Coma associated with microscopy-diagnosed plasmodium vivax

a prospective study in Papua, Indonesia

D LAMPAH, Tsin Yeo, Setiwan Hardianto, Emiliana Tjitra, Enny Kenangalem, Paulus Sugiarto, Ric Price, Nicholas Anstey

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Abstract

Background: Coma 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.

Methods: We 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.

Results: Of 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.
Original languageEnglish
Article numbere1032
Pages (from-to)1-7
Number of pages7
JournalPLoS Neglected Tropical Diseases
Volume5
Issue number6
DOIs
Publication statusPublished - 2011

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Plasmodium vivax
Indonesia
Coma
Microscopy
Prospective Studies
Plasmodium falciparum
Coinfection
Cerebrospinal Fluid
Polymerase Chain Reaction
Malaria
Infection
Vivax Malaria
Plasmodium
Falciparum Malaria
Antimalarials
Tremor
Leukocyte Count
Comorbidity

Cite this

LAMPAH, D ; Yeo, Tsin ; Hardianto, Setiwan ; Tjitra, Emiliana ; Kenangalem, Enny ; Sugiarto, Paulus ; Price, Ric ; Anstey, Nicholas. / Coma associated with microscopy-diagnosed plasmodium vivax : a prospective study in Papua, Indonesia. In: PLoS Neglected Tropical Diseases. 2011 ; Vol. 5, No. 6. pp. 1-7.
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title = "Coma associated with microscopy-diagnosed plasmodium vivax: a prospective study in Papua, Indonesia",
abstract = "Background: Coma 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. Methods: We 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. Results: Of 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.",
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Coma associated with microscopy-diagnosed plasmodium vivax : a prospective study in Papua, Indonesia. / LAMPAH, D; Yeo, Tsin; Hardianto, Setiwan; Tjitra, Emiliana; Kenangalem, Enny; Sugiarto, Paulus; Price, Ric; Anstey, Nicholas.

In: PLoS Neglected Tropical Diseases, Vol. 5, No. 6, e1032, 2011, p. 1-7.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Coma associated with microscopy-diagnosed plasmodium vivax

T2 - a prospective study in Papua, Indonesia

AU - LAMPAH, D

AU - Yeo, Tsin

AU - Hardianto, Setiwan

AU - Tjitra, Emiliana

AU - Kenangalem, Enny

AU - Sugiarto, Paulus

AU - Price, Ric

AU - Anstey, Nicholas

PY - 2011

Y1 - 2011

N2 - Background: Coma 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. Methods: We 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. Results: Of 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.

AB - Background: Coma 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. Methods: We 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. Results: Of 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.

KW - antibiotic agent

KW - artesunate

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KW - adult

KW - antigen detection

KW - article

KW - brain malaria

KW - cerebrospinal fluid examination

KW - child

KW - coma

KW - controlled study

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KW - Indonesia

KW - infection risk

KW - leukocyte count

KW - major clinical study

KW - malaria falciparum

KW - male

KW - microscopy

KW - mixed infection

KW - neurological complication

KW - neuropathology

KW - outcome assessment

KW - Plasmodium vivax malaria

KW - polymerase chain reaction

KW - preschool child

KW - prospective study

KW - risk factor

KW - school child

KW - serology

KW - tremor

KW - cytology

KW - genetics

KW - hospitalization

KW - infant

KW - isolation and purification

KW - parasitology

KW - Plasmodium vivax

KW - prevalence

KW - Adolescent

KW - Adult

KW - Child

KW - Child, Preschool

KW - Coma

KW - DNA, Protozoan

KW - Female

KW - Humans

KW - Infant

KW - Malaria, Vivax

KW - Male

KW - Microscopy

KW - Polymerase Chain Reaction

KW - Prevalence

KW - Prospective Studies

KW - Severity of Illness Index

KW - Young Adult

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U2 - 10.1371/journal.pntd.0001032

DO - 10.1371/journal.pntd.0001032

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JF - PLoS Neglected Tropical Diseases

SN - 1935-2727

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