Autor/a:
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Siqueira, André Machado; Lacerda, Marcus Vinícius Guimarães; Magalhaes, Belisa M. L.; Mourao, Maria P. G.; Melo, Gisely Cardoso de; Alexandre, Márcia A. A.; Alecrim, Maria G.; Kochar, Dhanpat K.; Kochar, Sanjay K.; Kochar, Abhishek; Nayak, Kailash; Portillo Obando, Hernando A. del; Guinovart, Caterina; Alonso, Pedro; Bassat Orellana, Quique
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Abstract:
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BACKGROUND: The benign character formerly attributed to
Plasmodium vivax infection has been dismantled by the increasing
number of reports of severe disease associated with infection
with this parasite, prompting the need for more thorough and
comprehensive characterization of the spectrum of resulting
clinical complications. Endemic areas exhibit wide variations
regarding severe disease frequency. This study, conducted
simultaneously in Brazil and India, constitutes, to our
knowledge, the first multisite study focused on clinical
characterization of P. vivax severe disease. METHODS: Patients
admitted with P. vivax mono-infection at reference centers in
Manaus (Amazon - Brazil) and Bikaner (Rajasthan - India), where
P. vivax predominates, were submitted to standard thorough
clinical and laboratory evaluations in order to characterize
clinical manifestations and identify concurrent co-morbidities.
RESULTS: In total, 778 patients (88.0% above 12 years old) were
hospitalized at clinical discretion with PCR-confirmed P. vivax
mono-infection (316 in Manaus and 462 in Bikaner), of which 197
(25.3%) presented at least one severity criterion as defined by
the World Health Organization (2010). Hyperlactatemia,
respiratory distress, hypoglycemia, and disseminated
intravascular coagulation were more frequent in Manaus.
Noteworthy, pregnancy status was associated as a risk factor for
severe disease (OR = 2.03; 95% CI = 1.2-3.4; P = 0.007). The
overall case fatality rate was 0.3/1,000 cases in Manaus and
6.1/1,000 cases in Bikaner, with all deaths occurring among
patients fulfilling at least one severity criterion. Within this
subgroup, case fatality rates increased respectively to 7.5% in
Manaus and 4.4% in Bikaner. CONCLUSION: P. vivax-associated
severity is not negligible, and although lethality observed for
complicated cases was similar, the overall fatality rate was
about 20-fold higher in India compared to Brazil, highlighting
the variability observed in different settings. Our observations
highlight that pregnant women and patients with co-morbidities
need special attention when infected by this parasite due to
higher risk of complications. |