Dyspepsia in acute falciparum malaria: a clinico-pathological correlation.

Gastrointestinal symptoms are common in acute falciparum malaria. Dyspepsia often occurs in such patients and sometimes it is exceptionally severe. However, the pathogenesis of the dyspeptic symptoms in malaria has not been clearly defined. Upper gastrointestinal endoscopy was performed in 40 patients with acute falciparum malaria in order to correlate the dyspeptic symptoms with the macroscopic (endoscopic) and microscopic (histologic) pathology of stomach and duodenum. The patients were divided into a dyspeptic group (n = 20, male/female ratio = 17/3, age range 18-50 years, mean age = 28.85 + 9.14 years), and a non-dyspeptic group (n = 20, male/female ratio = 16/4, age range 15-47, mean age 26.05 + 9.98 years). The findings revealed that dyspepsia correlated with topographic endoscopic pangastritis (p = 0.0014), the category of endoscopic antral gastritis (p = 0.013), and the histologic severity of antral gastritis (p = 0.0434). The results suggested that gastritis should be considered in acute falciparum malaria patients presenting with dyspepsia.     

Malaria in the Amazon. Prevalence of Plasmodium falciparum antibodies in Amerindians inhabiting the Venezuelan Amazon

The acquisition of antibodies to Plasmodium falciparum in various age groups was studied in 511 Amerindians inhabiting the north of the Venezuelan Amazon. The overall prevalence by ELISA was 91.2% and antibodies were acquired early in life. Seropositivity was 69.6% in the group aged two to five years and reached 86% at 10 years of age; 96.9% of the adults aged 31-40 years exhibited high ELISA values to P. falciparum. The high prevalence of malaria antibodies among Amazonians, from early on in life, reflects the high level of malaria transmission in that part of the world.     

Infectious reservoir of Plasmodium vivax and Plasmodium falciparum malaria in an endemic region of Sri Lanka

The infectious reservoir of Plasmodium vivax and P. falciparum in a malaria endemic region in Sri Lanka was defined in a population of 3,625 by directly feeding mosquitoes on a sample of infected individuals during a period of 17 months. The malaria case incidence in this population was concurrently monitored. P. vivax gametocyte densities were highest in the youngest age groups, and decreased steadily with increasing age. However, the infectivity per gametocyte appeared to be lower in the younger age groups than in the older ones. There was no significant correlation between the age of patients and their gametocyte densities for P. falciparum, to which this population was only recently exposed, nor was there a discernible trend in the infectivity per gametocyte in different age groups. The average infectivity of patients was lowest in the youngest (0-5 years) and the oldest (greater than 50) age groups. The contribution made by P. vivax patients in the different age groups to the reservoir of infection was estimated. Patients in the 6-25 year age groups made the largest contribution to the reservoir, followed by those in the 26-50 year age group. Patients in the youngest and the oldest age groups contributed least to the infectious reservoir. When population sizes in the different age groups were taken into consideration, the age groups between 6 and 50 years contributed almost equally to approximately 87% of the infectious reservoir. The reservoir of P. falciparum malaria was very small, being confined to 9% of the patients, and this appears to be a characteristic of epidemic malaria, as was the case with P. falciparum.     

Clinical features of children hospitalized with malaria--a study from Bikaner, northwest India

Severe Plasmodium vivax malaria in adults has been reported from Bikaner (northwestern India) but the reports on children are scanty. This prospective study was done on 303 admitted children of malaria. The diagnosis was done by peripheral blood smear and rapid diagnostic test. Further confirmation of severe P. vivax monoinfection was done by polymerase chain reaction (PCR). The proportion of P. falciparum, P. vivax, and mixed (P. falciparum and P. vivax) infection was 61.01%, 33.99%, and 4.95%, respectively. Severe disease was present in 49.5% (150/303) children with malaria, with the risk greatest among P. vivax monoinfection (63.1% [65/103]) compared with P. falciparum, either alone (42.7% [79/185]; odds ratio [OR] = 2.3 [95% confidence interval (CI) = 1.40-3.76], P = 0.001) or mixed infections (40% [6/15]; OR = 2.57 [95% CI = 0.88-7.48]). In children < 5 years of age, the proportion of severe malaria attributable to P. vivax rose to 67.4% (31/46) compared with 30.4% (14/46) of P. falciparum (OR = 4.7 [95% CI = 2.6-8.6], P < 0.0001) and 2.2% (1/46) of mixed infection (OR = 92 [95% CI = 24.6-339.9], P < 0.0001). The proportion of patients having severe manifestations, which included severe anemia, thrombocytopenia, cerebral malaria, acute respiratory distress syndrome, hepatic dysfunction, renal dysfunction, abnormal bleeding was significantly high in association with P. vivax monoinfection in 0-5 year age group, while the same was significantly high in association with P. falciparum monoinfection in 5-10 year age group. Similarly P. vivax monoinfection had greatest propensity to cause multiorgan dysfunction in 0-5 year age group (34.1% [17/41], P < 0.0001) in comparison to P. falciparum monoinfection, which had similar propensity in 5-10 year age group (36.8% [35/95], P = 0.039). Plasmodium vivax monoinfection was almost equally serious to cause significant mortality in comparison to P. falciparum (case fatality rate of severe P. vivax was 3.9% versus 3.2% of severe P. falciparum malaria; P = 1.0). This study reaffirms the evidence of severe P. vivax malaria in children in Bikaner.     

Quartan malaria--an investigation on the incidence of Plasmodium malariae in Bisra PHC, District Sundargarh, Orissa

A longitudinal study on the incidence of P. malariae was taken up from September 1988 to December 1989 in Bisra block, District Sundargarh, Orissa covering 38,615 population, which is mainly tribal. The area is a known hard-core malarious region in the Garhjat hill range in eastern India. In this study, out of 22,217 blood smears examined through weekly active surveillance, 7362 (33.1%) were found malaria parasite positive. Out of the total positive cases, 82 (1.1%) were P. malariae. These occurred mostly (91.4%) in persons below 40 years of age and children below 9 years accounted for 36.6% of total quartan malaria cases. In this age group the disease was found to be associated with splenomegaly (average enlarged spleen 2.07; spleen rate 45.9%) and 9 out of 13 mixed infections of P. malariae with P. falciparum and/or P. vivax were detected from this age group. This is the first report of quartan malaria from this area.     

IgE antibodies to Plasmodium falciparum and severity of malaria in children of one ethnic group living in Burkina Faso

Plasmodium falciparum malaria infection induces elevated blood levels of both total immunoglobulin and anti-plasmodial antibodies belonging to different isotypes. We have previously shown that donors living in areas of malaria transmission develop malaria-specific IgE antibodies that are present at highest concentrations in patients with severe disease, suggesting a role for this isotype in malaria pathogenesis. To establish the possible importance of IgE in the course and severity of this disease, we have analyzed a large and homogenous group of African children (age range = 6 months to 15 years) belonging to one ethnic group (Mossi) living in identical epidemiologic conditions in the same urban area (Ougadougo) of Burkina Faso. While IgG antibodies to P. falciparum increased to high concentrations in very young children and then remained at these levels in older patients, IgE antibodies increased with age, becoming most significantly elevated in children more than four years of age. In older children, those with severe malaria had significantly higher IgE antibody levels than those with non-severe disease. No significant differences between the patient groups were seen for IgG antibodies to P. falciparum. However, when the patients with severe malaria were divided into two groups distinguished by the presence of absence of coma, both IgG and IgE antibodies against malaria were lower in the comatous patients than in the non-comatous patients. The results support the conclusion that IgE antibodies against malaria, regardless of their possible protectivity, also contribute to disease severity in this large and homogenous group of African children.     

安徽肥东县输入性恶性疟疾现况与特征

目的 了解肥东地区输入疟疾的流行现况与特征,为输入性疟疾防治工作提供科学依据.方法 对近几年肥东县疟疾年报表、疟疾专网报告数据、疟疾个案调查表进行统计和描述性分析.结果 肥东县近几年疟疾病例呈上升趋势,自2009年出现输入性疟疾病例,2009年、2010年输人性疟疾病例数占年疟疾发病总数的比例分别为35.29％和67....     

A study of clinical profile of malaria in a tertiary referral centre in South Canara

BACKGROUND & OBJECTIVES: The incidence of malaria is on the raise in South Canara district of Karnataka in the recent years and there is not much information on malaria from this region. This study was undertaken to analyse and introspect the presentation of this disease in a tertiary referral centre. METHODS: This retrospective case analysis was done on patients over the age group of 15 yr admitted with diagnosis of malaria to the Medical Department in this tertiary health institution situated in South Canara. The outpatient and inpatient records from September 2002 to August 2004 were retrieved and scrutinised using a prepared case sheet performa on the basis of patient's demographic profile, clinical findings, investigations, treatment and complications. RESULTS: A total of 314 patients were diagnosed and treated for malaria, of them 124 were treated as outpatients and 190 cases were managed as inpatients. Males (81%) outnumbered females (19%) and many were within the age group of 21-30 yr. The incidence of malaria increased from the month of June onwards coinciding the monsoon season. Plasmodium vivax was the major parasite type (52.54%), followed by P. falciparum (33.75%), mixed malarial infection (13.69%) and most of them received combination therapy. Hepatopathy was the most common complication and all the deaths were due to cerebral malaria. INTERPRETATION & CONCLUSION: Malaria is responsible for major health concern in this region, particularly in rainy season and is found to affect comparatively the younger adult population. P. vivax was the major parasite type causing malaria and most of the complications were due to P. falciparum.     

Confirmation of the protective effect of Ascaris lumbricoides on Plasmodium falciparum infection: results of a randomized trial in Madagascar

A controlled randomized trial of anti-helminthic treatment was undertaken in 1996-1997 in a rural area of Madagascar where populations were simultaneously infected with Ascaris lumbricoides, Plasmodium falciparum, and Schistosoma mansoni. Levamisole was administered bimonthly to 107 subjects, whereas 105 were controls. Levamisole was highly effective in reducing Ascaris egg loads in the treated group (P < 10(-3) at all visits), whereas it had no effect on schistosomiasis. Subjects 5-14 years of age, treated with levamisole, had a significant increase of their P. falciparum densities compared with controls (P = 0.003). There was no effect of the treatment on children 6 months to 4 years of age, nor on adults > 15 years of age. This study confirms the results of a randomized trial, which showed a negative interaction in those > 5 years of age between Ascaris and malaria parasite density in another Malagasy population, submitted to a higher malaria transmission.     

Contribution of humoral immunity to the therapeutic response in falciparum malaria.

The contribution of humoral immunity to the therapeutic response in acute falciparum malaria was assessed in a case-control study. Forty adult Thai patients with acute falciparum malaria who had subsequent recrudescent infections and 40 patients matched for age, therapeutic regimen, and disease severity who were cured by Day 28 were studied. All cured patients had positive immunoglobulin (Ig) G to ring-infected erythrocyte surface antigen (RESA) in their admission plasma, compared with only 60% of patients who failed to respond to treatment (P < 0.001). The proportion of IgM-positive cases at admission was also higher in the successfully treated group than in the group with failure (70% versus 30%) (P < 0.001). The geometric mean (95% confidence interval) reciprocal IgG titer at admission was significantly higher in cured patients (187.0 [83.5-418.3]) compared with those who experienced treatment failure (11.6 [5.1-26.5]) (P < 0.001). The patients with uncomplicated malaria who were both IgG and IgM positive at admission had significantly shorter fever clearance times and lower admission parasitemia levels compared with those who were negative (P = 0.01 and P = 0.02, respectively). The median (range) in vitro parasite multiplication rate was significantly lower in cultures containing positive anti-RESA antibody plasma compared with those containing normal plasma (0.7 [0.1-3.5] versus 2.6 [0.1-12.1]; P < 0.001). These results suggest that antimalarial antibodies may play an important supportive role in the therapeutic response to antimalarial drugs during acute falciparum malaria.     

Parasitic co-infections: does Ascaris lumbricoides protect against Plasmodium falciparum infection?

A controlled randomized trial of antihelminthic treatment was undertaken in 1996-1997 in a rural area of Madagascar where populations were simultaneously infected with Ascaris lumbricoides and Plasmodium falciparum. Levamisole was administered bimonthly to 164 subjects, randomized on a family basis, whereas 186 were controls. While levamisole proved to be highly effective in reducing Ascaris egg loads in the treated group (P < 10(-3) at all bimonthly visits), subjects more than 5 years of age, treated with levamisole had a significant increase in their P. falciparum densities compared with controls (P = 0.02), whereas there was no effect of anti-helminthic treatment on children 6 months to 4 years of age. The demonstration of a clear negative interaction between Ascaris infection and malaria parasite density has important implications. Single community therapy programs to deliver treatments against several parasitic infections could avoid an increase of malaria attacks after mass treatment of ascariasis.     

Anemia and malaria at different altitudes in the western highlands of Kenya

Malaria associated severe anemia in children is the most important complication of Plasmodium falciparum infection in sub-Saharan Africa. To evaluate anemia and malaria in an area with recurrent malaria epidemics in the western highlands of Kenya, we conducted cross-sectional surveys in four "lowland" (1440-1660 m) and two "highland" (1960 and 2040 m) villages in 2002. Among 1314 subjects randomly selected from all age groups, the overall prevalence of anemia (hemoglobin, Hb < 11 g/dl) was 14% and P. falciparum infection 17%. In children < or =5 years, anemia prevalence ranged from 57% at 1440 m to 11% at 2040 m and correlated with altitude (r = -0.88, P < 0.05). Similarly, P. falciparum prevalence ranged from 31 to 0% and correlated with altitude (r = -0.93, P < 0.01). Malnutrition defined by a body mass index <15th percentile characterized 39% of the population and the hookworm prevalence was 3.9%. In the lowland villages, anemia was most common in children < or =5 years of age (34%) followed by women of childbearing age (16%). A similar pattern was also observed in the highland villages. In these vulnerable populations, hemoglobin concentration was significantly associated with malaria infection, but not with malnutrition or hookworm infestation and comparisons of anemia prevalence between highland and lowland villages revealed that two-thirds of anemia could be attributed to malaria infection. The prevalence of severe anemia (Hb < 8 g/dl) was 1.5%; of these, 90% resided in lowland villages, 70% were under-fives, while 20% were women of childbearing age. In severely anemic subjects, the Hb concentration decreased further with malnutrition (P < 0.05). Anemia was more prevalent in the lowland villages characterized by high prevalence of P. falciparum infection. We conclude that malaria may also be the main cause of anemia in the highland fringe areas of sub-Saharan Africa. Measures that reduce the prevalence of malaria will consequently reduce anemia in both, young children and adult women and the need for blood transfusions associated with the risk of HIV-transmission.     

Malaria in Leicester 1983-1988: a review of 114 cases

We have reviewed 114 episodes of malaria in 110 patients who were admitted to the Infectious Diseases Unit in Leicester during the 5 year period from February 1983-January 1988. There were 71 episodes of vivax malaria (62%), 33 episodes of falciparum malaria (29%), four patients with mixed infection and six patients with negative blood films who were diagnosed on clinical suspicion alone. Most patients presented in the summer months, 68% were aged under 40 years, 39% were born in the Indian subcontinent, 23% in East Africa and 23% in Britain. Eighty-two per cent of patients with falciparum malaria had recently returned from Africa whereas 82% with vivax malaria had visited Asia. Thirty six per cent had been given antimalarial chemoprophylaxis but only half of these took medication correctly. Seventy five per cent of episodes of falciparum malaria presented within 2 weeks of arrival in Britain, however vivax malaria could present at any time and 49% of cases occurred over 3 months after exposure. Presenting symptoms and signs were often non-specific. Twenty nine per cent of patients had been treated with antibiotics and 11% received antimalarials prior to admission. Vivax malaria was generally a mild infection but falciparum malaria was often severe with 39% of patients experiencing complications including one death. Although Plasmodium vivax and P. falciparum are morphologically similar the diseases caused by the two species of parasite are quite distinct. Physicians must ensure that malaria is excluded in anyone who has travelled to an endemic area.     

Malaria, leprosy and dapsone

Although the preventive action of dapsone against P. falciparum malaria was known for many years, there was no report about the incidence of P. falciparum malaria in leprosy patients treated with dapsone, especially from areas of Southeast Asia where both leprosy and malaria are endemic. Therefore, two clinic-based malaria surveys were undertaken at a gap of 12 years, comprising 506 lepromatous leprosy patients and 499 febrile nonleprosy control subjects. Both the surveys showed that the lepromatous patients treated with MDT had only P. vivax malaria (incidence comparable to the febrile nonleprosy controls) with complete freedom from P. falciparum. On the contrary, control sujects not taking any-leprosy drugs and staying with the leprosy patients at the same beggars' home, had both P. vivax and P. falciparum malaria. It is postulated that dapsone provided protection against P. falciparum among leprosy patients.     

Do African immigrants living in France have long-term malarial immunity?

Among populations living in areas endemic for malaria, repeated parasite exposure leads to a gradual increase in protective immunity to the disease. In contrast, this immunity is assumed to disappear after several years of non-exposure. This study was designed to investigate long-term immunity in subjects removed from the risk of exposure. Plasmodium falciparum malaria attacks occurring after short trips to sub-Saharan Africa were compared between 99 European patients and 252 African immigrants who had been resident in Europe for at least four years. Relative to the European patients, those originating from Africa had lower mean +/- SD parasite densities (0.8 +/- 1.5/100 red blood cells versus 1.4 +/- 2.8/100 red blood cells; P = 0.007), less frequent severe disease (4.4% versus 15.2%; P = 0.0005), accelerated parasite clearance and defervescence, and higher levels of antibodies to P. falciparum. These results suggest the persistence of acquired immunity to P. falciparum malaria after several years of non-exposure in African immigrants.     

Severe anaemia in Zambian children with Plasmodium falciparum malaria

BACKGROUND: Severe anaemia and cerebral malaria are highly prevalent complications of Plasmodium falciparum malaria among African children. The mechanisms of severe malarial anaemia, and the relative importance of this condition in comparison to cerebral malaria, are not known for many regions of Africa. METHODS We reviewed the records of 6200 children up to 6 years of age admitted to one rural Zambian hospital between 1994 and 1996. Severe malarial anaemia was defined as an haemoglobin concentration < 5.0 g/dl in a patient with asexual forms of P. falciparum in the peripheral blood. Cerebral malaria was defined as impaired consciousness (Blantyre coma score < 5) not attributable to any other cause in a patient with a positive malaria smear. RESULTS Severe malarial anaemia was found in 590 children (9.5% of paediatric admissions) and strictly defined cerebral malaria occurred in 286 children (4.6% of paediatric admissions); 98 of these patients had the combination of both complications. Severe malarial anaemia correlated strongly with the degree of parasitaemia, with malnutrition as indicated by low weight for age, with absence of fever and with presentation late in the malaria season. In comparison, patients with cerebral malaria were more often febrile and presented earlier in the malaria season. The case fatality rate of severe malarial anaemia (0.088) was about half that of cerebral malaria (0.189), but because severe malarial anaemia was more common, these two forms of complicated malaria were implicated in similar numbers of in-hospital paediatric deaths. CONCLUSION Severe anaemia is a more common complication of P. falciparum malaria in hospitalized Zambian children than cerebral malaria and is associated with a similar number of deaths. Malnutrition and changes in immune response patterns due to prolonged exposure to P. falciparum may contribute to the development of this complication.     

Differential regulation of IgG subclasses and IgE antimalarial antibody responses in complicated and uncomplicated Plasmodium falciparum malaria

The aim of this study was to assess the immunoglobulin (Ig)-subclass distribution of antimalarial antibody responses in 110 and 169 Thai patients with complicated and uncomplicated Plasmodium falciparum malaria, respectively. Antimalarial plasma IgG subclasses and IgE antibody levels against a crude malaria blood stages, and antigen preparation were determined using enzyme-linked immunosorbent assay (ELISA). On admission, the levels of anti-P. falciparum IgG1, IgG2 and IgG3 were significantly lower in patients with complicated malaria than uncomplicated malaria (IgG1, P < 0.0001; IgG2, P < 0.0001; IgG3, P < 0.0001). The levels of antimalarial IgE were slightly lower, but not statistically significant (P = 0.389) in the complicated malaria. After adjusting all antibody levels and age, anti-P. falciparum IgG3 levels remained significantly associated with complicated malaria. None of the other antibody concentrations showed statistically significant associations with complicated malaria. The anti-P. falciparum IgG3 levels were related to the IgG1 as well as IgG2 levels. A correlation between anti-P. falciparum IgG2 and IgE was observed in the complicated malaria group, and this may indicate their roles in the severity of disease. Our data suggest that anti-P. falciparum IgG3 is associated with a reduced risk of complicated malaria and that antimalarial Ig-subclasses are differently regulated in patients with complicated and uncomplicated malaria.     

Prevalence of malaria as co-infection in HIV-infected individuals in a malaria endemic area of southeastern Nigeria

BACKGROUND & OBJECTIVE: The present study was conducted on the prevalence of malaria as co-infection amongst 'asymptomatic HIV' and 'symptomatic HIV' subjects to see if such prevalence deviated from that commonly reported in apparently health individuals in same locality. METHODS: A prospective study that involved 196 participants grouped according to their HIV status as: 'asymptomatic HIV seropositive group' (n = 101); 'symptomatic HIV seropositive group' (n = 48) and 'control HIV-seronegative group (n = 47). Blood samples collected from the participants were used for double HIV screening by rapid immunoassay technique and immunochromatographic technique, and for the diagnosis of Plasmodium falciparum malaria using rapid P. falciparum antigen detection method. RESULTS: The result showed that the prevalence of P. falciparum malaria as a co-infection amongst the asymptomatic HIV seropositive group was 12 (11.8%) and amongst the symptomatic HIV seropositive group was 16 (33.3%). However, the prevalence rate of P. falciparum malaria amongst the control HIV seronegative group was 5 (10.6%) and the combined burden of P. falciparum malaria amongst both groups of HIV seropositives was 28 (18.9%). INTERPRETATION & CONCLUSION: The present study observed different prevalence rates of P. falciparum malaria amongst the three groups. The prevalence was tripled in symptomatic HIV seropositive group. This shows a clear departure from possible obtainable prevalence of malaria infection alone in this malaria endemic area. Due to the mortality rates associated with malaria infection in an endemic area, it may be necessary that routine malaria screening be adopted as part of the management policy to check the co-infection.     

Travellers returning to Sweden with falciparum malaria: pre-travel advice, behaviour, chemoprophylaxis and diagnostic delay

We have investigated pre-travel advice, behaviour, chemoprophylaxis and diagnostic delay in travellers returning to Sweden with falciparum malaria. Questionnaires were distributed to patients having been notified with falciparum malaria from 1994 to 2001. Of 408 notified patients, 237 (58%) returned the questionnaires; 62% were males and 43% above the age of 45 y. Africa was the travel destination in 90% of the cases, and 27% had travelled to Kenya. 69% had spent more than 1 night in the countryside, and 6% had stayed in modern urban areas only. 40% took an adequate dose of chemoprophylaxis, although this proportion decreased from 55% to 12% during the study period. Nine per cent used both bed nets and mosquito repellents regularly. The median time from onset of symptoms to contact with health care professionals was 2 d, and from that contact to start of malaria treatment the median time was less than 24 h.     

The clinical spectrum of severe imported falciparum malaria in the intensive care unit: report of 188 cases in adults

Little is known about severe imported malaria in nonendemic industrialized countries. The purpose of this retrospective study was to describe the clinical spectrum of severe imported malaria in adults and to determine factors that were present at admission and were associated with in-intensive care unit mortality. This retrospective study evaluated the 188 patients who were admitted to our intensive care unit in 1988-1999 with severe and/or complicated imported malaria. Among them, 93 had strictly defined severe malaria, and 95 had less severe malaria. The mean age was 38 years, 51% of patients were nonimmune whites, 94% acquired Plasmodium falciparum in sub-Saharan Africa, and 96% had taken inadequate antimalarial chemoprophylaxis. Mortality was 11% (10 patients) in the severe malaria group, whereas no patients died in the less severe malaria group (p = 0.002). In the bivariable analysis, the main factors associated with death in the severe malaria group were the Simplified Acute Physiology Score, shock, acidosis, coma, pulmonary edema (p < 0.001 for each), and coagulation disorders (p = 0.002). Bacterial coinfection is not infrequent and may contribute to death. Severe imported malaria remains a major threat to travelers. In our population, the most relevant World Health Organization major defining criteria were coma, shock, pulmonary edema, and acidosis.