Severe malarial thrombocytopenia: a risk factor for mortality in Papua, Indonesia.

Daniel A Lampah,Nicholas M Douglas,Jeanne Rini Poespoprodjo,Nicholas M Anstey,Paulus Sugiarto,Michael Malloy,Tsin W Yeo,Donny Ronaldo,Enny Kenangalem,Julie A Simpson,Ric N Price

doi:10.1093/infdis/jiu487

Abstract

BackgroundThe significance of thrombocytopenia to the morbidity and mortality of malaria is poorly defined. We compared the platelet counts and clinical correlates of patients with and those without malaria in southern Papua, Indonesia.MethodsData were collated on patients presenting to a referral hospital between April 2004 and December 2012.ResultsPlatelet measurements were available in 215 479 patients (23.4%), 66 421 (30.8%) of whom had clinical malaria. Patients with Plasmodium falciparum monoinfection had the lowest platelet counts and greatest risk of severe thrombocytopenia (platelet count, <50 000 platelets/µL), compared with those without malaria (adjusted odds ratio [OR], 6.03; 95% confidence interval [CI], 5.77–6.30]). The corresponding risks were 5.4 (95% CI, 5.02–5.80) for mixed infections, 3.73 (95% CI, 3.51–3.97) for Plasmodium vivax infection, and 2.16 (95% CI, 1.78–2.63) for Plasmodium malariae infection (P < .001). In total, 1.3% of patients (2701 of 215 479) died. Patients with severe malarial anemia alone (hemoglobin level, <5 g/dL) had an adjusted OR for death of 4.93 (95% CI, 3.79–6.42), those with severe malarial thrombocytopenia alone had an adjusted OR of 2.77 (95% CI, 2.20–3.48), and those with both risk factors had an adjusted OR of 13.76 (95% CI, 10.22–18.54; P < .001).ConclusionsSevere thrombocytopenia identifies both children and adults at increased risk of death from falciparum or vivax malaria, particularly in those with concurrent severe anemia.

Highlights

The significance of thrombocytopenia to the morbidity and mortality of malaria is poorly defined
Confirmed malaria was diagnosed in 18.3% of patient presentations (168 525), with P. falciparum accounting for 53.3% of monoinfections, P. vivax for 32.3%, P. malariae for 2.7%, and P. ovale for 0.07%
There was no significant difference in the risk of bleeding recorded in patients with (4.3% [21 of 490]) and those without (5.7% [126 of 2211]) severe thrombocytopenia (P = .228). In this very large hospital-based surveillance study, almost two thirds of patients with acute malaria had thrombocytopenia, with 13% of patients presenting with platelet counts of

Summary

Methods

Data were collated on patients presenting to a referral hospital between April 2004 and December 2012. Severe thrombocytopenia identifies both children and adults at increased risk of death from falciparum or vivax malaria, in those with concurrent severe anemia. Low platelet counts have been associated with mortality in patients with P. falciparum [15] and P. vivax infections [16, 17]. The present study is part of a prospective surveillance of clinical and laboratory data from Mitra Masyarakat Hospital in southern Papua, Indonesia, an area where 4 species of malaria are coendemic. This analysis was conducted to establish the comparative platelet counts of patients infected by the different Plasmodium species and to define the associated risks of morbidity and mortality

METHODS

RESULTS

DISCUSSION