Biology Reference
In-Depth Information
to pathology and disease severity in
P. vivax
infections. In a large Indian
series, malnutrition was present in 69% of severe vivax cases in children and
75% of deaths associated with severe vivax malaria (
Kochar et al., 2010
). In
Brazil, 17% of children with
P. vivax
requiring intensive care admission had
malnutrition (
Lanca et al., 2012
).
7.3. HIV Infection
HIV is a risk factor for both severe disease and death in children with fal-
ciparum malaria (
Berkley et al., 2009
;
Bejon et al., 2007
), but whether this
also applies to vivax malaria is unclear. HIV prevalence is increasing in PNG
and Indonesian Papua (
Pontororing et al., 2010
), where two large series of
patients with severe vivax were reported (
Tjitra et al., 2008
;
Genton et al.,
2008
) although neither study reported co-infection rates. In the Manaus
autopsy series, one of the 17 vivax-associated deaths occurred in a patient
with HIV infection listed as a contributing co-morbidity (
Lacerda et al.,
2012
). Prospective studies of the role of HIV infection in increasing risk
of severe disease are required, but in the interim, clinicians should consider
testing for HIV infection in those with severe vivax malaria.
7.4. Other Co-morbidities
A range of acute and chronic infectious and non-infectious co-morbidities
has also been proposed as contributory factors for severe and fatal disease in
P.
vivax
infection (see
Price et al., 2009
;
Lacerda et al., 2012
;
Anstey et al., 2009
for review). The haemodynamic effects of the systemic inflammatory response
to
P. vivax
and anaemia are likely to contribute to decompensation of concur-
rent acute and chronic disease with potentially fatal consequences, whereas
otherwise healthy children and adults may have made an uncomplicated recov-
ery (Douglas et al., 2012). Concomitant pneumonia is particularly important
since vivax-associated anaemia will exacerbate hypoxia and impair recovery.
Over 60 years ago, Kitchen described his experience of vivax malar-
iotherapy in neurosyphilis, remarking on the importance of underlying
co-morbidities in severe disease in adults: 'Our own experience suggests
that serious trends which develop during vivax infections ought properly
be classified as complications in practically all instances; events of this
sort that we have observed would appear to have been based on primary
deficiencies on the part of the patient, or due to intercurrent conditions'
(
Kitchen, 1949b
). In the Manaus autopsy series, 76% of
P. vivax
-associated
deaths had concurrent acute and chronic co-morbidities, including pneu-
monia, HIV, decompensated cirrhosis, emphysema, diabetes, haemorrhagic
