mainly of the gastrointestinal tract. Eosinophilia was present in 21 (63.6%) patients. Seven patients (21.2%) had an immunocompromising condition. Patients were classified into chronic asymptomatic infection (17/33, 51.5%), chronic symptomatic infection (11/33, 33.3%) and hyperinfection (5/33, 15.2%). Four of the latter (80%) had an immunocompromising condition. Strongyloides stercoralis infection should be considered in immigrants and travellers with eosinophilia or compatible symptoms coming from endemic areas. Diagnosis should always be sought in immunocompromised hosts.

Fiebre de katayama en turistas españoles: análisis de 25 casos / Katayama fever in Spanish tourists: analysis of 25 cases

FUNDAMENTO: Conocer la presentación clínica y el abordaje clínico y terapéutico de la esquistosomiasis aguda en viajeros no inmunes. PACIENTES Y MÉTODO: Pacientes con cuadro febril y con antecedentes de baños en zonas endémicas. Protocolo prospectivo, 1984-1999. RESULTADOS: El 21 por ciento de los pacientes diagnosticados de esquistosomiasis desarrolló el síndrome de Katayama. Nueve pacientes tuvieron un cuadro de 'dermatitis del nadador'. La sospecha se establece por la historia epidemiológica, fiebre y eosinofilia. La confirmación diagnóstica se obtuvo por serología en 10 casos, por parasitología en 11 y por ambos métodos en dos. CONCLUSIONES: La presencia de fiebre y eosinofilia tras una exposición en aguas infestadas debe hacer sospechar el síndrome. Se necesitan tests serológicos más asequibles y que se positivicen a corto plazo tras la infección. En España, dos tipos de viajes a Mali (país Dogón) y Uganda son la causa del 75 por ciento de las infecciones. Esta cuestión debería incluirse en nuestra práctica habitual de consejos a viajeros (AU)

Seroprevalencia de la toxoplasmosis en mujeres en edad fértil (1992-1999) / Seroprevalence of toxoplasmosis in women of childbearing age (1992-1999)

Fundamento: Averiguar si es necesario el cribado prenatal de la toxoplasmosis en nuestro hospital desde un punto de vista seroepidemiológico. Pacientes y métodos: Se ha analizado retrospectivamente la prevalencia de IgG anti-T. gondii en 7.090 mujeres en edad fértil visitadas en el Hospital Clínic de Barcelona desde febrero de 1992 hasta abril de 1999. Se ha comprobado la asociación entre la seroprevalencia y las variables año, edad, lugar de nacimiento (provincia de Barcelona/otras provincias) y de residencia (urbano/rural). Resultados: Se observó una tendencia decreciente de la prevalencia a lo largo del tiempo (p < 0,001), siendo actualmente menor de 40 por ciento en el conjunto de mujeres entre 15 y 45 años. La infección también estuvo directamente relacionada con la edad (p < 0,001) y el nacimiento fuera de la provin cia de Barcelona (p = 0,001). No se encontró asociación entre el lugar de residencia y la seroprevalencia. Conclusiones: Es aconsejable realizar el cribado prenatal de la toxoplasmosis por la alta tasa de mujeres seronegativas expuestas a la infección y la existencia de un número elevado de primoinfecciones en el período fértil de la vida. (AU)

Datación de igm anti-toxoplasma en el embarazo con métodos VIDAS-ELFA / Datation of IgM anti-Toxoplasma in pregnancy with VIDAS-ELFA methods

Fundamentos: Estudiar la utilidad de la titulación de anticuerpos IgG e IgM, y de la avidez de las IgG para la datación de IgM frente a Toxoplasma gondii. Métodos: Se usaron las pruebas VIDAS Toxo IgG, VIDAS Toxo IgM y VIDAS Toxo IgG Avidity. Se analizaron 64 sueros con IgM e IgG anti-T. gondii, 32 de ellos pertenecientes a 12 individuos con una infección de menos de 40 semanas (grupo I), y el resto pertenecientes a 17 individuos con una infección de más de 40 semanas (grupo II). Resultados: Un índice de IgM 12 semanas. Un índice de avidez > 0,164 excluyó el 100 por ciento de infecciones ó 12 semanas. Con índices de avidez > 0,26 y 0,45 se pudieron excluir infecciones ó 20 y ó 40 semanas, respectivamente. Conclusiones: Los métodos serológicos utilizados para el estudio son capaces de identificar correctamente anticuerpos IgM anti-T. gondii residuales y, por tanto, en muchas ocasiones hacen innecesario una segunda extracción para analizar la cinética de las IgG en pacientes embarazadas. (AU)