[Retinal manifestations of neuro-malaria or "malarial retinopathy" in Yaoundé]. / Atteintes rétiniennes du neuro-paludisme ou « rétinopathie paludique ¼ à Yaoundé.

AIM: Contribute to the improvement of diagnostic and prognostic approaches to treating children with neuro-malaria in Yaoundé. PATIENTS AND METHOD: A prospective and analytical study carried out in 2 hospitals of Yaoundé from October 2015 to March 2016. All patients aged 3 months to 15 years hospitalized for neuro-malaria in one of the 2 hospitals benefited from a fundus examination. The variables studied were: age, sex, Glasgow or Blantyre score, fundus examination and parasitaemia. For statistical analysis, we used the software R 3.3.0, Chi2, exact of Fisher or Kolmogorov-Smirnov tests with a significance P<5%. RESULTS: Out of the 178 children hospitalized during the study period, 44 had neuro-malaria (24.71%) and 26 (46 diseased eyes) among them presented retinal lesions at a frequency of 14.60%. The mean age was 5.54±3.49 years with a sex ratio of 1.09. The under 5-years-old were the most affected with 31 (70.45%) cases. The fundus lesions of 26 (59.09%) were retinal hemorrhages in 24 (54.54%), retinal whitening and vessel discoloration in 8 (18.18%) respectively. Papillary edema was associated in 4 (9.09%). Macular involvement was noted in 9 cases. These lesions were correlated with age, depth of coma, duration, and clinical course. The rate of parasitaemia did not affect their occurrence. CONCLUSION: Retinal lesions are frequent and serious during neuro-malaria in our environment, especially in children under five. They must therefore be an emphasis in the systematic exam to rule it out for a better prognostic evaluation and a fast and adequate multidisciplinary management.

Roth Spots in Ocular Toxoplasmosis.

PURPOSE: To report a case with unilateral preexisting ocular toxoplasmosis (OT) and newly occurred active retinochoroidal inflammation associated with white-centered retinal hemorrhages (Roth spots) in the healthy eye. DESIGN: Case report. METHODS: A 20 year-old man presented with a decrease of visual acuity in his right eye associated with 2+ cells in the anterior chamber. Ophthalmoscopy revealed an active retinochoroidal lesion on the upper nasal border of the optic disc associated with local hemorrhage and vitritis. The posterior pole presented white-centered flame-shaped retinal hemorrhages. RESULTS: Toxoplasmosis serology showed an IgG titer >300IU/ml and a negative IgM titer. A complete blood count revealed no abnormalities; other serologies were negative. After 2 weeks of treatment with sulfadiazine, pyrimethamine, folinic acid and prednisone, although the peripapillary lesion was still active, the Roth spots disappeared. CONCLUSION: OT may be one differential diagnosis of patients suffering Roth spots in association with retinochoroidal inflammation.

Laboratory evidence of disseminated intravascular coagulation is associated with a fatal outcome in children with cerebral malaria despite an absence of clinically evident thrombosis or bleeding.

BACKGROUND: A procoagulant state is implicated in cerebral malaria (CM) pathogenesis, but whether disseminated intravascular coagulation (DIC) is present or associated with a fatal outcome is unclear. OBJECTIVES: To determine the frequency of overt DIC, according to ISTH criteria, in children with fatal and non-fatal CM. METHODS/PATIENTS: Malawian children were recruited into a prospective cohort study in the following diagnostic groups: retinopathy-positive CM (n = 140), retinopathy-negative CM (n = 36), non-malarial coma (n = 14), uncomplicated malaria (UM), (n = 91), mild non-malarial febrile illness (n = 85), and healthy controls (n = 36). Assays in the ISTH DIC criteria were performed, and three fibrin-related markers, i.e. protein C, antithrombin, and soluble thrombomodulin, were measured. RESULTS AND CONCLUSIONS: Data enabling assignment of the presence or absence of 'overt DIC' were available for 98 of 140 children with retinopathy-positive CM. Overt DIC was present in 19 (19%), and was associated with a fatal outcome (odds ratio [OR] 3.068; 95% confidence interval [CI] 1.085-8.609; P = 0.035]. The levels of the three fibrin-related markers and soluble thrombomodulin were higher in CM patients than in UM patients (all P < 0.001). The mean fibrin degradation product level was higher in fatal CM patients (71.3 µg mL(-1) [95% CI 49.0-93.6]) than in non-fatal CM patients (48.0 µg mL(-1) [95% CI 37.7-58.2]; P = 0.032), but, in multivariate logistic regression, thrombomodulin was the only coagulation-related marker that was independently associated with a fatal outcome (OR 1.084 for each ng mL(-1) increase [95% CI 1.017-1.156]; P = 0.014). Despite these laboratory derangements, no child in the study had clinically evident bleeding or thrombosis. An overt DIC score and high thrombomodulin levels are associated with a fatal outcome in CM, but infrequently indicate a consumptive coagulopathy.

Malaria retinopathy and cerebellitis in a 9-year-old boy in the United States.

Malarial retinopathy is characterized by retinal whitening, vessel change, and hemorrhages usually associated with a white center. We present the case of a 9-year-old boy who presented with a systemic Plasmodium falciparum infection, hemorrhagic cerebellitis and malarial retinopathy characterized by "fire flare" hemorrhages (scleral icterus with subconjunctival hemorrhages), Roth spot-like hemorrhages, and subhyaloid hemorrhage. To our knowledge, this is the first reported case of hemorrhagic cerebellitis secondary to P. falciparum infection in the United States.

Automated detection of malarial retinopathy-associated retinal hemorrhages.

PURPOSE: To develop an automated method for the detection of retinal hemorrhages on color fundus images to characterize malarial retinopathy, which may help in the assessment of patients with cerebral malaria. METHODS: A fundus image dataset from 14 patients (200 fundus images, with an average of 14 images per patient) previously diagnosed with malarial retinopathy was examined. We developed a pattern recognition-based algorithm, which extracted features from image watershed regions called splats (tobogganing). A reference standard was obtained by manual segmentation of hemorrhages, which assigned a label to each splat. The splat features with the associated splat label were used to train a linear k-nearest neighbor classifier that learnt the color properties of hemorrhages and identified the splats belonging to hemorrhages in a test dataset. In a crossover design experiment, data from 12 patients were used for training and data from two patients were used for testing, with 14 different permutations; and the derived sensitivity and specificity values were averaged. RESULTS: The experiment resulted in hemorrhage detection sensitivities in terms of splats as 80.83%, and in terms of lesions as 84.84%. The splat-based specificity was 96.67%, whereas for the lesion-based analysis, an average of three false positives was obtained per image. The area under the receiver operating characteristic curve was reported as 0.9148 for splat-based, and as 0.9030 for lesion-based analysis. CONCLUSIONS: The method provides an automated means of detecting retinal hemorrhages associated with malarial retinopathy. The results matched well with the reference standard. With further development, this technique may provide automated assistance for screening and quantification of malarial retinopathy.

Retinal hemorrhage in Plasmodium vivax malaria.

Retinal hemorrhage is a frequently observed sign in Plasmodium falciparum infection. In Plasmodium vivax infection, however, retinal hemorrhage is very rare; only five cases have been reported in the literature. In this case report, we review the literature and the case of 52-year-old man who had retinal hemorrhages in P. vivax infection. We analyzed the structural characteristics of the lesions using fluorescein angiography and spectral-domain optical coherence tomography. Physicians should be aware of the possibility of retinal hemorrhage in malaria patients, even those with P. vivax infection, and should consider a diagnosis of malaria in a patient with unexplained retinal hemorrhage and fever.

Ophthalmoscopic findings in adult patients with severe falciparum malaria.

AIM: To report the systemic and ocular findings of four Indian adult patients with severe Plasmodium falciparum infection. MATERIALS AND METHODS: Case reports. RESULTS: The commonest findings seen were posterior pole hemorrhages that were seen in all patients. These included superficial and subretinal hemorrhages. Some of the eyes with subretinal hemorrhages were associated with a premacular hemorrhage. The findings of retinal whitening and vascular changes were seen in one patient. CONCLUSIONS: A spectrum of ocular lesions was noted, including pre-retinal, subretinal hemorrhages, retinal whitening, and retinal vascular anomalies.

Retinal haemorrhage in vivax malaria.

Retinal haemorrhage is often observed in patients with Plasmodium falciparum, especially when combined with cerebral malaria. However, few cases of retinopathy have been reported in P. vivax malaria. Benign tertian malaria has re-emerged among soldiers in the South Korean demilitarized zone since 1993. We report an indigenous case of retinal haemorrhage caused by P. vivax and review the relevant literature.

[Ophthalmic cysticercosis-case report]. / Cisticercoza oculara--caz clinic.

This paper presents a particular case regarding ophthalmic cysticercosis with subretinian localization associated with large subretinian hemorrhage, surgically addressed.

Correlation of retinal haemorrhages with brain haemorrhages in children dying of cerebral malaria in Malawi.

Retinal haemorrhages increase in number with severity of Plasmodium falciparum malaria and occur in 35-40% of children with cerebral malaria. We performed clinical retinal examinations and histopathological examinations of retina, and parietal and cerebellar sections of the brains, in 33 children in Malawi who died with cerebral malaria, severe malaria anaemia, or coma of other causes. Haemorrhages were counted in a standardized fashion: the Spearman correlation coefficient between the number of haemorrhages in retina and brain was 0.741 for parietal tissue and 0.703 for cerebellar (P < 0.01 for both). Severity of haemorrhage in the retina correlates well with that in the brain. Retinal examination in cerebral malaria is a useful tool in predicting some of the pathophysiological processes occurring in the brain.

New animal model for human ocular toxocariasis: ophthalmoscopic observation.

BACKGROUND/AIMS: Although human ocular toxocariasis causes severe vision defect, little is known about its aetiology, diagnosis, and treatment. To develop a new animal model for human ocular toxocariasis, ophthalmological findings of fundi in Mongolian gerbils, Meriones unguiculatus, and BALB/c mice were investigated following infection with Toxocara canis. METHODS: Using an ophthalmoscope, which was specifically developed to observe the fundi of small animals, ocular changes of fundi of 20 gerbils and 11 mice were monitored after oral infection with embryonated eggs of T canis. RESULTS: Vitreous, choroidal, and retinal haemorrhages were consistently observed in Mongolian gerbils, but rarely in mice. Severe exudative lesions and vasculitis were often present in gerbils but not in mice. Migrating larvae were also frequently observed in gerbils. CONCLUSION: Mongolian gerbils are more appropriate animal model for human ocular toxocariasis than previously used experimental animal such as mice, guinea pigs, rabbits, and monkeys because of its high susceptibility of ocular infection.

A review of the spectrum of clinical ocular fundus findings in P. falciparum malaria in African children with a proposed classification and grading system.

Ocular fundus pathology in Plasmodium falciparum malaria is common and has prognostic significance. We have made a collaborative effort to document the ocular features in several populations. Based on examination of 735 patients in Malawi, Kenya and The Gambia by direct and indirect ophthalmoscopy with dilated pupils, we have determined that the 5 distinct clinical features (in order of frequency) include retinal whitening, haemorrhages, unique vessel abnormalities, papilloedema, and cotton wool spots. Photographs and descriptions of these are presented, along with a proposed grading scheme.

Ophthalmoscopic abnormalities in adults with falciparum malaria.

We studied 424 adults with falciparum malaria admitted over 28 months. They were divided into three groups: cerebral malaria (n = 214); severe non-cerebral malaria (n = 58); and uncomplicated malaria (n = 152). Fundus examination was done daily from admission to discharge, and weekly thereafter in those with persistent changes. All patients were treated by a protocol based on WHO guidelines. Ophthalmoscopic abnormalities were: retinal haemorrhages, 40 (9.43%) (25 cerebral malaria, 10 severe non-cerebral and five uncomplicated malaria); papilloedema, 17 (7.94%) cerebral malaria and two uncomplicated malaria; blurring of disc margins, 25 (11.68%) cerebral and seven non-cerebral; retinal oedema, six (2.80%) cerebral and five non-cerebral malaria; disc pallor, five patients all with cerebral malaria; vitreous haemorrhage and hard exudate in one patient each, both cerebral malaria. Retinal haemorrhage was associated with cerebral malaria and severe non-cerebral malaria, especially with severe anaemia (p < 0.001), as compared to uncomplicated malaria (p < 0.01). The association of papilloedema and cerebral malaria was highly significant compared to severe non-cerebral malaria (p < 0.001). None of these findings was associated with statistically significant mortality, except disc pallor in cerebral malaria (p < 0.05).

Retinal haemorrhage in cerebral malaria.

We examined the fundi of 73 children aged between six months and six years with confirmed diagnosis of cerebral malaria at the Children's Emergency Ward of the University College Hospital, Ibadan. Normal fundi, papilloedema and retinal haemorrhages were present in 38(52.1%), 18(24.7%) and 17(23.3%), respectively on admission. There were no significant differences between the three groups with respect to age, sex, admission coma score, posture, packed cell volume, parasite density, serum glucose, and serum electrolyte profile on admission. The mortality rates were 16%, 22% and 47% in the normal, papilloedema and retinal haemorrhage groups, respectively (Chi-squared for linear trend = 5.587, p = 0.018). Retinal haemorrhage was significantly associated with death (chi 2 = 5.846, p = 0.0192; Crude Odds ratio = 4.1, 95% CI = 1.1, 15.6; p = 0.018). The association was still present after adjusting for other known risk factors for mortality, including age, sex, acidosis, parasite density, anaemia, deep coma, and hypoglycaemia (adjusted Odds Ratio = 4.6, p = 0.0688). Papilloedema alone was not associated with mortality when compared with normal fundi [Fischer's exact (p = 0.448)]. It is concluded that fundoscopic abnormalities are common in children with cerebral malaria, and that retinal haemorrhage is associated with a poor prognosis in such children with cerebral malaria. Therefore, fundoscopic examination is not only useful to rule out raised intracranial pressure before performing a lumbar puncture, but also a useful measure in assessing prognosis in children suffering from cerebral malaria.