Hyperparasitaemia during bouts of malaria in French Guiana

Abstract

Background: High circulating parasite load is one of the WHO criteria for severe falciparum malaria. During a period of 11 years (2000-2010), the frequency of hyperparasitaemia (HP) (≥4% infected erythrocytes) during bouts of malaria due to Plasmodium falciparum, Plasmodium vivax and Plasmodium malariae in patients referred to Cayenne General Hospital (CGH) in French Guiana and the frequency of their admission to the Intensive Care Unit (ICU) were evaluated.

Methods: A mean of 1,150 malaria cases were referred to the Parasitology Laboratory of CGH each year over the last decade. During this period, malaria diagnostic (microscopy) and parasitaemia evaluation have remained unchanged: determination of the parasitized erythrocytes percentage with asexual forms on thin blood smears for all cases of parasitaemia exceeding 0.1%. Patients admitted to the ICU can be counted by origin of the request for malaria testing. All the data collected retrospectively were anonymized in a standardized case report form and in database.

Results: Between 2000 and 2010, 12,254 bouts of malaria were confirmed at the Parasitology Laboratory of CHG: P. vivax: 56.2%, P. falciparum: 39.5%, co-infection with both species: 3.4%, P. malariae: 0.9%. HP was observed in 262 cases, at a frequency of 4.9% for P. falciparum and only 0.041% for P. vivax, with no recorded cases for P. malariae. The need for intensive care was correlated with P. falciparum parasite load: 12.3% of cases for parasitaemia of 4-9%, 21.2% for parasitaemia 10-19%, 50% for parasitaemia 20-29% and 77.8% for parasitaemia ≥30% (n=9). The patient with the highest parasitaemia (75% infected erythrocytes with asexual form) presented a major concomitant lupus flare-up treated with corticoids. He survived without obvious sequelae.

Conclusions: In French Guiana during bouts of malaria, HP was observed at a frequency of ~ 5% for P. falciparum and two orders of magnitude less frequent for P. vivax. HP is a severity criterion for falciparum malaria in this endemic area. However, two of the patients with HP ≥30% were not admitted to the ICU and sequel-free cure in malaria patients with 75% parasitaemia is, therefore, possible.

Figure 1

Blood smear from a patient with hyperparasitaemia (75% parasitaemia). This thin blood film shows strong HP (70/96 → 73% based on the photographs: Plasmodium-infected erythrocytes - red number- n=70, all eyrthrocytes - red and black numbers - n= 96 with young and mature schizonts (rosette) and pigmented leukocytes.

Figure 2

Thin blood film of Plasmodium vivax case with 6.5%. Morphological aspects are typical of P. vivax: throphozoites (blood red cells 1–5) and gametocyte (blood red cell with Gam). Five asexual forms for a total of 65 erythrocytes.

Figure 3

Hyperparasitaemia and hospitalization in an ICU (Cayenne Hospital).

Figure 4

Bouts of malaria recorded in the Emergency Unit of Cayenne Hospital from 2000 to 2010.