BackgroundAccording to the 2013 World Health Organization (WHO) World Malaria Report, malaria is a major cause of mortality and morbidity in malaria-endemic areas of the world. In 2018, 228 million cases of malaria were estimated to have been reported throughout the world with 85% of cases in sub-Saharan Africa and India. 1 This makes malaria the second most common cause of infectious disease-related deaths in the world, after tuberculosis. 2 Malaria is prevalent throughout most of the tropical regions of the world. 3 Plasmodium falciparum predominates in Africa, New Guinea, the Dominican Republic and Haiti. Plasmodium vivax is more common in Central America and Asia. 4 In South Africa, malaria is known to be endemic in three provinces, namely Mpumalanga, KwaZulu-Natal and Limpopo. 5 The highest transmission occurs in north-eastern Limpopo whilst Background: Globally, malaria is one of the six major causes of deaths from communicable diseases. In South Africa, malaria is known to be endemic in three provinces. Two large trials, AQUAMAT and SEAQUAMAT, demonstrated the superiority of intravenous (IV) artesunate compared to quinine. A systematic review (including the above trials) demonstrated a mortality benefit for adult patients treated with artesunate, but included studies that were conducted in Asia with no adult data available for Africa. Given the lack of local data, we conducted this study to investigate the use of artesunate for the treatment of severe malaria at two academic adult intensive care units (ICUs) in Johannesburg. Methods:We undertook a retrospective patient record review. All patients admitted to the two ICUs and treated for severe malaria using artesunate were included. The study period extended from April 2010 to April 2014. The primary outcome was to determine the observed mortality and relate it to the predicted mortality based on the Acute Physiology and Chronic Health Evaluation (APACHE II) severity of illness score. The ratio of the observed mortality to the expected mortality based on the APACHE II severity of illness score provides a standardised mortality ratio (SMR). Clinical and laboratory parameters data were analysed.Results: There were 56 patients included in the study, of which 40 were male (71.4%). The mean APACHE II score was 19 (standard deviation 5.4). We observed a lower than predicted mortality rate of 21.4% (SMR 0.66). Human immunodeficiency virus (HIV) was the most prevalent comorbidity (32%). There was no travel history in 26.8% of patients. Heart rate, respiratory rate and Glasgow Coma Scale (GCS) all improved significantly from admission to the time of discharge (p ≤ 0.01). Acidaemia, bilirubin, urea and bleeding risk (platelet count) also improved (p ≤ 0.01). Mechanical ventilation was associated with an increased risk of death (OR 35;. Conclusion:In this retrospective two-centre study, IV artesunate was associated with a lower than predicted mortality in adult patients with severe malaria requiring ICU admission.

Background: There is paucity of data on the modified Wells score (MWS) utility on patients with venous thromboembolism (VTE) in a South African setting where there is a high burden of HIV and tuberculosis (TB). This study analyses the performance of this score in HIV/TB-infected patients compared with non-infected patients.Objectives: To assess the performance of the MWS as an additional risk factor for VTE in hospitalised patients with a high burden of HIV/TB infections.Method: This study was a retrospective cross-sectional cohort analysis of the utility of the MWS in 156 HIV/TB-infected and non-infected adult patients diagnosed with VTE on compression ultrasonography (CUS) or computed tomography pulmonary angiography (CTPA) in a medical inpatient setting over six months. Patients with HIV and/or TB were assessed as having an additional risk factor (1 point for each), and this was compared with the MWS. A McNeymar’s paired sample chi-squared test was used to compare the sensitivity of this score against the MWS.Results: Of the 156 patients with VTE who were enrolled, HIV was the commonest risk factor (42.31%) with TB accounting for 10.90% of cases. When the MWS adjusted for HIV/TB was used, the sensitivity increased from 25% to 100% for the HIV–/TB+ category, it increased from 77.36% to 98.11% in the HIV+/TB– category and it increased from 84.62% to 92.95% in the HIV+/TB+ category. These differences were statistically significant at P  0.05 in all categories.Conclusion: The MWS performs better when the infectivity of HIV/TB is included as an additional risk factor in the score.

Background: Tuberculosis (TB) is a major cause of mortality in persons living with HIV (PLWH). Sputum-based diagnosis of TB in patients with low CD4 counts is hampered by paucibacillary disease and consequent sputum scarcity or negative sputum results. Urine lipoarabinomannan (LAM) has shown promise in the point-of-care detection of TB in this patient subset but lacks sensitivity, and its exact role in a diagnostic algorithm for TB in South Africa remains to be clarified.Objectives: The objective of this study was to better define the patient profile and the TB characteristics associated with a positive urine LAM (LAM+ve) test.Method: This multicentre retrospective record review examined the clinical, radiological, and laboratory characteristics of hospitalised PLWH receiving urine LAM testing with sputum-scarce and/or negative sputum GeneXpert ® (mycobacterium tuberculosis/resistance to rifampicin [MTB/RIF]) results.Results: More than a third of patients, 121/342 (35%), were LAM+ve. The positive yield was greater in the sputum-scarce than the sputum-negative group, 66/156 (42%) versus 55/186 (30%), P = 0.0141, respectively. Patients who were LAM+ve were more likely to be confused (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2–3.7, P = 0.0045), have a higher median heart rate (P = 0.0135) and an elevated quick sepsis-related organ failure assessment score (≥ 2), OR = 3.5, 95% CI = 1.6–7.6, P = 0.0014. A LAM+ve test was significantly associated with disseminated TB (dTB), P 0.0001, TB-related immune reconstitution inflammatory syndrome (IRIS), P = 0.0035, and abdominal TB, P 0.0001. Laboratory predictors of a LAM+ve status included renal dysfunction, P = 0.044, severe anaemia, P = 0.0116, and an elevated C-reactive protein, P = 0.0131. Of the 12 PLWH with disseminated non-TB mycobacteria cultured from the blood and/or bone marrow, n = 9 (75%) had a LAM+ve result (OR = 5.8, 95% CI = 1.6–20.8, P = 0.0053).Conclusion: Urine LAM testing of hospitalised PLWH with suspected active TB had significant diagnostic utility in those that were sputum-scarce or sputum-negative. A LAM+ve result was associated with dTB, clinical and laboratory markers of severe illness, and TB-IRIS. Disseminated non-tuberculous mycobacterial infection of hospitalised PLWH may also yield urine LAM+ve results, and mycobacterial cultures must be checked in those non-responsive to conventional TB treatment. Selective use of the LAM test in the critically ill is likely to maximise the diagnostic yield, improve the test’s predictive value, and reduce the time to TB diagnosis and initiation of treatment.