Comprometimento pulmonar na malária (revisão)

Marcos Boulos, Jane Margarete Costa, Carlos Eduardo Tosta

Pulmonary involvement occurs in 3 to 10% of the cases of Plasmodium falciparum malaria and represents the most serious complication of this infection, with a lethality of about 70%. The understanding of its pathogenesis is still very fragmentary, however it is recognized that activation of the immune system by antigens released by the parasite plays an important role in the induction and worsening of lung damage. Capillary endothelial cells, which control the flux of fluids to the interstitial space, appear to be the most involved structure. These cells are activated by cytokines, produced by lymphocytes and macrophages during the immune response, and express receptors and molecules of adhesion, allowing for sequestration of parasitized erythrocytes and adherence of cells, which will produce locally inflammatory mediators. The inflammatory reaction and lesion of endothelial cells that ensue, together with the hemodynamic alterations induced by the capillary blockade due to the sequestration of parasitized erythrocytes and leukocytes, cause alterations of the vascular permeability and transfer of liquid to intertitial space and alveoles. Severe cases are clinically expressed by a picture of Adult Respiratory Distress Syndrome. The clinical manifestations of pulmonary involvement may start suddenly at any time during the course of malaria, even after disappearance of circulating parasites. The inducing factors are unknown. Hyperparasitemia, renal failure and pregnancy are predisposing factors. The prognosis will depend on how fast the diagnosis is established and convenient treatment initiated. If parasites are present they shall be treated with schizonticidal drugs, hemodynamic parameters continuously evaluated, preferably through a Swam-Ganz catheter. Appropriate oxygen supply and fluid balance have to be warranted. Other complications of malaria, frequently associated to the pulmonary involvement, need special attention and proper treatment. A better understanding of the pathogenesis of lung damage associated to malaria will certainly help to improve treatment and reduce morbidity and mortality.