Novel presentation of Plasmodium vivax malaria with acute kidney injury and hemolytic uremic syndrome

Background

In India, epidemiologically, Plasmodium vivax predominates over Plasmodium falciparum malaria, and this produces a major public health problem due to the recent increase in severe vivax malaria. Malaria-related renal failure is usually ascribed to acute tubular necrosis (ATN) and interstitial nephritis, and rarely to cortical necrosis. Clinical features of hemolytic uremic syndrome (HUS) and thrombotic microangiopathy (TMA) on renal histology have not been described conclusively in relation to malaria.

Methods

This prospective observational study includes patients of vivax malaria with renal failure admitted to a tertiary care hospital during November 2011 to April 2012 with features of HUS (anemia, thrombocytopenia, and acute kidney injury). The diagnosis of P. vivax malaria monoinfection was established with detection of parasite in peripheral smear and malaria card test. Renal biopsies were performed after three weeks for nonrecovering renal failure and evaluated with light and immune-fluorescence microscopy.

Results

Five patients (2 males and 3 females) had clinical constellation of HUS associated with vivax malaria. All the patients required dialysis [1 peritoneal dialysis and 4 hemodialysis (HD)]. Renal biopsy performed in all the patients showed characteristic features of TMA like mucointimal proliferation, subintimal fibrin deposits with luminal thrombi along with ATN, and cortical necrosis. Three patients were dependent on dialysis [1 continuous ambulatory peritoneal dialysis (CAPD) and 2 HD]. The rest of the two patients had partial recovery at the end of 3 months. The patient on CAPD died due to pneumonia-related sepsis.

Conclusion

Clinical association of vivax malaria with TMA leading to HUS is novel and suggests parasite-related severe endothelial injury. Future studies are needed to demonstrate interaction of parasite with endothelium and factors related to it.