Accurate Diagnosis of Cerebral Malaria: A Role for
Parasite Histidine-Rich Protein 2? Chandy C. John Division of Global Pediatrics, University of Minnesota Medical School, Minneapolis (See the article by Seydel et al, on pages xxxxx.) The World Health Organization (WHO) denition of cerebral malaria requires Plas- modium falciparum parasitemia and coma not attributable to convulsions, sedatives, hypoglycemia, or another detectable non- malarial cause [1]. In a series of elegant autopsy-based studies, Taylor and col- leagues demonstrated that as many as 23% of children who meet this WHO denition of cerebral malaria actually die from other causes and that the presence of malaria retinopathy has a >90% sensitivity and specicity for predicting true cerebral malaria, in which parasite sequestration is documented in cerebral capillaries [2]. As- sessment of malaria retinopathy in cerebral malaria has led to signicant research ad- vances, but the assessment requires highly specialized training and equipment, so it has not been practical in clinical settings in most low-income countries. Parasite histidine-rich protein 2 ( pHPR2) is produced by P. falciparum throughout its life cycle [3]. It is released from infected erythrocytes as a water- soluble protein [4]. In areas of low to moderate transmission, plasma concen- trations of pHRP2 appear to correspond well to body parasite biomass [5]. Elevat- ed pHRP2 concentrations may, there- fore, reect a high level of sequestered parasites. In the current issue of the journal, Seydel and colleagues provide evidence that high pHRP2 concentra- tions are an excellent marker for biopsy- or retinopathy-conrmed cerebral malaria [6]. The study design has several strengths that boost condence in the accuracy of its ndings, including the use of 3 study groups, which allowed for initial testing, establishment of an optimized pHRP2 cutoff level, and prospective assessment of the sensitivity and specicity of that cutoff level. The rst study group consisted of children with WHO-dened cerebral malaria who died. The pHRP2 concentra- tions in children with autopsy-conrmed parasite sequestration were compared with the pHRP2 concentrations in those without sequestration. The pHRP2 con- centrations distinguished almost perfectly between the 2 groups (area under receiver operating characteristic curve, 0.98). The second study group consisted of children from an earlier study who had WHO- dened cerebral malaria and who did (cases) or did not (controls) have malaria retinopathy. The pHRP2 concentrations in this group were used to identify a cutoff pHRP2 concentration that yielded optimal sensitivity and specicity for malaria retinopathy. The third study group was a cohort of children with WHO-dened cerebral malaria who were examined prospectively for malaria retinopathy. The pHRP2 cutoff concentration established in the second study group was assessed in this third study group. The established pHRP2 cutoff concentration (1700 ng/ mL) had a positive predictive value of 94% and a negative predictive value of 79% for malaria retinopathy. With these positive and negative predictive values, a pHRP2 value above the cutoff in a child with a di- agnosis of cerebral malaria would greatly strengthen condence in the diagnosis, whereas a value below the cutoff might prompt more vigorous investigation of other potential causes of coma. Because almost a quarter of children classied as having cerebral malaria actually have other reasons for coma, a pHRP2 cutoff test may prompt the clinician to seek and address other diagnoses early in the disease process. This application is one for which a simple pHRP2 concentration- based test holds real promise as a tool that could improve disease outcome. So, are we ready to move to eld use of a pHRP2 concentration-based test to identify true cerebral malaria in children and adults with P. falciparum parasite- mia and coma? Not quite yet. First, other studies are needed to replicate the ndings reported here by Seydel et al. In particular, it will be important to assess whether ndings are similar in older children and adults in Southeast Asia who develop cerebral malaria. Second, uniform protocols for measurement of Received 6 March 2012; accepted 17 May 2012. Correspondence: Chandy C. John, MD, Division of Global Pediatrics, University of Minnesota Medical School, 717 Del- aware St SE, Rm 366, Minneapolis, MN 55414 (ccj@umn. edu). The Journal of Infectious Diseases The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/infdis/jis373 EDITORIAL COMMENTARY JID 1 Journal of Infectious Diseases Advance Access published June 11, 2012
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pHRP2 will need to be agreed upon, as multiple testing methods and protocols currently exist. The cutoff of 1700 ng/mL proposed might not be appropriate for a test using different pHRP2 standards or antibodies. Ideally, identical or highly similar testing kits and protocols should be used in the comparator studies. Third, the presence of pHRP2 deletions must be sought in areas where testing is conduct- ed or proposed. Parasite populations that lack pHRP2 have been documented in the Amazon [7], and populations with deletions in the histidine-rich repeat region of the hrp2 gene have been report- ed in Mali [8]. In these areas, pHRP2 concentrations may be low or unmeasur- able, and a test of pHRP2 concentration would be useless. This potential obstacle underscores the importance of conrma- tory studies in other malaria-endemic areas. Furthermore, in areas of high malaria transmission, pHRP2 concentra- tion may reect recent as well as current infections and may not predict disease severity [9]. Thus, in areas of high trans- mission, assessment of pHRP2 concen- tration may have little utility in the diagnosis of cerebral malaria. However, because most cerebral malaria occurs in areas of low to moderate and unstable transmission, this possibility is not a major concern. Finally, the study by Seydel et al was designed specically to differentiate in children with P. falcipa- rum parasitemia and coma those who were retinopathy positive ( presumed true cerebral malaria) from those who were retinopathy negative ( presumed to have another cause of coma). Children with other forms of severe malaria may have signicant parasite sequestration and high pHRP2 concentrations. The ndings of the study by Seydel et al do not support the use of a high pHRP2 concentration to differentiate cerebral malaria from other forms of severe malariathat is a clinical decisionbut rather support its use to improve accura- cy of the diagnosis of cerebral malaria in the child with P. falciparum parasitemia and coma. With all of these caveats, high-concentration pHRP2 is a great candidate for a rapid diagnostic test (RDT), because pHRP2 is already the basis of RDTs widely used in low- income countries for diagnosis of clinical P. falciparum malaria [10]. If current pHRP2 RDTs can be modied to detect pHRP2 above a specic concentration, a high-concentration pHRP2 RDT could be available for practical use in hospitals in low-income country in a relatively short period of time. It will take a few years and several more studies to know whether a point-of-care test based on a cutoff concentration of pHRP2 can improve the diagnosis of cere- bral malaria in the eld. It is likely that this test will not be useful in all areas where P. falciparum malaria is endemic. But to date no other biomarker for cere- bral malaria has demonstrated the high positive and negative predictive values seen for pHRP2 in the study by Seydel et al. A test of pHRP2 concentration could be the rst eld-based test since microsco- py to improve the diagnosis of cerebral malaria. That potential makes this study an exciting new contribution to research on severe malaria. Notes Financial support. The author receives funding from the National Institute of Neuro- logic Disorders and Stroke, the National Insti- tute of Child Health and Development, and the Fogarty International Center for malaria research and training. Potential conicts of interest. The author was one of multiple collaborators in a 1-year, multisite project of which Dr Terrie E. Taylor was principal investigator (20102011). He re- ceived no compensation for this project and has not published with Dr Taylor. All authors have submitted the ICMJE Form for Disclosure of Potential Conicts of Interest. Conicts that the editors consider relevant to the content of the manuscript have been disclosed. References 1. World Health Organization. Severe falcipa- rum malaria. Trans R Soc Trop Med Hyg 2000; 94(Suppl.):145. 2. Taylor TE, Fu WJ, Carr RA, et al. Differen- tiating the pathologies of cerebral malaria by postmortem parasite counts. Nat Med 2004; 10:1435. 3. Desakorn V, Dondorp AM, Silamut K, et al. Stage-dependent production and release of histidine-rich protein 2 by Plasmodium fal- ciparum. Trans R Soc Trop Med Hyg 2005; 99:51724. 4. Parra ME, Evans CB, Taylor DW. Identica- tion of Plasmodium falciparum histidine- rich protein 2 in the plasma of humans with malaria. J Clin Microbiol 1991; 29:162934. 5. Dondorp AM, Desakorn V, Pongtavornpinyo W, et al. Estimation of the total parasite biomass in acute falciparum malaria from plasma PfHRP2. PLoS Medicine 2005; 2:e204. 6. Seydel KB, Fox LL, Glover SJ, et al. Plasma concentrations of parasite histidine-rich protein 2 distinguish between retinopathy- positive and retinopathy-negative cerebral malaria in Malawian children. J Infect Dis 2012; doi:10.1093/jinfdis/jis371. 7. Gamboa D, Ho MF, Bendezu J, et al. A large proportion of P. falciparum isolates in the Amazon region of Peru lack pfhrp2 and pfhrp3: implications for malaria rapid diag- nostic tests. PloS One 2010; 5:e8091. 8. Koita OA, Doumbo OK, Ouattara A, et al. False-negative rapid diagnostic tests for malaria and deletion of the histidine-rich repeat region of the hrp2 gene{dagger}. Am J Trop Med Hyg 2012; 86:1948. 9. Manning L, Laman M, Stanisic D, et al. Plasma Plasmodium falciparum histidine- rich protein-2 concentrations do not reect severity of malaria in Papua new guinean children. Clin Infect Dis 2011; 52:4406. 10. Baker J, Ho MF, Pelecanos A, et al. Global sequence variation in the histidine-rich pro- teins 2 and 3 of Plasmodium falciparum: implications for the performance of malaria rapid diagnostic tests. Malaria J 2010; 9:129. 2 JID EDITORIAL COMMENTARY
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