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Haematological profile and its outcome in different species of malaria: a two year study

Malaria is a protozoan disease transmitted by the bite of infected female Anopheles mosquitoes. The most important of the parasitic diseases of humans, malaria is transmitted in 91 countries containing 3 billion people and causes ~1200 deaths each day. Six species of the genus plasmodium cause nearly all malarial infections in humans. These are P. falciparum, P. vivax, two morphologically identical sympatric species of P. ovale (as suggested by recent evidence), P. malariae, and in Southeast Asiathe Malaria monkey malaria parasite P. knowlesi. India harbors both P. vivax (50% to 55%) and P. falciparum (45% to 50%) and contributes 70% of malarial cases in the South East Asian region hematological changes, which are the most common systemic complications, play a significant role in these serious complications. The hematological abnormalities that have been reported to consistently companion which comprise anemia, thrombocytopenia, atypical lymphocytosis and infrequently disseminated intravascular coagulation. Leucopenia, leucocytosis, ABSTRACT


INTRODUCTION
Malaria is a protozoan disease transmitted by the bite of infected female Anopheles mosquitoes. The most important of the parasitic diseases of humans, malaria is transmitted in 91 countries containing 3 billion people and causes ~1200 deaths each day. Six species of the genus plasmodium cause nearly all malarial infections in humans. These are P. falciparum, P. vivax, two morphologically identical sympatric species of P. ovale (as suggested by recent evidence), P. malariae, and in Southeast Asia-the Malaria monkey malaria parasite P. knowlesi. 1 India harbors both P. vivax (50% to 55%) and P. falciparum (45% to 50%) and contributes 70% of malarial cases in the South East Asian region hematological changes, which are the most common systemic complications, play a significant role in these serious complications. 2 The hematological abnormalities that have been reported to consistently companion which comprise anemia, thrombocytopenia, atypical lymphocytosis and infrequently disseminated intravascular coagulation. 3 Leucopenia, leucocytosis, Neutropenia, Neutrophilia, Eosinophilia and monocytosis also have been reported. 4,5 Anemia is a particular problem in children, where profound anemia may lead to sudden death. These complications are particularly likely with haemoglobin concentrations below 5 g/dL (15% haematocrit) and the risk rises steeply below 4 g/dl. 6 Slight coagulation abnormalities are common in falciparum malaria, and mild thrombocytopenia is usual. The aim of present study was to study the hematological and coagulation abnormalities of malaria and its correlation with severity.

METHODS
The present study was carried out on 100 patients admitted during the period of November 2016 -October 2018 in Narayana medical college and hospital, Nellore. A detailed history was taken followed by a thorough clinical examination to assess clinical severity and complications. All the patients in this study were proved to be cases of malaria either by Peripheral smear examination (

RESULTS
Among the 100 cases of malaria, most commonly observed species was falciparum seen in more than half of patients which contributes to about 54% i.e 54 cases and vivax contributes to 44% i.e 44 cases and mixed infection with falciparum and vivax was observed in 2% i.e 2 patients (Figure 1).
Anaemia was present in 76% of patients and among them 40 patients had splenomegaly i.e. 52.6% of the patients with anaemia had splenomegaly. And 60.5% of patients who had splenomegaly were found to have anemia. It has a P value which is significant (p=0.018) ( Table 1).   (17) of total patients. It was observed that 20.3% (11) of falciparum, 11.6% (6) with vivax. Lymphocytosis occurred in 36% (36) of total patients of which falciparum were 42.5% (23) and vivax malaria patients were 25% (11) and in mixed infection 100% (2). Lymphopaenia was observed in 13% (13) of total patients. Among which in 16.6% (9) of falciparum and 9% (4) of vivax infected patients. Eosinophilia was observed in 5% (5) of total patients. Among this vivax were 6.8%(3) and falciparum were 3.6%(2). Monocytosis was observed in 15% (15) of total patients. Species wise monocytosis was found in 18.1% (8) of vivax, 12.9% (7) in falciparum and 50% (1) of mixed infection patients. Neutropenia, Lymphopenia and Eosinophilia were not present in the mixed infections (Table 3).  Chi-Square Value = 3.23, p value = 0.199 (Not Significant)  (2) in mixed infections had thrombocytopenia. Severe thrombocytopenia (platelet <50,000/mm3) was observed in 12% (12). Out of them, 9 patients (6.6%) were falciparum and 6.8% (3patients) were vivax ( infection died in our study. All patients recovered and discharged in good health condition. It was observed in our study that lymphocytosis is high and Lymphopenia is low. But in other studies it is lymphocytosis is at lower rate of incidence and lymphopenia at higher rate. Monocytosis was observed in 15% of the patients in our study. It was observed by N.K.D.Hakim et al, in their study that monocytosis in patients those on anti-malarial drugs may be an indicative of an anti-malarial effect by monocytes, thus monocytosis may enhance predisposition to a favourable outcome. 17 Eosinophilia was observed in 5% of the cases in our study. Eosiniophilia also noted in few cases in a study conducted by Surve KM et al, which constitutes only 1% of total cases. In another study Alberto Tobon et al, it was 14.8%. In present study percentage of patients with thrombocytopaenia is 63% out of which 37% are due to falciparum. Thrombocytopenia was present in 68.5% of the cases with falciparum malaria in our study. In study by Horstmann et al, the incidence of thrombocytopenia was 85 %). 18  In present study about five patients had an increase in bleeding time and all these cases were falciparum and mixed infection. Bleeding time was increased in 7.4% (4) of falciparum malaria cases and 50% (1) of mixed infection cases and bleeding time of all patients of vivax malaria were within normal range. Three out of these five patients had bleeding manifestations. In a study by Sharma et al, 6.7% of patients had increased bleeding time. 26 In a study by S Roy et al on-falciparum malaria cases 5% of the patients had increased bleeding time.
Authors observations were comparable to both these studies.
In present study 57% of the patients had normocytic normochromic blood picture. It was comparable to a study which was conducted by Sen et al, which showed about half the patients had normocytic normochromic blood picture. 27 In present study 25% of the patients had microcytic hypochromic blood picture. This might be due to the prevalence of iron deficiency anemia in our country. Sen et al, in their study also had microcytic hypochromic picture in about 20% of cases. Prevalence of dimorphic anemia was seen in 18% of the cases similar results were also observed by Sen et al, where the prevalence of dimorphic anemia was 20% in their study.