Utility of qSOFA and modified SOFA in severe malaria presenting as sepsis.

Sepsis can be caused by malaria infection, but little is known about the utility of the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) and SOFA score in malaria. We conducted a prospective observational study from March 2013 to February 2017 to examine adults admitted with community-acquired infection in a tertiary-care hospital in Ubon Ratchathani, Northeast Thailand (Ubon-sepsis). Subjects were classified as having sepsis if they had a modified SOFA score ≥2 within 24 hours of admission. Serum was stored and later tested for malaria parasites using a nested PCR assay. Presence of severe malaria was defined using modified World Health Organization criteria. Of 4,989 patients enrolled, 153 patients (3%) were PCR positive for either Plasmodium falciparum (74 [48%]), P. vivax (69 [45%]), or both organisms (10 [7%]). Of 153 malaria patients, 80 were severe malaria patients presenting with sepsis, 70 were non-severe malaria patients presenting with sepsis, and three were non-severe malaria patients presenting without sepsis. The modified SOFA score (median 5; IQR 4-6; range 1-18) was strongly correlated with malaria severity determined by the number of World Health Organization severity criteria satisfied by the patient (Spearman's rho = 0.61, p<0.001). Of 80 severe malaria patients, 2 (2.5%), 11 (14%), 62 (77.5%) and 5 (6%), presented with qSOFA scores of 0, 1, 2 and 3, respectively. Twenty eight-day mortality was 1.3% (2/153). In conclusion, qSOFA and SOFA can serve as markers of disease severity in adults with malarial sepsis. Patients presenting with a qSOFA score of 1 may also require careful evaluation for sepsis; including diagnosis of cause of infection, initiation of medical intervention, and consideration for referral as appropriate.

Malaria Severity in Mangaluru City in the Southwestern Coastal Region of India.

Dakshina Kannada district in the Southwestern region of Karnataka state, India, including Mangaluru city is endemic to malaria. About 80% of malaria infections in Mangaluru and its surrounding areas are caused by Plasmodium vivax and the remainder is due to Plasmodium falciparum. Malaria-associated clinical complications significantly occur in this region. Here, we report the pathological conditions of 41 cases of fatal severe malaria, admitted to the district government hospital in Mangaluru city during January 2013 through December 2016. The results of clinical, hematological, and biochemical analyses showed that most of these severe malaria cases were associated with thrombocytopenia, anemia, metabolic acidosis, acute respiratory distress, and single or multi-organ dysfunction involving liver, kidney, and brain. Of the 41 fatal malaria cases, 24, 10, and seven patients had P. vivax, P. falciparum, and P. vivax and P. falciparum mixed infections, respectively. These data suggest that besides P. falciparum that is known to extensively cause severe and fatal malaria illnesses, P. vivax causes fatal illnesses substantially in this region, an observation that is consistent with recent findings in other regions.

Anguillulosis: circumstances of infestation and evolution towards the malignant form.

INTRODUCTION: Anguillulosis is a ubiquitous digestive parasitosis. Rare in Tunisia, it is due to a round worm, strongyloid stercoralis, whose natural lodging is the duodeno-jejunal mucosa. Its malignant form is rare but it represents a potentially life-threatening disease. AIM: We report a case of malignant anguillulosis occurring in a context of immunosuppression. OBSERVATION: The case we report is about a 46-year-old man treated by a long-term corticosteroid therapy for Takayasu disease. He was hospitalized for an acute digestive syndrome. Biopsies were performed but the evolution was rapidly marked by multiorgan failure, sepsis and death of the patient. Histological analysis of the digestive biopsies concluded to an oeso-gastroduodenal anguillulosis. CONCLUSION: Anguillulosis is a rare parasitosis but it can pose a health problem especially in its malignant form wich can be a life-threatening.

Severe Babesia microti infection presenting as multiorgan failure in an immunocompetent host.

A previously healthy 67-year-old farmer presented to an outside hospital after a 2-week history of non-specific respiratory symptoms. A certain diagnosis was not initially apparent, and the patient was discharged home on a regimen for presumed chronic obstructive pulmonary disease exacerbation. He re-presented to the emergency department with shock and hypoxaemic respiratory failure requiring prompt intubation and fluid resuscitation. He was then transferred to our institution due to multiorgan failure. On arrival, the patient demonstrated refractory shock and worsening acute kidney injury, severe anaemia and thrombocytopaenia. The peripheral smear revealed absence of microangiopathic haemolytic anaemia. A closer review of the smear displayed red blood cell inclusion bodies consistent with babesiosis. The patient was started on clindamycin and loaded with intravenous quinidine, and subsequently transitioned to oral quinine. A red cell exchange transfusion was pursued with improvement of the parasite load. The patient was discharged home on clindamycin/quinine and scheduled for outpatient intermittent haemodialysis.

Plasma biomarkers of SIRS and MODS associated with canine babesiosis.

Canine babesiosis is a tick-borne disease caused by the haemoprotozoan parasites of the genus Babesia. Early detection of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) is of major importance in clinical practice for providing information about severity and outcomes of the disease and therapy. Plasma samples were taken at admission from five dogs with uncomplicated babesiosis caused by B. canis canis, five dogs with babesiosis and SIRS, five dogs with babesiosis and MODS, and five healthy dogs. After two-dimensional electrophoresis and capillary reversed - phase liquid chromatography coupled online with tandem mass spectrometry, 68 differentially expressed spots with level of significance P<0.05 were detected between groups. SIRS in babesiosis was characterised by increases in paraoxonase 1 and apoA-I, whereas MODS with decrease of complement inhibitors leading to prolonged complement activation and decrease of vitamin D binding protein due to haemolysis and activation of the coagulation cascade.

Hemoglobin concentration and parasitemia on hospital admission predict risk of multiple organ dysfunction syndrome among adults with malaria.

Risk factors for progression from acute malaria to multiple organ dysfunction syndrome (MODS) are poorly understood. The MODS is commonly diagnosed with the sequential organ failure assessment (SOFA) scale, but this scale has been understudied in patients with severe malaria. We conducted a cohort study among 426 adult males admitted to hospital with malaria in Bogotá, Colombia. We estimated SOFA scores and relative risks (RRs) for MODS during hospitalization according to patients' characteristics on admission. Risk of MODS was 7.3% over a median 6.0 days in hospital. Baseline hemoglobin was strongly, inversely associated with MODS (adjusted RR for hemoglobin ≤ 8.5 g/dL versus hemoglobin > 11 g/dL = 9.5, 95% confidence interval [CI]: 3.6, 25.3). Plasmodium falciparum malaria and parasitemia were positively associated with MODS. There was a strong interaction between baseline parasitemia and hemoglobin on MODS risk. In conclusion, the use of parasitemia and hemoglobin on admission to identify high-risk patients deserves consideration.

Severe Plasmodium knowlesi infection with multiorgan involvement in north east peninsular Malaysia.

Plasmodium knowlesi has been recently identified as the "fifth human malaria species" following the discovery in Malaysian Borneo of a large focus of this simian malaria parasite in humans. Even though it shares microscopic similarities with Plasmodium malariae, it may cause severe illness with risk of fatality. We describe a case of P. knowlesi infection causing multi-organ failure in a patient who was successfully managed due to early recognition of the infection. Clinicians in this region should be more aware of the infection as it is not as rare as previously thought. This case write up highlight the case of severe malaria infection which presented with multi organ involvement which is caused by P. knowlesi.

Plasmodium vivax malaria--is it really benign?

It is believed that most of the serious and life threatening complications are caused only by P falciparum infection while P vivax infections are relatively mild and run a benign course and usually not required hospitalisation but in the last few years hospitalisation rate and complications are also increasing in P vivax infection; so we planned this study to evaluate the severity and complicated presentation of P vivax malaria. This hospital-based study conducted in Jawahar Lal Nehru Hospital Ajmer, India. One hundred and two indoor patients with isolated P vivax malaria were included in this study with exclusion of other causes of fever including P falciparum malaria. All patients of severe and complicated P vivax malaria were admitted and treated as severe P falciparum malaria. Severe complications like significant hepatomegaly, thrombocytopenia, acute renal failure, severe anaemia, leucopoenia, electrolyte disturbance, acute respiratory distress syndrome, cerebral malaria, multiorgan dysfunction, hepatic dysfunction, pancytopenia, and death seen in 21.57%, 18.63%, 11.76%, 8.82%, 5.88%, 5.88%, 3.92%, 2.94%, 1.96%, 1.96%, 0.98%, 1.96% patients respectively. A significant proportion of morbidity and mortality in malaria also observed in P vivax infection as seen in P falciparum infection and require hospitalisation.

[Multiple-organ dysfunction caused by dissemination of Strongyloides stercoralis infection: A case report]. / Falla orgánica múltiple por estrongiloidiasis diseminada: Comunicación de un caso.

We report here the case of a 50-year-old male patient, from a rural setting, with past history of alcoholism. He was admitted in the Intensive Care Unit due to a worsening health status after a febrile syndrome of 25 days. In addition, he had diarrhea, intense muscle ache predominantly on upper extremities and abdomen, weight loss, confusion, seizures, psychomotor agitation, tachycardia, tachipnea, anuria, septic shock, coma, and multiple-organ dysfunction syndrome. The hyperinfection syndrome caused by Strongyloides stercoralis was suspected because of severe eosinophilia (52 percent of peripheral blood leukocytes). This diagnosis was verified by the parasitological examination of stool samples by direct wet mount and Baermann techniques. Treatment with thiabendazole at 25 mg/kg per day was started, as well as cefepime, vasoactive drugs, artificial mechanic ventilation, and hemodialysis. The patient died 12 hours after admission, probably due to secondary infection with Escherichia coli.

Falla orgánica múltiple por estrongiloidiasis diseminada: Comunicación de un caso / Multiple-organ dysfunction caused by dissemination of Strongyloides stercoralis infection: A case report

We report here the case of a 50-year-old male patient, from a rural setting, with past history of alcoholism. He was admitted in the Intensive Care Unit due to a worsening health status after a febrile syndrome of 25 days. In addition, he had diarrhea, intense muscle ache predominantly on upper extremities and abdomen, weight loss, confusion, seizures, psychomotor agitation, tachycardia, tachipnea, anuria, septic shock, coma, and multiple-organ dysfunction syndrome. The hyperinfection syndrome caused by Strongyloides stercoralis was suspected because of severe eosinophilia (52 percent of peripheral blood leukocytes). This diagnosis was verified by the parasitological examination of stool samples by direct wet mount and Baermann techniques. Treatment with thiabendazole at 25 mg/kg per day was started, as well as cefepime, vasoactive drugs, artificial mechanic ventilation, and hemodialysis. The patient died 12 hours after admission, probably due to secondary infection with Escherichia coli.

Se presenta el caso de un paciente masculino, de 50 años, con antecedentes de alcoholismo, procedente de área rural, que ingresó en la Unidad de Cuidados Intensivos por agravamiento de su estado general después de un síndrome febril de 25 días de evolución, presentando shock séptico, coma y falla orgánica múltiple. Se sospechó un síndrome de hiperinfección por Strongyloides stercoralis ante la presencia de una eosinofilia importante (52%), diagnóstico que fue confirmado con el examen parasitológico de las heces. Se inició tratamiento con tiabendazol a 25 mg/ kg al día, cefepima, fármacos vasoactivos, ventilación mecánica y hemodiálisis. Falleció 12 horas después del ingreso, posiblemente a causa de una infección secundaria por Escherichia coli.

Multiorgan dysfunction caused by travel-associated African trypanosomiasis.

We describe a case of multiorgan dysfunction secondary to Trypanosoma brucei rhodesiense infection acquired on safari in Zambia. This case was one of several recently reported to ProMED-mail in persons who had traveled to this region. Trypanosomiasis remains rare in travelers but should be considered in febrile patients who have returned from trypanosomiasis-endemic areas of Africa.

Toxoplasmosis in a post-transplant bronchoalveolar lavage: a case report.

Toxoplasma gondii usually causes an asymptomatic and then latent infection in human adults; however, a potentially fatal disseminated form can occur in immunocompromised patients. Given that the diagnosis of acute Toxoplasma infection, as opposed to latent disease, relies on finding direct evidence of T. gondii infection in tissue, pathologic examination is critical. There have only been a few reports describing the cytomorphology of Toxoplasma in exfoliative cytology, and no reports of the findings in Thin Prep. In this report, we describe a fatal case of toxoplasmosis in a cardiac transplant patient that was diagnosed by respiratory cytopathology. Although the extracellular organisms were well visualized on the Wright-Giemsa stained cytospin, they were only faintly seen on the Pap-stained cytospin trapped within mucin and were not easily appreciated on the ThinPrep slides nor the H&E stained cell block sections. An immunohistochemical stain for Toxoplasma performed on the cell block was strongly positive, and an autopsy performed on the patient confirmed disseminated infection. Our case illustrates that the diagnosis of Toxoplasma in exfoliative cytology specimens can be challenging since organisms are not well visualized on ThinPrep or Pap-stained material; therefore, Wright-Giemsa stained material can be particularly helpful.

[Epidemiology and prognostic value of organ failure during severe malaria in the Principal Military Teaching Hospital of Dakar, Senegal]. / Épidémiologie et valeurs pronostiques des défaillances viscérales au cours du paludisme grave à l'hôpital d'instruction des armées principal de Dakar, Sénégal

We report the results of a retrospective study in the medical intensive care unit of the Principal Military Teaching Hospital of Dakar. The objectives were to determine the epidemiological and clinical aspects of severe malaria and to evaluate the prognostic values of the failure of different organs. Eighty-seven patients were admitted for severe malaria. Their average age was 35 ± 18.53 with a sex-ratio of 1.71 for men. Mortality was 33.3% and concerned mainly young adults. Neurological failure was the most frequent (79.3%). Hemodynamic failure was the most relevant prognostic factor for mortality, followed by hypoglycemia, respiratory and renal failure. The Simplified Acute Physiology Score II (SAPS II) was reliable in predicting mortality. The mean SAPS II was 44.85, with an expected mortality of 32.6%.

Hidatidosis con afectación multiorgánica / Hydatic cyst with multiorgan involvement

La hidatidosis es una de las más importantes parasitosis zoonóticas de los países mediterráneos y de Sudamérica, en los que constituye un importante problema de salud. El contagio humano ocurre fundamentalmente en la infancia, por mecanismos de transmisión fecal-oral, al ingerir los huevos del parásito. En general, los pacientes permanecen asintomáticos durante mucho tiempo, debido al crecimiento lento de los quistes que pueden afectar a cualquier órgano de la anatomía, aunque se localizan en la mayoría de los casos en hígado y pulmón. Su diagnóstico se realiza fundamentalmente por técnicas de imagen y su tratamiento sigue siendo eminentemente quirúrgico (AU)

Hydatidosis is one of the most important zoonotic parasitic diseases of Mediterranean and South American countries where they constitute a significant health problem. The human contagion happens fundamentally in the infancy, by faecal-oral transmission, because of parasite´s eggs ingestion. In general the patients remain asymptomatic for a long time, due to the sluggish growth of the cysts that can concern any organ of the anatomy, though they are located in the majority of the cases in liver and lung. Its diagnosis is realized essentially by image techniques and its treatment continues being eminently surgical (AU)

High efficacy of bolus methylprednisolone in severe leptospirosis: a descriptive study in Sri Lanka.

BACKGROUND: In 2008, an outbreak of leptospirosis caused high mortality in Sri Lanka. The General Hospital, Peradeniya recorded nine deaths in May, which prompted the medical staff to change the treatment protocol. Addition of intravenous methylprednisolone (MP) to the treatment regimen of severely ill patients was implemented on the basis of immune mediated pathogenesis of the disease to reduce mortality. METHODS: The day MP commenced (25 May 2008), the study period was divided into a 'pre-MP period' and an 'MP period'. A clinical score ranging from 0-6 was applied to assess the severity of the infection. A score ≥2 was considered severe. Thus, 62 patients received bolus MP 500 mg intravenously for 3 days, followed by oral 8 mg for 5 days (MP given). Ten patients to whom MP was withheld were included in the MP period severe group (n=72). The same score was applied to pre-MP periods and 60 cases were identified as the historical control group (pre-MP period severe). RESULTS: There were 78 and 149 cases of leptospirosis in the pre-MP period and MP period, respectively. Of these cases, 17 and 16 patients died, with case death rates of 21.8% and 10.7%, respectively; the difference was significant (p=0.025). The survival rate at score 4 in the MP period severe group was 100% (16 of 16), compared to 38% (5 of 13) in pre-MP period severe group; this difference was highly significant (p<0.001). Six patients who died despite MP therapy had a clinical score of 5 or 6; four were alcohol consumers, and two had heart disease and hypertension. CONCLUSION: MP may reduce mortality in patients with severe leptospirosis, except in cases with established multiple organ dysfunction and comorbidities. Therefore, early administration of MP seems advisable.

IL-17 is necessary for host protection against acute-phase Trypanosoma cruzi infection.

IL-17A is a key cytokine that induces inflammatory responses through the organized production of inflammatory cytokines, such as IL-6, TNF-alpha, and GM-CSF, and induces neutrophil migration. The roles of IL-17A in infection of intracellular protozoan parasites have not been elucidated, although augmented immune responses by IL-17A are important for the resolution of some bacterial and fungal infections. Therefore, we experimentally infected IL-17A-deficient (IL-17A(-/-)) mice with Trypanosoma cruzi. IL-17A(-/-) mice had a lower survival rate and prolonged worse parasitemia compared with control C57BL/6 wild-type (WT) mice postinfection. In the infected IL-17A(-/-) mice, multiple organ failure was observed compared with WT mice, as reflected by the marked increase in serologic markers of tissue injury, such as aspartate aminotransferase, which resulted in increased mortality of IL-17A(-/-) mice. Expression of cytokines, such as IFN-gamma, IL-6, and TNF-alpha, was lower in liver-infiltrating cells from the IL-17A(-/-) mice compared with WT mice. A similar defect was observed in the expression of neutrophil enzymes, such as myeloperoxidase and lipoxygenase, whereas cellular infiltration into the infected tissues was not affected by IL-17A deficiency. These results suggested that the efficient activation of immune-related cells critical for the killing of T. cruzi was impaired in the absence of IL-17A, resulting in the greater susceptibility of those mice to T. cruzi infection. From these results, we conclude that IL-17A is important for the resolution of T. cruzi infection.

An analysis of possible mechanisms of unexpected death occurring in hydatid disease (echinococcosis).

Most cases of hydatid disease in human populations are due to Echinococcus granulosus. The hydatid life cycle involves passage between definitive hosts such as dogs and intermediate hosts such as sheep. Humans become accidental intermediate hosts following ingestion of food or water contaminated with eggs or by contact with infected dogs. Although hydatid disease may remain asymptomatic, occasional cases of sudden and unexpected death present to autopsy. Causes of rapid clinical decline involve a wide range of mechanisms including anaphylaxis (with or without cyst rupture), cardiac outflow obstruction or conduction tract disturbance, pulmonary and cerebral embolism, pericarditis, cardiac tamponade, myocardial ischemia, pulmonary hypertension, peritonitis, hollow organ perforation, intracerebral mass effect, obstructive hydrocephalus, seizures, cerebral ischemia/infarction, and pregnancy complications. The autopsy assessment of cases therefore requires careful examination of all organ systems for characteristic cystic lesions, as multiorgan involvement is common, with integration of findings so that possible mechanisms of death can be determined. Measurement of serum tryptase and specific IgE levels should be undertaken for possible anaphylaxis.

Septic shock in canine babesiosis.

The records of all canine patients (86) that had been diagnosed with babesiosis and that were admitted to the Clinic for Internal Diseases, Faculty of Veterinary Medicine, Zagreb from January 2007 to December 2007 were reviewed retrospectively. All dogs that had been diagnosed with canine babesiosis and that had systemic inflammatory response syndrome (SIRS) followed by multiple organ dysfunction syndrome (MODS), and refractory hypotension, were included in this study. Of 86 patients diagnosed with canine babesiosis that were admitted during the study period, 10 had evidence of septic shock and were included in this study. Seven of the 10 dogs had a level of parasitaemia above 1%, with the highest level being 20.2%, seven of the 10 dogs were anaemic and three of the 10 dogs were leucopoenic. Thrombocytopenia was present in nine dogs. Hypoglycaemia was noted in two dogs, and bilirubinaemia in nine dogs. Four patients had involvement of two organs, five had involvement of three organs, and one had involvement of four organs. The organ that was most frequently involved was the kidney (nine cases). Central nervous system dysfunction was the rarest complication noted (one case). The mortality rate in non-septic shock canine babesiosis was 2.6%. All dogs that developed septic shock died between the first and the fourth day after admission. The 100% mortality rate that is reported here reflects the fact that in cases in which progression of the inflammatory response leads to the development of septic shock, an unfavourable outcome should be expected.

Malarial hepatitis as a component of multiorgan failure--a bad prognostic sign.

A prospective study among the patients (n = 301) belonging to the coastal districts of Orissa having complicated falciparum malaria with multiorgan failure fulfilling modified APACHE II criteria, for a period of two years in this hospital setting was carried out with particular emphasis on hepatic involvement. There were 206 males and the rest females. Hepatic involvement in the form of raised serum bilirubin levels > or = 6 mg% and prothombin time > 4 compared to controls was found in 192 cases (63.8%). On analysis out of 192 cases predominantly conjugated hyperbilirubinaemia, mixed patterns and unconjugated hyperbilirubinaemia were seen in 115 (59.9%), 64 (33.3%) and 13 (6.8%) cases respectively. Serum bilirubin ranged from 6 to 38 mg%. Aminotransferase aspartate (AST, SGOT) and aminotransferase alkaline (ALT, SGPT) were raised almost two-fold in 98% cases of multiorgan failure with hepatic failure with mean values of 78 +/- 30.4 IU/l and 81 +/- 29.06 IU/l respectively. Nearly three-fold elevation of alkaline phosphatase was observed in 80% cases with mean (315 +/- 39.4 IU/l). Prothombin time was prolonged with mean 7 +/- 3 seconds. Serum proteins and albumin/globulin ratio were normal. There was no difference in glycaemic status over controls. In selected cases, liver histopathological study showed abnormalities in the form of Kupffer cell hyperplasia, mononuclear cell infiltration, hepatocyte necrosis, fatty changes and cholestasis. Majority of patients in multiorgan failure who died, had hepatic failure.