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BMC Med. 2015 May 27;13:122. doi: 10.1186/s12916-015-0365-9.

Microvascular obstruction and endothelial activation are independently associated with the clinical manifestations of severe falciparum malaria in adults: an observational study.

Author information

1
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. drjoshhanson@gmail.com.
2
Global Health Division, Menzies School of Health Research, Darwin, Australia. drjoshhanson@gmail.com.
3
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. sue@tropmedres.ac.
4
Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK. sue@tropmedres.ac.
5
Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh. amir_hossain_ctg@yahoo.com.
6
Global Health Division, Menzies School of Health Research, Darwin, Australia. Nicholas.Anstey@menzies.edu.au.
7
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Jib@tropmedres.ac.
8
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Richard@tropmedres.ac.
9
Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK. Richard@tropmedres.ac.
10
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. hwfkingston@googlemail.com.
11
Global Health Division, Menzies School of Health Research, Darwin, Australia. hwfkingston@googlemail.com.
12
Department of Medicine, Ispat Hospital, Rourkela, Orissa, India. sarojrkl@gmail.com.
13
Department of Medicine, Ispat Hospital, Rourkela, Orissa, India. sanjibmalaria@rediffmail.com.
14
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. kaplewes@gmail.com.
15
Global Health Division, Menzies School of Health Research, Darwin, Australia. Kim.Piera@menzies.edu.au.
16
Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh. mahtabnipu@yahoo.com.
17
Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh. anrdghs@yahoo.com.
18
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. drmafaiz@gmail.com.
19
Centre for Specialized Care and Research, Chittagong, Bangladesh. drmafaiz@gmail.com.
20
Dev Care Foundation, Dhaka, Bangladesh. drmafaiz@gmail.com.
21
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. nickwdt@tropmedres.ac.
22
Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK. nickwdt@tropmedres.ac.
23
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Nickd@tropmedres.ac.
24
Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK. Nickd@tropmedres.ac.
25
Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. arjen@tropmedres.ac.
26
Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK. arjen@tropmedres.ac.

Abstract

BACKGROUND:

Microvascular obstruction and endothelial dysfunction have both been linked to tissue hypoperfusion in falciparum malaria, but their relative contributions to the disease's pathogenesis and outcome are unknown.

METHODS:

Microvascular blood flow was quantified in adults with severe falciparum malaria on their admission to hospital; plasma biomarkers of endothelial function were measured simultaneously. The relationship between these indices and the patients' clinical findings and in-hospital course was examined.

RESULTS:

Microvascular obstruction was observed in 119/142 (84 %) patients; a median (interquartile range (IQR)) of 14.9 % (6.6-34.9 %) of capillaries were obstructed in patients that died versus 8.3 % (1.7-26.6 %) in survivors (P = 0.039). The proportion of obstructed capillaries correlated with the estimated parasite biomass (rs = 0.25, P = 0.004) and with plasma lactate (rs = 0.38, P <0.0001), the strongest predictor of death in the series. Plasma angiopoietin-2 (Ang-2) concentrations were markedly elevated suggesting widespread endothelial activation; the median (IQR) Ang-2 concentration was 21.9 ng/mL (13.4-29.4 ng/mL) in patients that died versus 14.9 ng/mL (9.8-29.3 ng/mL) in survivors (P = 0.035). Ang-2 concentrations correlated with estimated parasite biomass (rs = 0.35, P <0.001) and plasma lactate (rs = 0.37, P <0.0001). Microvascular obstruction and Ang-2 concentrations were not significantly correlated with each other (rs = 0.17, P = 0.06), but were independently associated with plasma lactate (P <0.001 and P = 0.002, respectively).

CONCLUSIONS:

Microvascular obstruction and systemic endothelial activation are independently associated with plasma lactate, the strongest predictor of death in adults with falciparum malaria. This supports the hypothesis that the two processes make an independent contribution to the pathogenesis and clinical manifestations of the disease.

PMID:
26018532
PMCID:
PMC4453275
DOI:
10.1186/s12916-015-0365-9
[Indexed for MEDLINE]
Free PMC Article

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