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BMC Medicine
Published in: BMC Medicine 1/2015

Open Access 01-12-2015 | Research article

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

Authors: Josh Hanson, Sue J. Lee, Md Amir Hossain, Nicholas M. Anstey, Prakaykaew Charunwatthana, Richard J. Maude, Hugh W. F. Kingston, Saroj K. Mishra, Sanjib Mohanty, Katherine Plewes, Kim Piera, Mahtab U. Hassan, Aniruddha Ghose, M. Abul Faiz, Nicholas J. White, Nicholas P. J. Day, Arjen M. Dondorp

Published in: BMC Medicine | Issue 1/2015

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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.
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Metadata
Title
Microvascular obstruction and endothelial activation are independently associated with the clinical manifestations of severe falciparum malaria in adults: an observational study
Authors
Josh Hanson
Sue J. Lee
Md Amir Hossain
Nicholas M. Anstey
Prakaykaew Charunwatthana
Richard J. Maude
Hugh W. F. Kingston
Saroj K. Mishra
Sanjib Mohanty
Katherine Plewes
Kim Piera
Mahtab U. Hassan
Aniruddha Ghose
M. Abul Faiz
Nicholas J. White
Nicholas P. J. Day
Arjen M. Dondorp
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Medicine / Issue 1/2015
Electronic ISSN: 1741-7015
DOI
https://doi.org/10.1186/s12916-015-0365-9

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