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ORIGINAL ARTICLE |
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Year : 2013 | Volume
: 6
| Issue : 2 | Page : 175-178 |
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Hematological aspects in malaria
Pradhan M Pagaro, Pradeep Jadhav
Department of Pathology, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
Date of Web Publication | 10-Apr-2013 |
Correspondence Address: Pradhan M Pagaro Department of Pathology, Dr. D. Y. Patil Medical College, Sant Tukaramnagar, Pimpri, Pune - 411 018 India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.110310
Background: Malaria is a major health problem at the global level. In Indian subcontinent, it is a major cause of mortality in immunosuppressed patients and in extreme ages of life. This study is based on early detection of malaria by hematological parameters to reduce the mortality in such cases. Materials and Methods: All patients with fever of less than 7 days in duration were included in the study. Hematological parameters were determined by using automated cell counter. Peripheral blood smear examination for malaria parasite was taken as gold standard for the diagnosis of malaria. Result: A total of 110 patients were included in the study. Ninety nine patients had a positive peripheral smear for malarial parasite. Thrombocytopenia (52.52%) alone (platelet count less than 1, 50,000/mm 3 ) was a predictor for malaria and in combination with anemia (Hb < 10 gm/dl) it was next best parameter. Leucocyte count was not predictive. Conclusion: The conclusion of this study is that the presence of thrombocytopenia in a patient with acute febrile illness increases the probability of malarial infection. Keywords: Malaria, P. falciparum, P. vivax, thrombocytopenia
How to cite this article: Pagaro PM, Jadhav P. Hematological aspects in malaria. Med J DY Patil Univ 2013;6:175-8 |
Introduction | | |
Malaria is an acute, recurrent and sometimes chronic vector borne protozoan disease which has worldwide distribution in tropical and subtropical regions. [1],[2],[3]
Infection is caused by a parasite of genus plasmodia which is transmitted to human beings by a preinfected female anopheline mosquito. [4] Genus plasmodium have 4 species- P. vivax (PV), P. falciparum (PF), P. malariae and P. ovale. In India, P. vivax and P. falciparum are the species commonly found. In spite of worldwide efforts to reduce malaria transmission, it is still the major cause of morbidity and mortality, with overall fatality rate of 10-30 % [5] was seen. The main areas where disease predominates are the rural and remote areas, where prompt treatment is not available or not detected in time. [6] Malarial parasite affects multiple organs of the body like liver, spleen, brain, gastro intestinal tract (G.I.T), gall bladder, pancreas, blood vessels and placenta. So, the clinical picture could be wide spectrum ranging from simple malaise to life threatening CNS symptoms like coma. Different organs get involved in various ways like parasitic sequestration in the internal organs, intravascular and immune mediated destruction of RBCs and platelets and cytokine mediated injury. [7] As the target of malarial parasite is RBC, peripheral blood smear examination is the major diagnostic tool of the disease. Some hematological changes are species specific. Thrombocytopenia is a common and early sign of malarial infection. [5] Thus, if hematological changes are noticed in time, the path of the disease and henceforth, the outcome can surely be modified is the motto of the present study.
Materials and Methods | | |
The present study was done in malaria positive patients for 18 months period. The details of patients including name, age, sex, ward in hospitalized patients and OPD unit in outdoor patients were noted. History was elicited for fever, jaundice, convulsions, nausea, vomiting, duration and progress and history of bleeding from any site, as well as drug history and similar complaints in the past and family history were noted. The diagnosis of malaria was established on peripheral blood film examination [Figure 1], [Figure 2], [Figure 3]. | Figure 1: Thick smear trophozoites and gametes of Plasmodium falciparum under oil immersion ×1000
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| Figure 2: Thin smear Plasmodium vivax schizont under oil immersion ×1000
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| Figure 3: Plasmodium falciparum rings under oil immersion (Leishmann stain ×1000)
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Further samples were collected in ethylene diamine tetra acetic acid (EDTA) and citrated tubes as anticoagulant for complete blood count (CBC) examination and ESR.
Thin film was stained with Leishman's stain. Thick smears were stained with Fields stain and grading of parasitemia was done. Thin and thick films were made on different slides by method described by Dacie and Lewis. [8]
Grading is as follows: 1-10 parasites per 100 thick film high power field (HPF): +; 11-100 parasites per 100 thick film HPF: ++; 1-10 parasites per one thick film HPF: +++; >10 parasites per one thick film HPF: ++++.
Hemoglobin (Hb) estimation was done calorimetrically, total white blood cell (WBC) count and platelet count were done using automated cell counter with complete profile including Hb, total WBC count, RBC count, hematocrit, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC).
In all samples, differential WBC count was done from peripheral blood film by counting 100 WBCs.
Corrected WBC count was applied wherever required as follows:
Corrected WBC Count = Calculated TC- (Calculated TC × % of Nucleated RBC)/100.
ESR samples were collected in sodium citrated anticoagulant tubes and done by Westergrens method. [8]
Result | | |
The present study was carried out between August 2009 to Feb 2011 (18 months period) in which 110 number of malaria patients were studied primarily on peripheral blood smear examination.
Age wise distribution
Age wise distribution in the present study showed that maximum patients were adults (21-30 years). There was a male preponderance with a ratio 1.8:1.
Severity of anemia
Anemia was a prominent feature and of severe nature in all cases of P.falciparum as compared to P. vivax infection as shown in [Figure 4].
Present study showed 20 patients (62.5%) of P. falciparum and 32 patients (47.76%) of P. vivax malaria had Hb value below 10 gm%. Seven cases out of 99 showed Hb levels below 6 gm% and hematocrit values less than 18%, mild to moderate reduction in Hb levels were found in 45 patients.
PCV
In present study, PCV values were decreased in 41 cases (41.41%) and normal in 58 cases. Decreased PCV values were seen in 21 cases (31.34%) of P.vivax and 20 cases (62.5%) of P.falciparum infection as shown in [Figure 5].
Blood indices
Out of 99 patients, MCV was normal in 61 patients (61.61%) and decreased in 38 patients (38.38%). Amongst the two species P.vivax had more number of patients with low MCV. MCH was normal in 67 (67.67%) patients and decreased in 32 (32.32%) patients. MCHC was normal in 62 (62.62%) patients and decreased in 37 patients (37.37%).
ESR
In the present study, ESR was raised in 70 cases (70.70%) while it was normal in 29 cases of malaria. In P.vivax infection the raised values were seen in 48 cases (71.64%) and in P.falciparum infection it was seen in 22 cases (68.75%) as showed in [Figure 6].
Platelet count
In present study, platelet counts were normal in 47 patients (47.47%) and decreased in 52 (52.52%) patients. Decreased platelet count was observed in 47.76% cases of P.vivax infection and 62.5% cases of P.falciparum infection. Severe thrombocytopenia was observed in 12.5% patients with P.falciparum infection and 2.98% patients with P.vivax infection, while 28.12% patients with P.falciparum infection had moderate thrombocytopenia as compared to 13.43% patients with P.vivax infection [Figure 7].
Discussion | | |
Malaria has a world- wide distribution mainly in the tropical and subtropical regions of Asia and West Africa. [1],[2],[3] The main areas where disease predominates are the rural and remote areas as compared to urban areas. It is still the major cause of morbidity and mortality. Peripheral blood examination is the major diagnostic tool along with and assisted by rapid malaria antigen immunoassay test. Thrombocytopenia is a common and early finding in malaria. This assists in early diagnosis and hence outcome of the disease. Anemia was present in significant number of cases of malaria.ESR was also increased but other blood indices like MCH, MCHC, MCV and leucocyte count were not significantly altered. Anemia and thrombocytopenia were more severe in P.falciparum then P.vivax and this difference was statistically significant. (P < 0.05). It is reported that immune and cytokine mediated destruction of platelets and RBCs, [7] thrombocytopenia and anemia. Thus presence of thrombocytopenia in a patient with acute febrile illness increases the probability of malarial infection.
Conclusion | | |
- Moderate fall in Hb, moderately raised ESR, mild leukocytosis, moderate to severe thrombocytopenia, normocytic hypochromic and normocytic normochromic anemia were the significant hematological abnormalities.
- Fall in Hb and platelet count while more degree increase in WBC count and ESR were noted in patients infected with P.falciparum compared to P.vivax, suggesting that difference in the hematological parameters do exist between the two species.
- P. vivax was the predominant species detected in the patients of malaria.
- Anemia, elevated ESR and thrombocytopenia were seen even in low grade parasitemia, simultaneous presence of three findings should prompt a diligent search for the plasmodium parasite.
References | | |
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3. | White N J. Malaria. In: Cook G, Zumla Z, editors. Manson's Tropical Diseases 22 nd ed, London: Saunders Elsevier; 2009. p. 1201-300. |
4. | Park K. Malaria, Park's textbook of Preventive and Social Medicine. 21 st Ed. Jabalpur, India: Banarsidas Bhanot; 2011. p.231-44 |
5. | Kumar AK, Shashirekha PB. Thrombocytopenia- an indication of acute vivax malaria. Indian J Pathol Microbiol 2006;49:505-8. [PUBMED] |
6. | Suryakantha AH. Vector borne diseases. In: Community Medicine with recent advances. Bengaluru: Jaypee; 2010. p. 399-436. |
7. | Nank NA, Agraval HM, Sharma MD, Singh MK. Systemic Manifestation of Malaria. J India Acad Clin Med 2007;2:189-204. |
8. | Dacie SJ, Lewis SM. Reference ranges and normal values, Practical hematology. 10 th ed, Philadelphia: UK, Churchill Livingstone Publication; 2006. p. 14-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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