title: Postmortem characterization of patients with clinical diagnosis of Plasmodium vivax malaria: to what extent does this parasite kill?
abstract: BACKGROUND
  Severe disease attributable to Plasmodium vivax infection is already well described worldwide; however, autopsies in these patients are scarce.
  
  
  METHODS
  From 1996 to 2010, 19 patient deaths with a clinical diagnosis of P. vivax infection occurred in a tertiary care center in the Brazilian Amazon. Seventeen of these 19 deaths were fully autopsied. Clinical charts, macroscopic autopsy reports, and stored paraffinized tissue blocks were retrieved. Nested polymerase chain reaction was performed in paraffinized samples of spleen and lung to confirm P. vivax monoinfection. Immunohistofluorescence was used to detect P. vivax parasitized red blood cells (RBCs).
  
  
  RESULTS
  Of 17 autopsies, 13 revealed that death could be attributed to P. vivax infection; in the remaining 4, acute diseases other than malaria were found to be the cause of death. The primary complication in patients in which malaria contributed to death was acute respiratory distress syndrome (ARDS) and pulmonary edema associated with the accumulation of neutrophils in the interalveolar space (6 cases). Spleen rupture (3 cases) and multiorgan dysfunction syndrome (3 cases) were the second most common complications. One child evolving with coma was also characterized, but no parasite was detected in the brain tissue. In one patient who developed ARDS and presented negative peripheral parasitemia by the time of death, scattered parasitized red blood cells were seen inside pulmonary capillaries, suggesting some sequestration in the lung.
  
  
  CONCLUSIONS
  In 13 of 17 deceased patients, P. vivax infection was the plausible cause of death. However, more studies are needed to understand pathogenesis related to severe disease.
authors: Laboratory of Malaria, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Manaus, Amazonas 69040-000, Brazil. marcuslacerda.br@gmail.com
authors: Marcus V G
authors: MV
authors: Lacerda
authors: Silvio C P
authors: SC
authors: Fragoso
authors: Maria G C
authors: MG
authors: Alecrim
authors: Márcia A A
authors: MA
authors: Alexandre
authors: Belisa M L
authors: BM
authors: Magalhães
authors: André M
authors: AM
authors: Siqueira
authors: Luiz C L
authors: LC
authors: Ferreira
authors: José R
authors: JR
authors: Araújo
authors: Maria Paula G
authors: MP
authors: Mourão
authors: Mireia
authors: M
authors: Ferrer
authors: Paola
authors: P
authors: Castillo
authors: Lorena
authors: L
authors: Martin-Jaular
authors: Carmen
authors: C
authors: Fernandez-Becerra
authors: Hernando
authors: H
authors: del Portillo
authors: Jaume
authors: J
authors: Ordi
authors: Pedro L
authors: PL
authors: Alonso
authors: Quique
authors: Q
authors: Bassat
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001344:Autopsy; D002648:Child; D005260:Female; D006651:Histocytochemistry; D006801:Humans; D007223:Infant; D016780:Malaria, Vivax / Q000175:diagnosis / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D010966:Plasmodium vivax / Q000302:isolation & purification*; D011654:Pulmonary Edema / Q000469:parasitology; D012128:Respiratory Distress Syndrome / Q000469:parasitology; D012189:Retrospective Studies