IJCCR 2013, Vol.3, No.3, 17
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22
dysfunction (Anstey et al., 2009; Rogerson and Carter,
2008).
Further
P. vivax
can induce enhanced
inflammatory response. In all cases of ARDS with
vivax malaria, the symptoms developed after
antimalarial therapy raising the possibility of
pulmonary inflammatory response to parasite killing.
Thus the inflammatory and immunological response
may play a significant role in pathophysiology of
severe vivax malaria (Anstey et al., 2009).
The present study also showed that elderly age, low
BMI, concurrent infections, high parasite count are
also important risk factors for the development of
severe disease. Majority patients of SVM belonged to
4
th decade. Additionally, increased incidence of sever
vivax malaria was found in paediatric population
(
Genton et al., 2008). Thus extremes of age are at risk
of development of SVM (Mohapatra et al., 2002;
Nadkar et al., 2012; Genton et al., 2008).
Associated infection is found to be a major risk factor
of SVM. The common infections are urinary tract
infection, upper respiratory tract infection, pneumonia,
enteric fever. In addition to sequestration additional
infection may play a role which was prevented by
appropriate antibiotic therapy in our series. Therefore,
in addition to parasitic killing, associated infection
also has a major role to play for enhanced inflammato-
ry response (Anstey et al., 2009). Associated disease
may also contribute to the development of sever
disease. Majority patients had diabetes mellitus,
hypertension, and other metabolic abnormalities. As
most patients are elderly, association of such non
communicable disease are likely to present.
Low BMI is another risk factor for the development
SVM. Severe vivax malaria had been described in the
past in Europe, which was related to malnutrition and
other associated diseases. Low BMI signifies under
nutrition which may be responsible for sever disease.
It may reduce the immunity increasing the chance of
severity. Study from Brazil showed that patients of
severe vivax malaria were younger, had short stay in
the malaria endemic area, and less previous episodes
of malaria signifying less immunity (Andrade et al.,
2010).
Strain variation may play a role in severe disease.
Cerebral vivax malaria has been reported occasionally
particularly with long incubation period of
P. vivax
multinucleatus in China (Warrell, 1993). In our series
though we observed severe vivax malaria we could
not able to identify the strain due to lack of facilities.
The present study showed that inj. artesunate is
effective in the treatment of severe vivax malaria. The
treatment of SVM has not been described clearly and
there is also no study to compare our results. All the
drugs that act against falciparum malaria also act
against vivax malaria with exception sulfadoxine
+pyrimethamine. In our study in 2002 we have treated
all patients of SVM with Injection quinine and we got
good response without any death (Mohapatra et al.,
2002).
After that WHO guideline for treatment of
malaria published in 2006 and suggested to treat
patients of SVM as sever falciparum malaria (World
Health Organization, 2006). Therefore, presently we
treated such cases with Artesunate and found that it is
effective with adequate response in 96.6% of cases.
This study also showed that in addition to antimalarial
suitable antibiotic should be added for treatment of
associated infection.
In the present series all patients of SVM recovered
completely without a single death. In SVM the
mortality was 9.0% and 1.8% in two different studies
from Mumbai, India (Nadkar et al., 2012; Limaye et
al., 2012). Low severity of the disease (assessed by
MSS), detection and treatment of associated infection
are the factors responsible for absence of mortality in
our study.
One of the limitations of the study is the identification
of the species by microscopy. It is known that this
method largely misses co-infection. Since PCR
method is costly and not yet accepted as a routine
investigation for diagnosis and treatment of malaria,
we used ICT test in addition to slide test for the
diagnosis of vivax malaria and to exclude falciparum
malaria. Most of the available studies have used only
the slide test for the diagnosis of malaria (Nadkar et
al., 2012; Limaye et al., 2012; Genton et al., 2008;
Tjitra et al., 2008).
In conclusion, severe vivax malaria is an emerging
recognized entity with multiple risk factors. The
response to treatment with Artesunate is satisfactory
with good outcome.
3
Material and Methods
This study was conducted in the Department of
Medicine of V.S.S. Medical College, Burla, Odisha, as