The aim of my study is to
determine the significance
of thrombocytopenia in malaria.
Patients and Methods.
It was a prospective observational study on
all febrile patients with thrombocytopenia presenting to the allied hospital
Faisalabad during august to November 2017.
Of the total of 75 patients with fever and
thrombocytopenia, patients 41(55per) proved to be suffering from malaria.
Out Of them 29 patients (71per) had falciparum malaria while 12 patients (29per) had vivax
Of these 41 patients, platelet counts ranged between 25,000 and 150,000/dL with
a mean value of 101,000/dL (SD ± 47,500)
and a median of 75,000/dL. Of the 34 patients who were not suffering from malaria, the
counts ranged between 10,000 and 150,000/dL with a mean value of 58,000/dL (SD ± 54,000) and median of
presence of thrombocytopenia may be a predictor of malaria in adult population.
Malaria is usually associated with various degrees of hematological disorder like anemia and thrombocytopenia. Thrombocytopenia is
an early and consistent characteristic of plasmodium falaciparum
and plasmodium vivex malaria (K. Ghosh et al, 2007).
in addition to
their central role in haemostasis, platelets also play their important role in wide range
of immune modulating, inflammatory and
angiogenic factors (S. N. Wickramasinghe et al,
advance studies have suggested that platelets play their vital role in the innate host defense at the
start of a malaria infection. McMorran
and co-workers showed that purified human platelets were able to kill P. falciparum parasites
within erythrocytes in an in
system, an effect that was dependent on platelet activation by adenosine
5′-diphosphate (ADP) (V. D’Acremont et al,
they showed that platelet deficient however the pathogenesis of
thrombocytopenia stays incompletely understood. In falciparum
malaria there is accelerated platelet intake as
evidenced by using shortened survival of radiolabelled platelets (S.
S. Jamal et al., 2008).
The anemia is generally because of varied reasons ranging from hemolysis
to comorbidities like parasitic infections, folate, iron, and vitamin B12 deficiencies in endemic regions, anti malaria and similarly complicated by
way of the coexistence of thalassemia and
different haemoglobinopathies (T. S. Faseelaet al.,
thrombocytopenia are the maximum frequent malaria-related hematological
complications (Rasheed et al., 2008).
response is, in any case, additionally fantastically blunted, and there is
decreased platelet depend and every so often diminished WBC considers
appropriately. Thrombocytopenia is a totally not surprising association of
jungle fever. in the past it move toward becoming thought that intestinal
sickness isn’t regularly connected with clinical elements of thrombocytopenia like draining
issue and is normally an accidental situating on blood testing. Most recent
logical confirmations have negated this account. it’s far relevant that the
situating of thrombocytopenia in influenced individual can be a showing for a
concentrated post into the blood spread to preclude intestinal sickness in
light of the fact that the motive.This actuality is particularly essential
inside the work up for thrombocytopenia in febrile patients. Thrombocytopenia
might be identified with draining inclination that is one of the urgent extreme
indications of P. falciparum jungle fever. The nearness of thrombocytopenia in
intense febrile vacationers getting backfrom tropical zones has come to be an
extraordinarily tricky logical marker for intestinal sickness visualization(G.
E. Grau et al.,2003).
Some of observational research have showed the association of
thrombocytopenia to malaria but till date the reason of thrombocytopenia is poorly understood. The
speculated mechanisms main to
thrombocytopenia are coagulation disturbances, splenomegaly, bone marrow alterations, antibody-mediated platelet destruction,
oxidative pressure, and the function of platelets as cofactors in triggering
excessive malaria.In an animal version of
cerebral malaria, platelet’s function has
been implicated. In autopsy research of kids loss
of life of cerebral malaria, clumps of
platelets with or without infected RBC’s were determined in
the mind capillaries.The platelet counts generally are normalized fast in a matter of few weeks whilst malaria
is handled effectively (A. Pain et al.,
Method and material:
It was a prospective observational study conducted at allied hospital
faisalabad . All the patients that with thrombocytopenia presenting to the
Allied during august to November 2017
were included in this study.Platelet
counts of 75,000 to 150,000/dL are defined as grade 1 thrombocytopenia, 50,000
to <75000 As grade 2, 25,000 to <50,000/dL as grade 3, and below 25,000/dL as grade 4 thrombocytopenia.Thrombocytopenia was thus divided into these groups. Further the results were visually confirmed by clinical hematologist after the counts were done by an auto analyzer machine. Two slides were made from one sample,One of them was thick and other was thin slides were prepared according to the World Health Organization guidelines and studied by a hematologist. Thick smears were made by using Geimsa stain and thin smears were made by using Wright stain and the patient was consider as nonmalaria only if three consecutive smears were negative. Thus these patients were further divided into two groups: malaria and non-malaria group. The non-malaria group was further evaluated for other causes of thrombocytopenia which was not part of this study. Laboratory tests done on these patients consisted of full blood counts, liver enzymes, renal function, vitamin B12 levels, folic acid levels, erythrocyte sedimentation rate, and peripheral blood smear. In undiagnosed cases and where suspicion of immune thrombocytopenia was high, bone marrow biopsy was done to differentiate whether the low platelet count is due to decreased production or peripheral destruction. Statistical calculation was done using Word Excel for diagnostic accuracy between the two groups, that is, between platelet count from 25,000/dL to 50,000/dL, 50,000/dL to 75,000/dL and 75,000/dL to 150,000/dL using the Wilson score with 95% confidence interval. Chapter 3: Result: Out of 75 patients with thrombocytopenia, 41 patients (53%) proved to be suffering from malaria. Of them 29 patients (68%) had falciparum malaria while 12 patients (32%) had vivax infection. In these patients, platelet counts extended 25,000 to 150,000/dL with a mean estimation of 101,000/dL and median of 75,000/dL. Of the 34 patients who were not suffering from malaria, the counts ranged between 10,000 to 150,000/dL with a mean value of 58,000/dL and median of 50,000/dL. Table 1: Thrombocytopenia in patients with malaria and without malaria. Grade Platelets count Total(%age) Positive case Plasmodium falaciparum positive( %age) Palasmodium vivax positive patient(%age) Malaria negative patient(%age) Total (n=75) 3 25,000–50,000 dL 9(12) 8(20) 1(3) 15(20) 24 2 50,000–75,000 dL 15(20) 10(24) 5(12) 16(21) 31 1 75,000–150,000 dL 17(23) 11(27) 6(14) 3(4) 20 Total 41(55) 29(71) 12(29) 34(45) 75 Table 2:Accuracy parameters between level 1(plateletsfrom25,000 to 50,000dL) and level 2 (platelets from 50,000 to 75,000dL) using Wilson score. Parameter Estimate Lower-upper 95% confidence interval Sensitivity 78.70% (70.48, 84.19) Specificity 51.48% (42.14, 59.76) Positive predictive value 64.03% (56.92, 71.26) Negative predictive value 67.70% (57.85, 75.97) Diagnostic accuracy 65.01% (59.52, 70.81) TABLE 3: Accuracy parameters between level 1 (platelets from 50,000 to 75,000 dL) and level 2 (platelets from 75,000 to 150,000 dL) utilizingWilson score. Parameter Estimate Lower-upper 95% confidence interval Sensitivity 39.67% (31.4, 48.57) Specificity 94.39% (88.3,97.4) Positive predictive value 88.89% (77.81,94.81) Negative predictive value 58.05% (50.62,65.13) Diagnostic accuracy 65.35% (58.97,71.23) Chapter 4: Discussion: Thrombocytopenia much of the time accompanies malaria and is typically moderate to moderate. it can however be symptomatic and extraordinary (G. A. Niazi et all, 1995). Fifty-three percent of patients with malaria fever indicating thrombocytopenia in our investigation is close others revealing low platelets as 57% and 48% (A. Mert et all 2003) In another essential investigation from India, Patel et al. reports the affectability of thrombocytopenia together with the acute febrile syndrome as 100% for malaria diagnosis, with a specificity of 70%, a positive predictive value of 86% and a negative predictive value of 100% (U. Patel et all, 2004). In our investigation we have calculated the sensitivity, specificity, positive and negative predictive value and diagnostic accuracy at various levels of platelet tallies and have concluded that the sensitivity and negative predictive value is high at low platelet checks (78% affectability and 67% negative predictive value 40% and 58% resp.) while the specificity and positive predictive value is high at generally higher platelet checks (94% specificity and 89% positive prescient incentive against half and 64% resp.). The analytic exactness remains nearly the same at both counts (around 65%). Mahmood and Yasir concluded an extended search for malarial parasite in patients having thrombocytopenia on spread smear. Gentle to-extreme thrombocytopenia observed in hospitalized patients was viewed as enough to alarm the likelihood of malarial disease, as P. falciparum was observed to be regular species in these patients. Our examination likewise connotes that falciparum malaria is more typical at bring down platelet count as compared to vivax disease and by and large the odds of discovering falciparum malaria are twice than that of discovering vivax jungle fever in thrombocytopenic patients (A. Mahmood et all,2008). It is a general agreement that thrombocytopenia is exceptionally basic in malaria (M. N. Akhtar et all, 2005). Also, beforehand it was trusted that it is more typical in F.malaria. recent studies have demonstrated that thrombocytopenia is similarly or significantly more typical in P. vivax malaria in opposition to the prevalent view that it might be seen in P. falciparum malaria (A. Aggarwa et all, 2005). Later information in India has demonstrated how thrombocytopenia showed an elevated frequency and seriousness among patients with P. vivax infection (D. K. Kochar et all, 2010). Recent studies from the Indian subcontinent have discovered noteworthy thrombocytopenia in P. vivax malaria (S. Srivastava et all,2011). Conclusion Malaria should be a consideration in all patients swith low platelets and after excluding this common and effortlessly treatable cause, further evaluation of thrombocytopenia should be undertaken. References 1 K. Ghosh and K. Ghosh, "Pathogenesis of anemia in malaria: a concise review," Parasitology Research, vol. 101, no. 6, pp. 1463–1469, 2007. 2.S. N. Wickramasinghe and S. H. Abdalla, "Blood and bone marrow changes in malaria," Bailliere's Best Practice and Research in Clinical Haematology, vol. 13, no. 2, pp. 277–299, 2000. 3 V. D'Acremont, P. Landry, I. Mueller, A. Pecoud, and B. Gen-´ ton, "Clinical and laboratory predictors of imported malaria in an outpatient setting: an aid to medical decision making in returning travelers with fever," American Journal of Tropical Medicine and Hygiene, vol. 66, no. 5, pp. 481–486, 2002. 4 S. S. Jamal Khan, F. R. Khan, M. Usman, and S. 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