2219

NARRATIVE REVIEW
Utilization of the complete blood count in diagnosing endemic diseases in
Pakistan
Noor Khalid1, Muhammad Umer2

Abstract Most common diseases in Pakistan have distinct

Numerous infectious diseases, including enteric fever, haematological patterns that can be detected on a CBC,
malaria, dengue fever, and, most recently, coronavirus and aid in diagnosis. A thorough clinical evaluation
disease-2019, are prevalent in Pakistan. All these diseases combined with a CBC can frequently be enough to
have overlapping clinical symptoms and can present a diagnose a condition and save time, money and resources.
diagnostic challenge for the general practitioner. Since The current narrative review was planned to highlight CBC
definitive testing for these disorders is time-consuming patterns in various endemic diseases in Pakistan and to
and expensive, basic clinical testing, such as a complete guide the decision-making process in general practice. For
blood count, should be utilised to supplement clinical the purposes of the review, CBC did not include peripheral
diagnosis, when possible. The current narrative review was blood film or erythrocyte sedimentation rate (ESR).
planned to present specific alterations in haematological However, because a few laboratories do report them along
parameters for each of these disorders. The review was with the CBC, a small section on ESR and peripheral blood
intended as a guide for practising physicians in their films has also been included.
decision-making.
Enteric fever
Keywords: Complete blood count, Typhoid fever, Malaria,
Dengue, COVID-19. Enteric fever, commonly referred to as typhoid fever, is a
systemic febrile illness caused by bacterium Salmonella (S.)
DOI: https://doi.org/10.47391/JPMA.8459 typhi. Typhoid is transmitted via the faeco-oral route and
Submission completion date: 23-11-2022 is typically spread through the consumption of
Acceptance date : 03-08-2023 contaminated food or water. Major risk factors that
Introduction contribute to a high prevalence of enteric fever in low-
Complete blood count (CBC) is the most ordered routine income nations include a lack of safe drinking water and
investigation in general practice worldwide.1 It is a low- inadequate sanitary facilities. The World Health
cost, quick and reliable test that can provide information Organisation (WHO) estimates that 11-20 million people
about almost all common conditions of the blood and can are infected with typhoid each year.2
aid in the diagnosis of any underlying pathology. A CBC is In Pakistan, typhoid fever is highly endemic: 493.5 out of
also commonly ordered at patient admission as a baseline 100,000 cases in South Asia in 2018 were reported from
investigation, with repeat CBCs indicating the clinical Pakistan.3 This number is the highest among countries in
course of inpatients. the region, and various regional factors put Pakistan at high
Over the last few decades, clinicians have used CBC as the risk of a widespread typhoid outbreak including but not
first test to aid in the diagnosis of many clinical conditions. limited to lack of sanitation, poor socioeconomic status
Haematological parameters exhibit specific patterns of (SES) of majority of the population, and limitations in terms
change in various diseases, which can guide clinicians in of access to safe drinking water.3 During the summer and
their decision-making. This is especially important in the monsoon seasons, typhoid outbreaks are common, and
diagnosis of various epidemic and endemic diseases. patients typically present with a gradual onset of high-
Definitive diagnostic testing for these conditions takes grade fever often reaching a plateau of 102-104°F, fatigue,
longer, is more expensive, and is unaffordable for many rash and gastrointestinal (GI) symptoms. If left untreated,
people, particularly those in developing countries that bear typhoid can lead to life-threatening complications, such as
half the global disease burden. intestinal perforation and bleeding.4

1Department of Medicine, Benazir Bhutto Hospital, Rawalpindi, Pakistan; Blood cultures have traditionally been described as the
2Department of Medicine, Combined Military Hospital, Rawalpindi, Pakistan. gold standard for the diagnosis of enteric fever, but blood
cultures are expensive and often take several days to
Correspondence: Noor Khalid. e-mail: nbks1024@gmail.com
produce results. According to a 2016 systematic review, the
ORCID ID: 0000-0003-4928-8479

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2220 N. Khalid, M. Umer

sensitivity of blood cultures in diagnosing typhoid fever is Thrombocytopenia, although more important in other
66%, which means that one out of every three culture febrile illnesses, can also be observed in enteric fever. A
results can be a false-negative outcome.5 The other transient decrease in platelet (PLT) count can be observed
serological tests have the drawback of being non-specific in typhoid patients after almost one week of illness. It is
and non-confirmatory.4 As a result, clinicians in endemic important to note that thrombocytopenia, if present, is
areas, particularly those in low- and middle-income mild in contrast to thrombocytopenia seen in other viral
countries (LMICs), must actively seek to diagnose typhoid fevers.4,7
fever using clinical suspicion and certain diagnostic clues
from basic laboratory testing. Malaria
Malaria is a potentially life-threatening febrile illness caused
Haematological changes are common in typhoid fever and by the protozoan plasmodium (P.), which is transmitted via
may include anaemia, leukopenia or leukocytosis, and the bite of the female Anopheles mosquito. There are five
sometimes thrombocytopenia.6 Haemoglobin (Hb) counts different parasite species that cause disease in humans, of
are typically unaffected, but certain complications, such as which malaria caused by P. falciparum is the most severe.
GI bleeding, haemophagocytosis, bone marrow Malaria is endemic in tropical and subtropical regions, and
suppression, and prolonged toxaemia may result in in the year 2020, a total of 241 million people were infected,
anaemia.7 As a rule, patient’s Hb level is always normal at with an estimated 627,000 deaths.12
the initial stage of infection and may decline slowly,
depending on the progression of the disease.6 Significant Pakistan has a high number of malaria cases, with an
anaemia at the onset of a fever may point to an alternative annual incidence reported to be greater than 300,000.
diagnosis, like malaria. According to WHO malaria statistics, Pakistan is one of the
seven countries in the Eastern Mediterranean Region that
Leukopenia has been described as a classical finding in account for 98% of the total malaria burden. The number
typhoid infections, and occurs secondary to a bacterial- of people estimated to be at moderate and high risk for
mediated leukocyte shift from the circulation to the malaria are 217 million and 63 million, respectively.13 More
marginal zone.8 In actual clinical practice, leukopenia is than two-thirds of these cases are caused by the species P.
seen only in approximately one-fourth of patients, and vivax, and peak incidence is observed from July to
studies report the incidence of leukopenia in typhoid fever November after the monsoon rains.14 Malaria usually
to be around 20-25%. Leukopenia, when present, can be presents with a non-specific intermittent fever with chills,
an important indicator for the diagnosis of enteric fever, GI symptoms, such as vomiting and generalised fatigue. In
but a normal or elevated white blood cell (WBC) count on severe cases, organ dysfunction may occur, including the
the CBC does not rule out typhoid infection.7 The involvement of central nervous system (CNS), called
differential WBC counts frequently show a decrease in cerebral malaria, and kidneys, which is the blackwater
neutrophils and an increase in the lymphocyte percentage, fever.15
which suggests relative lymphocytosis.9
Traditionally, the visualisation of protozoans using
Notably, enteric fever in children more commonly presents microscopy has been described as the gold standard
with leukocytosis than in adults, in whom leukopenia may method for the diagnosis of malarial infections. However,
be more common.10 Leukocytosis may also be due to microscopy is often not accessible in rural areas where
complications, such as intestinal perforation.4 However, a malaria is common, and up to three blood smears taken
study conducted on paediatric patients in Pakistan found during a fever spike must be examined independently by
leukopenia to be present in approximately half of typhoid an expert to rule out the diagnosis of malaria.16 For this
patients, indicating that leukopenia is an important reason, malaria is usually diagnosed on clinical grounds,
diagnostic marker in local clinical settings.8 which often leads to the indiscriminate use of antimalarial
Eosinopenia, defined as a decrease in the number of drugs.
eosinophils, is often described as an important Certain haematological abnormalities invariably
independent predictor for typhoid fever, and current accompany malaria; these include anaemia,
literature has described its frequency to be 30-50%.7 In a thrombocytopenia and atypical leukocytosis or
study conducted on Pakistani population in 2020, 35% of leukopenia.17 Anaemia is haemolytic in nature and occurs
patients with enteric fever were found to have eosinopenia, due to a combination of different factors, including
with an odds ratio (OR) of 9.63.11 In paediatric patients in haemolysis of parasitised cells, hypersplenism leading to
Pakistan, this frequency was found to be 67.1%.8 increased red blood cell (RBC) removal and/or pooling, and
other factors such as RBC structural changes and increased

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Utilization of the complete blood count in diagnosing endemic diseases in Pakistan 2221

RBC clearance.17 In addition, complicated malaria is linked Dengue fever

to bone marrow depression, which can result in anaemia. DF is a mosquito-borne febrile illness caused by a flavivirus
A study comparing haematological parameters between transmitted via the bite of the female mosquito Aedes
febrile illnesses in Thailand demonstrated that anaemia aegypti. Four distinct, but closely related virus serotypes
with Hb <11.0 was frequently observed in patients with are responsible for infection: dengue virus-1 (DENV-1),
malaria. Other RBC indices, including haematocrit (HCT), DENV-2, DENV-3 and DENV-4.22 According to the WHO, the
mean corpuscular volume (MCV), mean corpuscular number of dengue cases have increased dramatically over
haemoglobin (MCH), and mean corpuscular haemoglobin the last two decades, 96 million people every year present
concentration (MCHC), were also found to be significantly with clinical symptoms of dengue infection, with Asia
low.18 Anaemia in malarial infections is often progressive accounting for 70% of the global disease burden.23
and correlates with the severity of the infection. Hb DF is endemic in Pakistan, and the number of cases is
<7.0g/dL in adults and <5.0g/dL in children is an important constantly increasing. Data for 2021 reported 48,091 cases
diagnostic criterion for severe malaria, indicating need for and 183 deaths due to the virus.24,25 This situation is highly
hospitalisation.19 alarming due to the steep rising trend over the years
Malaria is known to cause both leukocytosis and (Figure 1). Dengue usually presents as DF, a nonspecific
leukopenia, with varying findings reported in literature.17 febrile illness with myalgia, headache, retro-orbital pain,
Leukopenia occurs secondary to splenic sequestration and and rash. In some cases, patients develop dengue
marginal localisation of WBCs, but this finding is not haemorrhagic fever (DHF), a severe form of infection
universal. A study conducted on malaria patients in characterised by bleeding, plasma leakage and organ
Pakistan found no significant change in total leukocyte impairment, which can also result in shock and collapse,
count (TLC), irrespective of the degree of parasitaemia.16 called the dengue shock syndrome (DSS).22
Eosinophilia can be observed among the differential WBC DF is usually confirmed by rapid diagnostic tests for the
counts. Malaria does not by itself cause an increase in dengue nonstructural protein-1 (NS-1) antigen during days
eosinophil counts; neutrophils containing hemozoin are 1-5 of illness, and by serological testing after the 5th day.22
responsible for pseudo-eosinophilia commonly reported However, patients in LMICs frequently cannot afford these
in CBC analysis.20 Plasmodium infections may result in tests due to the high cost. They may also be unreliable early
monocytosis, owing to the large number of activated in the course of the disease.26 Since early diagnosis and
monocytes in the circulation.20 management of DF is important to avoid complications,
Thrombocytopenia is the most common haematological basic blood testing combined with clinical suspicion in
abnormality observed in malaria patients, and in endemic endemic areas must be used to diagnose and treat dengue
areas, the presence of a low PLT count in patients with patients in a timely manner.
acute febrile illness is considered virtually diagnostic for Haematological parameters, such as HCT, TLC and PLT
malaria.21 Increased peripheral destruction and increased count show specific variations in DF and can be used as
PLT consumption both contribute to thrombocytopenia, reliable parameters to diagnose dengue infection. In
and counts are negatively correlated with the parasite patients with simple DF, RBC indices, such as Hb and HCT,
index.16 A PLT count of <150,000/μl has been described to
have a sensitivity and specificity of approximately 80% in
the detection of malaria in endemic regions.21
A low PLT count can also be observed in dengue fever (DF),
but PLT counts tend to fall later in dengue and are often
normal at the onset of infection; a finding that can help
differentiate DF from malaria. Kumar et al. analysed
haematological parameters between the two diseases and
suggested a combination of four variables, which, when
taken together, have a post-test probability of 69% and a
positive likelihood ratio of 7.2 for malaria if all 4 are present;
Hb <10.0g/dL, TLC <5.0×106, PLT <100,000/μl, and red cell
distribution width (RDW) >15.17 Figure-1: Annual number of dengue cases reported in Pakistan over the years.
Data source: National Institute of Health (NIH), Islamabad, and Disaster
Response Emergency Fund (DREF) Final Situation Report, Pakistan
(June 2022).24,25

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2222 N. Khalid, M. Umer

are frequently unchanged. In DHF, plasma leakage and neutrophil-to-lymphocyte ratio (NLR), which can help
haemoconcentration occur, leading to an increase in both distinguish it from other febrile infections.30
the parameters. An increase in the HCT level of ≥20% is one
of the WHO defining criteria for DHF.27 An increased HCT Among other WBCs, an increase in the number of
level, while important in diagnosis, is not prognostic and monocytes can be seen in the early stages of illness,
cannot be used to predict disease severity.28 whereas an increase in the number of basophils and
eosinophils is frequently seen in the convalescent
Leukopenia, defined as TLC count <4.0×106, can be phase.30,31 In approximately 80% cases, the resurgence of
observed as early as day 2 of illness and can be used as an the TLC precedes the recovery of the PLT count during the
early marker for diagnosis.29 Leukopenia has a positive recovery phase.31
predictive value (PPV) of 70-80% for DF in endemic areas.22
The decrease in TLC is primarily due to a decrease in Thrombocytopenia is the most common haematological
neutrophil count, which occurs as a result of decreased abnormality seen in dengue patients, and it can be caused
granulocyte production secondary to virus-mediated bone by increased peripheral destruction and bone marrow
marrow suppression.18 In contrast, the lymphocyte count depression. PLT counts may be normal in the early stages
is increased owing to the presence of atypical lymphocytes of DF, which helps distinguish it from malaria. PLT counts
in response to viral infections.30 DF is characterised by a low are typically lowest 3-6 days after disease onset, when the
patient is no longer febrile.18 PLT count is also a prognostic
indicator, with higher values indicating disease
Patient presents with symptoms
of an acute febrile illness
progression. Lower PLT counts are linked to more
haemorrhagic manifestations.28

Get a CBC
The haematocrit-platelet index (HPI) has recently been
introduced as a prognostic marker for severe dengue, and
is strongly associated with length of hospital stay.
Check
Neutrophil
According to Haider et al., an HPI of 1.0 or higher on day 3
count is associated with a severe clinical course.32 As a result, a
CBC can not only help diagnose DF, but also predict its
< 2.8 x 103 > 2.8 x 103 clinical course and severity.
Kotepui et al. in Thailand in 2017 determined the
Check Malaria
haematological parameters that could be used to
Haemoglobin
level
differentiate DF and malaria. The study had 683 patients,
and, after analysis, a decision tree was devised that could
be used to differentiate between the two fevers (Figure 2).18
<11 g/dl ³11 g/dl

COVID-19
Check
Dengue The emergence of severe acute respiratory syndrome
Lymphocyte coronavirus 2 (SARS-CoV-2) and the resulting coronavirus
count
disease-2019 (COVID-19) pandemic resulted in over six
million deaths, making it the deadliest global health crisis
< 2.8 x 103 ³ 2.8 x 103
since the 1918 influenza pandemic.33 The virus is highly
contagious and spreads from person to person via
Malaria
Check respiratory droplets. COVID-19 has now entered an
MCHC
'endemic phase' as a result of vaccine development and
global vaccination efforts.34 New strains of the virus
>33 g/dL £33 g/dL continue to emerge and spread in the community,
infecting people.34
Male Patient Female Patient Dengue
Pakistan, like other countries, was severely affected by the
Dengue
virus, with approximately 1.57 million reported cases and
Malaria
over 30,000 deaths.35 COVID-19 has a broad clinical
Figure-2: Algorithm to differentiate between malaria and dengue fever based on spectrum, from asymptomatic or mildly symptomatic
complete blood count (CBC) parameters.18 forms to severe pneumonia, that causes organ failure and
MCHS: Mean corpuscular haemoglobin concentration. frequently necessitates mechanical ventilation.33 Among

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Utilization of the complete blood count in diagnosing endemic.... 2223

those who are symptomatic, the most common symptoms These immature PLTs are more functional and may
are fever, cough, dyspnoea, sore throat, anosmia and contribute to an increase in COVID-19 thrombotic events.
myalgias.33
Formica et al. developed a clinical score based on CBC
The standard test for COVID-19 diagnosis is molecular parameters with >80% sensitivity and specificity for the
testing for the virus using polymerase chain reaction (PCR) diagnosis of COVID-19. Each of these parameters were
on nasopharyngeal or oropharyngeal swab samples. The scored accordingly; MCV ≤90fL, age ≥45 years, PLT
drawbacks of this test include its high cost, sample ≤180,000/μl, and eosinophil count <0.1/μL. Individuals with
collection errors, low sensitivity, and prolonged waiting a mean absolute percentage error (MAPE) score ≥173 have
time for the results.36 The gold standard for diagnosing a high probability of testing positive by COVID-19 PCR
COVID-19 is a high-resolution computed tomography testing.44 Such scores have yet to be clinically applied, but
(HRCT) chest scan, but radiological testing is costly and not they highlight the importance of a CBC in diagnosing
widely available. Other tests, such as rapid antigen testing, endemic diseases early and effectively.
serological testing, and plain chest films, have low
sensitivity and are frequently not used for diagnosis.33 Erythrocyte sedimentation rate (ESR)
The erythrocyte sedimentation rate (ESR) is a test that
The CBC of COVID-19 patients shows several changes that measures the descent of RBCs in a vertical column of
can be used to predict infection and guide diagnostic anticoagulated blood over a period of one hour. ESR is a
testing. COVID-19 patients' mean Hb and HCT levels are simple and inexpensive test that is often used as a
frequently unchanged or mildly decreased, except in nonspecific marker of inflammation in the body.45 ESR
critically ill patients, where the Hb level may be significantly values, like the other CBC parameters already discussed,
low.37 RDW is typically increased, as are serum ferritin frequently show characteristic patterns in infectious
levels.38 diseases, and, when available, can aid in diagnosis. In
Lymphopenia has been identified as the most common typhoid fever, ESR levels do not increase in the first few
and significant CBC abnormality in COVID-19 patients.39 weeks, rather show a significant decrease when compared
When compared to baseline levels, TLC is low, and the to ESR levels in healthy individuals.46 Approximately 80%
neutrophil count is often high. Lymphopenia is progressive, of individuals with malaria have an elevated ESR during the
and people with severe disease frequently become more acute phase of illness, which returns to normal during
lymphopenic as the disease progresses.40 These findings recovery.47 Most DF patients have normal ESR levels, but in
are similar to those of DF, but NLR is higher in COVID-19 cases of DHF with shock, ESR levels are low.48 COVID-19 has
patients than in DF patients, which can help distinguish significantly elevated ESR levels, as well as other
between the two.41 inflammatory markers, such as C-reactive protein (CRP) and
serum ferritin levels.39
An important finding observed in COVID-19 patients is
eosinopenia. Tanni et al. found that 60% of COVID-19 Role of the blood peripheral film
patients had an eosinophil count of 0 at the time of While the role of the peripheral blood smear has been
presentation.42 Persistently, low eosinophil counts are also widely recognised for malaria diagnosis, the utility of the
associated with severe disease and low recovery rates. The blood film in diagnosis of other infectious fevers remains
pathophysiology behind this abnormality is uncertain and unclear and less well recognised. For malaria, a drop of
is most likely multifactorial.38 Among the other types of blood is smeared on a slide and stained with Giemsa to
WBCs, basophil counts are low, whereas monocyte counts visualise the plasmodium parasites, which results in
remain unchanged.37 definitive diagnosis. Often, both thin and thick blood
smears are prepared and visualised under a microscope. In
COVID-19, like other viral infections, also causes P. falciparum infections, the infected RBCs will show either
thrombocytopenia, which is usually mild. Unlike DF, where ring forms or crescent-shaped gametocytes. Trophozoite
the PLT count drops during defervescence days 3-5, and schizont forms are rarely visualised.49 In DF,
thrombocytopenia in COVID-19 occurs later in the clinical plasmacytosis has been suggested as a diagnostic marker
course.41 PLT counts remain above 100,000/μl on average. on blood film in some cases.50
A progressively falling PLT count, on the other hand, may
indicate the presence of an underlying coagulopathy and Literature suggests that morphological abnormalities on
is associated with a severe clinical course.37 It is interesting blood smear can be used to predict disease severity in
to note that in COVID-19, the immature platelet fraction COVID-19 rather than using it for diagnostic purposes.51
(IPF) is elevated even when the total PLT count is normal.43

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2224 N. Khalid, M. Umer

Table: A simplified summary of the most common changes in haematological parameters amongst endemic infectious diseases in Pakistan.
Disease Changes in CBC parameters
Hb HCT TLC Neutrophils Lymphocytes NLR Eosinophils Monocytes Basophils Platelets
Typhoid N N ↓ (↑ in children) ↓ N or ↑ ↓ ↓ N ↓ (often zero) N or ↓(late)
Malaria ↓ ↓ N or ↓ ↓ ↓↓ ↑↑ ↑ ↑ N or ↓ ↓↓(early)
Dengue N or ↑ N or ↑ ↓(early) ↓ ↑ ↓ ↑(late) ↑(early) ↑(late) ↓↓(late)
COVID-19 N or ↓ N or ↓ ↓ ↑↑ ↓ ↑↑ ↓↓ (often zero) N ↓ ↓
CBC: Complete blood count, Hb: Haemoglobin, HCT: Haematocrit, NLR: Neutrophil-to-lymphocyte ratio. N: Normal, ↑: Increased, ↓: Decreased, COVID-19: Coronavirus disease-2019.
Clinical application and limitations 7. Shah AK. Diagnosis of Enteric Fever. Pediatr Infect Dis 2021;3:165–9.
doi: 10.5005/jp-journals-10081-1323
The primary infectious diseases in Pakistan have particular 8. Rafiq F, Shafqat F, Kahif Z, Rehman MU, Ali SS, Warriach SZ.
alterations in CBC values (Table). In real life, the outcomes Histopathological and Haematological Manifestations of Typhoid
might not be as uniform, and a diagnosis might be difficult. Fever in Pediatric Age Group. Pak J Med Heal Sci 2022;16:60. doi:
Since the majority of these disorders share comparable CBC 10.53350/pjmhs2216360
readings and overlapping clinical characteristics, a single 9. Shrivastava K, Vahikar S, Mishra V. Haematological profile in typhoid
fever. Trop J Pathol Microbiol 2019;1:16–20. doi: 10.17511/JOPM.
CBC test might not provide a conclusive diagnosis. 2015. I01.04
Moreover, most of these diseases have CBC patterns that 10. Bhandari J, Thada PK, DeVos E. Typhoid Fever. Treasure Island, FL:
differ based on the day after infection. It is crucial to keep StatPearls Publishing; 2023.
in mind that routine laboratory testing should always 11. Ishaq U, Malik J, Asif M, Zaib H, Haider I, Zahid T, et al. Eosinopenia in
support clinical judgement, and caution must be taken to Patients With Typhoid Fever: A Case-Control Study. Cureus
2020;12:e10359. doi: 10.7759/cureus.10359
account for all confounding variables when utilising CBC
12. Andrade M V, Noronha K, Diniz BPC, Guedes G, Carvalho LR, Silva VA,
as a diagnostic tool. et al. The economic burden of malaria: a systematic review. Malar J
2022;21:283. doi: 10.1186/s12936-022-04303-6.
Conclusion 13. World Health Organization (WHO). World Malaria Report 2021.
Certain infectious diseases that are endemic in Pakistan [Online] 2021 [Cited 2023 May 23]. Available from: URL:
carry a significant burden on the healthcare system in https://www.who.int/teams/global-malaria-programme/reports/
world-malaria-report-2021
terms of economic and healthcare resources. When there
14. Ghanchi NK, Shakoor S, Thaver AM, Khan MS, Janjua A, Beg MA.
is a high degree of clinical suspicion, a simple and Current situation and challenges in implementing Malaria control
inexpensive CBC test can often be the only investigation strategies in Pakistan. Crit Rev Microbiol 2016;42:588-93. doi:
needed for diagnosis. It can also help direct prompt 10.3109/1040841X.2014.973368
management, saving valuable time and resources. 15. Garcia LS. Malaria. Clin Lab Med 2010;30:93-129. doi: 10.1016/j.cll.
2009.10.001
Disclaimer: None. 16. Khan MQ, Zafar L, Zulfiqar A, Abbas A, Salim H, Afzal A. The
Haematological parameters in Malaria and its correlation with
Conflict of Interest: None. parasite Index: A cross-sectional study in Pakistan. J Haematol Stem
Cell Res 2022;2:31–4.
Source of Funding: None. 17. Jairajpuri ZS, Rana S, Hassan MJ, Nabi F, Jetley S. An Analysis of
Haematological Parameters as a Diagnostic test for Malaria in
References Patients with Acute Febrile Illness: An Institutional Experience. Oman
1. Susan H, Kenneth AF, Modupe K, Lai-Meng L, Sanjay AP, Shahin S, et Med J 2014;29:12–7. doi: 10.5001/omj.2014.04.
al. The Top 25 Laboratory Tests by Volume and Revenue in Five 18. Kotepui M, PhunPhuech B, Phiwklam N, Uthaisar K. Differentiating
Different Countries. Am J Clin Pathol 2019;151:446–51. doi: between dengue fever and malaria using haematological
10.1093/ajcp/aqy165 parameters in endemic areas of Thailand. Infect Dis Poverty
2. World Health Organization (WHO). Typhoid. [Online] 2019 [Cited 2017;6:27. doi:10.1186/s40249-017-0238-x
2022 November 03]. Available from: URL: https://www.who.int/ 19. White NJ. Severe malaria. Malar J 2022;21:284. doi: 10.1186/s12936-
news-room/fact-sheets/detail/typhoid 022-04301-8
3. Tharwani ZH, Kumar P, Salman Y, Islam Z, Ahmad S, Essar MY. Typhoid 20. Nishimura J, Dharap P, Raimbault S. The utility of basic blood counts,
in Pakistan: Challenges, Efforts, and Recommendations. Infect Drug WBC histogram and C-reactive protein in detecting malaria. BMC
Resist 2022;15:2523–7. doi: 10.2147/IDR.S365220. Infect Dis 2021;21:1–13. doi: 10.1186/s12879-021-06704-5
4. Basnyat B, Qamar FN, Rupali P, Ahmed T, Parry CM. Enteric fever. BMJ 21. Gebreweld A, Erkihun Y, Feleke DG, Hailu G, Fiseha T.
2021;372:n437. doi: 10.1136/bmj.n437. Thrombocytopenia as a Diagnostic Marker for Malaria in Patients
5. Mogasale V, Ramani E, Mogasale VV, Park J. What proportion of with Acute Febrile Illness. J Trop Med 2021;2021:5585272. doi:
Salmonella Typhi cases are detected by blood culture? A systematic 10.1155/2021/5585272
literature review. Ann Clin Microbiol Antimicrob 2016; 15:32. doi: 22. Kularatne SAM. Dengue fever. BMJ Br Med J 2015;351:h4661. doi:
10.1186/s12941-016-0147-z 10.1136/bmj.h4661
6. Uplaonkar S V, Kauser SH, Tengli MB. Haematological profile in 23. World Health Organization (WHO). Dengue and severe dengue.
typhoid fever. Indian J Pathol Oncol 2017; 4:263–5. doi: 10.18231/ News release. The WHO Media Centre. [Online] 2022 [Cited 2022
2394-6792.2017.0054 November 11]. Available from: URL: https://www.who.int/news-

Open Access J Pak Med Assoc

Utilization of the complete blood count in diagnosing endemic diseases in Pakistan 2225

room/fact-sheets/detail/dengue-and-severe-dengue 38. Dhinata KS. Common Change of Complete Blood Count Parameters
24. Khan U, Azeem S. The rising toll of dengue cases in Pakistan every in COVID-19: a Literature Review. J Med Heal 2021;3:198-207. doi:
year: An incipient crisis. Ann Med Surg (Lond) 2022;76:103549. doi: 10.28932/jmh.v3i2.3097
10.1016/j.amsu.2022.103549. 39. Pourbagheri-Sigaroodi A, Bashash D, Fateh F, Abolghasemi H.
25. United Nations Office for the Coordination of Humanitarian Affairs Laboratory findings in COVID-19 diagnosis and prognosis. Clin Chim
(OCHA). Pakistan: Dengue Response Emergency Plan of Action Acta 2020;510:475–82. doi: 10.1016/j.cca.2020.08.019.
(EPoA) DREF operation n MDRPK022. [Online] 2021 [Cited 2023 40. Pozdnyakova O, Connell NT, Battinelli EM, Connors JM, Fell G, Kim
August 11]. Available from: URL: https://reliefweb.int/report/ AS. Clinical Significance of CBC and WBC Morphology in the
pakistan/pakistan-dengue-response-emergency-plan-action-epoa- Diagnosis and Clinical Course of COVID-19 Infection. Am J Clin Pathol
dref-operation-n-mdrpk022. 2021;155:364–75. doi: 10.1093/ajcp/aqaa231.
26. Priyanka P, Dinesh U. Differentiating between Dengue Fever from 41. Rosso F, Parra-Lara LG, Agudelo-Rojas OL, Martinez-Ruiz DM.
Other Febrile Illnesses Using Haematological Parameters. J Natl Lab Differentiating Dengue from COVID-19: Comparison of Cases in
Med 2018;7:6–10. doi: 10.7860/NJLM/2018/37424:2311 Colombia. Am J Trop Med Hyg 2021;105:745–50. doi: 10.4269/
27. Butt N, Abbassi A, Munir SM, Ahmad SM, Sheikh QH. Haematological ajtmh.20-0912.
and biochemical indicators for the early diagnosis of dengue viral 42. Tanni F, Akker E, Zaman MM, Figueroa N, Tharian B, Hupart KH.
infection. J Coll Physicians Surg Pak 2008;18:282–5. Eosinopenia and COVID-19. J Osteopath Med 2020;120:504–8. doi:
28. Huy BV, Toàn NV. Prognostic indicators associated with progresses 10.7556/jaoa.2020.091.
of severe dengue. PLoS One 2022;17:e0262096. doi: 10.1371/journal. 43. Wool GD, Miller JL. The Impact of COVID-19 Disease on Platelets and
pone.0262096. Coagulation. Pathobiology 2021;88:15–27. doi: 10.1159/000512007
29. Day ME, Mejia Sang ME, Puello YC, Diaz Brockmans EJ, Defillo SR, 44. Formica V, Minieri M, Bernardini S, Ciotti M, D’Agostini C, Roselli M,
Taveras Cruz KM, et al. Complete Blood Count Values Vary in Degree et al. Complete blood count might help to identify subjects with high
of Change with Day of Fever in Children with Dengue Fever. Open probability of testing positive to SARS-CoV-2. Clin Med (Lond)
Forum Infect Dis 2021;8(Suppl 1):S461–2. doi: 10.1093/ofid/ 2020;20:e114-9. doi: 10.7861/clinmed.2020-0373.
ofab466.922 45. Brigden ML. Clinical utility of the erythrocyte sedimentation rate. Am
30. Jameel T, Mehmood K, Mujtaba G, Choudhry N, Afzal N, Paul RF. Fam Physician 1999;60:1443–50.
Changing haematological parameters in dengue viral infections. J 46. Ndako JA, Dojumo VT, Akinwumi JA, Fajobi VO, Owolabi AO, Olatinsu
Ayub Med Coll Abbottabad 2012;24:3–6. O. Changes in some haematological parameters in typhoid fever
31. Ananda Rao A, U RR, Gosavi S, Menon S. Dengue Fever: Prognostic patients attending Landmark University Medical Center, Omuaran-
Insights From a Complete Blood Count. Cureus 2020;12:6–13. doi: Nigeria. Heliyon 2020;6:e04002. doi: 10.1016/j.heliyon.2020.e04002
10.7759/cureus.11594. 47. Kumbhar SS, Kanetkar SR, Mane A, Agarwal G, Bansal S. Clinico-
32. Haider MF Bin, Zafar H, Shah SZH, Akram M, Malik KN, Niaz A. haematological profile of malaria cases in a tertiary care hospital.
association of haematocrit-platelet index and haematocrit shift with Galore Int J Heal Sci Res 2019;4:79-89.
warning signs and hospital stay in dengue patients at a tertiary care 48. Souza LJ de, Reis AFF, Almeida FCR de, Souza LA de, Abukater M,
hospital. Pak Armed Forces Med J 2021;71(Suppl 1):s277-82. doi: Gomes MAE, et al. Alteration in the erythrocyte sedimentation rate
10.51253/pafmj.v71iSuppl-1.4785 in dengue patients: analysis of 1,398 cases. Brazilian J Infect Dis
33. Cascella M, Rajnik M, Aleem A, Dulebohn SC, Di Napoli R. Features, 2008;12:472–5. doi: 10.1590/s1413-86702008000600005.
Evaluation, and Treatment of Coronavirus (COVID-19). Treasure 49. Centers for Disease Control and Prevention (CDC). Laboratory
Island, FL: StatPearls Publishing; 2022. diagnosis of malaria: Plasmodium falciparum. [Online] [Cited 2023
34. Biancolella M, Colona VL, Mehrian-Shai R, Watt JL, Luzzatto L, Novelli May 23]. Available from URL: https://www.cdc.gov/dpdx/resources/
G, et al. COVID-19 2022 update: transition of the pandemic to the pdf/benchAids/malaria/Pfalciparum_benchaidV2.pdf
endemic phase. Hum Genomics 2022;16:19. doi: 10.1186/s40246- 50. Tanaka Y. Plasmacytoid Lymphocytes: A Diagnostic Clue for Dengue
022-00392-1 Fever. Intern Med 2018;57:2917. doi: 10.2169/internalmedicine.0179-
35. Our World In Data. Pakistan: Coronavirus Pandemic (COVID-19). 17.
[Online] [Cited 2022 November 03]. Available from: URL: 51. Berber I, Cagasar O, Sarici A, Berber NK, Aydogdu I, Ulutas O, et. al.
https://ourworldindata.org/coronavirus/country/pakistan Peripheral Blood Smear Findings of COVID-19 Patients Provide
36. Pascarella G, Strumia A, Piliego C, Bruno F, Del Buono R, Costa F, et Information about the Severity of the Disease and the Duration of
al. COVID-19 diagnosis and management: a comprehensive review. Hospital Stay. Mediterr J Hematol Infect Dis 2021;13:e2021009. doi:
J Intern Med 2020;288:192–206. doi: 10.1111/joim.13091 10.4084/MJHID.2021.009.
37. Palladino M. Complete blood count alterations in COVID-19 patients:
A narrative review. Biochem medica 2021;31:30501. doi: 10.11613/
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