International Journal of Research in Medical Sciences

Surve KM S et al. Int J Res Med Sci. 2017 Jun;5(6):2552-2557

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20172446
Original Research Article

Study of haematological parameters in malaria

Ketaki Motram Surve, Anjali S. Kulkarni, Santosh G. Rathod*, Rajan S. Bindu

Department of Pathology, Government Medical College, Aurangabad, Maharashtra, India

Received: 26 March 2017

Accepted: 25 April 2017

*Correspondence:
Dr. Santosh G. Rathod,
E-mail: drsrathod2007@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Malaria causing plasmodia are parasites of blood and hence induce haematological
alterations. The haematological changes that have been reported to accompany malaria include anemia,
thrombocytopenia and leucocytosis, leukopenia, mild to moderate atypical lymphocytosis, monocytosis,
eosinophilia and neutrophilia.
Methods: Total hundred smear positive malaria cases were taken and various hematological parameters and
biochemical parameters were studied.
Results: Out of 100 smear positive cases, P. vivax was positive in 55 cases while P. falciparum was positive in 45
cases. It was seen in 86.67% of falciparum Malaria patients and in 72.72% of vivax Malaria patients. Severe anemia
was seen in 9% of patients. Normocytic normochromic blood picture was the most common type in anaemic patients
(51.89%). Thrombocytopenia was seen in 71% of the patients. Mild thrombocytopenia was more common and present
in 52% of patients while Severe thrombocytopenia was seen in 19% of cases. In falciparum malaria
thrombocytopenia was present in 66.66% of the patients while it was present in 74.54% of the patients in vivax
malaria. Total Leucocyte Count was normal in 72% of the patients.
Conclusions: Various haematological findings can help in early diagnosis of malaria which is essential for timely and
appropriate treatment which can limit the morbidity and prevent further complications.

Keywords: CBC, Haematological parameters, Malaria, Thrombocytopenia

INTRODUCTION Malaria causing plasmodia are parasites of blood

and hence induce hematological alterations. The
"Malaria" received its name from Italian as it was hematological changes that have been reported to
believed to arise due to foul air common near marshy accompany malaria include anemia, thrombocytopenia
areas. More than 100 countries in the world are and leucocytosis, leucopenia, mild to moderate
considered malarious, and more than 2.4 billion of the atypical lymphocytosis, monocytosis, eosinophilia and
world’s population is at risk. The worldwide annual neutrophilia.3-8 Platelet abnormalities are both
incidence of malaria is estimated to be about 300-500 qualitative as well as quantitative.
million cases. Malaria kills between 1.1 and 2.7 million
people annually of which majority are children under five Thrombocytopenia is common occurrence in acute
years.1 malaria and it is observed in vivax and falciparum
malaria to varying degrees.6-10 Cases of malaria
Malaria is a major health problem in India, being one of associated renal and hepatic impairment have been
the biggest burdens in terms of morbidity and mortality reported from different parts of malaria endemic
among all infectious diseases.2 countries.11 Hepatic involvement in P. falciparum malaria

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is not an uncommon presentation and presence of Kidney function test (KFT)

jaundice (bilirubin >3mg/dl) is one of the indicators of
severe malaria as defined by the WHO. Jaundice in The patient’s samples were processed for Kidney
falciparum malaria may vary from mild to severe and is function tests including-Serum creatinine and blood urea
associated with high incidence of complications and with the help of Fully Automated Biochemistry Analyser
mortality.12 Erba-640.

There are two major renal syndromes associated with Peripheral blood smear examination
Malaria. (1) A chronic and progressive glomerulopathy
that mainly affects African children, classically Peripheral blood smears were prepared using fresh finger
complicating quartan malaria and (2) ARF associated prick blood. One drop of blood placed on one side of the
with falciparum malaria in Southeast Asia, India, and slide 1 cm away from end and blood was spread using a
sub-Saharan Africa.13 Renal impairment is commonly spreader slide at angle of 30 degree over the length of
caused by P. falciparum; however, vivax malaria also slide then slides were left to air dry. Slides were fixed and
causes renal impairment.14 stained with Leishman stain. Peripheral blood smear
examination was done systematically under low, high and
Hence the present study is undertaken to evaluate the oil immersion of microscope for
various haematological parameters as well as biochemical
parameters affected in malaria and to observe the • RBC morphology
variations if any, in P. falciparum, P. vivax and mixed • Total leukocyte count and differential count
infections. The aim of the study is to study the changes in • Platelet adequacy
haematological parameters in smear positive malaria • Type of malaria parasite.
cases. To study the changes in biochemical parameters in
smear positive malaria cases. To compare these changes RESULTS
in P. vivax and P. falciparum infection.
Total hundred smear positive malaria cases were taken
METHODS and various hematological parameters and biochemical
parameters were studied. Out of 100 smear positive cases,
Source of data P. Vivax was positive in 55 cases while P. falciparum
was positive in 45 cases. Out of 100 cases, P. vivax was
This is a prospective and retrospective study conducted in the most common observed species. It was seen in 55%
present institute during the period December 2011 to of cases. Next common was P. falciparum accounting for
November 2013. 100 patients showing smear positivity 45% of cases.
for one or more species of malaria parasite were included
in study. Table 1: Malaria cases with different
species distribution.
The blood samples of these patients were subjected for
following laboratory investigations before starting anti- Type of parasites No of patients Percentage (%)
malarial drugs in all these cases. P. Vivax 55 55
P. Falciparum 45 45
Collection of blood Mixed 0 0
Total 100 100
CBC was carried out on Mythic 18 Automated
Hematology Cell Counter and following readings were
Most of the cases (57%) were in the adults between 21-40
noted.
years age group. There were 20 % of cases below 20 yrs
of age group. People of all age groups were seen.
• Hemoglobin (HB%)
Youngest was 1 year old female child with P. vivax
• HCT
infection and oldest was 78 years old female with P.
• Total leukocyte count (TLC) falciparum infection. There were 57 male patients and 43
• Differential leukocyte female patients. Falciparum cases were almost equal in
• Platelet count. both sexes while Vivax infections were found slightly
more in males. Fever was seen in all cases expect one
Biochemical Investigations case. Chills and rigor was the next commonest symptom
seen in 64% of the cases. Nausea and vomiting was
Liver function test (LFT) present in 25 cases out of which majority (16 cases) were
due to falciparum malaria. Myalgia was present in 14%
The patient’s samples were processed for Liver function of cases. Altered sensorium was seen in 3 cases of
tests including-Serum Bilirubin, AST, ALT with the help falciparum and 1 case of vivax infections.
of Fully Automated Biochemistry Analyser Erba-640.

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Table 2: Clinical signs in malaria infection. equal distribution in Falciparum and Vivax malaria.
Icterus was present in 11% of cases. CNS involvement
P. seen in 3 cases of P. falciparum and 1 case of P. vivax.
Sign P. vivax Total%
falciparum
Pallor 29 26 55% Investigations
Icterus 7 4 11%
Pedal edema 3 2 5% Haemoglobin concentration (Hb%)
Splenomegaly 19 13 32%
Hepatomegaly 11 9 20 % Majority of the patients had either mild (40%) or
Hepatosplenomegaly 9 8 17 % moderate degree (30%) of anemia. Hb Concentration <7
CNS involvement 3 1 4% gm% was seen in 9% of the cases; more in Falciparum
infection. Haematocrit values less than 20 were seen in
9% of the patients which was slightly more common in
Pallor was the most common clinical sign and was
Falciparum infection. (11.11%). Most of the patients
present in 55% of cases. Splenomegaly was present in 32
(68%), showed haematocrit level in the range of 20-35%.
% of cases. splenomegaly seen in 17% of cases with near

Table 3: Platelet count.

Platelet count P. falciparum (n=45) P. vivax (n=55) Total %

Thrombocytopenia (less than 1.5lakhs/mm3) 30 (66.66%) 41 (74.54%) 71%
Normal platelet count (more than 1.5lakhs/mm3) 15 (33.33%) 14 (25.46%) 29%

Decreased platelet counts were a constant feature of both

types of malaria with 71% of cases showing Platelet
Count less than 1.5 lakhs/mm3.Severe Platelet Reduction
(<50,000) was seen in 19 cases.

Figure 1: Gametocyte of P. falciparum.

Total leucocyte count (TLC) Figure 2: Schizont of P. vivax.

Majority of the patients had normal Total WBC count In anemic patients, most commonly RBC’s were
(72%).Reduced WBC count was seen in 18% of the cases Normocytic Normochromic (64.55%) followed by
and increased counts in 10%, with near equal distribution Microcytic Hypochromic (29.11%) Microcytic
in vivax and falciparum malaria. Increased WBC count Hypochromic blood picture was seen nearly equal in both
seen in 10% of cases.5 cases of increased neutrophil falciparum and vivax infection. T
count were seen, with more in vivax infection (4 cases).
Three cases of Macrocytic and two cases of dimorphic
Reduced neutrophil count was seen in 12 cases with blood picture were also seen. Out of the 100 patients, 11
equal distribution in vivax and falciparum malaria cases. had jaundice. Among them, 7 had falciparum malaria and
One case of eosinophilia and 6 cases of lymphocytosis 4 had vivax malaria. The diagnosis of malarial hepatitis
were seen in falciparum malaria cases. Two cases of was made in 3 patients of falciparum malaria on basis of:
lymphocytosis were seen in vivax infection. Seventy-four Demonstration of Plasmodium infection, at least 3-fold
cases showed normal differential count.

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raise in transaminase (especially ALT), with or without India, vivax is the most common species encountered
conjugated hyberbilirubinaemia, absence of clinical and followed by falciparum. However, in recent years there
serological evidence of viral hepatitis and response to has been an upswing in the falciparum cases.
antimalarial drugs.

Figure 4: Ring form of P. falciparum (heavy

Figure 3: Ring Worm of P. vivax. parasitemia).

Renal function tests Malaria can affect any age group. However, most studies
show more of adults as compared to children. The present
Serum creatinine level >3.0 mg/dL. It was seen in 1 adult study had 80 adult patients and 20 patients below age 20
patient. She had Falciparum malaria. yrs. The mean age of the present study is 30.4 years.
Most other studies have mean age groups between 25 and
DISCUSSION 40. The adult age group is more affected due to their
greater mobility and greater risk of exposure due to more
Malaria is transmitted by the female anopheles mosquito, outdoor activity. Present study had 57% male patients as
causes clinical illness and pathological changes in various compare to 45% female patients. Other studies with
body organs with the parasites invading and multiplying comparable results include Jadhav UM et al with 58.3%
in the circulating red blood cells. Malaria causes males, Erhart LM et alwith 69% males and Bashawri
numerous hematological alterations of which anemia and LAM et al with 75.9% males.3,16,17
thrombocytopenia are the most important.
In present study, Fever was the commonest presenting
The most common species of malaria in the present study symptom in 99% of the patients. Chills and rigor was
was vivax (55%) followed by falciparum (45%). In present in 64% of the patients. Nausea and vomiting was
studies conducted by Erhart LM et al, Jadhav UM et al, seen in 25% of the patients. Headache was seen in 22%
vivax was the most common species while Bashawri of the patients while Altered Sensorium was seen in 4%
LAM et al reported higher falciparum prevalence.3,16,17 In of patients.

Table 4: Comparison of malaria caused by different species.

Type of infection (%) Bashawri LAM et al3 Erhart LM et al16 Jadhav UM et al17 Present study
P.vivax 39 59 62.17 55
P. falciparum 54.1 38 37.69 45
Mixed 2.33 2 0.04 0

As seen in other studies and our study, Fever is most In present study, Pallor was seen in 55% followed by
common symptom. Also chills and rigor, nausea and splenomegaly in 32% of cases, hepatomegaly in 20%,
vomiting, headache are still the common symptoms of Icterus in 11% and CNS involvement in form of seizures
malaria. Even though malaria is commonly associated and altered sensorium in 4%, and Pedal oedema in 5% of
with thrombocytopenia, rash and petechial hemorrhages the patients. Variations in different studies may be due to
in the skin or mucous membranes are not the common some studies having concentrated only on malarial
presentation features. hepatitis and jaundice in malaria and others on
hematological parameters only. Anaemia is a frequent

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 Surve KM et al. Int J Res Med Sci. 2017 Jun;5(6):2552-2557

finding in malaria cases, particularly in developing Echieverri M et al studying vivax cases had only 5%
nations. In the present study, anaemia (<11.5 gm %) was cases of leucocytosis.15,23
seen in 79% of the cases. In other studies carried out,
Sharma Set al had anaemia in 86.7% of the cases, while Changes in the WBC are less definite in malaria and there
in a study conducted by Biswas R et al, 94.4% of the is a wide variation seen among the studies. Usually Total
cases had anaemia.8,21 In study conducted in Saudi counts in majority of the patients are within normal
Arabia, Bashawri LAM et al had 59.2 % cases showing limits. In the present study 72% of the patients had
Anaemia.3 normal counts. In the present study; increase in
Leucocytes in Vivax is seen in 7.8% of the cases while in
Table 5: Comparison of patient age distribution (mean age). Falciparum, 10.4% cases show increased Leucocyte
count.
Studies Mean age in years
Bashawri LAM et al3 25.4 Leucopenia was seen in 18% of the total cases in the
Jadhav UM et al17 37.4 present study. In cases of vivax infection, 19.6% of the
Erhart LM et al16 28 cases show fall in Leucocytes while in Falciparum
Present study 30.47 infection 16.6% of the cases show leucopenia. Sharma
SK et al observed leucopenia in 6.6% cases in falciparum
In present study, severe anaemia (<7gm%) was seen in malaria and Ladhani S et al in 10.2% in falciparum
9% of cases, while study conducted by Bashawri LAM et malaria.8,15 Bashawri LAM et al had leucopenia in 13.3%
al had severe anaemia in 5.5% of cases.3 There is a wide of the total malaria cases. Study by Echieverri M et al had
variation in anaemia due to malaria infection depending 29% cases of leucopenia in vivax malaria cases.3,23
upon the geographical location of the study. In study
conducted by Richard MW et al in London only 15% While all studies show some changes in the total WBC
cases of malaria show anaemia.22 counts, there is a difference in values. Hence an alteration
in the WBC count is not unprecedented either for P.
Studies conducted in developing countries show higher falciparum or P. vivax though the quantum of changes
levels of anaemia. In the present study, Leucocytosis was may vary. Present study showed increased neutrophils in
seen in 10% of the cases. Study by Bashawri LAM et al 5% of the cases and neutropenia in 12% of the cases.
show 7.2% cases with Leucocytosis.3 Sharma SK et al
and Biswas R et al show 13.3% and 12.2% cases Similar values are seen in study by Bashawri LAM et al
respectively which are almost similar to the present showing 8.3% and 11.6% neutrophilia and neutropenia
study.8,21 More prominent rise (20%) was reported by respectively. Lymphocytosis was seen in the present
Ladhani Set al who studied falciparum cases only, and study in 8% of the cases. Similarly, Biswas et al reported
8.5% cases with lymphocytosis.3,21

Table 6: Comparison of clinical signs.

Signs Pallor Icterus Splenomegaly Hepatomegaly CNS Involvement

Farogh A et al.18 92% 14% 72% 48% 40%
Muddaiah A et al.19 11.5% 15.7% 15.7% 4.2% 4.21%
Piplani S et al.20 13.1% 6.5% 65.7% 53.9% -
Present study 55% 11% 32% 20% 4%

In the present study, the percentage of patients showing cases. Study conducted by Richards MW et al had
thrombocytopenia (<1.5 lacs) were 66.66% in case of thrombocytopenia in 67% of the case.22
falciparum malaria and 74.54% in case of vivax malaria.
The percentage of cases showing thrombocytopenia in Jaundice was seen in 11% of study group. This Incidence
falciparum infections and vivax infections varies in of jaundice is similar to study conducted by Kochar D et
different studies. Studies conducted by Bashawri LAM et al who had 12% of cases with jaundice.24 One had
al and Jhadav UM et al had thrombocytopenia more in unconjugated hyperbilirubinemia. Majority had
Vivax as in the present study while in study conducted by conjugated hyperbilirubinemia (10 out of 11).7 had
Erhart LM et al, thrombocytopenia is more in cases of falciparum malaria and 4 had vivax malaria. Three cases
falciparum malaria.3,16,17 Thrombocytopenia is a common fulfilled criteria of Malarial hepatitis. This was almost
finding in cases of malaria both vivax and falciparum as similar to study of Anand AC et al, who had incidence of
shown by most of the studies conducted. In the present malarial hepatitis in 2.4% of cases.25 Renal failure in the
study thrombocytopenia was seen in 71% of all malaria form of acute renal failure was noted in one patient with

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 Surve KM et al. Int J Res Med Sci. 2017 Jun;5(6):2552-2557

falciparum malaria (2.77%). Study by Kochar D et al had 9. Srichaikul T, Pulket C, Sirisatepisarn T, Prayoonwiwat
the incidence of renal failure to be 2%. No patients with W. Platelet dysfunction in malaria. Southeast Asian J
vivax malaria had renal failure.24 Trop Med Public Health. 1988; 19(2):225-33.
10. Kakar A, Bhoi S, Prakash V, Kakar S. Profound
CONCLUSION thrombocytopenia in plasmodium vivax malaria. Diagn
Microbiol Infect Dis. 1999;35(3):243-4.
11. Ogbadoyi EO, Tsado RD. Renal and Hepatic
Malaria is one of the most common infections in Indian
Dysfunction in Malaria Patients in Minna, North
Subcontinent. Malaria affects mostly adults with male
Central Nigeria. Online J Health Allied Sci. 2009;8(3).
predominance. Fever, Pallor and Splenomegaly are 12. Abro AH, Ustadi AM, Abro HA, Abdou AS, Younis
common clinical features in malaria. Malarial infection NJ, Akaila SI. Jaundice with hepatic dysfunction in P.
causes various haematological and biochemical changes. falciparum malaria. J Coll Physicians Surg Pak.
Anaemia and thrombocytopenia of varying severity are 2009;19(6):363-6.
most frequently observed haematological findings 13. Barsoum RS. Malarial acute renal failure. J Am Soc
however bleeding manifestations are uncommon. In a Nephrol. 2000;11(11):2147-54.
patient with febrile illness, observation of 14. Rajapurkar MM. Renal involvement in malaria. J
thrombocytopenia warrants careful search for malaria Postgrad Med. 1994;40:132-4.
parasite. P. falciparum is associated with serious 15. Ladhani S, Lowe B, Cole AO, Kowuondo K, Newton
complications like Severe anemia, Malarial hepatitis and RJC. Changes in white
Renal failure hence P. falciparum infection on suspicion blood cells and platelets in children with falciparum
of complication should be further evaluated. Various malaria: relationship to disease outcome. Brit J
haematological findings can help in early diagnosis of Haematol 2002;119(3):839-47.
malaria which is essential for timely and appropriate 16. Erhart LM, Yingyuen K, Chuanak N, Buathong N,
treatment which can limit the morbidity and prevent Laoboonchai A, Miller RS et al. Haematologic and
further complications. Clinical Indices of Malaria in a Semi-Immune
Population of Western Thailand. Am J Trop Med Hyg.
Funding: No funding sources 2004;70(1):8-14.
Conflict of interest: None declared 17. Jadhav UM, Patkar VS, Kadam NN.
Ethical approval: The study was approved by the Thrombocytopenia in Malaria - Correlation with Type
and Severity of Malaria. J Assoc Physicians India.
Institutional Ethics Committee
2004;52(2):615-8.
18. Farogh A, Qayyum A, Haleem A, Ghaffar A.
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