Parasitic Infections in Malaysia: Changing and Challenges
Parasitic Infections in Malaysia: Changing and Challenges
Parasitic Infections in Malaysia: Changing and Challenges
CHALLENGES
V Nissapatorn1, YAL Lim1, I Jamaiah1, LSH Agnes2, K Amyliana2, C Chian Wen2, H Nurul2,
2
2
2
2
1
S Nizam , CT Quake , C Valartmathi , C Ying Woei and A Khairul Anuar
1
Department of Parasitology, University of Malaya Medical Center, Kuala Lumpur; 2Faculty of Medicines
Medical Students, University of Malaya, Kuala Lumpur, Malaysia
Abstract. A total of 1,885 blood and stool samples of four main protozoan parasitic infections were retrospectively
reviewed from January, 2000 to April, 2004. Eleven of the 1,350 stool samples were shown positive for
Cryptosporidium and Giardia infections; one of the 5 cases was clinically diagnosed as gastrointestinal
cryptosporidiosis, while 6 cases were giardiasis. In patients with giardiasis, children were among the high-risk
groups, making up 66.7% of these patients. The common presenting signs and symptoms were: diarrhea (83.3%),
loss of appetite (83.3%), lethargy (83.3%), fever (66.7%), nausea/vomiting (50.0%), abdominal pain (16.7%),
dehydration (16.7%) and rigor and chills (16.7%). Metronidazole was the drug of choice and was given to all
symptomatic patients (83.3%). For the blood samples, 28 of the 92 peripheral smears for Plasmodium spp infection
were diagnosed as malaria. The age range was from 4 to 57, with a median of 32.5 years. The sex ratio (M:F) was
3.6:1, while the age group of 30-44 years was the most commonly affected in both sexes. The majority of
patients were foreigners (60.7%) and non-professional (39%). Plasmodium vivax (71%) infection was the most
common pathogen found in these patients, along with a history of traveling to an endemic area of malaria (31%).
The predominant presenting signs and symptoms were: fever (27%), rigor and chills (24%), nausea/vomiting
(15%) and headache (8%). Chloroquine and primaquine was the most common anti-malarial regimen used (78.6%)
in these patients. The seroprevalence of toxoplasmosis in different groups was 258/443 (58%): seropositive for
IgG 143 (32.3%); IgM 67 (15%); and IgG + IgM 48 (10.8%). The age range was from 1 to 85, with a mean of 34
( SD 16.6) years. The predominant age group was 21 to 40 years (126; 28.4%). The sex ratio (M:F) was 1.2:1.
Subjects were predominantly male (142; 32%) and the Malay (117; 26.4%). Of these, 32 cases were clinically
diagnosed with ocular toxoplasmosis. The range of age was from 10 to 56 years with a mean of 30.5 ( SD
12.05) years. The sex ratio (M:F) was 1:1.7. The majority were in the age group of 21 to 40 years, female (20;
62.5%), and Malay (17; 53%). They were also single (16; 50%), unemployed (12; 37%), and resided outside
Kuala Lumpur (21; 65.6%). The more common clinical presentations were blurring of vision (25; 78%), floaters
(10; 31%) and pain in the eye (7; 22%). We found that funduscopic examination (100%) and seropositivity for
anti-Toxoplasma antibodies (93.7%) were the main reasons for investigation. Choroidoretinitis was the most
common clinical diagnosis (69%), while clindamycin was the most frequently used antimicrobial in all cases.
Among HIV-infected patients, 10 cases were diagnosed as AIDS-related toxoplasmic encephalitis (TE) (9 were
active and 1 had relapse TE). In addition, 1 case was confirmed as congenital toxoplasmosis.
INTRODUCTION
Infectious diseases, once expected to be eliminated
as public health problems, remain the leading cause of
death worldwide (Marshall et al, 1997). To our
knowledge, parasitic infections remain highly
prevalent in the global arena, particularly in developing
countries. Among tropical diseases, malaria has been
identified as one of the most important public health
problems (Moe Lwin and Umenai, 1999) and is the
most important human parasitic disease, affecting over
200 million people and causing more than one million
Correspondence: Dr Veeranoot Nissapatorn,
Department of Parasitology, University of Malaya
Medical Center, 50603 Kuala Lumpur, Malaysia.
Tel: 603-7967 6618
E-mail: [email protected]
50
Table 1
Demographic characteristics and clinical relevant of
28 patients with malaria.
Characteristics
Number of
patients (%)
2 (7)
16 (57)
10 (35.7)
22 (78.6)
6 (21.4)
1
4
6
17
(3.6)
(14.3)
(21.4)
(60.7)
7 (25)
19 (68)
2 (7)
13 (46.4)
0
8 (28.6)
7 (25)
10 (35.7)
18 (64.3)
14
6
2
1
(50)
(21.4)
(7.2)
(3.6)
27
24
15
8
7
6
5
4
4
3
2
(96.4)
(85.7)
(53.6)
(28.6)
(25)
(21.4)
(17.9)
(14.3)
(14.3)
(10.7)
(7.1)
28 (100)
Continued
Characteristics
Number of
patients (%)
Hemoglobin count
(range = 10 to 172; mean 95.5 46.7)
Normal value
6 (21.4)
Anemic condition
(mild, moderate and severe)
22 (78.6)
White blood cell count
(range = 1.03 to 12.4; mean = 5.9 2.5)
Normal value
20 (71.4)
Below or above normal value
8 (28.6)
Red blood cell count
(range = 1.94 to 5.85; mean = 4.1 0.89)
Normal
8 (28.6)
Below normal value
20 (71.4)
Diagnosis
Vivax malaria
20 (71.4)
Falciparum malaria
4 (14.3)
Malariae malaria
1 (3.6)
Mixed infection
(P. faiciparum and P. malariae)
3 (10.7)
Treatment
Chloroquine + primaquine
22 (78.6)
Chloroquine + doxycycline
5 (17.9)
Fansidar + quinine
1 (3.6)
Table 2
Demographic characteristics of 443 individuals who came to this hospital during January 2000 to April 2004.
Characteristics
HIV-patients
(162)
The range of age = 1 to 85 years
Mean = 34 ( SD) 16.6 years
The sex ratio (M:F) = 1.2 : 1
Age Group
20
21-40
41
No information
Sex
Male
Female
Race
Malay
Chinese
Indian
Foreigner
Seroprevalence of toxoplasmosis
b
No
Yes: IgG
IgM
IgG+IgM
Total Ig
4
108
47
3
(2.5)
(66.7)
(29)
(2)
Number of patients
a
Ocular patients
Others
(161)
(121)
33
57
69
2
(20.5)
(35.4)
(43)
(1.2)
41
47
25
8
(34)
(38.8)
(20.7)
(6.6)
Total
(443)
77
212
141
13
(17.4)
(48)
(31.8)
(3)
107 (66)
55 (34)
66 (41)
95 (59)
68 (56.2)
53 (43.8)
241 (54.4)
202 (45.6)
29
114
12
7
(18)
(70.3)
(7.4)
(4.3)
85
37
37
2
(52.8)
(23)
(23)
(1.2)
55
44
20
2
(45.5)
(36.4)
(16.5)
(1.7)
168
195
69
11
(38)
(44)
(15.6)
(2.5)
69
58
24
11
93
(42.6)
(35.8)
(14.8)
(6.8)
(57.4)
54
50
31
26
107
(33.5)
(31.1)
(19.3)
(16.1)
(66.5)
63
35
12
11
58
(52)
(29)
(10)
(9.1)
(48)
185
143
67
48
258
(41.8)
(32.3)
(15.1)
(10.8)
(58.2)
Others mean individual with pregnancy, congenital, generalized lymphadenopathy, or any immunosuppressed conditions.
The significant association were found between age group with HIV, ocular patients and others (p<0.05); sex with HIV and ocular
patients (p<0.05); and race with HIV, and ocular patients (p<0.05).
b
There were 2 cases who had no evidence of Toxoplasma status but clinically proven of ocular toxoplasmosis.
53
Table 3
Demographic profiles of 32 cases of ocular
toxoplasmosis.
Demographic
characteristics
The range of age = 10 to 56 years
Mean = 30.5 12.05 years
The sex ratio (M:F) = 1 : 1.7
Age Group
10
11-20
21-30
31-40
41-50
51
Sex
Male
Female
Race
Malay
Chinese
Indian
Foreigner
Marital status
Single
Married
No information
Occupation
Laborer
Non-laborer
Unemployed
Not recorded
Address
Kuala Lumpur
Outsider
Not recorded
Number of
patients (%)
1
7
9
8
5
2
(3.1)
(22)
(28.1)
(25)
(15.6)
(6.3)
12 (37.5)
20 (62.5)
17
8
5
2
(53.1)
(25.0)
(15.6)
(6.3)
16 (50.0)
11 (34.4)
5 (15.6)
3
6
12
11
(9.4)
(18.8)
(37.5)
(34.4)
5 (15.6)
21 (65.6)
6 (18.8)
Table 4
Clinical manifestation, investigation and treatment
outcome of these patients.
Characteristics
54
Number of
patient (%)
3 (9.4)
25 (78.1)
4 (12.5)
25 (78.1)
3 (9.4)
4 (12.5)
Table 4 (continued)
Characteristics
Number of
patient (%)
Floaters
No
Yes
Not recorded
Redness of eye
No
Yes
Not recorded
Pain in the eye
No
Yes
Not recorded
Fever
No
Yes
Not recorded
Headache
No
Yes
Not recorded
Affected eye(s)
Left
Right
Bilateral
Not recorded
Investigation
Funduscopy examination
Serology
IgM
IgG
Both
Not recorded
Diagnosis
Retinochoroiditis
No
Yes
Uveitis
No
Anterior uveitis
Posterior uveitis
Panuveitis
Treatment
Clindamycin
Prednisolone
Azithromycin
Fansidar
Combination
(clindamycin +prednisolone,
fansidar, and azithromycin)
Prednisolone + azithromycin
Not recorded
18 (56.3)
10 (31.3)
4 (12.5)
26 (81.3)
2 (6.3)
4 (12.5)
21 (65.6)
7 (21.9)
4 (12.5)
28 (87.5)
0
4 (12.5)
24 (75.0)
4 (12.5)
4 (12.5)
9
17
3
3
(28.1)
(53.1)
(9.4)
(9.4)
32 (100)
4
18
8
2
(12.5)
(56.3)
(25.0)
(6.3)
10 (31.2)
22 (68.8)
22
3
1
6
(68.8)
(9.4)
(3.1)
(18.8)
6
1
3
1
12
(18.8)
(3.1)
(9.4)
(3.1)
(37.5)
6 (18.8)
3 (9.4)
Table 5
A report of clinically evident case of congenital toxoplasmosis.
Characteristics
Patient
Age
3 years old
Gender
Male
Ethnic
Malay
Nationality
Malaysian
Antenatal history
His mother was 41 years old with G5P4 and all normal children before
his birth. During her 6 months pregnancy, she had fever for 1week
with exposed to chicken pox
Ventriculomegaly appeared on the fetal brain
Ultrasound examination
Postnatal history
In 2001: Clinical manifestation
Investigation
Serodiagnosis
CT scan
Treatment
In 2002: Clinical manifestation
Investigation
MRI
VEP studies
Ophthalmoscopic examination
Serodiagnosis
Treatment
Follow-up
Other complications
DISCUSSION
Seven cases of symptomatic gastrointestinal
protozoan infections mostly occurred in children. This
indicates that parasitic infections are still encountered in
our setting, even though in small numbers. The prevalence
of these two organisms varied according to geographical
distribution (Cross et al, 1985; Kamel et al, 1994;
Gambhir et al, 2003). In a case of cryptosporidiosis, no
specific treatment was given to the patient; however, her
condition spontaneously improved. This could be due to
the fact that Cryptosporidium is an acute, self-limiting
gastro-enteritis in immunocompetent patients, whereas
it is a chronic and possibly life-threatening illness in
Vol 36 (suppl 4) 2005
1985;38:1321-36.
Cheah WC, Fah CS, Fook CW. Pattern of Toxoplasma
antibodies in Malaysian pregnant women. Med J
Malaysia 1975;29:275-9.
Chirgwin K, Hafner R, Leport C, et al. Randomized
phase II trial of atovaquone with pyrimethamine
or sulfadiazine for treatment of toxoplasmic
encephalitis in patients with acquired immunodeficiency syndrome: ACTG 237/ANRS 039
Study. AIDS Clinical Trials Group 237/Agence
Nationale de Recherche sur le SIDA, Essai 039.
Clin Infect Dis 2002;34:1243-50.
Cohen BA. Neurologic manifestations of toxoplasmosis in AIDS. Semin Neurol 1999;19:201-11.
Collazos J. Opportunistic infections of the CNS in
patients with AIDS: diagnosis and management.
CNS Drugs 2003;17:869-87.
Combee CL, Collinge ML, Britt EM. Cryptosporidiosis
in a hospital-associated day care center. Pediatr
Infect Dis 1986;5:528-32.
Congpuong K, Na-Bangchang K, Thimasarn K,
Tasanor U, Wernsdorfer WH. Sensitivity of
Plasmodium vivax to chloroquine in Sa Kaeo
Province, Thailand. Acta Trop 2002;83:117-21.
Couvreur J, Thulliez P, Daffos F, et al. Fetal
toxoplasmosis. In utero treatment with
pyrimethamine sulfamides. Arch Fr Pediatr
1991;48:397-403 (in French).
Cross JH, Alcantara A, Alquiza L, Zaraspe G, Ranoa
C. Cryptosporidiosis in Philippine children.
Southeast Asian J Trop Med Public Health
1985;16:257-60.
de Graaf DC, Spano F, Petry F, Sagodira S, Bonnin A.
Speculation on whether a vaccine against
cryptosporidiosis is a reality or fantasy. Int J
Parasitol 1999;29:1289-306.
de Lalla F, Rinaldi E, Santoro D, Nicolin R, Tramarin
A. Outbreak of Entamoeba histolytica and Giardia
lamblia infections in travelers returning from the
tropics. Infection 1992;20:78-82.
Dupouy-Camet J, de Souza SL, Maslo C, et al.
Detection of Toxoplasma gondii in venous blood
from AIDS patients by polymerase chain reaction.
J Clin Microbiol 1993;31:1866-9.
Furrer H, Cohort Study Ts t. Management of
opportunistic infection prophylaxis in the highly
active antiretroviral therapy era. Curr Infect Dis
Rep 2002;4:161-74.
57
Mets MB, Holfels E, Boyer KM, et al. Eye manifestations of congenital toxoplasmosis. Am J
Ophthalmol 1996;122:309-24.
Moe Lwin AM, Umenai T. Cost analysis of malaria
patients in Taikkyi Township Mymmar. AsiaPacific J Public Helth 1999;11:94-100.
Munoz Batet C, Guardia Llobet C, Juncosa Morros T,
et al. Toxoplasmosis and pregnancy. Multicenter
study of 16,362 pregnant women in Barcelona.
Med Clin (Barc) 2004;123:12-6 (in Spanish).
Nissapatorn V, Nor Azmi MA, Cho SM, et al.
Toxoplasmosis: prevalence and risk factors. J
Obstetr Gynecol 2003;23:618-24.
59