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Malaria: Hematological Aspects

2002; King Faisal Specialist Hospital and Research Centre; Volume: 22; Issue: 5-6 Linguagem: Inglês

10.5144/0256-4947.2002.372

0975-4466

Layla Bashawri, Ahmed Mandil, Ahmed Bahnassy, Mirghani A.M. Ahmed,

Viral Infections and Vectors

Brief ReportsMalaria: Hematological Aspects Layla A.M. Bashawri, FCP Ahmed A. Mandil, DrPH Ahmed A. Bahnassy, and PhD Mirghani A. AhmedMD Layla A.M. Bashawri Address reprint requests and correspondence to Dr. Bashawri: Consultant Hematopathologist, King Fahd Hospital of the University, P.O Box 2208, Saudi Aramco, Al Khobar 31952, Saudi Arabia From the Departments of Pathology and Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia. , Ahmed A. Mandil From the Departments of Pathology and Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia. , Ahmed A. Bahnassy From the Departments of Pathology and Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia. , and Mirghani A. Ahmed From the Departments of Pathology and Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia. Published Online:1 Sep 2002https://doi.org/10.5144/0256-4947.2002.372SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionInspite of intensive worldwide efforts to reduce its transmission, malaria remains the most serious and widespread protozoal infection of humans. Over 40% of the world's population are at risk of contracting malaria, which is endemic in 91 countries, mostly developing.1 Malaria has long featured prominently in the grey area between parasitology and hematology. In a classical European textbook of hematology published in the 1930s, malaria was defined as a "typical blood disease" characterized by fever, anemia and splenomegaly.2 It is currently considered a typical example of a hemolytic anemia in more recent hematology textbooks, due to an acquired extra-corpuscular cause. As parasites of the blood for the majority of their complex life cycle, they expectedly induce hematological alterations. The hematological abnormalities that have been reported to invariably accompany infection with' malaria include anemia, thrombocytopenia, splenomegaly, and mild-to-moderate atypical lymphocytosis and rarely disseminated intravascular coagulation (DIC).3,4 There have also been reports of leucopenia and leucocytosis.3–5 Other hematological reactions to malaria that have been reported, include neutropenia, eosinophilia, neutrophilia and monocytosis.6,7 Some controversies appear to exist however. Many of the studies on the hematological abnormalities have been conducted in endemic countries, some only in children and some only in severe malaria patients.6,8–10 Relatively few studies have been done among non-immune or semi-immune travelers returning from endemic areas or patients returning from their endemic countries.3,11,12 The aim of this study was to investigate and find the hematological changes that may occur in acute malaria infection in non-immune and semi-immune patients returning from endemic areas.MATERIALS AND METHODSThe study design utilized in this review was a retrospective clinical case series study. All confirmed cases of malaria who presented to King Fahd Hospital of the University (KFHU) at Al-Khobar in the Eastern Province of Saudi Arabia, between January 1988 and December 1999, were included in the study. A case was defined as a positive thin and/or thick blood film recorded in the Hematology Department laboratory records.A specially designed form of three sections was used for the purpose of these studies. Section A (basic demographic data): included variables as age, sex, residence, education, occupation, and travel history to an endemic area. Section B (clinical data): inquired about fever pattern, presence of jaundice, organomegaly and lymphadenopathy. Section C (hematological data): recorded information about blood counts, complete blood counts (CBC), Plasmodium species and the parasite level in some cases. CBC were performed using an automated Coulter counter STKS model and WBC differential was done on almost all the cases where CBC was done. All malaria-positive smears were reviewed by a hematologist for confirmation, identification of species, review of smear for platelet count, and in some cases, estimation of parasite level. Due to the different nationalities encountered, normal values (reference ranges) for the hematological findings were based on recommendations by Dacie and Lewis.13The forms were completed by abstracting the relevant information from the medical records of the malaria cases diagnosed at KFHU during the specified period. Data was entered and analyzed using SPSS version 7.0.14 Statistical analyses included descriptive statistics, bivariate analysis i.e., Mest, chi-square and analysis of variance (ANOVA). Level of significance was set at ) had a positive travel history to an endemic area. The most common type of malaria was P. falciparum (54.2%), followed by P. vivax (39%), then (mixed) infections in 17 (2.4%), while in 32 (4.4%) of the cases, the species could not be identified.Hematological ResultsA total of 430 patients (59.2%) were anemic at presentation, and the anemia was normochromic normocytic except in 129 cases (17.7%), where it was microcytic hypochromic. In these latter cases, 90 were found with iron deficiency anemia and 39 with thalassemia. More than half of the patients (55.6%) had thrombocytopenia, with high and normal mean platelet volume (MPV) values. WBC findings showed the vast majority 569 (78.3%) to be in the normal range. Differential leukocyte count showed neutrophil counts in the normal range in 494 (67.9%) cases, while 510 (70.2%) had a slight increase in band forms, mean band percentage 5.03±5.78. About half the patients (42.9%) had low lymphocyte counts (lymphopenia), while 227 (31.2%) had lymphocyte counts in the normal range, and atypical lymphocytes were found in 38.7%. Monocytes, eosinophils and basophils were in the normal range in the majority of the cases (66.6%, 57.2%, and 98.8% respectively, Table 1).Table 1. Summary of hematological values of malaria cases at KFHU (1988-1999).*Table 1. Summary of hematological values of malaria cases at KFHU (1988-1999).*When hematological results were compared with age (children ≤14 years of age vs. adults), it was found that 81.8% of all children were anemic compared to only 48.8% of the adults (P value =0.0001). Severe anemia (hemoglobin ≤7g/dL) was occasionally, seen but mostly among infants and young children (40 cases, 5.5%). With regards to the WBC differential, there was no significant age differences, except for the lymphocyte count where it was higher (lymphocytosis) in children compared to adults (41.7% vs. 7.1%, P value = 40 <80 mg/mL (normal range <10 µg/mL). Our patient recovered with treatment of malaria, however, and no further intervention was needed.In conclusion, the hematological aspects of malaria infection constitute a very interesting area in various reports. Mainly anemia and thrombocytopenia are the classical changes. Changes in the white blood cell are less dramatic and there has been conflicting reports regarding these changes. It would be interesting to study further and compare the different reports discussing the hematological findings in both immune and semi-immune patients living in endemic areas, and those returning with imported malaria. It would also be beneficial to carry out prospective studies on other aspects, which have not been conclusive, e.g., coagulation parameters, bone marrow changes and the direct antiglobulin test (to help in understanding the anemia). In fact, results of direct antiglobulin tests and 51Cr red cell survival studies have shown some evidence for increased destruction of non-parasitized and parasitized erythrocytes by possible immune-mediated mechanisms. Laborarory and clinical studies, however, failed to establish the presence of antibodies on erythrocyte surface and hemolysis in malaria infected patients. These aspects were studied by Facer3 and Abdalla.6ARTICLE REFERENCES:1. WHO. World Health Director General's Report. Fighting disease, fostering development. Geneva: WHO, 1996. Google Scholar2. Luzzatto L. "Genetics of red cells and susceptibility to malaria" . Blood. 1979; 54:961–76. Google Scholar3. Facer CA. Hematological aspects of malaria. In: Infection and Hematology. Oxford: Butterworth Heinmann Ltd., 1994:259–94. Google Scholar4. Perrin LH, Mackey LJ, Miescher PA. "The hematology of malaria in man" . Sem Hematol. 1982; 19:70–81. Google Scholar5. Murphy GS, Oldfield EC. "Falciparum malaria" . Infect Dis Clin North Am. 1996; 10:747–70. Google Scholar6. Abdalla SH. "Peripheral blood and bone marrow leucocytes in Gambian children with malaria: numerical changes and evaluation of phagocytosis" . Ann Trop Paediatr. 1988; 8:250–8. Google Scholar7. Jandl JH. Hemolytic anemias caused by infection of red cells. In: Blood. 2nd. edition. New York: Little Brown and Company, 1996: 473–501. 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Zahid for his secretarial assistance.InformationCopyright © 2002, Annals of Saudi MedicinePDF download