Abstract
BackgroundComa complicates Plasmodium falciparum infection but is uncommonly associated with P. vivax. Most series of vivax coma have been retrospective and have not utilized molecular methods to exclude mixed infections with P. falciparum. MethodsWe prospectively enrolled patients hospitalized in Timika, Indonesia, with a Glasgow Coma Score (GCS) ≤10 and P. vivax monoinfection on initial microscopy over a four year period. Hematological, biochemical, serological, radiological and cerebrospinal fluid (CSF) examinations were performed to identify other causes of coma. Repeat microscopy, antigen detection and polymerase chain reaction (PCR) were performed to exclude infections with other Plasmodium species.ResultsOf 24 patients fulfilling enrolment criteria, 5 had clear evidence for other non-malarial etiologies. PCR demonstrated 10 mixed infections and 3 P. falciparum monoinfections. 6 (25%) patients had vivax monoinfection and no apparent alternative cause, with a median GCS of 9 (range 8–10) and a median coma duration of 42 (range 36–48) hours. CSF leukocyte counts were <10/ul (n = 3); 2 of the 3 patients without CSF examination recovered with antimalarial therapy alone. One patient had a tremor on discharge consistent with a post-malarial neurological syndrome. No patient had other organ dysfunction. The only death was associated with pure P. falciparum infection by PCR. Vivax monoinfection-associated risk of coma was estimated at 1 in 29,486 clinical vivax infections with no deaths. In comparison, the risk of falciparum-associated coma was estimated at 1 in 1,276 clinical infections with an 18.5% mortality rate.Conclusions P. vivax-associated coma is rare, occurring 23 times less frequently than that seen with falciparum malaria, and is associated with a high proportion of non-malarial causes and mixed infections using PCR. The pathogenesis of coma associated with vivax malaria, particularly the role of comorbidities, is uncertain and requires further investigation.
Highlights
Severe complications in malaria are normally associated with Plasmodium falciparum infections
Routine hospital surveillance identified a total of 246 patients admitted with coma and microscopy confirmed parasitemia; of these patients 174 (71%) had monoinfection with P. falciparum, 41 (17%) monoinfection with P. vivax and 31 (13%) with mixed infections
Of the 41 patients with P. vivax monoinfection by routine microscopy, 24 patients were admitted with coma (GCS #10) and were enrolled in the study
Summary
Severe complications in malaria are normally associated with Plasmodium falciparum infections. A serious manifestation of falciparum malaria is associated with a 10–40% mortality [1]. It is defined clinically as unarousable coma in the presence of any degree of P. falciparum parasitemia without evidence of other infectious or metabolic etiologies [2]. While it has long been considered to be clinically uncomplicated, three recent large prospective epidemiological studies from Indonesia, Papua New Guinea and India have challenged this perception, associating P. vivax infections with severe manifestations of disease including anemia, respiratory distress, coma and death [7,8,9]. Most series of vivax coma have been retrospective and have not utilized molecular methods to exclude mixed infections with P. falciparum
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
