Severe malaria in Europe: an 8-year multi-centre observational study

Abstract

BackgroundMalaria remains one of the most serious infections for travellers to tropical countries. Due to the lack of harmonized guidelines a large variety of treatment regimens is used in Europe to treat severe malaria.MethodsThe European Network for Tropical Medicine and Travel Health (TropNet) conducted an 8-year, multicentre, observational study to analyse epidemiology, treatment practices and outcomes of severe malaria in its member sites across Europe. Physicians at participating TropNet centres were asked to report pseudonymized retrospective data from all patients treated at their centre for microscopically confirmed severe Plasmodium falciparum malaria according to the 2006 WHO criteria.ResultsFrom 2006 to 2014 a total of 185 patients with severe malaria treated in 12 European countries were included. Three patients died, resulting in a 28-day survival rate of 98.4%. The majority of infections were acquired in West Africa (109/185, 59%). The proportion of patients treated with intravenous artesunate increased from 27% in 2006 to 60% in 2013. Altogether, 56 different combinations of intravenous and oral drugs were used across 28 study centres. The risk of acute renal failure (36 vs 17% p = 0.04) or cerebral malaria (54 vs 20%, p = 0.001) was significantly higher in patients ≥60 years than in younger patients. Respiratory distress with the need for mechanical ventilation was significantly associated with the risk of death in the study population (13 vs 0%, p = 0.001). Post-artemisinin delayed haemolysis was reported in 19/70 (27%) patients treated with intravenous artesunate.ConclusionThe majority of patients with severe malaria in this study were tourists or migrants acquiring the infection in West Africa. Intravenous artesunate is increasingly used for treatment of severe malaria in many European treatment centres and can be given safely to European patients with severe malaria. Patients treated with intravenous artesunate should be followed up to detect and manage late haemolytic events.

Systematic Analysis of Direct Antiglobulin Test Results in Post-artesunate Delayed Hemolysis

“…Three patients (15.8%) with PADH received blood transfusions, and two (10.5%) needed to be re-hospitalized (for 3 and 5 days, respectively). PADH has attracted attention because it often occurs well after resolution of malaria-related symptoms and after complete parasite clearance [23,24] and is neither directly related to active infection nor to the presence of parasites. Currently, weekly follow-up visits up to one month following artemisinin derivatives treatment are strongly recommended to detect and manage this condition, mainly, in case of both high baseline parasitemia and intravenous artesunate treatment [11].…”

The Overview of Malaria Cases in Trenggalek District based on The Epidemiological Triangle

“…Hal ini sesuai dengan penelitian di Jerman yang menyatakan bahwa laporan kasus malaria pada penduduk asli Jerman dan penduduk dengan latar belakang migrasi menunjukkan tren yang meningkat selama 10 tahun terakhir (Vygen-Bonnet & Stark, 2018). Hal ini sejalan dengan penelitian di Eropa bahwa mayoritas pasien dengan penyakit malaria di Eropa adalah turis atau migran yang memperoleh infeksi malaria dari wilayah Afrika bagian barat (Kurth et al, 2017).…”

Approach to the Patient With Malaria

“…Deaths generally occur among those not taking antimalarial chemoprophylaxis and in those facing delayed diagnosis and treatment by geographic isolation/travel, reluctance to seek medical attention, misdiagnosis, or inappropriate/ ineffective therapy. [4][5][6] Promptly diagnosed and treated uncomplicated malaria very rarely progresses to life-threatening severe malaria.…”

“…In one European series of 185 patients with imported severe malaria (2006 WHO criteria), the main features seen were (i) hyperparasitemia >5% (~71%), (ii) jaundice (44%), (iii) impaired consciousness/coma (25%), (iv) acute kidney injury (19%), (v) shock (15%), (vi) respiratory failure/ARDS (12%), (vii) spontaneous bleeding (7%), (viii) acidosis (5%), (ix) hypoglycemia (3%), and (x) multiple convulsions (2%). 4 The median number of WHO criteria was 2, and some 40% of patients had an underlying comorbidity. These data are broadly consistent with those from an earlier series of 400 patients, reported by Bruneel et al 5 who highlighted the contribution of microscopy-few of the many available kits detect parasitemia <100/µL, and lower sensitivity for P. vivax malaria is typical.…”

“…6%) bacterial infections to malaria-related morbidity. One important consequence of treating nonimmune, severe malaria patients with intravenous artesunate (IV AS) is delayed (up to ~3 weeks) acute hemolytic anemia (AHA), which may require transfusion; this occurred in 19 (27%) of 70 IV AS-treated patients 4. …”