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. 2020 Nov 19:7:589379.
doi: 10.3389/fmed.2020.589379. eCollection 2020.

Does Malaria Cause Diarrhoea? A Systematic Review

Isatou C M Sey  1 , Ajoke M Ehimiyein  1   2 , Christian Bottomley  3 , Eleanor M Riley  1 , Jason P Mooney  1
Affiliations

Does Malaria Cause Diarrhoea? A Systematic Review

Isatou C M Sey et al. Front Med (Lausanne). .

Abstract

Malaria is a systemic febrile disease that may progress to prostration, respiratory distress, encephalopathy, anemia, and death. Malaria is also an established risk factor for invasive bacterial disease caused, in the majority of cases, by invasive enteropathogens and in particular by non-Typhoidal Salmonella (NTS). Whilst various malaria-related pathologies have been implicated in the risk of NTS bacteraemia in animal models, including intestinal dysbiosis and loss of gut homeostasis, clinical evidence is lacking. As a first step in gathering such evidence, we conducted a systematic review of clinical and epidemiological studies reporting the prevalence of diarrhoea among malaria cases and vice versa. Database searches for "plasmodium" and "diarrhoea" identified 1,771 articles; a search for "plasmodium" and "gastroenteritis" identified a further 215 articles. After review, 66 articles specified an association between the search terms and referred primarily, but not exclusively, to Plasmodium falciparum infections. Overall, between 1.6 and 44% of patients with acute malaria infection reported symptoms of diarrhoea (812 of 7,267 individuals, 11%) whereas 5-42% of patients presenting to hospital with diarrhoea had an underlying malaria parasite infection (totaling 749 of 2,937 individuals, 26%). However, given the broad range of estimates, a paucity of purposeful case control or longitudinal studies, and varied or poorly specified definitions of diarrhoea, the literature provides limited evidence to draw any firm conclusions. The relationship between malaria and gastrointestinal disturbance thus remains unclear. Carefully designed case-control studies and prospective longitudinal studies are required to confidently assess the prevalence and significance of intestinal manifestations of malaria parasite infection.

Keywords: coinfection; diarrhoea; intestine; malaria; plasmodium; systematic review.

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Figures

Figure 1
Figure 1
An illustration of the search process, as outlined by the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).” Following database searches for “Plasmodium AND Diarr*,” “Plasmodium AND Diarrhoea OR Diarrhea,” or “Plasmodium AND Gastroenteritis” a total of 2,550 articles were identified. One relevant article was added which was not found by the search scheme (29). All abstracts were imported into Covidence software for subsequent double-blind review. Five hundred sixty-four duplicates were removed, leaving 1,986 for title and abstract screening. Articles were included if keywords were mentioned in the title or abstract; including “malaria,” “Plasmodium,” “diarrhoea,” “dysentery,” “gut,” and “intestine.” Articles were then grouped according to study type and primary presenting syndrome. *Of the 1,576 excluded articles, 50 were randomly re-reviewed for exclusion, with reasons reported in Supplementary Table 1. Four hundred ten full-text articles were screened and 344 were excluded, with reasons reported in Supplementary Table 2. In all, 66 articles qualified for data extraction. ‡Case reports accounted for 22 articles. §Thirty-six articles reported diarrhoea secondary to the presentation of malaria parasite infection. ||Eight articles reported malaria as a condition underlying the presentation of diarrhoea.
Figure 2
Figure 2
Prevalence of diarrhoea in subjects with malaria. Studies are grouped by setting: (A) patients seeking care in a hospital setting in an endemic area, (B) community survey; (C) malaria in travelers admitted to hospital on their return home. Dotted line represents the prevalence estimate from the combined data: (A) 13%, (B) 9%, and (C) 9%. Symbols denote the age of the studied cohort: children (circle), adults (square), or all ages (diamond).
Figure 3
Figure 3
Prevalence of malaria parasitaemia in patients with diarrhoea. Summary of studies where diarrhoea was the primary presentation and malaria parasite infection was subsequently ascertained. Dotted line represents the prevalence estimate from the combined data (26%). All studies were conducted in children.
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