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Indian Journal of Medical Sciences, Vol. 60, No. 9, September, 2006, pp. 376-379 Case Report HIV immunosupression and malaria: Is there a correlation? Suri V, Bhalla A, Sharma N, Jain S, Varma S Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh Correspondence Address:Department of Internal Medicine, PGIMER, Chandigarh - 160 012 Email: ashish_ritibhalla@yahoo.com Code Number: ms06054 Abstract The human immunodeficiency virus (HIV) epidemic has resulted in an increase in the prevalence of many opportunistic infections and has caused re-emergence of certain diseases in the developing world. In tropical countries, immunosupression due to HIV infection has resulted in changes in the clinical presentation of endemic infections. Although the immune deficiency caused by HIV infection should presumably lead to an increased frequency of clinical malaria in areas with endemic malarial infection, like India, evidence of the association between HIV and malaria in India is scanty, with only a few studies showing a positive correlation. We hereby report a case of concurrent infection with Plasmodium falciparum malaria and human immunodeficiency virus type 1 (HIV-1) in a young male patient.Keywords: Complicated malaria, concurrent infection, falciparum malaria, HIV infection, immunosupression, malaria Introduction The human immunodeficiency virus type 1 (HIV-1) pandemic has emerged in many regions of the developing world already suffering from the burden of malaria.[1] Either infection might influence the clinical course of the other. Patnaik et al. in their prospective cohort study in the rural population of Malawi found that HIV-infected adults in these malaria-endemic areas were at increased risk for malaria;[2] while on the contrary, Chandramohan et al. found no convincing evidence for an interaction between malaria and HIV, but with the possible exception of an interaction between placental malaria transmission and HIV infection.[3] The immune deficiency caused by HIV infection should, in theory, reduce the immune response to malaria parasitemia and therefore lead to an increased frequency of clinical attacks of malaria. Kublin and Patnaik et al. assessed the effect of Plasmodium falciparum malaria on concentrations of HIV in blood of adults in rural Malawi and they found that HIV-infected individuals with malaria have a significantly increased viral load and that the increases in HIV-1-RNA were greatest for people with fever, parasite density 2000/ μL or greater and CD4 count more than 300 cells per μL.[4] We encountered one such case of concurrent infection with P. falciparum malaria and human immunodeficiency virus type 1 (HIV-1) in a young male patient.Case report A 36-year-old male patient, a truck driver, presented to our hospital with complaints of high spiking fever with chills and rigors, decreased urine output and altered sensorium. He also had history of passage of cola-colored urine. The examination revealed a restless patient with no signs of meningeal irritation. He had hepatosplenomegaly and few scattered crepitations in the left infra scapular area. His work-up at admission revealed high total leukocyte count (25,000), low platelet count (10,000), high urea and creatinine (110/2.2 mg/dl) and unconjugated bilirubinemia with metabolic acidosis. Ring forms of P. falciparum were detected in the peripheral blood film with a high parasite index of 51%. In view of high-risk sexual behavior, an HIV screening was performed by the ELISA technique, which revealed positive reactivity for HIV 1 and 2. He was treated with antimalarials quinine (10 mg/kg loading dose and then infusion of 10 mg/kg of quinine dihydrochloride over 2-3 h every 8 h) and artesunate (120 mg IV od on the first day followed by 60 mg daily for 4 days). In view of altered sensorium, multiorgan dysfunction and a very high parasite index, exchange transfusion was planned. He received two sessions of exchange transfusion (total of 5 L). Subsequently, a marked improvement in sensorium and a decrease in parasite index (1.5% on day 2 and 0% by day 5) were observed. The patient′s general condition improved significantly, but in view of deteriorating renal functions and oligurea, hemodialysis was done on the fourth day of admission. Further investigations revealed a low CD4 to CD8 ratio (0.11). Antiretroviral therapy was considered in this patient but could not be initiated as he continued to have high-grade fever even after the clearance of heavy parasitemia. His septic screen (blood and urine culture) was negative but in view of underlying immunodeficiency, he was managed with third-generation cephalosporins. On day 15, his condition deteriorated and he developed tachypnea, worsening of his sensorium, fresh infiltrates on X-ray chest with a normal computerized tomogram scan of head and cerebrospinal fluid analysis. He was treated for nosocomial pneumonia (third-generation cephalosporins and vacomycin, both modified according to creatinine clearance) with oral septran (modified according to creatinine clearance) as a cover for pneumocystis jiroveckii and IV fluconazole. Ventilation was considered for worsening respiratory distress, but the patient was discharged without any further treatment as requested by his attendants.Discussion To the best our knowledge, this is the second report of P. falciparum infection in a HIV-positive patient from India. Khasnis and Karnad in a study sample of urban India demonstrated that HIV infection was associated with increased risk of severe malaria.[5] Both infections are independently responsible for staggeringly high morbidity and mortality in sub-Saharan Africa. CD4 + T cells, in conjunction with B cells and antigen-presenting cells, are integral to the immune response to malaria.[6] Since leucopenia is common in advanced HIV infection, one may overestimate the parasite density of patients with lower CD4 cell counts; therefore, one has to be careful while reporting these slides. Conflicting reports of the effect of HIV infection on the severity of malaria have been published. In 1998, a comprehensive meta-analysis concluded that among children and nonpregnant adults, there was no evidence of an interaction between HIV infection and malaria;[3] while on the contrary, the more recent studies by Kublin and Patnaik demonstrated that HIV-infected adults were at an increased risk for severe malaria.[2],[4] In their study among HIV-1 infected adults in rural Uganda, Whitworth et al found that HIV-1 infection was associated with an increased frequency of clinical malaria and parasitemia and this association tends to become more pronounced with falling CD4 cell counts, i.e., increased immunosupression.[7] However, the incidence of recurrent clinical malaria (i.e., 128 days after the first episode) was not affected by CD4 cell count in the study by French et al in the same subgroup of patients.[8] The evidence for an interaction between HIV-1 and malaria in pregnancy is convincing, with more peripheral and placental parasitemia, higher parasite densities, more clinical malaria, more anemia and increased risks of adverse birth outcomes.[9] Various studies have shown that HIV-infected patients were more likely to present with atypical clinical features of malaria (gastrointestinal or respiratory presentations), renal failure, acidosis and severe anemia.[10] Impaired immunity associated with HIV infection could diminish the effectiveness of antimalarial treatment. Kamya et al found that HIV-1 infection was associated with an increased risk of clinical treatment failure for adults, but there was no increased risk for HIV-1 infected children.[11] Although more-immunosuppressed individuals appear to be somewhat more susceptible to malaria, they are even more vulnerable to other opportunistic infections that may occur coincidentally with malaria, such as mycobacteria, Streptococcus species, nontyphi salmonellae and other gram-negative organisms.[12] This complex of infections is a common cause of worsening patients with multiple infections as seen in our patient. Malaria is endemic in many parts of India. As the number of HIV-positive patients increases, we are likely to witness many more cases like the ones presented in this report. A high index of suspicion of coexistent infections, prompt recognition and early treatment should be strongly recommended in managing these patients. References
Copyright 2006 - Indian Journal of Medical Sciences |
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