Plasmodium falciparum infection with dihydroartemisinin-piperaquine (DHA-PIP) with documented evidence of concomitant seropositivity for Chikungunya infection.The mechanism of massive intravascular haemolysis occurring during the treatment of malaria infection resulting in haemoglobinuria, commonly known as blackwater fever (BWF), remains unknown. BWF is most often seen in those with severe malaria treated with amino-alcohol drugs, including quinine, mefloquine and halofantrine. The potential for drugs containing artemisinins, chloroquine or piperaquine to cause oxidant haemolysis is believed to be much lower, particularly during treatment of uncomplicated malaria. Here is an unusual case of BWF, which developed on day 2 of treatment for uncomplicated  Plasmodium falciparum infections, but has also been documented in Plasmodium vivax, Plasmodium malariae and mixed infections [Haemoglobinuria is a feature of complicated malaria syndromes as defined by the World Health Organization (WHO) . Blackwafections -6. Thougfections ,4,7.P. falciparum malaria with or without a single dose of primaquine 45 mg to prevent transmission of gametocytes (NCT 01849640). During the three days before enrollment, he reported experiencing mild fever, chills and fatigue, and self-treated with paracetamol and ampicillin. On the day of enrollment, he was found to have P. falciparum infection with 31,218 parasites per μl on peripheral blood smear at an outside medical facility, and was referred to the study team. He denied having taken any anti-malarial or traditional herbal medications, but he did inform the study team that he has been consuming 1–2 cans per day of an energy drink containing taurine, caffeine, and B vitamins for the past year. He reported no chronic underlying illnesses. He had suffered four malaria episodes since 2010 which were variously treated with chloroquine, artesunate and mefloquine, but reported no prior history of adverse reactions to anti-malarials or history of BWF.A 43-year old male Cambodian farmer was screened and enrolled on 21 July 2013 to participate in a clinical trial evaluating the efficacy of a course of dihydroartemisinin-piperaquine (360 mg/2880 mg) divided over three days for uncomplicated Initial vital signs included a heart rate of 70, blood pressure of 108/69 mmHg, and a tympanic temperature of 38.1°C. He was not ill-appearing and had no jaundice, icterus, conjunctival pallor or rash. The remainder of the physical examination was unremarkable, including a normal neurologic examination and no hepatosplenomegaly. Urine was light tea coloured. Initial laboratory assessment revealed mild anaemia , low serum calcium (6.7 mg/dl), and normal serum creatinine (0.92 mg/dL). His G6PD activity was normal , and serial 10-second surface EKG tracings were normal, with an average manual QTcF of 444 ms.Twenty-eight hours following admission, after completing the first two doses of DHA-PIP, he was observed to have dark 'coca-cola’ coloured urine. His fever was still present and new signs and symptoms developed including pallor, dizziness, fatigue, anorexia and semi-watery diarrhea with abdominal pain in the right lower quadrant. Acute renal injury with an increase in serum creatinine from 0.92 to 1.7 g/dL, along with a decline in haemoglobin to 8.1 g/dL (21% decrease from baseline), was observed. He was switched to intravenous artemether  for severe malaria with blackwater fever. He continued to have an appropriate response to anti-malarial therapy, with a decline in peripheral parasitaemia to 286 parasites/μl within 48 hours, and was smear negative by day 5  with levels thereafter remaining stable at approximately 8.0 g/dL (7.7-8.8 g/dL). Serology for co-infections was negative for IgM against leptospira, all four dengue serotypes, scrub typhus, HIV and P. falciparum parasitaemia, partial malaria immunity, G6PD deficiency, and treatment with amino-alcohol drugs [There are not well-defined predictive risk factors for BWF, and the syndrome is often diagnosed only after malaria patients undergoing treatment are noted to have dark-coloured urine. The mechanisms of BWF remain unknown though it has been associated with low levels of ol drugs -5,7. In ol drugs ,4,5,8. Tol drugs ,2, but iol drugs -11 and 2ol drugs  with morversus 1.2% respectively) [This is the first report of a patient with uncomplicated malaria who developed BWF after administration of DHA-PIP. BWF is classically associated with the amino-alcohols quinine, mefloquine and halofantrine of which quinine is the most common culprit. Since chloroquine was introduced after World War II supplanting quinine as first-line treatment of uncomplicated malaria, there has been an observed decrease in BWF . A recenctively) . Dihydroctively) . There hctively) . The dihctively) . The patctively) . Howeveret al. [In this case, the patient did have serologic evidence of Chikungunya infection, but he lacked classic findings of Chikungunya including arthritis, arthralgia, petechiae or maculopapular rash. In a 2001 study by Bruneel et al.  five of et al. . The strEthical approval and patient informed consent was obtained from the patient for the study and for publication of this case report.The authors have declared that there are no financial or non-financial competing interests.CL, MS, SS, RB, SC, CL1 and DS designed and wrote the article. CL, MS, CL1, DS, MI, NB conducted the study. SS, RB, SC and CL diagnosed and treated the patient and collected all the clinical and diagnostic laboratory data. KT, NK, YY, WK and laboratory team designed, performed and assessed the laboratory tests. All authors read and approved the final version.


WHO estimates that 80% of mortality due to malaria occurs among infants and young children. Though it has long been established that malaria disproportionately affects children under age five, our understanding of the underlying biological mechanisms for this distribution remains incomplete. Many studies use age as an indicator of exposure, but age may affect malaria burden independently of previous exposure. Not only does the severity of malaria infection change with age, but the clinical manifestation of disease does as well: younger children are more likely to suffer severe anaemia, while older children are more likely to develop cerebral malaria. Intensity of transmission and acquired immunity are important determinants of this age variation, but age differences remain consistent over varying transmission levels. Thus, age differences in clinical presentation may involve inherent age-related factors as well as still-undiscovered facets of acquired immunity, perhaps including the rates at which relevant aspects of immunity are acquired. The concept of "allometry" - the relative growth of a part in relation to that of an entire organism or to a standard - has not previously been applied in the context of malaria infection. However, because malaria affects a number of organs and cells, including the liver, red blood cells, white blood cells, and spleen, which may intrinsically develop at rates partly independent of each other and of a child's overall size, developmental allometry may influence the course and consequences of malaria infection. Here, scattered items of evidence have been collected from a variety of disciplines, aiming to suggest possible research paths for investigating exposure-independent age differences affecting clinical outcomes of malaria infection. In 2009, an estimated 243 million cases of malaria led to approximately 863,000 deaths around the world, 80% of which WHO estimates were in infants and young children . It is wPlasmodium falciparum parasite life cycle begins when an Anopheles mosquito injects sporozoites into the human host. The parasites travel through the bloodstream into the liver, where they invade and replicate, releasing approximately 30,000 merozoites per hepatocyte [The patocyte . The merP. falciparum infections typically present two distinct clinical manifestations: severe malarial anaemia (SMA) or cerebral malaria (CM). In both, severe disease is generally associated with higher levels of parasitaemia and consequently exaggerated pathogenesis of infection, including rosetting (in which 10 or more uninfected cells clump together around a single infected RBC), cytoadherence, and increased clearance of both infected and uninfected RBCs, discussed in detail below. SMA is associated with high peripheral parasitaemia, low haematocrit, and decreased haematopoiesis [Severe opoiesis . Increasopoiesis . SMA in opoiesis . ChangesDespite numerous studies and the identification of several significant contributing factors, the pathogenesis of CM remains somewhat opaque. Although parasitaemia and CM appear correlated, no causal relationship between degree of parasitaemia and CM has been firmly established ,8. Many Numerous studies have shown that the severity of malaria infection, as well as its clinical manifestations, changes with age. The incidence of severe anaemia and cerebral malaria is higher in children -17, and This paper explores the concept of "allometry" - the relative growth of a part in relation to an entire organism or to a standard - as a possible explanation for some age-related differences in malaria infection. Since malaria affects a number of organs, including the liver, red blood cells, white blood cells and spleen, all of which may develop at rates independent of each other and of the child's overall size, each may influence the course and consequences of malaria infection differently at different times. For example, children have a much larger liver mass in relation to body weight than adults, which may influence the rate at which drugs and toxins are metabolized and cleared, and thus the strength of their effects . The nonIn areas of high endemicity, children between six months and five years of age develop the most severe clinical response to infection, while in areas of low endemicity, older children and adolescents are most at risk . The firP. falciparum transmission, to holo-endemic Irian Jaya, the previously unexposed Javanese children and adults showed unique patterns of malaria symptoms relative to each other and to age-matched locals. In local residents, younger children had more frequent and more severe infections than did adults, as would be expected. The transmigrant children and adults had similar incidence of infection upon initial measurement; however, after three months of residence the prevalence of clinically severe malaria was significantly higher in adults than in children. After one to two years, adult migrants had less frequent and less severe infections than their children who had experienced the same exposure to infection, indicating that they had acquired immunity more rapidly than their children. Thus, apparently, among non-immunes the risk of severe malaria increases with increasing age, but after a period in an endemic area this is offset by rapid acquisition of immunity with increasing age. This result has been supported by other studies suggesting that significant protective factors arise during development, apart from previous exposure [In areas of high transmission compared to low transmission, children develop protection against severe clinical malaria at early ages and less often present with CM, while adults rarely develop symptoms . Separatexposure ,32.A number of important and possibly clinically relevant changes occur in blood and red blood cells during infancy and early childhood: a switch from foetal haemoglobin (HbF) to adult haemoglobin (HbA), a shift in the overall age profile of RBCs due to different rates of production and decay, and changes in overall blood volume, cell size and cell surface proteins.It is difficult to isolate the possible protection of HbF due to potentially confounding variables in infants under six months of age, such as nutritional differences (e.g. nursing) or transferred maternal antibodies, which occur in similar time frames . For insAfter this initial period of protection, children in endemic areas become highly susceptible to severe infection. Progression from infection to severe disease and death can be very rapid, particularly in small children. The simple number of available RBCs may be a contributing factor in this progression. Presumably, the biological process of parasite invasion and multiplication in RBCs is independent of the age of the host during malaria infection (i.e. the parasite does not "know" the age of its host). As a child grows, its blood volume grows at a rate correlated with lean body mass ,36. HaemP. falciparum infection: as many as nine to 10 uninfected cells may be cleared for every infected cell, a phenomenon known as the "bystander effect" [The rate of RBC clearance increases disproportionately during  effect" . It is n effect" ,46, and  effect" . Since s effect" .P. falciparum (as well as Plasmodium vivax) preferentially infects young RBCs [The rate of production of RBCs differs between children and adults. Since young children are growing at a faster rate than adults, and increasing their blood volume in proportion to their lean body mass, they must produce erythrocytes at a faster rate to keep up. At birth, all bone marrow is RBC-producing red marrow, but this proportion continually declines until, in adulthood, only half is red marrow . In infaung RBCs . Furtherung RBCs , its effAge-related differences in total cerebral blood flow (tCBF) and regional cerebral blood flow (rCBF) may contribute to observed clinical patterns of CM. tCBF increases drastically within the first few years of life and then gradually declines to adult levels . White mA recent study of fatal paediatric CM cases showed that CM affected both the white and grey matter, although most haemorrhages occurred in the white matter. The increase in CBF with age may predispose older children to clogged blood flow and haemorrhaging. In addition, the majority of cases had a significant increase in brain weight due to oedema compared to that of an uninfected child of the same age, a trend which was not observed in fatal adult cases .Myelination, the process of adding myelin around neural axons, begins before birth and continues through adolescence . Given tP. falciparum, both infected and uninfected erythrocytes lose deformability, exaggerating these effects [In addition to the overall change in blood volume and flow, mean red cell volume (MCV) increases with age ,60. How  effects . Because effects .These reductions in size and deformability of RBCs change blood flow dynamics and decrease the ability of a RBC to fit through the splenic filter (see below) . The smaThere is evidence to suggest age differences in surface proteins on RBCs, which impact both binding properties and recognition by the spleen . Age-relTwo other complement proteins, CD55 (decay-accelerating factor) and C3b, are age-dependent and have a significant role as part of the innate immune system during malaria infection . CD55 blP. falciparum, binds to CD36 and is responsible for sequestration of parasites. However, CD36 is not present on brain endothelium and is not responsible for sequestration of parasites in the brain during CM. Rather, it is thought that PfEMP1 binds to platelets, which then secrete cytokines activating the brain endothelium, or, perhaps, themselves bind to endothelium. Some studies have shown an increase in platelet count in the brain during cerebral infection, compared to those without cerebral malaria, possibly due their role in cytoadherence [The complement cascade, as well as the surface protein CD36, has also been associated with platelet activation. CD36 is present on platelets, macrophages, dendritic cells (DCs), and some endothelium. PfEMP1, a protein expressed by dherence . Thrombodherence . It is ndherence . Althougdherence . If platIn addition to the cells themselves, blood vessels may change in size or chemical properties with host age, influencing blood flow, cytoadherence, and parasite clearance rate. For example, there is evidence that levels of VCAM-1, a cell-adhesion molecule important in malaria, decrease throughout childhood, but research on such changes across ages is still sparse .In summary, HbF, small MCV, inherent size differences  and surface concentrations of CR1, CD55, and C3b that change during infancy and early childhood may increase susceptibility to SMA. These same size differences and changes in CBF and platelets may increase susceptibility to CM with age.Finally, there may be interaction between clinical features of SMA and CM. SMA might provide some protection against CM by reducing the number of RBCs in circulation. If CM is significantly related to rosetting, a reduction in the number of total RBCs, and thus their concentration, would reduce the probability of the cells contacting each other and forming a cluster ,78. AlthThe spleen filters RBCs, and destroys them if infected or senescent. The spleen clears RBCs through two distinct structural mechanisms: physical selection and cell-cell interaction. The spleen is composed of the red pulp, where mechanical filtration occurs, and the white pulp, where most contact with immune-system cells occurs . The splTo filter RBCs, the spleen uses both fast microcirculation, a closed vascular system, and slow microcirculation, an open system in which RBCs enter a large pool and must filter through the cords in the red pulp and the endothelial cells. Ten to 20% of RBCs are continuously filtered through slow microcirculation; their successful passage depends on the deformability of the cell . RBCs coFoetal RBCs have a shorter lifespan due to differences in haemoglobin chemistry, enzyme concentration, and surface proteins  that maySplenomegaly is common in malaria infection, sometimes extreme to the point of rupture, and has been associated with increased rates of clearance of infected erythrocytes in mice ,88. The Structural differences between infant and adult spleens may contribute to differences in clinical response to infection. Both the marginal zone and red pulp seem to take part in the clearance of infected RBCs, but the marginal zone only begins to appear about 8.5 months after birth, and is not fully developed in human infants until age two ,90. The A host of any age responds to infection by attempting to destroy the multiplying parasite, but the capacities of immune and other response systems may be more limited in infants. The immaturity of the immune system in neonates is widely recognized, in general terms -96. YounThough some vaccines given to newborns and young infants work well, others do not elicit effective, durable protection, presumably due to the presence of passively transferred maternal antibodies, weak and abbreviated antibody responses and developmental differences in T-cells and antigen-presenting cells. There seems to be some contribution of both genetics and environment in the patterns of early cytokine response . When MePlasmodium infection triggers both innate and acquired immune responses. Because the ratio of naïve cells to memory cells declines as the human matures, due to cumulative foreign antigen exposure, it is difficult to differentiate the effects of age per se and previous exposure on these responses [esponses . ExposurThe thymus loses its functionality with age, slowing T cell production and differentiation. In fact, the rate of T cell production peaks in early childhood. Maximum thymic cellularity occurs between six months and one year of age, at which point it begins a slow, steady, decline ,102; thyThe immune system includes Th1 CD4+ T cells and Th2 CD4+ T cells among several other T cell subsets. T regulatory (Treg) cells control the differentiation and function of T cells, regulated by the transcription factor Foxp3, as well as the cytokine environment . A balanNeonates and young infants produce a Th2 response to antigens but gradually shift to a dominant Th1 response with age . Both toThe inflammatory cytokine TNF-α is associated with cerebral malaria, and it is possible that the bias against producing a Th1 response in young children - whether it is due to inherent age-related properties or exposure and environment - helps to protect them from developing cerebral malaria ,109. ExpThe Th2 CD4+ T cell bias in infants influences the proportions and levels of cytokines produced, and may affect which antibodies are produced in response to an infection by influencing different B cells . TypicalP. falciparum antigen. But there may be more involved than the antigen presented. One study showed that children trigger an IgG1 response to the MSP-2 (merozoite surface protein-2) antigen, while their maternally-derived antibodies to MSP-2 were IgG3 [The subclass of IgG response - IgG1 or IgG3 - varies, but the cause of this variation remains unclear. Some research indicates that in malaria the subclass varies by ere IgG3 . Infant ere IgG3 . Infantsere IgG3 .P. falciparum, so the possibly diminished antibody response and IgG1 bias in children might be involved with increased severity of disease in infants and young children [The IgG3 response to MSP-2 serogroup A is highly correlated with clinical immunity to children . Howeverrate of acquisition of the different antibody subclasses [P. falciparum based on age and the intensity of transmission. One study looked at the ratio of IgG1/IgG3 response across four different levels of transmission, and showed that age and endemicity both independently increase IgG1 subclass at younger ages and increase IgG3 with age for anti-MSP-2 antibodies [Another recent study found that adult non-immune travelers had a strong IgG1 (rather than IgG3) response compared to immune adults during infection, suggesting that previous exposure is a significant factor in determining the IgG1 vs. IgG3 response . Howeverbclasses . Recent tibodies .persistence of antibodies, as well as the rate of production, increases with age. A recent study in the Gambia found that the half-life of antibodies to an array of P. falciparum antigens in older children (ages four to six) was three times that of younger children (ages one to three) during and after malaria infection [There is evidence that the nfection . Similarnfection ,120. TheThis concept of varying half-lives is further supported by evidence that IgG levels in children have been shown to fluctuate seasonally, while the levels of antibodies in adults remained much more stable ,122. ThiLong-lived plasma cells are necessary to provide an extended effective response to (non-chronic) infection, but are apparently lacking in young children ,123, as Thus, the combination of different rates of antibody production and decay with age, as well as the absolute amount of antibodies produced by plasma cells, may cause significant differences in the quantity of antibody over time, independently of effects from previous exposure Figure .This review focuses on the observation that infants, young and older children, adolescents, and adults each show markedly different susceptibility, clinical manifestations, and morbidity and mortality with respect to malaria. While exposure, and thus acquired immunity, may vary with age, studies suggest that a number of independent age-related factors may help to explain these differences.Malaria affects many organs, each of which play a role in the protection from, development of, and presentation of malaria infection. Well-documented developmental changes in immunity may play a major role in the susceptibility of infants and young children to malaria, but other developmental changes in the liver, spleen, blood cells and blood flow occur at ages that correspond to noted changes in malaria susceptibility and manifestations. The relative impact of these anatomic and physiologic developmental changes, alone or in combination, has not yet been systematically examined. However, if the aim of a malaria vaccine is to shift the response of a young child to that of an older child - i.e. to minimize the frequency and severity of clinical episodes - then expectations must be calibrated to allow for the effects of development that arise with age per se, as well as with exposure.WHO: World Health Organization; RBC: Red blood cell; CM: Cerebral malaria; SMA: Severe malarial anaemia; BBB: Blood-brain barrier; HbF: Foetal haemoglobin; HbA: Adult haemoglobin; tCBF: Total cerebral blood flow; rCBF: Regional cerebral blood flow; MCV: Mean cell volume; CR1: Complement receptor 1; DC: Dendritic cell; TI: T-cell independent; TRE: Recent thymic emigrants; IgG: Immunoglobulin G; IgM: Immunoglobulin M; MSP: Merozoite surface protein.The authors declare that they have no competing interests.EB conducted the literature review. All authors wrote, read and approved the final manuscript.What is allometry? [lometry? -132.Click here for file


Plasmodium vivax malaria with sub-microscopic parasitaemia and polyclonal B-cell activation (PBA)  was diagnosed by polymerase chain reaction (PCR) after consecutive negative rapid diagnostic test results and blood films. The patient, a 44-year-old man from Rio de Janeiro state, Brazil, had visited the Atlantic Forest, a tourist, non-malaria-endemic area where no autochthonous cases of ’bromeliad malaria‘ has ever been described. The characteristic pattern of fever, associated with PBA, was the clue to malaria diagnosis, despite consecutive negative thick blood smears. The study highlights a need for changes in clinical and laboratory diagnostic approaches, namely the incorporation of PCR as part of the current routine malaria diagnostic methods in non-endemic areas.A case of autochthonous  Malaria is a potentially fatal disease, especially for individuals exposed for the first time. The chances of death are 108 times higher if a malaria case is diagnosed and treated in non-endemic areas, such as Rio de Janeiro . The resThe non-specificity of clinical presentation of acute malaria makes it even harder to distinguish from other febrile conditions on only clinical grounds, before the spiking pattern of fever shows up or even if it never appears. Thus, a travel history is essential in any febrile patient to evocate malaria diagnosis, mainly in areas of other endemic infectious diseases, such as dengue in Rio de Janeiro, where tropical diseases are not prevalent .Anopheles (Kerteszia) bellator and Anopheles (Kerteszia) cruzii that can transmit Plasmodium and use the water collection in bromeliad to their breeding and larval habitat [2 distributed over 17 states) are reported mainly in the states of São Paulo [Plasmodium vivax[Although the extra-Amazonian region is considered a non-endemic area for malaria, autochthonous cases known as the "bromeliad-malaria" are reported in areas inside or near the Atlantic Forest, which provides an excellent environment for  habitat ,6. Autocão Paulo  and Espíão Paulo , in the ium vivax. In the ium vivax,12,13, aium vivax and a moium vivax, the staium vivax,16.This case describes the first authochtonous reported case in a new touristic region, in Mata Atlantica in the state of Rio de Janeiro and emphasizes the difficulty of malaria diagnosis when no history of prior exposure in endemic areas is associated with consecutive negative rapid diagnostic tests (RDTs) and negative blood film examinations for the presence of the parasite, even by an expert team.Although polymerase chain reaction (PCR) can detect parasites down to a density of 0.01 parasites per microlitre and would, therefore, be very useful in sub-microscopic parasitaemia malaria, it is not usually available in routine laboratory practice  and the A 44-year-old male engineer from Rio de Janeiro, Brazil, presented at Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz , with a history of persistent fever (39°C) for 16 days: initially continuous during the first week followed by intermittent high febrile peaks every 48 hours over the most recent nine days. The fever was accompanied by severe headache and chills, and followed by sweating. The man also complained of abdominal pain, nausea, myalgia, and arthralgia. Eleven days prior to his first consultation at IPEC, the patient had visited the emergency department of another hospital for these symptoms and for a single episode of gum haemorrhage, attributed to dengue fever that was not confirmed by laboratory tests. Because his symptoms did not resolve, he visited IPEC for two walk-in consultations (on days 16 and 18 of the disease).Serra do Mar mountain range. The reserve of Sana is situated at an altitude of 735 m and is 165 km northeast of Rio de Janeiro. The median temperature in the area ranges from 10°C to 18°C, in the summer and winter, respectively.During the first consultation, the patient reported a stay at a small farm in Sana, in the Atlantic Forest during a three-week holiday, 23 days before the onset of fever. The Atlantic Forest is a commonly visited touristic region in the The patient had no co-morbid diseases or any history of blood transfusion, tissue/organ transplantation, intravenous drug use, or travel to a malaria-endemic area. He had not been injured by needle sticks, nor lived or recreated near ports or airports. Furthermore, he had not experienced high fevers in the years prior to this event, and he had not taken drugs with anti-malarial activity either prior to or after the onset of the disease. During physical examination, his body temperature was 39°C, his blood pressure was 110/60 mmHg, and his pulse rate was 93 beats per minute. He appeared pale and had hepatomegaly and abdominal pain, but neither his spleen nor any of his lymph nodes were enlarged, and he did not have a cutaneous rash or any obvious clinical manifestations of bleeding.A routine laboratory tests diagnosis for fever of undeterminated origin was performed: complete blood count, routine blood chemistry determinations, chest radiograph, erythrocyte sedimentation rate, antinuclear antibodies, rheumatoid factor, blood and urine cultures, Cytomegalovirus IgM antibodies, heterophile antibody, Human immunodeficiency virus antibodies, tuberculin skin test, and, considering the presented fever pattern, blood films, RTC and PCR were requested to exclude the possibility of malaria in the individual.th day of disease were as follows: C-reactive protein, 5 mg/dL; haemoglobin, 11.9 g/dL; haematocrit, 35%; white blood cell count, 4,440/L ; platelet count, 258,000/mm3; total serum bilirubin, 0.36 mg/dL ; creatinine, 0.94 mg/dL; alanine aminotransferase (ALT), 45 IU/L; aspartate aminotransferase (AST), 129 IU/L; serum albumin, 3.8 g/dL; urea, 37 mg/dL; creatinine, 0.94 mg/dL; LDH, 115 UI/L; sodium, 144 mmol/L; potassium, 4.4 mmol/L and glucose, 91 md/dL.Laboratory test results on admission on the 16Plasmodium[Plasmodium vivax[Routine blood cultures, microscopic urinalysis, and urine cultures were all negative. Serologic tests for toxoplasmosis and cytomegalovirus were positive for both IgG and IgM antibodies. The test results for ANF and RF were also positive, showing antibody titres of 320 (speckled pattern) and 64, respectively, whereas the test result for anti-HIV was negative. Abdominal ultrasound, echocardiography, and chest radiography results were normal. A microscopic direct blood examination (thick and thin blood films) was performed every 48 hours and assessed by two independent experts , and rapid malaria tests  repeatedly reported negative results. On day 18 of the disease, single PCR tests for ium vivax were posTreatment with chloroquine and primaquine was initiated, and the patient’s fever resolved 24 hours after the start of treatment. He made a full clinical recovery and the laboratory abnormalities had normalised by the end of the treatment. The PCR tested negative for the first time on the second day and further negative results were reported on days 7, 21, 28, 40, 60, and 100 after treatment initiation, confirming that the treatment was curative. Serologic test results for toxoplasmosis and cytomegalovirus were negative on day 100 after the onset of symptoms, whereas the titres for both RF and ANF were reduced on the eighth day after treatment.Written informed consent to the publication of this case report was obtained from the patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal.This is the first report of autochthonous, probably ‘bromeliad malaria’  from AtlThe essential clue for the diagnosis of malaria in febrile patients is an accurate history of malaria exposure in endemic areas. The patient described here did not visit the Amazon region, which accounts for 99.8% of registered malaria cases in Brazil , and hadThe patient’s long-lasting fever made the diagnosis of dengue and leptospirosis unlikely, in the same way that the absence of enlarged lymphonodes or spleen made infectious mononucleosis and lymphoma improbable. Other infectious diseases, such as typhoid fever, Q fever, rickettsial infections, and hepatitis virus, were not considered or tested for because the resolution of fever after the institution of specific therapy provided good evidence to support the presumptive diagnosis of malaria.General laboratory finds (blood cells count and biochemistry) were normal, except for the raised C-reactive levels, as commonly described in malaria ; a slighPlasmodium genera and P. vivax. Although PCR assays obviously cannot resolve the significant problem of lack of clinical suspicion in the diagnosis of imported malaria [P. vivax DNA in the peripheral blood, together with the classic clinical symptoms of malaria, allowed the initiation of anti-malarial treatment.In spite of the negative RDTs and negative parasitaemia by direct examination of blood smears after consecutive 48-hour intervals, despite no previous treatment, PCR tests were positive for  malaria , it is cP. vivax, as already demonstrated by others [The lack of effectiveness of the Optimal® test, which is considered insufficient at less than 100 parasites/μL, was not surprising. Commercially-available RDTs do not have a satisfactory sensitivity in detecting y others . A stronThe presence of ANF and RF at titres of 320 and 64, respectively, at the time of diagnosis and the decrease of these titres after treatment initiation suggest that the up-regulation of these auto-antibodies could have been triggered by a state of PBA accompanying the plasmodial infection. The IgM and IgG antibodies indicating cytomegalovirus and toxoplasmosis, which were present at the time of diagnosis, and the absence of these antibodies after treatment also support this premise.Acute and chronic malaria, in both rodent experimental models ,23 and nIn addition to malaria, other infectious diseases, such as African Trypanossomiasis, acute Chagas disease, CMV or EBV infection and leishmaniosis, are also associated with PBA and would have to be excluded by appropriate laboratory tests in other clinical and epidemiological scenarios.P. vivax causing malaria in this case is not in the scope of this paper and was not explored by the authors. It is, however, an important issue because unusual P. vivax strains have been reported in other Atlantic forest cases [The genetic characterization of the strain of st cases ,9. FurthP. vivax malaria may be a difficult challenge outside endemic regions and this type of observation should be primarily reported to clinicians who are apparently prone to look for possible dengue fever infection but might be less likely to consider a diagnosis of malaria.Accurate identification of Medical practitioners should remain aware of the possibility of malaria in patients presenting fever together with polyclonal lymphocyte activation detected by multiple serological positive reactions.Although expensive and time-consuming, PCR testing for malaria can be a useful and even exclusive diagnostic tool in areas with very low or unusual malaria transmission, where parasitaemia might be undetectable by microscopic examination. The morbidity of malaria, when misdiagnosed and mistreated, outweighs drawbacks in the use of PCR as part of the current routine diagnostic methods in non-endemic areas.The authors have declared that they have no competing interests.PB attended the patient and described the case, conceived the study and reviewed the manuscript. APC contributed to data collection and the case description and drafted the manuscript. CLL contributed to data collection and the case description. SS performed the microscopic examination. MFFC performed the molecular genetic diagnosis and contributed to the review of the manuscript. CTDR contributed to the conception and review of the manuscript. All authors read and approved the final manuscript.


In areas where visceral leishmaniasis (VL) and malaria are co-endemic, co-infections are common. Clinical implications range from potential diagnostic delay to increased disease-related morbidity, as compared to VL patients. Nevertheless, public awareness of the disease remains limited. In VL-endemic areas with unstable and seasonal malaria, vulnerability to the disease persists through all age-groups, suggesting that in these populations, malaria may easily co-occur with VL, with potentially severe clinical effects.A retrospective case-control study was performed using medical records of VL patients admitted to Tabarakallah and Gedarif Teaching Hospitals (Gedarif State) and Al`Azaza kala-azar Clinic (Sennar State), Sudan (2005-2010). Patients positively diagnosed with VL and malaria were identified as cases, and VL patients without microscopy-detectable malaria as controls. Associations between patient characteristics and the occurrence of the co-infection were investigated using logistic regression analysis. Confirmation of epidemiological outcomes was obtained with an independently collected dataset, composed by Médecins Sans Frontières (MSF) at Um-el-Kher and Kassab Hospitals, Gedarif State (1998).The prevalence of malaria co-infection among VL surveyed patients ranged from 3.8 to 60.8%, with a median of 26.2%. Co-infected patients presented at hospital with deteriorated clinical pictures. Emaciation (Odds Ratio (OR): 2.46; 95% Confidence Interval (95% CI): 1.72-3.50), jaundice  and moderate anemia  were found to be positively associated with the co-infection, while severity of splenomegaly  and, to a less extent, hepatomegaly  appeared to be reduced by concomitant VL and malaria. The in-hospital case-fatality rates did not significantly differ between co- and mono-infected patients . Conversely, a significantly increased mortality rate  was observed by MSF amongst co-infected patients enrolled at Um-el-Kher and Kassab Hospitals, who also suffered an enhanced risk of severe anemia  compared to VL mono-infections.In endemic VL areas with unstable seasonal malaria, like eastern Sudan, VL patients are highly exposed to the risk of developing concomitant malaria. Prompt diagnosis and effective treatment of malaria are essential to ensure that its co-infection does not result into poor prognoses. In areas where malaria is co-endemic with visceral leishmaniasis (VL), co-infections with both diseases are common . PreviouOf the 30,000 to 50,000 annual VL cases estimated in East Africa, the second largest VL focus after South-Asia, half as many  are thought to occur in Sudan ,9. HyperPlasmodium falciparum, prevails in most areas of Gedarif and Sennar States, where prevalence rates of 1.6% and 1.1%, respectively, were confirmed among the communities surveyed in 2009 [Leishmania parasites may, therefore, have dramatic consequences on ability to control both infections, potentially resulting in an aggravated clinical picture.Unstable seasonal malaria, due to  in 2009 . This ep in 2009 ,25. Subc in 2009 . ConcomiTo describe the clinical impact of VL-malaria co-infections in patients with low malaria immunity, we investigated the epidemiology of VL-malaria co-infections in a VL endemic area characterized by unstable seasonal malaria. By surveying three strategically located hospitals, we obtained a semi-representative data collection of Gedarif and Sennar States (2005-2010), whereby the risk for local VL patients of acquiring a malaria co-infection was assessed. The high prevalence of this co-morbidity and its negative impact on patients’ clinical condition, as observed in this study, highlighted the existence of a clinically significant condition, whose life-threatening implication was indirectly confirmed by an independently collected dataset, gathered by MSF-H at Um-el-Kher and Kassab Hospitals, Gedarif State, in 1998.The study area lies in Sudan, between the Blue Nile River in the central region of Sennar State and the lower Atbara River, which borders Gedarif State in the northeast. The Rahad River and the Dinder River, both tributaries of the Blue Nile River, flow across the region with seasonal regime, marked by major floods during the rainy season (from June to October) and long periods of dry-off throughout the rest of the year. Al`Azaza kala-azar Clinic (Sennar State), Gedarif Teaching Hospital and Tabarakallah Hospital (Gedarif State) Figure  were selLeishmania infection in lymph node or bone marrow aspirates was categorized according to the WHO-recommended grading system [A retrospective case-control study was performed on patients positively diagnosed for VL. Patients with a laboratory-confirmed diagnosis of both VL and malaria at hospital admission or during hospitalization were identified as cases, while controls were patients similarly diagnosed with VL, whose blood smears tested negative for malaria. Laboratory-confirmation of VL was obtained either through microscopic examination of lymph node, bone marrow or spleen aspirates, or using serological tests, such as the direct agglutination test (DAT) (titer ≥1:6400) and the rk39 antigen-based dipstick , in combination with the clinical case definition of the World Health Organization (WHO) . Intensig system ,29. BrieMedical records of patients hospitalized between January 2005 and December 2010 in the three hospitals, were retrospectively reviewed. Data from patients positively diagnosed with VL were collected manually, by using paper Case Record Forms (CRF) specially designed for the study. Data included patients’ demographic details, clinical signs and symptoms, test results, medical treatments and relative outcomes. Upon completion of the collection process, data were single-entered using SPSS 15.0  and Microsoft Excel softwares.n = 22, 2.0%) were found to be non-anemic (Hb ≥11 g/dl), while the majority  had mild anemia (Hb 7.3-10.9 g/dl), the groups with no and mild anemic patients were combined in one category, more truly representative of the patient set for anemia risk assessment. Seasonality of the co-infection was examined by categorizing hospital admissions during wet season (from June to October) or dry season (from November to May). Odds ratio (OR) with 95% confidence intervals (CI) were calculated to test whether a variable significantly differed between cases and controls. Multivariable logistic regression models were used to identify independent patients’ characteristics associated with the co-infection. All variables with a P-value <0.10 in the univariate analyses were entered stepwise in the multivariate analysis, whose final model only comprised significant variables  and variables which significantly increased the model fit, as assessed by the −2 Log Likelihood test.Descriptive analyses were conducted to examine the features of the overall study population and to assess prevalence and case-fatality rates of the co-infected patients. Statistical analysis was performed using SPSS 15.0 software. Characteristics of cases and controls were individually compared, using the Pearson Chi-square test or the Fisher Exact Probability test. Continuous variables were categorized in predefined groups: age  based on malaria risk, spleen size  by percentiles and anemia based on hemoglobin level . As only few patients  and no history of previous anti-leishmanial treatment. Microscopic search for malaria was also performed on all study subjects at enrollment. Treatment for VL consisted of either Pentostam or generic sodium stibogluconate given intramuscularly (20 mg/kg/day for 30 days), while SP and quinine were administered as first-line treatment for uncomplicated and severe malaria, respectively. Using the same case-control definition as in the survey, descriptive and statistical analyses (Person Chi-square test) were performed to assess prevalence and mortality rates of the VL-malaria co-infection and to measure its association with explanatory variables.Demographic and clinical data of VL patients enrolled in a clinical trial conducted by MSF-H at Um-el-Kher and Kassab Hospitals 1998) were analyzed for comparison with the survey outcomes. Both hospitals lie in Gedarif State  and from the Ethics Review Board of MSF (19th July 2012).Data were collected as part of routine patient care, with no need for additional investigations. Data extraction from medical records was performed by anonymizing the information recorded in the CRFs. Ethical approval for the study was obtained from the Health Directorates of Gedarif and Sennar States , bone marrow  and/or spleen  aspirates, was used for the diagnosis of VL. Serology was performed in 17 patients, 13 of whom were confirmed by DAT and 4 by rk39 antigen-based dipstick. Overall, 404 (31.2%) of the VL-confirmed patients were co-diagnosed with malaria at hospital admission or during hospitalization. In all cases but one, in which diagnosis was established with an RDT, malaria was confirmed by microscopy. Stratification of the study population by hospital resulted into an unevenly distributed co-infection rate, with a prevalence of 3.8% in Gedarif Teaching Hospital (n = 18), followed by Tabarakallah Hospital (n = 84) and Al`Azaza kala-azar Clinic (n = 302) with 26.2% and 60.8%, respectively. With the exception of one P. vivax-infection, all malaria cases for which the Plasmodium species was determined, were attributed to P. falciparum .A total of 1324 medical records reporting on VL-diagnosed patients hospitalized in Gedarif Teaching Hospital, Al`Azaza kala-azar Clinic and Tabarakallah Hospital during the study period were reviewed for the survey. Of these, 1295 reported on patients with a laboratory-confirmed VL infection, who were included in the study, while the remaining 29 were excluded for lack of laboratory diagnostic evidence. Microscopy, mainly performed on lymph node (n = 120/296) and progressively reduced until 29 years (data not shown), indicating that the chance of detecting malaria in patients already diagnosed for VL declined as age increased. Residents of Sennar State appeared to be mostly stricken by the co-infection, particularly in the villages of Al`Azaza (28.0%), Om Bagraa (8.7%) and Jaldook (5.2%). Anemia (hemoglobin level <11 g/dl) was a hallmark of nearly all co- and mono-infected patients , with most patients being diagnosed with mild or moderate anemia on hospital admission. Co-occurrence of malaria in VL patients resulted in increased severity of the anemia status, as shown by the decrease in median hemoglobin level . Despite most co- and mono-infected patients presented with enlarged spleen, frequency  and severity of splenomegaly  appeared to be slightly reduced by concomitant malaria.With a median age of 12 years (inter-quartile range 5-23 years), nearly three quarters of VL-malaria co-infected patients were under 20 years old. Stratified by age, the percentage of cases was highest among children aged between 0 and 4 years    and gradually increased as VL infection intensified   , indicating that concomitant malaria did not represent a risk factor for poor prognosis. When stratified by malaria treatment, in-hospital fatalities clustered amongst co-infected patients treated with artemether and quinine, whose mortality risk was 13-fold  and 15-fold  higher, respectively, than in patients receiving artesunate+SP  and 15  times more likely to die, respectively , jaundice  and, particularly, weight loss  were more commonly reported among co-infected cases.Associations between demographic and clinical variables and the co-infection, as described by univariate analysis, are summarized in Table All 11 variables associated with the VL-malaria co-infection in the univariate analysis were included in the multivariable models. Due to the high number of missing data in reporting clinical signs and symptoms, three different models were designed to explore the association between the selected variables and the VL-malaria co-infection: model A, in which the independent risk factors were identified, model B describing the association between clinical signs and symptoms and the co-infection and model C, which combines all variables  in one analysis. Model A Table  shows thIn model B Table , logistiMassive splenomegaly was less common among co-infected patients , who instead suffered frequent exacerbations of their anemic status, as observed in the group with moderate anemia .Combining all variables in one model , whose diagnosis was occasionally confirmed, as for all patients with borderline DAT titers (from 1:400 to 1:6400), by parasitological evidence in lymph node or spleen aspirates . Microscopy-confirmed malaria was co-diagnosed in 89 VL patients (17.2%), 10 of whom died (11.2%). Given the lower case-fatality rate among controls (2.8%), here co-infections significantly increased the mortality risk of VL patients by nearly four and half fold  (Table versus the mono-infected VL patients (8.2 g/dl) could be detected, the proportion of patients with severe anemia (Hb <5.3 g/dl) was significantly higher among cases (15.7%) than among controls (5.2%) . No other major differences in nutritional status, spleen size below the costal margin and duration of on-going disease prior to hospitalization were observed between co- and mono-infected patients, except their distribution between the two treatment centers. With more than 80% of the co-infection cases recorded in Um-el-Kher Hospital, the risk here, of being co-diagnosed with VL and malaria was nearly double  than at Kassab Hospital.Between November and December 1998, 516 primary-VL cases were diagnosed in the MSF kala-azar treatment centers of Um-el-Kher and Kassab. Positive DAT results were obtained for most patients  and confirms its clinical relevance by comparing prevalence and mortality rates with an antecedent (1998), independently collected dataset from the same region . Not only the risk of co-acquiring VL and malaria appears to be substantial in these areas, with a significant geographical variation, but the clinical implications deriving from being co-infected provide the evidence for a public health concern. Exacerbated clinical pictures and increased mortality risk, possibly due to inadequate antimalarial treatment, were highlighted by this survey, suggesting that prompt diagnosis and effective therapy of concomitant malaria is needed to ensure positive resolution of the VL-malaria co-infection.Ranging from 3.8 to 60.8% and with a median of 26.2%, the prevalence of malaria co-infection among VL surveyed patients 2005-2010) confirms the frequent superimposing of the two diseases in rural areas of Gedarif and Sennar States. Although these estimates may be higher than expected, based on the local malaria transmission rates, similar figures have been found in the MSF’s dataset from Um-el-Kher and Kassab Hospitals, where 19.7% and 11.3%, respectively, of the VL patients enrolled in the clinical trial (1998) were positive for malaria. Again at Um-el-Kher Hospital, clinical studies conducted between January 2004 and early 2005 revealed that 15% of pregnant VL women enrolled in the trial  and 31% 0 confirmLeishmania parasites observed in aspirates of co-infected patients, the first speculation may be supported by the peculiar symptom pattern. Jaundice, in fact, is rarely described among VL patients, while it is not uncommon in P. falciparum malaria [Concomitant malaria partly exacerbated the clinical picture of VL patients, who presented with more frequent emaciation, icterus and moderate anemia. Two scenarios may be postulated: co-infected patients may either have suffered from malaria-associated symptoms which, in addition to the VL ones, have caused deterioration of their clinical condition and/or have run an exacerbated course of VL due to concomitant malaria, in which case symptoms may be related to VL rather than to malaria. If this latter hypothesis may find its rationale in the increased number of  malaria . Weight P-value 0.001) associated with co-infected patients enrolled by MSF at Um-el-Kher and Kassab Hospital in 1998. During this trial, co-infected patients were nearly four and half times more likely to die compared with the VL mono-infected patients, whose mortality (2.8%) on the other hand, compares well to what found in the most recent survey (3.1%). Different anti-malarial regimen were used within the two study groups: SP and quinine in 1998 for uncomplicated and severe malaria, respectively; artemisinin derivatives  and more rarely quinine between 2005 and 2010. Sudan’s choice to introduce artemisinin-based combination therapies (ACTs) for treatment of uncomplicated and severe malaria was implemented nation-wide in 2004 [Leishmania intensities, was observed when quinine  and artemether  were administered as antimalarials, suggesting either increased malaria severity or inadequate drug treatment.In antithesis to the positive resolution of VL-malaria co-infections during the 2005-2010 survey, is the significantly higher fatality rate  exceedsBased on the results of this study, we conclude that VL patients living in areas with unstable seasonal malaria, such as eastern Sudan, are highly exposed to the risk of developing concomitant malaria. Large variation in the geographical distribution of co-infection cases highlights the presence of environmental and/or social factors, whose identity and relevance in the risk of co-acquiring VL and malaria still remain to be elucidated. Clinical concerns should arise when the two diseases co-occur in the same patients, as significant exacerbation of their clinical condition was observed, along with an increased mortality risk, possibly associated with inappropriate anti-malarial treatment. Local health care policies should take into account the high co-infection burden borne by VL foci with unstable malaria, by recommending systematic malaria screening for all VL patients and ACTs for treatment of malaria.The authors declare that they have no competing interests.EvdB contributed in conceiving of the study, drafted the study protocol and the manuscript and participated in the data analysis. MB performed the data entry and the statistical analysis and helped to draft the manuscript. AN performed the collection and entry of data. PM and EA participated in conceiving of the study and reviewed the study protocol and the manuscript. AT participated in the collection and entry of data and helped to draft the study protocol. HA participated in the collection and entry of data. SA reviewed the study protocol and the manuscript. KR participated in the data analysis and reviewed the manuscript. BN coordinated the collection and entry of data, organized local logistics, and helped to review the study protocol and the manuscript. HS conceived the study and participated in its design, and reviewed the study protocol and the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/332/prepub


Plasmodium falciparum malaria in industrialized countries where the disease is not endemic because most studies have been case reports or have included <200 patients. To identify factors independently associated with the severity of P. falciparum, we conducted a retrospective study using surveillance data obtained from 21,888 P. falciparum patients in France during 1996–2003; 832 were classified as having severe malaria. The global case-fatality rate was 0.4% and the rate of severe malaria was ≈3.8%. Factors independently associated with severe imported P. falciparum malaria were older age, European origin, travel to eastern Africa, absence of chemoprophylaxis, initial visit to a general practitioner, time to diagnosis of 4 to 12 days, and diagnosis during the fall–winter season. Pretravel advice should take into account these factors and promote the use of antimalarial chemoprophylaxis for every traveler, with a particular focus on nonimmune travelers and elderly persons.Little is known about severe imported  Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn CME credit.This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Medscape, LLC designates this Journal-based CME activity for a maximum of 1 www.medscape.org/journal/eid; (4) view/print certificate.All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation at Release date: April 22, 2011; Expiration date: April 22, 2012Upon completion of this activity, participants will be able to:Describe the diagnosis and prognosis of malaria among travelersDistinguish characteristics of returning travelers with malaria in the current studyAnalyze variables associated with a higher risk for severe malaria among returning travelersBeverly Merritt, Technical Writer/Editor, Emerging Infectious Diseases. Disclosure: Beverly Merritt has disclosed no relevant financial relationships.Charles P. Vega, MD, Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine. Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.Disclosures: Elise Seringe, MD; Marc Thellier, MD; Arnaud Fontanet, MD; Fabrice Legros, MD; Olivier Bouchaud, PhD; Thierry Ancelle, MD; Eric Kendjo; Sandrine Houze, MD; Martin Danis, MD; and Rémy Durand, MD, have disclosed no relevant financial relationships. Jacques Le Bras, PhD, has disclosed the following relevant financial relationships: received grants for clinical research from GlaxoSmithKline; received grant from GlaxoSmithKline on application of AFSSAPS phase 4 requirement on Malarone. Plasmodium falciparum infection must be considered in all febrile persons who return from an area where malaria is endemic. Depending on the country of importation and the year, ≈2%–16% of P. falciparum imported malaria infections are severe cases according to the World Health Organization (WHO) definition, and ≈10% of severe cases end with the death of the patient despite appropriate antimalarial treatment  suggested that these cases represented 50%–55% of the total number of imported P. falciparum malaria cases in France during the study period  France. Data for this study were collected by a reporting network of 120 selected hospital laboratories and were analyzed by the French National Reference Center for Imported and Autochthonous Malaria Epidemiology (CNREPIA). Participants of the network were asked to report imported malaria cases whenever asexual forms of P. falciparum–infected patients reported to CNREPIA during 1996–2003. We used WHO criteria for the definition of severe P. falciparum malaria as the primary outcome  to expand the definition of severe malaria. In addition, 2 criteria were changed: acute renal failure with urine output of <400 mL/24 h and serum creatinine >265 μmol/L and >2 generalized seizures within 24 h.www.hcsp.fr).The case severity rate per 100 patients was calculated for all relevant exposure variables. Various exposure categories created for the first study  and 95% confidence intervals (CIs) for the association between exposure variables and severe cases. Dummy variables were used for variables with >2 categories. Variables with p values <0.25 were introduced in the multivariate logistic regression model. A manual backward stepwise approach was used to remove nonsignificant variables; only variables with p values <0.05 were retained in the final model. Interactions were sought by introducing interaction terms in the logistic regression model and testing for their significance at the 0.05 level. Moreover, because our data ranged from 1996 through 2003 and we used 2 WHO definitions for severe disease , among which 20,431 (93.3%) were uncomplicated, 832 (3.8%) were severe, 433 (2%) were asymptomatic, 160 (0.7%) showed hyperreactive malarial splenomegaly, and 32 (0.1%) were unspecified. Among the 21,888 P. falciparum cases, 96 deaths  were related to malaria. The annual number of malaria cases reported by the network increased to ≈3,000 cases up to 1999–2000 and then incidence began to regularly decrease. The CFR of severe P. falciparum malaria was higher during 2000–2003 than before, reaching 15.3% in 2003 ; 6% of patients had low hemoglobin levels (<8 g/dL).Most patients were male (sex ratio M:F = 1.7), and the median age was 29.6 (range 0–96) years. African travelers were most numerous (44.6%), followed by European travelers (26.5%), African residents (12.9%), and European expatriates living in Africa (5.4%); “others” represented 10.6%. Most patients (97.5%) became infected with malaria in Africa: 59.2% in western Africa, 26.2% in central Africa, 11.2% in Madagascar and the Comoros Islands, and 0.9% in eastern Africa . Others P. falciparum cases. Since 2000, we observed a slow decrease in the total number of imported P. falciparum cases, whereas severe cases increased in number and proportion . From 1996 through 2003, the evolution of the number of severe cases was the inverse of that of the total number of imported oportion .Of the 832 patients who had severe malaria, 386 (46.4%) were European travelers, 98 (11.8%) European expatriates, 190 (22.8%) African travelers, 73 (8.8%) African residents, and 85 (10.2%) others. Sex ratio (M:F) was 2.3, and the median age was 38.2 years (range 0–92 years). Twenty-seven patients (3.2%) were >70 years of age, and 127 (15.3%) were <15 years of age. With a 15.3% CFR, eastern Africa accounted for the highest proportion of severe cases. Two-hundred-fourteen (27.9%) of these patients stated they had taken an appropriate chemoprophylaxis. Initial visit to a general practitioner instead of a hospital occurred for 351 (43.8%) patients. A total of 803 patients (98.5%) were hospitalized, 540 (66.2%) in an intensive care unit; the median hospitalization length was 6 days (range 0–169 days). The description of the 96 fatal cases has been reported elsewhere (2 test or trends test). Many factors were associated with an increased risk of severe malaria in univariate analysis, including older age, male gender, European origin, infection in East Africa, short stays (<21 days), inappropriate chemoprophylaxis, initial visit to a general practitioner, time to diagnosis, and diagnosis during the fall–winter season , and 3 were new risk factors . Increasing age is a well-recognized risk factor for severe . The odds of severe malaria developing were increased by 40% when the patient’s initial visit was to a general practitioner rather than to a hospital. This effect remained after controlling for time to diagnosis and suggests that this association was not due to a simple delay of diagnosis.,Time between onset of symptoms and diagnosis of 4–12 days was associated with an increased risk of severe malaria. Shorter delays of diagnosis enabled prompt treatment of malaria episodes and probably prevented their potential evolution towards severity. Diagnosis >12 days postsymptom onset usually reflected controlled parasitemia and uncomplicated malaria. These data emphasized once again the need for early diagnosis and prompt therapy. The higher severity found during the fall–winter season has been related previously to a potential mismanagement of malaria patients initially misdiagnosed with influenza  and from 2.5% to 4.5% (p = 0.3) respectively, whereas the CFR of severe cases remained stable (from 14.3% to 15.3%). These figures may be caused by fluctuations over time but may also be partially explained by the revision of WHO criteria for severe malaria in 2000. This revision may have led to a better categorization of severe cases, judging by the increased odds of death associated with severity after the 2000 reclassification . However, no interaction was identified between year of diagnosis and relevant associations and all analyses were adjusted for the year of diagnosis.This study has several limitations. Our surveillance network accounted for only 50%–55% of total malaria cases  imported to France. Two annual exhaustive studies  and, second, because parasitemia (10% of missing data), hemoglobin, and platelet counts are directly or indirectly part of the definition of severe malaria. Thus, parasitemia, although strongly associated with severe forms of malaria in univariate analysis, was not introduced in the final multivariate model because it is in the causal pathway between several factors and disease. For instance, delay to diagnosis leads to high parasitemia, which itself leads to severe forms of malaria. Adjusting for high parasitemia in the final model would make the relationship between delay to diagnosis and severe malaria disappear.P. falciparum malaria were available  credits are accepted in the US as evidence of participation in CME activities. For further information on this award, please refer to http://www.ama-assn.org/ama/pub/category/2922.html. The AMA has determined that physicians not licensed in the US who participate in this CME activity are eligible for AMA PRA Category 1 Credits™. Through agreements that the AMA has made with agencies in some countries, AMA PRA credit is acceptable as evidence of participation in CME activities. If you are not licensed in the US and want to obtain an AMA PRA CME credit, please complete the questions online, print the certificate and present it to your national medical association.To obtain credit, you should first read the journal article. After reading the article, you should be able to answer the following, related, multiple-choice questions. To complete the questions and earn continuing medical education (CME) credit, please go to 1. You are seeing a 30-year-old man with fever for 5 days. He returned from a trip to Kenya 3 days ago.Which of the following statements regarding malaria among travelers is most accurate?A. Malaria is the most common cause of fever among travelers returning from the developing worldB. Most cases of malaria among returning travelers are classified as severeC. Death due to malaria, even severe malaria, is extremely rare among returning travelersD. Adults from endemic areas are at the highest risk for death from malaria acquired during travel to areas with a high prevalence of malaria2. You suspect malaria in the patient described in question 1. What were characteristics of patients with malaria in the current study?A. Malaria was most common among European travelersB. Most patients had received appropriate chemoprophylaxisC. Most patients had symptoms before returning from travelD. 75% of patients were hospitalized3. The patient in question 1 is diagnosed with malaria. Which of the following demographic and travel variables was most associated with a higher risk for severe malaria in the current study?A. Male sexB. African originC. Travel to East AfricaD. Lower socioeconomic status4. Which of the following medical variables was most associated with a higher risk for severe malaria in the current study?A. ThrombocytopeniaB. Initial presentation to a hospitalC. Absence of chemoprophylaxisD. Normal serum leukocyte countMembers of the National Reference Center Study Group for Imported Malaria in Metropolitan France.


The area is characterized by unstable malaria transmission.Accuracy of diagnosis is the core for malaria control. Although microscopy is the gold standard in malaria diagnosis, its reliability is largely dependent on user skill. We compared performance of CyscopeSocio-demographic characteristics and obstetrics history were gathered using pre-tested questionnaires. Blood samples were collected from febrile pregnant women who were referred as malaria case following initial diagnosis by general microscopist.Plasmodium falciparum malaria was detected in 82 (64.1%) and 80 (62.5%) by the Giemsa-stained light microscopy and the Cyscope® fluorescence microscope, respectively. The sensitivity of the Cyscope® fluorescence microscope was 97.6% (95% CI: 92.2%-99.6%). Out of 46 which were negative by Giemsa-stained light microscopy, 5 were positive by the Cyscope® fluorescence microscope. This is translated in specificity of 89.1% (95% CI: 77.5%-95.9%). The positive and negative predictive value of Cyscope® fluorescence microscope was 94.1% (95% CI: 87.4% -97.8%) and 95.3% (95% CI: 85.4% - 99.2%), respectively.During the study period 128 febrile pregnant women presented at the hospital. Among them, ® fluorescence microscope is a reliable diagnostic, sensitive and specific in diagnosing P. falciparum malaria among pregnant women in this setting. Further studies are needed to determine effectiveness in diagnosing other Plasmodium species and to compare it with other diagnostic tools e.g. rapid diagnostic tests and PCR.This study has shown that Cyscope It has been estimated that 90% of the global malaria burden occurs in Sub-Saharan Africa, where during pregnancy 40% women are exposed to malaria infections . MalariaIn the tropics, practitioners are preoccupied by malaria diagnosis, not only in feverish patients but also for many undiagnosed systemic disorders . Such maPlasmodium nucleic acid fluorescent dyes was found to facilitate detection of the parasites even in low parasitaemia conditions due to the contrast with the background [® microscope is a mobile, battery-operated microscope with ready slides with malaria parasite DNA specific staining reagents in the dried form. All that is needed is the addition of a drop of blood and viewing the slide under the microscope, saving time and preparation and relatively cheap (£818 for the microscope and £0.40 per test). An optional add-on enables viewing the slides on a computer to facilitate the diagnostic procedure and storage and retrieval of results [® microscope in malaria diagnosis are available [® fluorescence microscope in reference Giemsa stained light microscopy as the gold standard in malaria during pregnancy at Medani Hospital Sudan.Many diagnostic procedures have been developed to reduce the time, preparation, and training needed to diagnose malaria. The use of ckground . Cyscope results . Howevervailable ,15-17. WP. falciparum is the sole species in the area [P. falciparum malaria regardless to their age or parity and severe case of malaria including cerebral malaria were reported [The study was conducted at Medani Maternity Hospital, Central Sudan during August -October 2010. The area is characterized by unstable malaria transmission and the area . Malariareported . Accordireported . Followireported . After sThick and thin blood films were prepared and were air-dried and thin film was fixed in methanol, heat fixed and both thin and thick film were immersed in a freshly prepared 10% pre-filtered Giemsa stain solution for 5-10 minutes, washed with water and left to dry, figure Plasmodium DNA [The detail of the method was mentioned in our previous work  and the dium DNA . After m® was calculated as true positives/, specificity as true negatives/, positive predictive value as true positives/, negative predictive value as true negatives/ [Diagnostic performance of fluorescent microscopy was established using Giemsa-stained light microscopy as gold-standard. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. Sensitivity of the Cyscopegatives) .The study received ethical clearance from the ethical committee of the Faculty of Medicine, University of Khartoum, Sudan.During the study period 128 febrile pregnant women presented at Medani Maternity Hospital. Thirty-three (25.8%) of these women were primigravidae. The admitted characteristics of these women were shown in table P. falciparum malaria. The parasite count ranged from 280-23505 with the mean of 19884.3 parasites/μl. There was no case of other Plasmodium species. The Cyscope® fluorescence microscope results showed that 80 (62.5%) of these tested 128 samples were positive for malaria. Out of 82 positive tested by the Giemsa-stained light microscopy, 80 have been found to be positive by the Cyscope® fluorescence microscope while two were negative, Table ® fluorescence microscope was 97.6% (95% CI: 92.2%-99.6%). Out of 46 which were negative by Giemsa-stained light microscopy, 5 were positive by the Cyscope® fluorescence microscope. This is translated in specificity of 89.1% (95% CI: 77.5%-95.9%), table The Giemsa-stained light microscopy showed that 82 (64.1%) out of 128 pregnant women were positive for ® fluorescence microscope, 80 were positive by the Giemsa-stained light microscopy, while five were negative. This is translated into a positive predictive value of 94.1% (95% CI: 87.4% - 97.8%). Of those tested negative by the Cyscope® fluorescence microscope, 43 were negative according to Giemsa-stained light microscopy while two were positive. This translated into a negative predictive value of 95.3% (95% CI: 85.4% - 99.2%), table Of those tested positive by the CyscopeP. falciparum malaria by referral lab examinations [P. falciparum malaria. This might be explained by the extensive training to the general microscopists in the area following the previous results and the recommendations.Previously; it has been shown that only 8.6% of febrile pregnant women presented at Medani Hospital after initial general microscopist had inations . In the ® fluorescence microscope in comparison with Giemsa-stained light microscopy as the gold standard. A sensitivity of 98.2% and specificity of 98.3% (gold standard: light microscopy) was obtained in cross-sectional facility-based analytical study of the diagnostic performance of the Cyscope® fluorescence microscope in Sudan [et al., reported a high sensitivity (100%) and specificity (97.4%) of the Cyscope® fluorescence microscope among Ghanaian children [® fluorescence microscope for malaria examination using Giemsa-stain light microscopy as the gold standard [® fluorescence microscope in cross-sectional community-based studies leads to many false positives and this was attributed to small fluorescent bodies of unknown origin mistaken as malaria parasites [P. falciparum infections [Plasmodium nucleic acid fluorescent dyes was found to facilitate detection of the parasites even in low parasitaemia conditions due to the contrast with the background [® fluorescence microscope was 62.2%  and 96.0% , respectively using real-time PCR as the gold standard [The main finding of the current study was a high performance in term of sensitivity (97.6%) and specificity 89.1% of Cyscopein Sudan . Recentlchildren . Howeverstandard . Thus, aarasites . Howeverfections . In the fections . The useckground . Recentlstandard .® fluorescence microscope. Recently, it has been shown that parasite count obtained from Cyscope® fluorescence microscope were significantly lower than those obtained from Giemsa-stained light microscopy [Generally, the accepted level of sensitivity for a rapid diagnostic test (RDT) in diagnosing malaria is a sensitivity of 95% at a parasite density of 100 parasites/μl . One of croscopy .® fluorescence microscope, and the fact that reagents do not require cold storage, make the method a potentially attractive alternative for malaria diagnosis in the rural setting [® fluorescence microscope requires very little training and has a short turnaround time of averagely 5 minutes per test [Plasmodia species as the disadvantage of Cyscope® fluorescence has to be remembered. Thus, Cyscope® fluorescence microscope would be very helpful in areas mainly endemic with P. falciparum. Generally RDTs are easy to perform by travelers and even for home management of malaria. Moreover RDTs distinguishes Plasmodium species although they are less accurate in this respect than microscopy.Thus, the affordable pricing, portability and compact design of the Cyscope setting . Furtherper test ,16. Yet,® fluorescence microscope is a reliable diagnostic, sensitive and specific in diagnosing P. falciparum malaria among pregnant women in this setting. Further studies are needed to determine effectiveness in diagnosing other Plasmodium species and to compare it with other diagnostic tools e.g. rapid diagnostic tests and PCR.This study has shown that CyscopeThe authors declare that they have no competing interests.EBM and ADH carried out the study and participated in the statistical analysis and procedures. SHH, EMM and IA coordinated and participated in the design of the study, statistical analysis and the drafting of the manuscript. All the authors read and approved the final version.


Background. The diagnosis of cerebral malaria is problematic in malaria-endemic areas because encephalopathy in patients with parasitemia may have another cause. Abnormal retinal findings are thought to increase the specificity of the diagnosis, and the level of histidine-rich protein 2 (HRP2) may reflect the parasite biomass.Methods. We examined the retina and measured plasma HRP2 levels in children with acute nontraumatic encephalopathy in Kenya. Logistic regression, with HRP2 level as an independent variable and World Health Organization–defined cerebral malaria and/or retinopathy as the outcome, was used to calculate malaria-attributable fractions (MAFs) and retinopathy-attributable fractions (RAFs).Results. Of 270 children, 140 (52%) had peripheral parasitemia, 80 (30%) had malaria retinopathy, and 164 (61%) had an HRP2 level of >0 U/mL. During 2006–2011, the incidence of HRP2 positivity among admitted children declined by 49 cases per 100 000 per year (a 78% reduction). An HRP2 level of >0 U/mL had a MAF of 93% for cerebral malaria, with a MAF of 97% observed for HRP2 levels of ≥10 U/mL (the level of the best combined sensitivity and specificity). HRP2 levels of >0 U/mL had a RAF of 77% for features of retinopathy combined, with the highest RAFs for macular whitening (99%), peripheral whitening (98%), and hemorrhages (90%).Conclusion. HRP2 has a high attributable fraction for features of malarial retinopathy, supporting its use in the diagnosis of cerebral malaria. HRP2 thresholds improve the specificity of the definition. Cerebral malaria is the most severe neurological complication of falciparum malaria and is associated with significant morbidity and mortality . The WorThe pathognomonic feature of pathological cerebral malaria is sequestration of parasite-infected erythrocytes in the cerebral microvasculature. Taylor et al found that 23% of Malawian children who died after fulfilling WHO-defined criteria for cerebral malaria antemortem did not have sequestered parasite-infected erythrocytes . They foPlasmodium falciparum throughout its 48-hour cycle and remains intraerythrocytic until mature schizonts release it into blood  =[ a + tbx], where p is the probability that a child with HRP2 at density x has cerebral malaria/malarial retinopathy, and t is the power function that stabilizes the maximum likelihood estimation. The coefficient b was then used to calculate the MAF for WHO-defined cerebral malaria and the RAF for sequestration-defined cerebral malaria for each child, first at any HRP2 level and then at different HRP2 thresholds. The risks of a group with cerebral malaria and/or retinopathy were averaged to estimate the proportion of the group whose encephalopathy is caused by malaria rather than by another illness with coincidental HRP2. The averaged risks gave the MAF for WHO-defined cerebral malaria or the RAF for sequestration-defined cerebral malaria for the group analyzed [P value of ≤.05 was considered statistically significant.We used the logistic regression model log[analyzed , as defianalyzed ) and yeaPermission to conduct this study was granted by the Kenyan Medical Research Institute National Ethics Committee (Scientific Steering Committee no. 1249).Indirect fundoscopy was performed in 270 children admitted with acute encephalopathy to KDH. Of the children who met the WHO definition for cerebral malaria, 164 (60.7%) were positive for HRP2 in plasma, and 140 (51.9%) had peripheral parasitemia  and significantly greater among children with than among those without retinopathy  and more common among children with than among those without retinopathy (P = .001). Malnutrition was less common among slide-positive admitted children than among slide-negative admitted children (P < .0001). Additionally, previous hospitalization during the perinatal period was less common among children with than among those without retinopathy (P = .028). The median levels of HRP2 were higher among children with retinopathy than among those without retinopathy for all features except vessel color changes  had at least 1 feature of retinopathy: hemorrhages were observed in 41 (51·3%), papilledema in 24 (30.0%), macular whitening in 21 (26.3%), vessel color changes in 18 (22.5%), and peripheral whitening in 15  for WHO-defined cerebral malaria; the MAF was 96.0%  for ≥3 U/mL, the threshold with the best combined sensitivity and specificity  for at least 1 feature of retinopathy; the RAF increased to 83.6%  for levels of ≥5 U/mL, the threshold for the maximum combined sensitivity and specificity. Higher levels of HRP2 reduced the sensitivity.For macular whitening, HRP2 levels of >0 U/mL had a RAF of 98.8% ; levels of ≥5 U/mL had a RAF of 99.8%  and the best combined sensitivity and specificity Table . For perThe following alternative causes of coma were more common among children with HRP2 levels below the modeled thresholds , compared with children with greater HRP2 levels, for WHO-defined cerebral malaria: meningitis, 19 of 22 (86.3%) versus 2 of 22 (13.7%); undetermined encephalopathy, 37 of 49 (75.5%) versus 12 of 39 (24.5%); epilepsy, 3 of 5 (60.0%) versus 2 of 5 (40.0%); and sepsis, 2 of 3 (66.7%) versus 1 of 3 (33.3%).The incidence of HRP2-positive encephalopathy among admitted children decreased by 78%, from 63 cases per 100 000 per year in 2006 and 2007 to 14 cases per 100 000 per year in 2010 and 2011  , furtherHRP2 levels of >0 U/mL were associated with the highest RAF for retinal whitening . The RAF increased to almost 100% for macular and peripheral whitening and to 95% for the hemorrhages at an HRP2 level of 5 U/mL, which is a balance between both sensitivity and specificity. Retinal whitening may be more specific to malaria, since it is rarely seen in other childhood illnesses . It is tAt any level of HRP2, the RAF for hemorrhages was high (90%) but was expected to be lower than that for retinal whitening, since hemorrhages may be caused by other conditions, such as severe anemia . The lowThese HRP2-determined attributable fractions computed in this study have implication in design of intervention trials for cerebral malaria. For example, the AQUAMAT study found that artesunate reduced mortality by 22.5%, compared with quinine , and thiThe proportion of healthy community children with malarial retinopathy is not known, since it is technically difficult to perform indirect fundoscopy on conscious children, so we assumed that retinopathy in our study subjects was related to the hospital admission. The attributable fractions modeled are based on HRP2 data assessed with an ELISA that may not be 100% sensitive, and the long duration of storage of some samples may have affected the validity. Furthermore, the levels of HRP2 may have been affected for children who were treated with antimalarials in periphery facilities, which can further complicate modeling of attributable fractions.This study confirms that the HRP2 level can reliably be used to distinguish cerebral malaria from other acute encephalopathies, since it was associated with high attributable fractions for cerebral malaria and/or retinopathy . Further inclusion of HRP2 thresholds and exclusion of alternative causes of coma would improve the specificity of the definition of cerebral malaria in intervention studies. The study also confirms that papilledema is not specific to malaria and that assessment of vessel color changes may require an experienced clinician, but there may be regional differences in this sign. These findings need to be replicated in other areas before the HRP2 level can be universally accepted for the diagnosis of cerebral malaria.