Impact of Plasmodium falciparum Infection on Hematological Parameters in Children Living in CONTRACEPTION, FERTILITY AND PREGNANCY DECISION MAKING AMONG

HIV DISCORDANT COUPLES Robert N Maina, Bernhards R. Ogutu Western Kenya Walter Reed Project, Kenya Medical Research Institute, Kisumu, Kenya
Introduction
Malaria is a major cause of morbidity in the tropics
800
1 2

Association between parameters

platelet count x103/L

400 200 0

MPV (fl)

Hematological abnormalities are hallmark of malaria infection, common and more pronounced in P. falciparum malaria infection Changes in hematological parameters are likely to be influenced by any disease condition which affects the haemopoetic physiology at any level

600

1 0

10

20
% parasitemia

30

40

4 0 20 0 40 0 60 0 80 0

Platelet count x 10 3/ul

Objectives
1. To elucidate the hematological changes in children infected with P. falciparum malaria 2. Assess the impact of hematological alterations on improved diagnosis and therapy of childhood malaria
Platelet counts x 103 <150 151-450 >450 Patient Category Malaria Negative Malaria Positive Malaria Negative Malaria Positive Malaria Negative Malaria Positive

Platelet aggregate flags

Samples in the Group 16 255 356 258 56 10 Samples with Platelet aggregate flag 3 59 13 73 2 1

% 18 23 3.6 28 4 10

Materials and Methods

A retrospective review of the hematological parameters in 961 children (+) n=523 and (-) n=438 children living in Kisumu West District, a holoendemic transmission area. Data collected as part of malaria clinical trials between 2005-06 at the KEMRI/Walter Reed Project Kisumu Blood counts performed using ACT5 Diff hematology Analyzer (Beckman Coulter Inc, Miami, Florida, USA) as per local SOPs on EDTA blood. Malaria Blood films prepared and stained with Giemsa for microscopic examination to determined presence of parasites, the species and the number of asexual parasites

Significantly more children in the malaria infected group had platelet aggregate flag (25% vs. 4%, p<0.0001). The flag was associated with platelet counts and not malaria status

Sensitivity , specificity and predictive values of hematological parameters in malaria

Variable

Results of (+) Vs (-)

Variable

Sensitivity Specificity* * (95% CI) (95% CI) PLT< 150x103/uL 90 (86,95) 61 (57,66) Hb<10g/dl 74 (69,78) 65 (61,68) MO >1.5x103/L 74 (67,79) 54 (50,57) LY< 2x103/L 75(59,87) 46(43,49) NE >7.5x103/L 72(60,82) 38(34,42) WBC> 17 x 70 (56,81) 46 (43,49) x103/L

PPV* (95% CI) 69 (64,73) 60 (55,64) 38 (35,43) 6(4,8) 10(7,12) 8 (6,1)

NPV* (95% CI) 86 (84,89) 78 (74,81) 84 (80,87) 97(95,98) 93(90,96) 96 (93,98)

OR (CI) 13.8 (7.2,24) 5 (3.9,6.7) 3.3(2.5, 4.6) 2.7(1.3,5.8) 1.6(0.9,2.8) 2.1 (1.1,3.7)

LR 2.3 2.1 1.6 1.4 1.2 1.3

Malaria, n=523 Mean (Median)

31.2 (24) 9.5 (9.2) 195 (174) 8.43 (8.4) 11.2 (10) 4.7 (4.2) 1.6 (1.3) 4.0 (4.1) 3.8 (2.8) 0.2 (0.14) 16.4 (15.9)

No malaria, n=438 Mean (Median)

31.6 (24) 10.9 (10.8) 334 (312) 7.65 (7.7) 10.4 (9.1) 5.3 (4.95) 1.2 (1.02) 4.7 (4.6) 3.3 (2.6) 0.4 (0.23) 16.7 (16.4)

P- Value PE
0.72 <0.0001 <0.0001 <0.0001 0.27 0.0009 <0.0001 <0.0001 0.0076 0.0001 0.15

Age (months) Hgb (g/dl) Plt (103/L) MPV (fl) WBC(103/L) Ly# (103/L) MO# (10 /L)
3

PA GP MP

Platelet aggregates, Giant platelets, malaria pigments and phagocytozed erythrocytes Diagnostic Value of hematologic parameters Low lymphocyte, high WBC and high neutrophil counts had fairly good sensitivities but lacked specificity to accurately diagnose malaria Low platelet count, low Hemoglobin and high monocyte counts had better sensitivities and specificity for diagnosis of malaria Combination of thrombocytopenia and anemia with high sensitivity (80%), specificity (84%) and odds ratio (22)increases the diagnostic yield significant Children with this combination are 22 times more likely to have malaria than children without this combination Conclusions P. falciparum produces significant changes of hematological parameters in children living in malaria endemic regions with platelets, Hb, moncytes and MPV being most affected Thrombocytopenia and monocytosis are associated with parasite density and therefore may be a marker of disease severity Platelet aggregate flags associated thrombocytopenia not parasitemia with

RBC (106/L) NE#(103/L) EO#(103/L) RDW (%)

Association between parameters

Thrombocytopenia weekly associated with, anemia in the malaria infected group (r=0.2, P=0.0003) and age (r=0.14, p=0.0073) Monocyte count was positively correlated with parasite density (r=0.23, p=0.0003) and negatively with age (r=-0.15, p=0.0042) There was a strong inverse correlation between platelet count s and Mean Platelet Volume (r=-0.4, p<0.0001) There was an inverse relationship between parasitemia and platelet count (r=-0.44, p<0.0001)

Presence of thrombocytopenia in combination with anemia and monocytosis in children from endemic areas may be useful as supportive diagnostic criteria for malaria

Recommendations Further studies are required to characterize platelet aggregates and explain their association with malaria