New WHO guidelines already point to hyperbilirubinaemia (total bilirubin > 3.0 mg/dL) as being a weak marker of severity, unless it is followed by any other vital organ dysfunction [106] . This finding seems to be the most frequent among children and adults with vivax disease considered as 'severe' [122, 123] . Since haemolysis is not usually as severe as to cause significant clinical jaundice, most of these patients actually have some hepatocyte necrosis as evidenced by the mild to moderate liver enzymes (AST/ALT) increase with subsequent cholestasis [124] . It was shown that icteric syndrome was a common cause of hospitalization in pregnant women with vivax malaria in Manaus [87] . It was also detected in newborns [59, 74] , which makes vivax malaria an obligatory differential diagnosis of neonatal sepsis. Jaundice in the presence of vomiting and upper abdominal pain should raise suspicion on acalculous cholecystitis, a poorly described complication apparently with good prognosis [125] . Other diseases that may evolve to an icteric syndrome may be ruled out, especially because they are also more frequent in the tropics, such as leptospirosis [34] and typhoid fever [126, 127] . Hepatitis A virus (HAV) and vivax co-infection has already been reported as cause of jaundice and high elevation of transaminases [45] . Hepatitis B virus (HBV) is also highly prevalent in Brazil, especially in the Amazon [128] and there is some evidence that P. vivax/HBV co-infection may be related to more frequent jaundice [80] and higher transaminase levels.