Malaria and the lung

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Classification of malaria

For clinical and research purposes, P falciparum malaria is classified either as acute and uncomplicated or severe and complicated. The benign malarias are simply described as, for example, acute vivax malaria. A spectrum of symptoms, signs, and pathologies exists that falls outside strict definitions. Of interest are reports of vivax malaria with features of complicated disease, including pulmonary edema [4], [5]. When malaria presents as an acute febrile illness, species differentiation is

Lung disease in malaria

Nonhydrostatic/noncardiogenic pulmonary edema is the most significant malaria-induced pulmonary manifestation of malaria [10]. This condition has been well described in P falciparum malaria and, occasionally, in association with P vivax and P ovale [5], [11]. Other important pulmonary pathologic conditions include iatrogenic fluid overload and pneumonia (eg, postconvulsive aspiration or nosocomial pneumonia) [12]. In areas in which malaria and respiratory diseases are common, diagnostic

Physiologic and hemodynamic studies

Pulmonary function tests conducted in one study of American soldiers showed changes in pulmonary function with differences between soldiers with clinical (cough, dyspnea, crepitations) and radiologic signs (pulmonary edema, unilateral infiltrates) and soldiers without pulmonary involvement [24]. Compared to controls, the nonpulmonary group (n= 16) had a lower PaCO2, mildly increased respiratory rate (mean = 20) increased tidal volume, ventilation, and total and resistive work. In the pulmonary

Respiratory signs and their clinical significance in malaria

Most data are from African children with uncomplicated and severe malaria in whom there is often diagnostic uncertainty. The overlap of malaria and pneumonia in a clinic setting was described in a study of young Gambian children who presented with clinical pneumonia (cough or difficulty in breathing and a raised respiratory rate [≥60 (age <2 months), ≥50/min (<12m), ≥40 (age 12–59 months)]. During the high transmission (wet) season, one third of 666 children had radiologic evidence of pneumonia

Respiratory arrest

Respiratory arrest is a common terminal event in severe malaria. It is often preceded by breathing abnormalities that suggest brain stem dysfunction (Cheyne-Stokes breathing, phasic hyperventilation, respiratory pauses). In some cases there are other signs of brain stem dysfunction. This has been interpreted as evidence of transtentorial or foramen magnum herniation, although this is not confirmed usually by radiologic or autopsy studies. The pathologic basis remains to be fully characterized.

Lung histopathology

In her classic series, Spitz reported on 50 US Army soldiers, aged 18 to 40 years, who died of severe malaria in World War II; most (45) had been admitted to hospital in coma [21]. Her report is paraphrased:

Parasitized alveolar capillaries were of similar intensity as those of the brain. Alveolar septal alveolar capillaries were hyperemic and dilated; the latter proportional to the number of parasites. Parasitized red blood cells were found in all alveolar vessels but mostly in the septal

Nonmalarial acute lung injury and acute respiratory distress syndrome

Acute lung injury and ARDS are rapidly evolving inflammations of the pulmonary endothelial and epithelial surfaces that lead to loss of alveolar-capillary integrity and the passage of protein-rich fluid from the circulation into the pulmonary interstitium and air spaces (nonhydrostatic edema). Proliferation of type II epithelial cells and fibroblasts leads to the deposition of connective tissue matrix and scar proteins [55]. The mechanism chiefly involves cytokines, neutrophils, and endothelial

Drug-induced lung disease

Antimalarial drug-induced lung toxicity is rare. Sulfadoxine and pyrimethamine are the main culprits. Sulfadoxine and pyrimethamine hypersensitivity reactions may be systemic or involve specific organs, such as the lungs [65], [66]. Lung manifestations include lung infiltrates, noncardiogenic pulmonary edema, pulmonary eosinophilia, and allergic alveolitis [67], [68], [69]. Traditional medicines used for malaria also may cause pulmonary edema [70]. Methemoglobinemia is well described after use

Brief notes on clinical management of severe malaria

The first step in effective and timely management is to make the diagnosis. A history of travel to an endemic area or residence near an airport should heighten suspicion of malaria. Diagnosis rests on the examination of a thick and thin blood film. Rapid antigen tests are also available and useful if expertise in blood smear examination is lacking [73]. The management of severe malaria is detailed elsewhere [2]. A few principles are outlined as an aide memoire for the busy clinician.

Summary

Pulmonary edema that results from increased pulmonary capillary permeability is the most important pulmonary manifestation of malaria. It is a common feature of severe malaria but also occurs rarely in milder disease. Mortality rate is high. The pathophysiologic basis is unclear. In the field, there is much clinical overlap between malaria and pneumonia in children. For physicians in nonmalarial areas, malaria always should be considered in the differential diagnosis of a sick patient who has

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    Disclaimer: The views expressed herein have nothing to do with those of the World Health Organization.

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