Blood Film Examination Research Articles

Prevalence of Malaria and Associated Factors among Patients Attending at Hallaba Health Center, Southern Ethiopia

Back ground: Malaria is usually an important hazard in order to open health and economic progress inside the African continent. Throughout sub-Saharan the African continents, 90% of all demise largely below 5 youngsters tend to be due to malaria. Yearly you can find in relation to 270-480 million circumstances associated with malaria leading to in relation to one million demise, largely inside The African continent as well as especially within 5 youngsters. Almost all of the full division of Ethiopia is actually malarious, doing malaria the best open health problem inside Ethiopia. The purpose of this particular review seemed to be to look into your frequency as well as associated factors among patients attending at Hallaba health center based on thick and thin blood film examination. Thus, this research was launched to determine the prevalence of malaria and associated factors among patients who attended at Hallaba health center. Methods: Health center based cross sectional study was conducted from April 19 to June 21, 2009 at Hallaba health center on a total of 204 individuals who were selected conveniently. Structured questionnaire was used to obtain socio-demographic and other data. Then the data were entered and analyzed by using SPSS software. Statistical tables and graphs were used to present the result. Chi-square tests and OR (95% CI) were used to test the association. Results: The analyses showed that the highest prevalence of malaria was found between age group of 0-19 year. There was association between age group and prevalence of malaria (X2= 77.07, P<0.005) and also there was association between prevalence of malaria and sign and symptom like fever (OR=11.84%, 95%CI, 4.62-30.27, P<0.005). Vomiting (OR=8.29, 95% CI 3.39-20.49, P<0.005).Chills (OR=8.76, 95% CI 3.71-20.70, P<0.005) Joint and back pain (OR=3.85, 95%CI 1.26-11.94, P<0.005), headache (OR=75.17, 95% CI 21.12-270.43, P<0.005). Conclusion: Those with inadequate socio-economic conditions are really linked to malaria contamination. On the result it can be concluded that most of the respondents were infected with Plasmodium vivax. The respondents' knowledge or having information about malaria has no association with the prevalence of malaria. Age, altitude, rainfall and socio-economic factors contribute to high prevalence of malaria at Hallaba health Center. This kind of facts is vital to style increased strategic involvement with the lessening connected with malaria pandemic in Halaba town. Generally, from the result of this study it can concluded that the prevalence of Plasmodium vivax and Plasmodium falciparum is different from the national figure.

Haemato-biochemical and thyroxin status in Trypanosoma evansi infected dogs.

Inone year period of study, dogs with inappetence, fever, ocular discharges, dullness, enlarged lymph nodes were screened for the presence of haemoprotozoans at College Hospital of College of Veterinary Science, Tirupati. Wet blood film examination and stained blood smear examination was done to confirm the condition. Peripheral blood smears of dogs revealed the presence of Trypansomes. Trypanosoma evansi was confirmed based on the morphology and measurements of the organisms in the stained blood smears. Haematology revealed decreased total erythrocyte count, packed cell volume, haemoglobin and total leucocyte count values. Total serum proteins, albumin and glucose levels were decreased significantly (P<0.01), but a significant increase (P<0.01) in cholesterol, blood urea nitrogen, serum alkaline phosphatase, serum aspartate aminotransferase and serum alanine aminotransferase levels were observed. Decreased total T4 and free T4 were also observed in the T. evansi infected dogs.

Anemia and associated factors among school-age children in Filtu Town, Somali region, Southeast Ethiopia.

BackgroundAnemia is one of the major public health problems affecting more than half of school-age children in developing countries. Anemia among children has been conclusively seen to delay psychomotor development, poor cognitive performance, impaired immunity and decrease working capacity. The purpose of this study is to determine the prevalence and associated factors of anemia among school-age children in Filtu Town, Somali region, Southeast Ethiopia.MethodsA community based cross-sectional study was conducted from July to August, 2013 in Filtu Town. A total of 355 school-age children between 5–15 years old were included in the study. Socio-demographic data were obtained from each participant using structured questionnaire. Hemoglobin concentration was determined by HemoCue 201+ photometer (HemoCue, Angelholm, Sweden) analyzer. Hemoglobin values below 11.5 g/dl and 12 g/dl were considered as anemic for age ranges of 5–11 and 12–15 years, respectively. Anthropometric data were taken from each study participant. Peripheral blood film and stool examination were done for hemoparasite and intestinal parasite screening, respectively. Data were analyzed using SPSS version 16.0.ResultsOver all, prevalence of anemia was found to be 23.66%. The vast majority (73.81%) of the anemic children had mild anemia. Moderate and severe anemia accounted for 25% and 1.19% of the anemic children, respectively. Being from a family with low income (AOR = 9.44, 95% CI: 2.88, 30.99), stunted (AOR = 5.50, 95% CI: 2.83, 10.72), underweight (AOR = 2.07, 95% CI: 1.06, 4.05) and having intestinal parasite infection (AOR = 2.99, 95% CI: 1.05, 8.46) were identified as associated factors for anemia.ConclusionAnemia is a moderate public health problem in school-age children for the study area. Interventions targeting nutritional deficiencies and parasitic infections are recommended.

Declined Presentation: Peripheral blood smear findings in burn patients

Microscopic examination of peripheral blood films plays an important role to supplement the information by automated hematology analyzers. Various hematologic changes were reported after burn injury. In this study, we examined the peripheral blood smears and investigated the characteristics in burn patients.

Description, molecular characterization, and patterns of distribution of a widespread New World avian malaria parasite (Haemosporida: Plasmodiidae), Plasmodium (Novyella) homopolare sp. nov.

Plasmodium (Novyella) homopolare, a newly described Plasmodium species, was found in a wide range of Passeriformes species in California, USA, and Colombia. This parasite infected more than 20% of the sampled bird community (N = 399) in California and was found in 3.6% of birds sampled (N = 493) in Colombia. Thus far, it has been confirmed in North and South America where it is present in numerous species of migratory and resident birds from six families. Based on 100% matches, or near-100% matches (i.e., ≤2-nucleotide difference), to DNA sequences previously deposited in GenBank, this parasite is likely also distributed in the Eastern USA, Central America, and the Caribbean. Here, we describe the blood stages of P. homopolare and its mtDNA cytochrome b sequence. P. homopolare belongs to the subgenus Novyella and can be readily distinguished from the majority of other Novyella species, primarily, by the strictly polar or subpolar position of meronts and advanced trophozoites in infected erythrocytes. We explore possible reasons why this widespread parasite has not been described in earlier studies. Natural malarial parasitemias are usually light and co-infections predominate, making the parasites difficult to detect and identify to species when relying exclusively on microscopic examination of blood films. The combined application of sequence data and digital microscopy techniques, such as those used in this study, provides identifying markers that will facilitate the diagnosis of this parasite in natural avian populations. We also address the evolutionary relationship of this parasite to other species of Plasmodium using phylogenetic reconstruction.

Spatially Heterogeneous Land Cover/Land Use and Climatic Risk Factors of Tick-Borne Feline Cytauxzoonosis

Feline cytauxzoonosis is a highly fatal tick-borne disease caused by a hemoparasitic protozoan, Cytauxzoon felis. This disease is a leading cause of mortality for cats in the Midwestern United States, and no vaccine or effective treatment options exist. Prevention based on knowledge of risk factors is therefore vital. Associations of different environmental factors, including recent climate were evaluated as potential risk factors for cytauxzoonosis using Geographic Information Systems (GIS). There were 69 cases determined to be positive for cytauxzoonosis based upon positive identification of C. felis within blood film examinations, tissue impression smears, or histopathologic examination of tissues. Negative controls totaling 123 were selected from feline cases that had a history of fever, malaise, icterus, and anorexia but lack of C. felis within blood films, impression smears, or histopathologic examination of tissues. Additional criteria to rule out C. felis among controls were the presence of regenerative anemia, cytologic examination of blood marrow or lymph node aspirate, other causative agent diagnosed, or survival of 25 days or greater after testing. Potential environmental determinants were derived from publicly available sources, viz., US Department of Agriculture (soil attributes), US Geological Survey (land-cover/landscape, landscape metrics), and NASA (climate). Candidate variables were screened using univariate logistic models with a liberal p value (0.2), and associations with cytauxzoonosis were modeled using a global multivariate logistic model (p<0.05). Spatial heterogeneity among significant variables in the study region was modeled using a geographically weighted regression (GWR) approach. Total Edge Contrast Index (TECI), grassland-coverage, humidity conditions recorded during the 9(th) week prior to case arrival, and an interaction variable, "diurnal temperature range × percent mixed forest area" were significant risk factors for cytauxzoonosis in the study region. TECI and grassland areas exhibited significant regional differences in their effects on cytauxzoonosis outcome, whereas others were uniform. Land-cover areas favorable for tick habitats and climatic conditions that favor the tick life cycle are strong risk factors for feline cytauxzoonosis. Spatial heterogeneity and interaction effects between land-cover and climatic variables may reveal new information when evaluating risk factors for vector-borne diseases.

The unexpected traveling companion: Interactive cases in migratory helminthiases

Increasingly exotic travel for pleasure, business or science, coupled with ever more adventurous ethnic eating, means increased exposure of travellers to a variety of pathogens, including helminth parasites. In this contribution, several case reports highlight infections that may be well known in some parts of the world, but which presented as clinical and diagnostic challenges when they accompanied travelers either visiting or returning to South Africa. A scientist investigating haemorrhagic fever ecology in West Africa reported minor, transient skin rashes and itching several months after returning from the field. A full blood count done for an unrelated reason showed a high eosinophil count, and blood film examination revealed the diagnosis. A party of tourists enjoying a houseboat cruise on the Okavango presented with diarrhoea, abdominal pain, and painful migratory skin lesions on returning to South Africa a few days later. Their hosts in Botswana did an internet search and alerted them to earlier reports of a similar disease, which led to the likely diagnosis and appropriate treatment. A South African veterinarian, who had travelled to Thailand for a temple tiger experience, presented with the same condition. A South African medical student spent a holiday in Mozambique, and on return complained of a pruritic, serpiginous lesion on the sole of her foot. Topical application of a veterinary remedy provided relief. Two men, respectively Cameroonian and Malawian immigrants, presented in Johannesburg with red, irritated eyes. Clinical and laboratory investigations provided satisfactory diagnoses for both. Most of these helminthic infections presented diagnostic surprises, usually reflecting lack of local clinical experience, and were also challenging because optimal laboratory investigations and treatment were not always available.

Complex karyotype in a polycythemia vera patient with a novel SETD1B/GTF2H3 fusion gene

The patient had been diagnosed with polycythemia vera (PV) in 1999, at the age of 61, according to the criteria of the Polycythemia Vera Study Group (PVSG) on the basis of the increased red cell mass by isotope determination, normal oxygen saturation, low plasma erythropoietin level, presence of endogenous erythroid colonies (EEC), and splenomegaly. Histopathology of bone marrow biopsy was also consistent with polycythemia vera with no evidence of increased reticulin fibrosis. A karyotype analysis was not performed at that time. He had been treated initially with phlebotomies and then with hydroxyurea with the aim to obtain a better control of hematocrit; he was under low-dose aspirin. In 2009, 10 years after the diagnosis, while the patient was still being treated with hydroxyurea and phlebotomies, he noticed worsening of general conditions and fatigue, and the appearance of night sweats; he also reported that his spleen volume had increased rapidly in the past few months. He complained of severe pruritus especially after (but not limited to) a shower. He was referred to our center for further evaluation. At presentation, his blood counts were as follows: hemoglobin 157 g/L, hematocrit 54.7%, leukocytes 13.1 × 10⁹ /L, platelets 238 × 10⁹ /L, LDH 856 U/L (normal upper limit, 250 U/L). Blood film examination showed neutrophilia (8.9 × 10⁹ /L) but immature myeloid cells and nucleated erythroblasts were absent. The spleen was 14 cm below the left costal margin, the liver was at 4 cm below the right costal margin. He was found to harbor the JAK2V617F mutation with an allele burden of 85% and the circulating CD34⁺ cell count was 14 × 10⁶ /L. A bone marrow biopsy showed the presence of hyperplasia of myeloid and erythroid lineages, increased number of scattered megakarocytes without overt morphologic abnormalities; reticulin fibrosis was grade 1 according to the European classification. On these basis, we considered the patient as presenting the features of PV according to the 2008 WHO classification of myeloid neoplasms associated with grade 1 reticulin fibrosis.

Epidemiological Factors in Prevalence of Malaria Parasites in Primary Health Facilities Attendees, Ogun State, Nigeria

Malaria caused by Plasmodium species is often observed in areas where malaria is endemic. Malaria prevalence in metropolitan Abeokuta of Ogun State, Nigeria was studied between October, 2012 and January 2013. Oral interviews were used to get personal data of participants. Blood samples were obtained from 384 consented participants from the seven primary health centers. Blood film examination using Giemsa staining techniques was used to detect malaria parasites in the blood. From the 384 participants examined 273 (71.1%) were positive with malaria parasites. Species detected included Plasmodium falciparum (95.6%), Plasmodium malariae (3.3%), P. ovale (0.7%) and P. vivax (0.4%). The age-group 1-11 years had the highest malaria prevalence 94 (81%) while 51-60 had the least 6(54.5%). The malaria prevalence in relation to age was significant (p=0.011, p 0.05). Malaria prevalence was significantly higher among those with no formal education 80 (81.6%) and least among post-secondary educational. Prevalence among occupational groups showed significant difference, where the unemployed group were more infected and the retiree group had the least infection (p=0.014, p<0.05). The singles (56.4%) were more infected than the married (43.6%). The prevalence in relation to age was significant (p=0.000, p<0.05). The study has revealed that malaria disease can affect all age groups and both males and females’ sexes irrespective of their educational and occupational cadre. Public enlightenment efforts need to be intensified towards the prevention of malaria.

Dietary supplementation of chloroquine with nigella sativa seed and oil extracts in the treatment of malaria induced in mice with plasmodium berghei.

Background:The aim of the study was to investigate the effects of dietary combination of Nigella sativa seed and oil extracts with chloroquine (CQ), and how these combinations enhance CQ efficacy in mice infected with Plasmodium berghei and their survival rates.Materials and Methods:Chloroquine sensitive P. berghei, NK65 strain was used for the study. This was passaged intraperitoneally into albino mice with a 0.2ml standard inoculum consisting of 106 parasitized erythrocyte suspension in phosphate buffer solution (PBS). Parasitaemia was ascertained by microscopical examination of blood films under oil immersion at X100 magnification.Results:Nigella sativa seed in feed (NSSF), NSSF + CQ on day 4, produced 86.1% and 86.0% suppression respectively, while Nigella sativa oil extract in feed (NSOF) and in combination with CQ had 86.0% and 99.9% suppression respectively. The degree of suppression with the combination was significantly higher compared to CQ alone (P < 0.001) (36.1%). Complete parasitaemia clearance was obtained on the 20th and 15th day of treatment for NSSF, NSSF + CQ respectively, while that for NSOF and NSOF + CQ was on days 26 and 12 respectively. For CQ parasite clearance was 12 days with treatment. Also, the combinastion of 10 mg/kg Nigella sativa oil treatment injected intraperitoneally with oral CQ produced very significant parasite suppression (P < 0.0001) (93%). Survival rate in NSSF and NSOF and in combination with CQ groups was 100 and 60.0% for CQ alone.Conclusions:This study shows that the use of Nigella sativa seed and oil extract as dietary supplements in combination with CQ has a potential in enhancing the efficacy of CQ and could be of benefit in management of malaria.

A clinicohaematological profile of elderly patientsbeing investigated for anaemia in a tertiary care centre in north-west India

Background There are plenty of studies on prevalence of anaemia in high-risk groups such as pregnant and lactating women and children. Reliable data on the prevalence and causes of anaemia in the elderly population are not available, particularly in this region. Thus, the present study was carried out to profile anaemia in geriatric patients in our setup. Objectives The aim of this study was to profile anaemia clinicohaematologically among elderly. Materials and methods A total of 168 geriatric patients aged 65 years and above, male and female patients with haemoglobin less than 12 g/dl admitted in the Tertiary Care Hospital, were included in the study. Investigations were carried out, mainly haematological with supporting biochemical parameters, which included complete blood count, peripheral blood film examination, serum B12 and folate studies, bone marrow cytology, iron studies, liver and renal function tests, urine examination and radiological examination when required. Detailed clinical history, systemic examination and complete haematological, biochemical and radiological investigations were carried out when patients were being managed in the respective wards/units. Results Various underlying pathologies encountered were nutritional deficiency anaemia (47.6%), anaemia of chronic disease (20.2%), bone marrow infiltration (8.3%), multiple myeloma (7.1%), myelodysplastic syndrome (4.8%), myelofibrosis (4.8%), acute myeloid leukaemia (3.6%), anaemia of renal disease (2.4%) and chronic lymphocytic leukaemia (1.2%). Anaemia associated with chronic diseases included cases of pulmonary tuberculosis, rheumatoid arthritis, bronchiectasis, pneumonia and ischaemic heart diseases, which predisposed the patient to greater morbidity.Conclusion The incidence of anaemia is quite high among elderly patients, more so when associated with chronic diseases and malignancies. The major cause found is nutritional anaemia due to deficiency of iron, folic acid/vitamin B12 or dual deficiency. It is very important to diagnose the cause of anaemia by detailed investigations before initiating the required therapy. Egypt J Haematol 39:-0 © 2014 The Egyptian Society of Haematology.

Peripheral blood film examination a necessity for plateletpheresis in eastern India

Peripheral blood film examination a necessity for plateletpheresis in eastern <scp>I</scp>ndia

Ethylenediaminetetraacetic Acid (EDTA) - dependent pseudothrombocytopenia: a case report.

We present a case of 26-year-old female patient who was presented as a case of Isolated Thrombocytopenia and found to have EDTA induced Pseudo-Thrombocytopenia with no associated pathologies. Pseudo-thrombocytopenia (PTP) is defined by falsely low platelet counts on automated analysers and is caused by in vitro phenomena including large platelet aggregates in blood samples. Platelet aggregates on account of their large size are frequently not included in the platelet window of auto-analysers, but are counted as leukocytes, leading to misleadingly low platelet counts and high leukocyte counts [1]. The phenomenon can be suspected on examining the platelet histogram and review of the smear should confirm the presence of aggregates. Ethylenediaminetetraacetic acid (EDTA) is a well-known anticoagulant since early 1950s and it has certain advantages over other anticoagulants [2]. It inhibits clotting by removing or chelating calcium from the blood. EDTA most important advantage is that it does not distort blood cells, making it ideal for the most hematological tests. It is known to cause erroneous results of platelet counts by automated hematological analysers yielding low platelets counts. This relatively rare phenomenon has been found in the normal population as well as being associated with some disease entities. It occurs with an incidence of approximately 0.1% of the normal population [3]. it has never been reported to be associated with bleeding tendency or dysfunction of platelets. Far from being a harmless curiosity, undiagnosed PTP is a pitfall leading to unwarranted investigations, platelet transfusions, and treatment with glucocorticoids and may lead to surgical procedures being cancelled. A 26-year-old female patient was referred to our lab for investigations as a case of newly diagnosed thrombocytopenia. She presented to a local physician with fever and Upper Respiratory Tract Infection (URTI). The CBC revealed normal parameters apart from a low platelet count; 10 x10^9/L. A blood film [Table/Fig-1] was ordered and it revealed platelet aggregations. History, physical and systemic examination was unremarkable. Other laboratory investigations were normal as well as brain CT scan and abdominal ultrasound. The lab asked for CBC to be drawn in a citrate tube as well as a Heparin tube to diagnose if this could be an EDTA induced platelet clumping. The CBC and the blood film results were the same in both tubes and similar to the EDTA tube results except that the count was higher with the Heparin tube; 72x10^9/L. [Table/Fig-1]: Blood film revealing platelet aggregations EDTA induced PTP was first reported by Gowland et al., (1969). It is attributed to EDTA induced alteration of surface glycoproteins (GP) and anionic phospholipids, which enables binding of antiplatelet antibodies, which in turn cause agglutination. Antibodies against the platelet GPIIb/IIIa have been reported in this context [4]. Platelet agglutinins generally belong to the immunoglobulin M class. However, immunoglobulin G and immunoglobulin A are also described. Around 20% of cases with EDTA induced PTP show the phenomenon in citrate anticoagulant as well [5]. Oxalate and heparin have also been implicated in PTP. Normal platelet function seems to be a criterion for platelet aggregation. Some resources state that clumping of platelets in patients with EDTA- induced Pseudo-Thrombocytopenia can be prevented by the use of other anticoagulants such as Sodium Citrate or Heparin. Other resources have found that even these agents can induce platelet clumping as well. This is comparable to the results in our case. We drew blood of the pateint in three tubes containing three different types of anticoagulants; EDTA, Sodium Citrate and Heparin. The three blood samples were run in fully automated Hematology analyser. The platelet count with the EDTA tube was 11.0 x10^9/L, with the Sodium Citrate tube was 22.0 x10^9/L and with the Heparin tube was 72 x10^9/L. The peripheral blood morphology of the three blood samples revealed platelets aggregations. A prospective study of 20,761 routine clinical blood specimens was conducted to evaluate the incidence and causes of thrombocytopenia [6]. It revealed that the incidence was 0.15% and 72% of which had EDTA induced platelet clumping, 28% had spuriously low platelet counts due to large platelets. Another study states that when Theophylline was used as an anticoagulant in blood samples showing aggregation with EDTA, blood film examination revealed no platelet clumping [6]. Kamath et al., [1] reported resolution of Pseudothrombocytopenia using 37°C incubation and Kanamycin. Unrecognized Pseudo-Thrombocytopenia may result in unnecessary laboratory testing and unwarranted interventions. Examination of a well prepared peripheral blood smear is mandatory for every case of thrombocytopenia to rule out platelet clumping (Pseudo-Thrombocytopenia). For a definitive diagnosis of EDTA Induced Thrombocytopenia, the simultaneous collection of blood into EDTA citrate and Heparin containing or other anticoagulant containing tubes may provide a simple, rapid mean of identifying the presence of EDTA- Induced Pseudo-Thrombocytopenia.

Congenital Acute Lymphoblastic Leukemia: A Rare Presentation in a One Month Old Boy

A one month old boy of non-consanguineous parents was admitted with gradual distension of abdomen, yellow coloration of whole body, progressive pallor and respiratory distress since birth. Septic investigations were done and found negative. His complete blood count with peripheral blood film examination revealed hyperleukocytosis, thrombocytopenia and presence of significant number of blasts cell. Cerebrospinal fluid (CSF) examination showed central nervous system (CNS) status 3(≥5 WBC/cmm3 with blasts). Other causes of leukemoid reaction were ruled out. Karyotyping had done and found normal chromosomal pattern (46XY). Bone marrow aspiration findings were suggestive of ALL-L1.His myeloperoxidase (MPO) and Sudan black stain was negative but Periodic acid schiff (PAS) stain was positive. Immunophenotype showed blasts cells which were positive for CD5(1.10%), CD8(0.4%), CD10(0.74%), CD13(13.7%) and CD19(62.4%). Finally, the boy was diagnosed as congenital acute lymphoblastic leukemia (ALL-L1, B-lineage, CNS status 3). Following chemotherapy, the child suddenly deteriorated and on the second day of therapy suddenly he expired possibly due to leukostasis or coagulopathy or non responsive of drugs or MLL gene translocation.So, congenital acute lymphoblastic leukemia (CALL) should be kept in mind in a newborn child with clinical features of sepsis, leukocytosis, thrombocytopenia, huge hepatosplenomegaly.

Haematological Parameters of Malaria Infected Patients in the University of Calabar Teaching Hospital, Calabar, Nigeria

Malaria is a blood disease caused by the bite of Anopheles mosquito. Malaria causes the death of more than one million in Africa every year. Ten percent (10%) of death in children aged below three years are estimated to be from malaria in some parts of the tropical regions. In Sub-Sahara Africa including Nigeria, it is a major public health problem, hence this study to control and discriminate between these infections for possible early diagnosis. The study was conducted to statistically analyze hematological parameters including packed cells volume (PCV), total and differential white blood cells count (WBC), platelet count and erythrocyte sedimentation rate (ESR) of malaria infected patients in the University of Calabar Teaching Hospital, Calabar. The method adopted made use of 140 samples collected from seventy (70) apparently healthy individuals (controls). The other seventy (70) were malaria parasite positive patients. De-haemoglobinized Giemsa-stained thick blood film examination was carried out on both the patients and controls. Standard techniques were used to determine their hematological parameters. The results were analysed using student t-test and indicated significant difference in the hematological parameters between the malaria infected and non-infected subjects (p<0.05). The mean values of hematological parameters of malaria infected male patients were significantly higher than those of their female counterparts (p<0.05). This present research has shown that hematological parameters could be good and reliable adjunct in the early diagnosis of malaria in severely infected patients.

Predictors of hyperlactataemia among children presenting with malaria in a low transmission area in The Gambia

BackgroundHyperlactataemia and metabolic acidosis are important risk factors for malaria death, but measuring lactate at the point of care is not financially viable in many resource-poor settings. This study aimed to identify combinations of routinely available parameters that could identify children at high risk of hyperlactataemia.MethodsUsing data from a study of Gambian children aged six months to 16 years with severe or uncomplicated malaria, logistic regression modelling with a forward stepwise model selection process was used to develop a predictive model for hyperlactataemia from routinely available demographic, clinical and laboratory parameters. Potential predictors of hyperlactataemia considered for the modelling process were patient characteristics (age, sex, prior use of anti-malarials, and weight percentile for age), respiratory symptoms (deep breathing, irregular respiration, use of accessory muscles of respiration, lung crepitations, grunting respiration, cough, and age-specific respiratory rate), other clinical parameters recorded at presentation (duration of symptoms, Blantyre coma score, number of convulsions prior to admission, axillary temperature, dehydration, severe prostration, splenomegaly) and laboratory measures from blood tests (percentage parasitaemia, white cell count, lymphocyte count, neutrophil count, monocyte count, platelet count, haemoglobin level, blood glucose level).Results495 children were included, and 68 (14%) had laboratory-confirmed hyperlactataemia (lactate > 7 mmol/L). Four features were independently associated with increased hyperlactataemia risk in a multivariable age- and sex-adjusted model: lower Blantyre score (odds ratio (OR) compared to score 5 = 2.68 (95% CI, 1.03-6.96) for score 3–4 and 6.18 (95% CI, 2.24-17.07) for score 0–2, p = 0.001), higher percentage parasitaemia (OR = 1.07 (1.03-1.11) per 0031% increase, p < 0.001), high respiratory rate for age (OR = 3.09 (1.50-6.38) per unit increase, p = 0.002), and deep breathing (OR = 2.81 (1.20-6.60), p = 0.02). Cross-validated predictions from the final model achieved area under the receiver operating characteristic curve of 0.83.ConclusionsThis study identified predictors of hyperlactataemia requiring only simple bedside clinical examination and blood film examination that can be carried out in resource-limited settings to quickly identify children at risk of dangerously raised lactate. A simple spreadsheet tool implementing the final model is supplied as supplementary material.

Are Outcomes Worse For Patients With Polycythemia Vera compared to Polycythemia Of Unknown Cause? – a Retrospective Analysis Of Single Institution Patient Cohorts

BackgroundThe JAK2 V617F mutation is present in almost 95% of patients with Polycythemia Vera (PV). Prior to the discovery of this mutation, red cell mass and plasma volume measurement to establish the presence of true erythrocytosis was required first, before the diagnosis could be confirmed using other criteria. The revised WHO criteria no longer mandate this. Besides, access to this test is restricted in our region, due to non-availability of radio-isotopes. We previously showed the utility of early JAK2 mutation screening when used with history, physical examination, oxygen saturation, complete blood count, blood film examination, splenomegaly, serum erythropoietin, phlebotomy trial, bone marrow biopsy and, when available, red cell mass studies. PatientsBetween 2002 and 2006 we screened 231 consecutive patients referred to our institution with raised hemoglobin and hematocrit for JAK2 mutation. PV was diagnosed in 27 patients. Polycythemia of unknown cause (idiopathic) was identified in 40 patients after excluding patients with transient polycythemia and secondary polycythemia due to hypoxia, sleep apnoea, excessive smoking, alcohol abuse, renal disease, androgens or inherited causes. All PV patients were assessed at 3-6 monthly intervals from diagnosis until death or to present day. All idiopathic polycythemia patients were assessed at 6-12 monthly intervals until discharge, death or to present day. Patients with idiopathic polycythemia were discharged from follow-up when their hematocrit returned to normal range without any interventions for at least 12 months. All patients received thromboprophylaxis with aspirin or vitamin K antagonists as appropriate unless contra-indicated. ResultsOf 27 PV patients, 15 were males and 13 females. The median age at diagnosis was 69 years (range 21-88 years). Leucocytosis was present at diagnosis in 14 and thrombocytosis in 15 patients. Patients were treated with phlebotomy to a target hematocrit<0.45 (18 patients), hydroxycarbamide (16 patients), alpha-interferon (1 patient) and busulfan (1 patient). Nine patients were treated with phlebotomy alone and the remainder (18 patients) started with phlebotomy and switched to cytoreductive therapy. The median follow-up was 9 years (range 7-11 years). One patient transformed to myelofibrosis and 2 patients developed acute myeloid leukemia. Thrombotic complications included stroke in 7 patients, retinal vein and mesenteric vein thrombosis in 1 patient each. Bleeding occurred in 1 patient. Eleven patients died (40%) and death was likely related to underlying PV in 4 patients. Of 40 idiopathic polycythemia patients, 30 were males and 10 females. The median age at diagnosis was 59 years (range 30-84 years). Patients with idiopathic polycythemia were treated with phlebotomy to a target hematocrit<0.50 (36 patients) or hydroxycarbamide (3 patients). The median follow-up was 6 years (2-11 years). One patient developed acute myeloid leukemia after 8 years of hydroxycarbamide therapy. Thrombosis was observed in 15 patients: stroke in 5 patients, acute coronary syndrome in 6 patients and venous thrombosis in 4 patients. Red cell indices returned to normal without any interventions in 25 patients over a median duration of 5 years (range 2-8 years). Seven patients died and death was related either to polycythemia or hydroxycarbamide in 1 patient. ConclusionDisease progression occurred in 11% (3/27) and thrombosis in 33% (9/27) of patients with PV. Idiopathic polycythemia was associated with thrombosis in 37% (15/40) of patients. Our findings indicate that thrombosis occurs with equal or higher frequency in idiopathic group when compared to PV group. These patients require a stricter target hematocrit control to <0.45. However, in the absence of red cell mass studies to confirm the presence of true erythrocytosis, it is unclear as to who will benefit from this approach. This lack of clarity is reflected in our finding that 62% eventually normalised their red cell indices without any interventions, indicating that at least a proportion of these patients had apparent polycythemia. Disclosures:Chacko:Amgen : Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees. Killick:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Inter-observer agreement according to malaria parasite density

BackgroundRecent developments in diagnostic techniques for malaria, particularly DNA probes and sero-immunology, have raised questions as to how these techniques might be used to facilitate malaria diagnosis at the most peripheral levels of the primary health care system. At present, malaria diagnosis is based on the standard microscopic examination of blood films in most field epidemiologic studies and is likely to remain so in the immediate future in Africa. The objective of this study was to assess inter-observer agreement for the examination of Giemsa-stained slides for Plasmodium falciparum parasites.MethodsChildren aged 0 to 10 years were enrolled yearly in Bancoumana village (West Africa), mainly during the transmission season (June to October). The blood smears obtained from the persistently negative children in June 1996, August 1996, October 1996 and March 1997 were systematically re-examined. A stratified random sample (10%) proportional to the following parasite density classes 1–100, 101–5000, and 5001 and over was taken from the slides collected. The kappa statistics and the intra-class correlation were used as measures of agreement the first and the second slide examinations.ResultsThe weighted kappa statistic, widely used as a chance-corrected measure for nominal agreement, showed excellent inter-observer agreement (κw=0.7926; 95% CI [0.7588, 0.8263]; p=0.01). The intra-class correlation co-efficient had the same value of 0.7926 confirming the appropriateness of the weighted kappa statistic. Inter-observer agreement for slides read as negative by one observer, or as containing more than 100 parasites per μl, was excellent: 97% (493/506) and 92% (145/158), respectively. In contrast, the inter-observer agreement for slides read by one observer as containing 1–100 parasites/μl was poor, 36% (96/268).ConclusionsIn field conditions in Mali, there was a high reproducibility for slides reported as negative or as having more than 100 parasites per μl. However, smears with readings of 1–100 parasites per μl were less reproducible and should be re-examined carefully.

Clinical burden and correlates of HIV and malaria co-infection, in northwest Nigeria

The clinical burden of malaria and HIV/AIDS in sub-Saharan Africa is well-described, but the dynamics of the interaction between the two diseases remain poorly understood. Using a cross-sectional study design, we assessed the prevalence and predictors of malaria infection among HIV-positive patients attending a referral center in urban Kano, northwest Nigeria. Structured questionnaires covering socio-demographic characteristics, HIV diagnosis and treatment, malaria preventive practices, clinical events and treatment were administered to HIV-infected adults (n=363). Information from questionnaires was supplemented with data from case notes. In the preceding year, nearly a third of respondents (32.2%; 95% CI=27.4–37.3) had at least one episode of fever, diagnosed as malaria on blood film examination. Half of all respondents (53.5%) admitted to using insecticide treated nets (ITN). One-third (35.8%) of participants were on malaria chemoprophylaxis at the time of the study. Female sex (adjusted Odds Ratio [aOR]=1.54, 95% confidence interval (CI): 1.32–2.73), immunosuppression (CD4+ cell count <350/μL vs. 600/μL, aOR=2.41, 95% CI 1.23–3.74) and non-use of ITN (aOR=1.97, 95% CI 1.17–2.85) predicted the occurrence of clinical malaria in patients. We report a high burden of malaria in HIV-infected patients attending a tertiary facility in urban Kano, Nigeria. Health communication, standardized protocols and ITN distribution should be integrated into comprehensive HIV programs in this setting.