THE

EFFECTS
CAPTAIN

OF MALARIA
HOWARI) B. SPRAWE.

ON THE
KC.,

HEART

USNR

LTHOUGH it is probably true that malaria is the most widespread and

serious disease in the world, this knowledge had not had a proportionate
influence upon medical thinkin g in the United States until our experience in the
Pacific during World War II brought the problem to the fore. Of the so-called
tropical diseasesbrought back IO us frown the comljat areas, malaria is the one
about which there arise the most frequent questions. There is concern not onl),
about the public health aspects of malaria, but also al)ont its permanent effects
upon individuals infected with the plasmodia.
Though malaria is a discasc from which no organ or tissue is exempt, this
paper is concerned with its influence nl~on the circulation, and more particnlarl?
upon the heart itself. Of the characterist its peculiar to malaria, those whic*h
might be expected to affect. t,he hc>art are (1 ) its chronic alit1 recurrent nature.
(2) the systemic t-osemia 01 the paroxysm, (3) the l)roiound anemia produced
by hemolysis and suppression of hemopoiesis,and i-1-) t hc occlrlsion of cxpillaries
and arterioles of the myocardinm. The 1~nblishcd cl in ical and pat.hcJogic st,udicas
of malaria indicate that ihcsc arc, ill ia~t, the m~~(*ll:lt~is1~~s
in\-olved.

Medical literature, cspcriall!- that from l~rallcc, Italy, and llatin America.
abounds with refercnccs to a grc;11 1111ml~rof cardiov:lsc~ulnr injllries altribut,ed
t,o malaria. While in genc>ralIlic~ 1x1
Fcrc~iccssccni t.0 1~ :I massof snpposititious
material, it must be conccdecl that th(l in~l~licntions in these papers are partl)
based on observations OClong-standing. inadequatel;v t rcated caseswhich would
not be seen in 0~11Army. Navy, an<1Jlarillc Corps personnel.
Long before the malarial l>;tr;lsitc was tlisco\-crctl in 1830, it was bclievecl
that the heart was frequently injured 1);~the disease. liaveran published a dcbscription of such cases,and in lP90 they wcrc summarized by Ranzier. Durozicz
reported instances in whic*h malari;l hilt1 1~1~odnced
various valvular and myo
cardial changes in whic~h pigmcnl atioll was prominent. Iremoli&es and Caussade described aort,ic> caoronar:-, c~ndocardial, mural, and arterial injuries in
acute and chronic casts of nlalaria.
Tlley found 42 rdascsof patients with
cardiac involvement among 1,000 patients with malaria. In 17 of these 42 casts.
the involvement was fnnc:t.ional : four had precordial pain ; four, palpitation :
three, breathlessness: and five, permallent, and one, l);\rosSsmal, tachycnrdia.
Castellani reported w cast oc heart block in n midcllc-agod man cured by the uw
The opinions c?ntained in t!lis article are the private ones of the writer and are not to
,; ggtruetrued as offlcml or reflectmg the Views of the Navy Department or the Naval servir~
Rewived

for publication

Jnly 20. 11145.

426

SPRAGUE

EFFECTS

OF

MALARIA

ON

427

HEART

ot quinine and three cases of angina pectoris cured by the same drug. Iz~nceraus
quotes the case of a woman 31 years of. age with angina pectoris and a double
aortic murmur which lx believed were due to malarial aortitis.
It is of int,crest to remember that the de Musset sign, nodding of the
Ilead with each heart beat when there is pronouncc~l aortic regurgitation,
was
named for Alfred de Mnssct IQ; his brother, w1~1 ascribccl his nortitis to malaria
xquircd
in Italy.

Cli)ticuZ Llsl~cc~s---The
effect (Jf malaria on the Awulxt,ion
differs with the
stagxl an(l scverit,v of the disease. In malarial clamaye to the brain, it has been
our cslwrience
t.hat fnn~tional c>crelnxl disturbances
most often owixr and true
*cc~t~l~txl malaria in which tllromhosis
of the lmiu capillaries is the charactcristic I~1tliology occurs but rnrel~-. SII in cxdiac m;rlarin a series ol functional
alwrrat ions may hc commonly found, hut the syndrome oi heart failure is s-rr~.
infrequc~nt.
~~askcll and Pillar, in a review of their espcrienw
in World WiII.
I a wit II very severe cases of malaria in Serbians, divitled thcl fatal cases into tlic.
true ccxi7>hral. the selbticemic, ill1l.l the cardiac types.
Thq- stated that, Thus
c~;lrdiac t>-I)e is only lilxl\- to lx fatal when hospital arrangements
11aw to wpt~
with an owr~vlictlming
numhcr of serious cases.
It n-as shown hy Brown and Loercnhart
(1913 1 tilat the inject,ion of alkaline
11emafin into clogs ant1 cats caused dilatation
{If ili(l splanchnic
vessels, cnnstrict ion ot cutaneous vcsscls, and market1 fall in I~10~~11
l)ressurc.
The sloxving
01 the hcnrt arid rcdnction ia c~artline ont,pnt arc 11111~
mainly to the toxic effect
011 t.hc v:isoniotor and cal,clioilihiIJitory
centers.

fc~fllolm/ic
P,indi,~!/s.--Pallic,lo~ic studics ui the heart in fatal malaria hare
bwn estc~nsive. Over 40 years ago Ewing dcwrilxd the clilntcd, pale. or slightly
brownish-tinged heart muwlc wit II ~Xrinuclcirr masws of greenish pigment, in
thct rclls. In one exceptional case the distcnclctl caIGllarics of the heart wall
were filled with young parasites and pigmented ~11s. Ill 1917
Salonica
Dudgeon and Cl;wBe found mym~clinl changes in malaria similar to those
0C diphtheritic myocnrditis. Of tlwir 45 fatal C;LSCS.
23 showed fatty degeneration of the heart muscle. There was also l)locl;inc of the capillaries and arterioles, local hemorrhage, and deposit of pigment. Eragmentation of the muscle
may he extreme. Gasliell and Jlillar found the sulJlertian parasites among or
iIt

428

AMERICAK

HEART

JOURNAT,

In describing the effects of malaria on the peripheral vascular sys~cm, tht,

older writers
describe malarial arteriosclerosis,
obliterative endarteritis,
veiloxs
thrombosis, and the previously mentioned aortitc
paludkcne.
Contemporary
authors generally
agree, howcver~ with the rcvwlt statrtllent of Cannon that the reticula-endotlielial
system is most commoiil~- iIlffWtec1
ill malaria, and that the myocardi~un and other organs are rarely affcrtctl. Endothelial phagocytosis
fortunat cl,v occurs mainly, ilt not \~l~oll,v, ill t11e sl~leci~,
liver, and bone marrow.
kurtherrnorc,
it mrlst Iw em~~ltasized that t IIc malignant
trrtiail
(falciparum)
malaria parasite is tlic l)rcclo2nitinfing
orgauism ii1 fillminating, vascular occlusive, fatal malaria regardless of the type of t.erminal
process.
EXPERIENCE

WITH

SOUTH

PACIFIC

MALARIA

The author served as Chief of Medicine in a Naval Mobile Hospital in Nex

Zealand for a year hetwcen Aug. i, 1942, when the Marines started the Solomon
Islands Campaign, and August, 1943, when 1~ joined a hospital ship in the
South Pacific Area.
Since January,
1944, hc has hecn Chief of Medicine in a
ol)servation trf
large continental
Naval hospit al. These 1~~1s haw permitted
malarial patients from 1.1~ carlj- days of their infection to a time almost three
years later, when the men with r~lapscs are still being admitted to the hospital.
Although many thousands of patients with malaria have passed through these
medical scrvkes, there has been no clear-cut case of malarial heart disease. The
~ilost severe cases of malaria, of co~trsc,
wwt
sccll
ill
New Zealand
in iMarines
from Guadalcanal.
At this time prophylasis,
therapy, and malaria control were
121thongh three patients died iwnt malaria with ccrcl~ral
llut we11 understood.1
lnanifestatiuns,
there was Ito slwific
palholog~ ill lh:
hct21*l
at autcll,s>~.
Thcs
IJldv
patient showing rtillic%l
cffcvt.
\Vas
ollc
Who,
during iIitravellOLlS
cluininc therapT, de\-clopc~l p~~~~ltal~lcc~~nrl~lcl~~L\-V hloclr with ventricular
fit,rilIntion.
The electl,~,r:artlicl~ral!!
I ake~i after Ihe pat,iwt
had responded to illIravenous
adrenalin shoncd allriculur
paroxysmal
tachycardia
with right axis
cleviation.
The patient made a complete cardiac recovery.
Patients with many relapses of vii-as malaria continue to enter Naval hospilals iI1 the TTnited States.
We hare ohserved approsimately
2,000 relapse a&
Cilditlca

tnission cases in the past sistecn months.

In none of these patients with chronk
relapsing malaria was any cardiac condition discovered which could be spcl
cifically attributed
to malaria.
,4ny chronic disease, especially one resultinq in
anemia, may produce the symptoms of irritable heart with tachycardia and premature lwats.
Functional
systolic murmurs may be found but even these have
tlot lwn common among the patients at the hospital.
B swies of 50 cases oi rccurrcnt
malaria, all bnt one of the vivas type,
w<rc st Iitlicd clcctrocnrdio~raphicall~~.~
All of the lbaticnts had had recurrent
mal;l~i:~i attacks, some over a period of thirty-three
11lolItl~s.
Two had cerebral
syml)toms indicating a probable organic change caused by rascular occlusion an(l
1wu1t in: in the malarial enceplialopathy syndrome.
The electrocardiograms
n-wr
~~ltcn ~worded directly after the chill, while the patient n-as still febrile. Sonic
of tllc lwticnts
had had owr a dozen relapses.
One patient, in addition to cl?\-cn
~wurml~~y
had had scrub typhus and scarlet fever, but the cardiac findinzs
were normal.
In two typical patients observed directly
after the vhill thci
clcctroc~nrdio~rams
were normal, ant1 the pnlsc
rates ww
76 and 7s. The O~IP
patient with falciparum
parasites in the 1~100~1had acqnircd the infection thaw
months ljcforc on the wst
African
coast, Again 1 ll?lY? IVClC? 110 PilrfliilP
alinormalities.
Among the entire group of 50 patients there wnh no clectrocardic~~ral,hic
finding which could not bc considered either within normal variants or of nonspecific import.
In tracings
of malarial
patients
studied
in the Tarious
Kavnl activities
mentioned, we have recorded writ ricular and auritrular prrmatlwe beats, low T lvavcs associated with anemia. nodal tachpcardia,
right
axis deviation of slight degrer, sinns bradycardia
and tachvcardia,
an(l a P-I<
interval of 0.21 second.
DISCUSSIOY
I~rurrl
the evidence presented in the literature
it seems justifiable
to consider that malaria? especially of the malignant tertian type, may rarely l,e fatal
by- its direct nlyocardial effect, which is cithcr toxic or anoxic through coronaqcapillary occl~~sion. 011 the other Iland! cveil when malarial patients (lie frolti
septiccmic 01 cerclnxl Iiicclianisnis, the heart seems 11, 1~ vcr~- infreqilcntly
:lffected.
There is also evidence in the literature tllat, l~rulongecl relapsing malaria in
11:11
iv(3s of malarions count,ries may rwult in chronic cardiac disturl,anccs.
n-liicli
may progress even to the point of cardiac dilatation. ventricular
aneurysm, and
cardiac rupture.
In chronic malaria the influence oi malarial cachesia. n-liicil
is a complex nutritional
and hemo~lnstic affair, ncwmpanied
b- witlcspwarl
pigment deposit throughout
the body and 1,~ capilla~~~- occIusion, 111ay ~l+Odll(~CL
vliangcs in the circulation indistinSuislial~le
from tliosc~ of chronic anemia. Tll~rc
is no evidence of critical value to show that val\-alar heart rlisc,ase or ;lol*titis
results from malaria.
The possibility
that members of our own Armed Services may develop
liardiac pathology from recurrent
malaria is very remote. 0nr men are treated
charge

*This
of

was done
the mal:wia

with
the
servicr.

Cooperation

of

Commander

William

:\.

Costos.

N.C.,

T!SNR,

in

430

AMERICAN

HEART

JOURNAL

early and adequately;

the factors of malnutrition,
avitaminosis,
complications
(such as blackwal er fever) iire vjgoronsly atlacked.
izntion is readily availahlc.

anemia, and
and hospital-

CONCLUSIONS

According
to the literature
heavy plasmodial iilfccticln
(eslwially
with
Plasmodiunz
fulcipurwm)
, or untrcatcd
or inadequately
treated malaria can
cause death from myocardial
inflammution
or capillary infarction,
and chronic
recurrent
malaria can produce myocardial pathology similar to that caused 1~
prolonged anemia. However, malaria, in our experience with several thousand
cases occurring
in members of the Armed Forces of the United States, has
resulted neither in acute cardiac death nor in any proved
chronic cardiac diseaw.
REFERENCES
Malari:tl
Psychoses
and Neuroxs,
Oxford
Press,
London,
1927.
1. Anderson,
W. K.:
(Extensive
bibliography.)
Blalari:~,
Riforma
med. 56:
Right
Bundle
Branch
Block
in clhronic
2. Giordano,
F.:
408, 1940.
Arch.
Iatino
am. de cardiol.
)E. G.:
Cardiovascular
Apparatus
in BIalaria,
3. Carillo,
hemat.
9: 209, 1939.
stu(licb
on Malignant
Xalari:i
in Mal~cilIJnia,
Qmr1.
4. Gaskell,
J. F., and Millar,
VV. L.:
J. Med. 13: X31, 1919-1920.
The Physiological
Pathology
of Ill:Llari;t,
Section
V, in A Symposium
5. Meleney,
H. E.:
on Human
Malaria,
p. 229.
Publication
No. 15 of the American
Assocmtion
for
the Advancement
of Science,
Washington,
1941.
Die
Malaria.
In
Henke,
F.,
alld
I,ubarsch,
0.:
Handlr.
dcr
spezicllen
6. Seyf arth,
C. :
pathologischen
Anatomie
und Histologie,
Berlin,
1926, Springer,
,~ol. 3, p. 190.
Contributions
to Pathological
Anatomy
of Vnlarial
Fever,
J. Espcr.
Jlc~l.
7. Ewing,
J.:
6: 119, 1901.
:\ (!ontrilmt,ioll
Ii) lllr- .\Iir~rc,sc~~~l)il~:tl Histology
i)f
8. Dudgeon,
L. S., and Clarke,
C.:
Malaria,
Lancet
2: 153, 1917.
I disturbi
cardiac;
nella
m:Llnrin,
Str(l. I:ln(~ic.
clrgli.
o>l)c(l.
11i I(~
1: ::,
9. Gallenga,
1902.
Section
17, in A Symposium
on Human
10. Some Pathologic
Aspects
of Human
Malaria,
Malaria,
v.5 Supra,
p. 215.
11. MeGinn,
S., and Carmody.
.T. T. B. (crellral
Symptoms
in Malaria.
TT, R. Nav. RI. Bull.
13: 1157, 1944.
12. Reference
1, p. 61.