A study of serum calcium level in cases of malaria in a tertiary care hospital

Background: Malaria is a tropical disease caused by Plasmodium species, commonly P. falciparum and P. vivax. Carpopedal spasm has been noted in many patients presenting with malarial fever. Most of the patients are later found to have hypocalcaemia. Hypocalcaemia associated with malaria can cause many clinical manifestations, including life threatening conditions such as arrhythmias, convulsions etc.Methods: A cross-sectional study was conducted with the aim to determine the prevalence and clinical profile of hypocalcaemia in different types of malarial fever. 88 patients of malarial fever were studied. Patients were stratified according to the species of plasmodium and into complicated and uncomplicated malaria. Total serum calcium level and QTc interval were analysed in each patient. Data collected were analysed.Results: Prevalence of hypocalcaemia in malaria was found to be 54.45% in our study. Hypocalcaemia was more prevalent in complicated malaria than uncomplicated malaria. Complicated falciparum malaria showed highest prevalence of hypocalcaemia. Status of complexity of malaria was not found to be related to occurrence of hypocalcaemia in any types of malaria. Prevalence of QTc prolongation in malaria was found to be 48.46%. Prevalence of QTc prolongation was found to be more in complicated malaria than uncomplicated malaria. QTc prolongation was most prevalent in complicated falciparum malaria. 83.3% of those with QTc prolongation had hypocalcaemia.Conclusions: Hypocalcemia and QTc prolongation were more prevalent in complicated malaria than in uncomplicated malaria. Both Hypocalcaemia and QTc prolongation were most prevalent in complicated falciparum malaria.

CHANGING PATTERN OF HAEMOGLOBIN LEVEL FOLLOWING ANTI-MALARIAL TREATMENT AMONG MALARIA CASES ATTENDING A TERTIARY CARE HOSPITAL IN KOLKATA

Anaemia is one of the major causes of severe and complicated malaria. Malaria associated anaemia are due to decreased production of RBCs and lysis of infected and uninfected erythrocytes. The role of anti-malarial treatment in correcting anaemia are not studied extensively. The present work was undertaken to study the changing pattern of haemoglobin level following anti-malarial therapy. A total of 201 microscopically positive mono-infected with P. vivax (103) and P falciparum (98) patients were recruited and treated with antimalarial drugs and followed up on day 3, 14, and 28 to study the changing pattern of haemoglobin level. Among the P. falciparum positive patients mean haemoglobin level on Day 0 and day 28 was 13.17 g/dl and 13.31 g/dl whereas among P. vivax cases mean haemoglobin level was 13.28 g/dl and 13.29g/dl, respectively. Among the P. falciparum cases (n = 98), 4.08%, 16.33% and 79.59% was classied as moderate anaemia, mild anaemia and normal, respectively. Similarly, among the P. vivax cases (n = 103), 1.94%, 17.47% and 80.58% had moderate anaemia, mild anaemia and normal, respectively. Mean haemoglobin level was declined on day 3 which gradually increased to its initial level by day 28 among both P. falciparum and P. vivax cases. Similar study in other malaria endemic areas will be helpful for better understanding the changing pattern of haemoglobin level among malaria patients.

Influence of Gender on Some Red Cell Indices, L-Arginine and D-dimer in Malaria Parasite Severity amongst Children Resident in Rivers State, Nigeria

Aim: The aim of the study was to assess the influence of gender on malaria parasite severity in children resident in Rivers State, Nigeria. Study Design: The study was cross-sectional observational study. Place and Duration of Study: University of Port Harcourt Teaching Hospital, Rivers State, Nigeria, between the month of March and August 2020. Methodology: A total of 822 pediatrics (0-16 years), were randomly selected for this study after due parental consent. 5ml of venous blood was collected from each subject: 1ml was dispensed into paediatric EDTA (for haematologic and parasite density) and 4 ml into sodium citrate bottle for L-arginine assay by ELISA-method, while Full blood count was determined using haematological auto-analyser, Mindray BC-6800. Malaria density was determined by microscopic method using thick and thin Giemsa stained blood smears. Level of significance was set at P<0.05. Results: There was a significant decrease (p<.05) in the mean (41.04±3.80%) neutrophil count in female subject with complicated malaria compared with the control (42.81±0.98%) as against a significant decrease in mean (37.71±0.96%) neutrophil count of female subject with uncomplicated malaria. A significant decrease in neutrophil (28.05±3.37%) of male subjects with complicated malaria and uncomplicated malaria (36.10±0.79%) was seen when compared to control (44.32±0.88%). Again, a significant decrease (p<.05) in eosinophil count of female with complicated malaria (3.32±0.74%) was seen when compared with the control subject (3.81±0.19%) and no significant difference was seen in female subjects with uncomplicated malaria (3.62±0.19%) when compared with the control. A significant increase in eosinophil was seen in male subjects with complicated malaria (4.47±0.66%) and uncomplicated malaria (4.52±0.16%) when compared with the control (3.88±0.17%). There was observed a significant difference (p<.001) in the mean L-arginine values of female subjects with complicated (39.22±9.57pg/ml) and uncomplicated (65.13±2.41 pg/ml) malaria compared with the control (42.85±2.48 pg/ml). However, no significant difference was seen in male subjects with complicated (33.21±8.49) and uncomplicated (45.51±2.00 pg/ml) malaria when compared with control (47.97±2.21 pg/ml). Also, a significant difference (p<0.0019) was seen between the mean D2D values of female subjects with complicated (6436.64±568.94 pg/ml) and uncomplicated (2824.55±143.46 pg/ml) malaria among the study subjects as against the control (1866.39±147.35 pg/ml). Conclusion: In conclusion, this study showed a trend between gender and malaria type did not significantly change haematological parameters with the exception of the immune cells such as NEU, LYM, and EOS. However, a significant increase in L-arginine among female subjects was seen indicating a faster rate of malaria clearance.

High Prevalence of viral and bacterial coinfections in malaria in Venezuela

Background Malaria remains a significant public health problem worldwide. Simultaneous infections with other pathogens complicate its diagnosis and can also change the clinical course of the disease. The similarities in the clinical presentation of malaria and other infections and the superimposed endemicity result in underdiagnosis of coinfections and increase mortality. No studies have focused on the presence of coinfections in patients with malaria in Venezuela. Methods Between June and November 2018, we conducted a cross-sectional study in patients with malaria who presented to any of the three reference medical centers in Ciudad Bolívar, Venezuela. A clinical and laboratory evaluation searching for coinfections with Dengue (DENV), Chikungunya (CHIKV), Viral Hepatitis (VH) (A, B, and C), and Leptospirosis (LEP) was performed using ELISA to test each patient. Results We studied a total of 161 patients of whom 106 (65.8%) presented P. vivax infection, 43 (26.7%) P. falciparum, and 12 (7.5%) had mixed malaria infections. Coinfections were found in 55/161 (34.2%) patients and were more frequent in patients with P. falciparum (48.8%) than in those with P. vivax (29.2%), or mixed infection (25%) [OR = 2.43; 95% CI = 1.39–4.25; p = 0.018]. The most prevalent coinfection was with DENV (14.9%), followed by HAV (11.8%), HBV (6.2%), CHIKV (5.5%), and LEP (3.7%). Coinfection with HCV was absent. Complicated malaria was significantly more frequent in coinfected individuals (56.4%) than those without coinfection (35.8%) [OR: 2.31; 95% CI = 1.18–4.92; p = 0.013]. Conclusion We found a high prevalence of coinfections in patients with malaria in this region, which was related to a worse outcome. Further prospective studies with samples at different points of infection and the use of molecular tools are needed.

Drug treatment and prevention of malaria in pregnancy: a critical review of the guidelines

Background Malaria caused by Plasmodium falciparum in pregnancy can result in adverse maternal and fetal sequelae. This review evaluated the adherence of the national guidelines drawn from World Health Organization (WHO) regions, Africa, Eastern Mediterranean, Southeast Asia, and Western Pacific, to the WHO recommendations on drug treatment and prevention of chloroquine-resistant falciparum malaria in pregnant women. Methods Thirty-five updated national guidelines and the President’s Malaria Initiative (PMI), available in English language, were reviewed. The primary outcome measures were the first-line anti-malarial treatment protocols adopted by national guidelines for uncomplicated and complicated falciparum malaria infections in early (first) and late (second and third) trimesters of pregnancy. The strategy of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) was also addressed. Results This review evaluated the treatment and prevention of falciparum malaria in pregnancy in 35 national guidelines/PMI-Malaria Operational Plans (MOP) reports out of 95 malaria-endemic countries. Of the 35 national guidelines, 10 (28.6%) recommend oral quinine plus clindamycin as first-line treatment for uncomplicated malaria in the first trimester. As the first-line option, artemether–lumefantrine, an artemisinin-based combination therapy, is adopted by 26 (74.3%) of the guidelines for treating uncomplicated or complicated malaria in the second and third trimesters. Intravenous artesunate is approved by 18 (51.4%) and 31 (88.6%) guidelines for treating complicated malaria during early and late pregnancy, respectively. Of the 23 national guidelines that recommend IPTp-SP strategy, 8 (34.8%) are not explicit about directly observed therapy requirements, and three-quarters, 17 (73.9%), do not specify contra-indication of SP in human immunodeficiency virus (HIV)-infected pregnant women receiving cotrimoxazole prophylaxis. Most of the guidelines (18/23; 78.3%) state the recommended folic acid dose. Conclusion Several national guidelines and PMI reports require update revisions to harmonize with international guidelines and emergent trends in managing falciparum malaria in pregnancy. National guidelines and those of donor agencies should comply with those of WHO guideline recommendations although local conditions and delayed guideline updates may call for deviations from WHO evidence-based guidelines.

Where have all the parasites gone? Unusual Plasmodium falciparum monoparasitaemia in a cross-sectional malariometric survey in northern Nigeria

Background: Malaria is caused by one of five currently known Plasmodium parasite species causing disease in humans. While modelling has provided information of the vector, the same is not entirely the case for the parasite. The World Malaria reports of 2014 to 2016 reported 100% of confirmed cases from Nigeria being due to Plasmodium falciparum. Generally, about 98% of cases of uncomplicated malaria in most regions surveyed in Nigeria recently is due to P. falciparum, with the remainder being due to P. malariae. This study aimed to determine the proportions of Plasmodium parasites causing uncomplicated malaria in Wamakko Local Government Area of Sokoto State, north-western Nigeria. Methods: The study was a descriptive, cross-sectional study conducted during the rainy season and dry season in north-western Nigeria. The area has a ‘local steppe’ climate and Sudanian Savannah vegetation. Sampling was via multistage cluster sampling. Selected participants were examined for pallor, palpable splenomegaly and signs of complicated malaria. Blood samples were also taken for rapid diagnosis of malaria and thick and thin films to identify parasitaemia and the parasite species. Participants found to have malaria were treated with Artemether/Lumefantrine and those with complicated malaria were referred to the nearest hospital. Results: We found a parasite prevalence of 34.8% overall, which was higher in the rainy season (49.3%) than in the dry season (20.2%). There was monoparasitaemia of Plasmodium falciparum throughout the study area, irrespective of the clinical status of the participant. Mapping of the parasite was extended throughout the Local Government Area and the State. Conclusions: Despite the intermediate endemicity in the area. P. falciparum monoparasitaemia affirms theories of disappearance of other parasite species, either due to faltering control of P. falciparum or more efficient control of other species.

P0608TROPICAL FEVER ASSOCIATED ACUTE KIDNEY INJURY - RISK PREDICTION MODEL IN A RESOURCE LIMITED SETTING IN SOUTH INDIA

Background and Aims Acute kidney Injury (AKI) is a serious medical condition estimated to affect more than 10 million people around the world annually, resulting in a 1.7- to 6.9-fold increased risk of hospital mortality. Out of 1.7 million deaths per year caused by AKI globally, around 1.4 million occur in low- and middle-income countries, sepsis being the leading cause. AKI occurs in 40–50% of patients with sepsis and increases the mortality six- to eight-fold. By comparing the prevalence of potential risk factors in populations of patients who had developed AKI with control groups with no AKI, several risk assessment tools have been proposed and generated for specific clinical settings such as intensive care units, cardiac surgery, general surgery, those undergoing radiological investigations involving intravenous contrast and those presenting to the emergency department. The AKI Risk Assessment (ARA F4) model incorporated newer biomarkers of kidney injury (TIMP-2, IGFBP7) along with clinical parameters to detect patients at risk for AKI as fast as possible and to prevent further damage. However, they are yet to be available freely in our country. To the best of our knowledge, no risk assessment tool in the setting of tropical fever associated AKI has been proposed till date. The aim of this study is to provide a practical model to identify patients at high risk for tropical fever associated AKI in a resource limited setting in the absence of newer biomarkers. Method Ours is a retrospective, single center study. Patients who had an increase in serum creatinine (S.Cr) ≥0.3 mg/dL within 48 hours; or an increase in S.Cr to ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days or a urine volume of &lt;0.5 mL/kg/h for 6 hours were included. We recruited 342 consecutive admissions with tropical fever associated AKI and evaluated them based on clinical and biochemical profiles. Results We analyzed data of 342 patients. Our population of patients had representation from all age groups, 72% were between 21 to 60 years, 20.4% were &gt;60years and 34.7% were females. There was a clear relationship between age and the number of AKI risk factors. Baseline serum creatinine was available for 117 patients, the average S.cr was 0.9591mg/dL and the average rise in S.cr was 1.22mg/dL. Leptospirosis (11.98%), dengue (84.79%), malaria (2.63%) and complicated malaria (0.29%) were the etiologies for AKI. 19,21 and 2 patients with leptospirosis had &lt;=5, 6 to 10 and &gt;10 risk factors respectively. 258,32 and 0 patients with dengue had &lt;=5, 6 to 10 and &gt;10 risk factors respectively. 8,1 and 0 patients with malaria had &lt;=5, 6 to 10 and &gt;10 risk factors respectively. One patient with complicated malaria had &lt;=5 risk factors. 15/42 with leptospirosis, 2/290 with dengue, none with malaria and 1/1 with complicated malaria required renal replacement therapy. Five patients expired, out of which three were on renal replacement therapy. 3/286 with total risk score &lt;5, 14/53 with total risk score between 6-10 and one out of two with total risk score &gt;10 required renal replacement therapy. Conclusion Tropical fever associated AKI is a major public health burden in southern India. Our aim was to propose a risk stratification model to assess severity of tropical fever associated AKI and dialysis requirement in a resource limited setting. In our study, the number of risk factors, incidence of AKI and dialysis requirement were more in people with leptospirosis. We also observed that as the risk scores went up, the need for hemodialysis increased irrespective of the etiology. In the absence of availability of newer biomarkers this risk prediction score is quite useful. Ours is the first risk assessment tool in tropical fever associated AKI in resource limited setting. We are planning on a prospective evaluation of the same in the near future to validate our Tropical fever associated Acute Kidney Injury Risk assessment (TAKIR) tool. Figure In-lined.

Where have all the parasites gone? Unusual Plasmodium falciparum monoparasitaemia in a cross-sectional malariometric survey in northern Nigeria

Background: Malaria is caused by one of five currently known Plasmodium parasite species causing disease in humans. While modelling has provided information of the vector, the same is not entirely the case for the parasite. The World Malaria reports of 2014 to 2016 reported 100% of confirmed cases from Nigeria being due to Plasmodium falciparum. Generally, about 98% of cases of uncomplicated malaria in most regions surveyed in Nigeria recently is due to P. falciparum, with the remainder being due to P. malariae. This study aimed to determine the proportions of Plasmodium parasites causing uncomplicated malaria in Wamakko Local Government Area of Sokoto State, north-western Nigeria. Methods: The study was a descriptive, cross-sectional study conducted during the rainy season and dry season in north-western Nigeria. The area has a ‘local steppe’ climate and Sudanian Savannah vegetation. Sampling was via multistage cluster sampling. Selected participants were examined for pallor, palpable splenomegaly and signs of complicated malaria. Blood samples were also taken for rapid diagnosis of malaria and thick and thin films to identify parasitaemia and the parasite species. Participants found to have malaria were treated with Artemether/Lumefantrine and those with complicated malaria were referred to the nearest hospital. Results: We found a parasite prevalence of 34.8% overall, which was higher in the rainy season (49.3%) than in the dry season (20.2%). There was monoparasitaemia of Plasmodium falciparum throughout the study area, irrespective of the clinical status of the participant. Mapping of the parasite was extended throughout the Local Government Area and the State. Conclusions: Despite the intermediate endemicity in the area. P. falciparum monoparasitaemia affirms theories of disappearance of other parasite species, either due to faltering control of P. falciparum or more efficient control of other species.

Awareness of national malaria management guidelines among house officers in Khartoum state teaching hospitals. Sudan 2018

Background Malaria is a protozoan disease which can lead to serious complications if not treated early and correctly. The aim of this study to assess the knowledge about malaria management guidelines among house officers. Methods this is the cross-sectional observational study conducted at 6 of Khartoum teaching hospitals Results The study showed that among the 115 participants evaluated there were 70.4% females and 29.6% were males. 94.8% of participants knew there are malaria management guidelines and 5.2% didn't know about the presence of these guidelines, 58.3% have some information and 10.4% just hear about these guidelines. 89.6% knew the management of simple malaria is outpatient management. 65.2% of the participants were aware of where to manage the cases of complicated malaria (inpatient or in ICU). 27.8% of the participants were aware of the management of simple malaria in the second and third trimester.