Study of Hematological Alterations in Malaria at a Tertiary Health Care Center of South Gujarat, India. Int J Sci Stud 2020;8(4):108-113.

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108108International Journal of Scientic Study | July 2020 | Vol 8 | Issue 4
Study of Hematological Alterations in Malaria at a
Tertiary Health Care Center of South Gujarat, India
Pinal Shah1, Arpita Nishal2, Sejal Gamit1, Archana Patel3, Sheetal Sheth4
1Assistant Professor, Department of Pathology, Government Medical College, Surat, Gujarat, India, 2Associate Professor, Department of
Pathology, Government Medical College, Surat, Gujarat, India, 3Tutor, Department of Pathology, Government Medical College, Surat, Gujarat,
India, 43rd Year Resident, Department of Pathology, Government Medical College, Surat, Gujarat, India
resistance of the parasite, the insecticide resistance of its
vectors, human travel, and migration has contributed to its
resurgence and is a leading cause of mortality and morbidity
in developing areas of the world.[3]
According to the WHO World Malaria Report 2018,
an estimated 219 million cases of malaria occurred
worldwide in 2017, compared with 216 million cases in
2016, 214 million cases in 2015. Most malaria cases in 2017
were in the WHO African Region (200 million or 92%),
followed by the WHO Southeast Asia Region with 5% of
the cases and the WHO Eastern Mediterranean Region
with 2%. Fifteen countries in Sub-Saharan Africa and
India carried almost 80% of the global malaria burden.
Five countries accounted for nearly half of all malaria
cases worldwide: Nigeria (25%), the Democratic Republic
of the Congo (11%), Mozambique (5%), India (4%), and
INTRODUCTION
“Malaria” received its name from Italian, as it was believed
to arise due to foul air common near marshy areas. It is
one of the most prevalent parasitic infection common
in tropical, subtropical countries, particularly Asia and
Africa.[1,2] It is a protozoan disease transmitted by the
bite of infected Anopheles mosquito, and the incubation
period varies from 8 to 30 days depending on species.
Despite enormous control efforts, an increase in the drug
Original Article
Abstract
Background: Malaria is a disease with a great global burden. It is one of the most prevalent parasitic infection common in
tropical, subtropical countries, particularly Asia and Africa. Malaria causing plasmodia is parasites of blood and hence induces
hematological alterations. The hematological changes that have been reported to accompany malaria include anemia,
thrombocytopenia, leukocytosis as well as leukopenia, mild-to-moderate atypical lymphocytosis, monocytosis, eosinophilia,
and neutrophilia. Hence, the present study is undertaken to evaluate the various hematological parameters affected in malaria
and to observe the variations, if any, in Plasmodium falciparum, Plasmodium vivax, and mixed infections.
Materials and Methods: The present study was carried out in the Department of Pathology at Tertiary Health Care Center
of South Gujarat from August 2018 to October 2018. A total of 480 smear-positive malaria cases were analyzed and various
hematological parameters were studied.
Results: Out of 480 smear-positive cases, P. vivax was positive in 77% of cases, P. falciparum was positive in 22% of cases
and mixed infection in 1% of cases. Most of the cases were seen in the age group of 21–40 years. Anemia was seen in 53.1%
of cases. Normocytic normochromic blood picture was the most common type in anemic patients (46.6%). Thrombocytopenia
was seen in 84.58% of the patients. Out of which, 75.86% were affected by P. vivax, 23.15% were affected by P. falciparum,
and 0.98% were affected by the mixed infection. About 28.75% of cases showed hematological features of leukopenia, and
5.2% of cases were having leukocytosis.
Conclusions: Various hematological ndings can help in early diagnosis of malaria which is essential for timely and appropriate
treatment which can limit the morbidity and prevent further complications
Key words: Anemia, Hematological parameters, Malaria, Prevention, Thrombocytopenia
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Month of Submission : 06-2020
Month of Peer Review : 06-2020
Month of Acceptance : 07-2020
Month of Publishing : 07-2020
Corresponding Author: Dr. Sheetal Sheth, 37, Karmayogi Society, Nr. Sarojini Naydu Garden, Umra, Ichchhanath, Surat, Gujarat, India.
Print ISSN: 2321-6379
Online ISSN: 2321-595X

Shah, et al.: Study of Hematological Alterations in Malaria
109109 International Journal of Scientic Study | July 2020 | Vol 8 | Issue 4
Uganda (4%).[1] In India, in the year 2017, a total of 8.76
million malaria cases had occurred, out of which about
48% of cases were Plasmodium vivax malaria.[1] The annual
parasite index of India for the year 2015 was 0.9. Annual
Blood Smear Examination (ABER) of India for the year
2015 was 9.6.
The incidence rate (i.e., the number of cases per 1000
population) of malaria globally reduced between 2010 and
2017; it fell from 72 in 2010 to 59 in 2017. India reported
more than 3 million fewer cases (24%) from 2016 to 2017.[1]
Clinical presentations of malaria include – fever with
chill and rigor, headache, diarrhea, vomiting, abdominal
distension, cough, hepatomegaly, and splenomegaly.[2]
Malaria causing plasmodia is parasites of blood and hence
induces hematological alterations. The hematological
changes that have been reported to accompany malaria
include anemia, thrombocytopenia, leukocytosis as well
as leukopenia, mild-to-moderate atypical lymphocytosis,
monocytosis, eosinophilia, and neutrophilia. Platelet
abnormalities are both qualitative as well as quantitative.[4]
The high mortality rate in malaria infection is usually
associated with heavy parasite load, anemia, low platelet
count, jaundice, and delay in diagnosis.[2]
Hence, the present study is undertaken to evaluate the
various hematological parameters affected in malaria and
to observe the variations, if any, in Plasmodium falciparum,
P. vivax, and mixed infections. The aim of the study is to
nd out changes in different hematological parameters in
smear-positive malaria cases and to compare these changes
in P. vivax and P. falciparum infection.
MATERIALS AND METHODS
Study Setting
The present study was carried out in the Department of
Pathology at Tertiary Health Care Center of South Gujarat
from August 2018 to October 2018. A total of 480 smear-
positive malaria cases were analyzed.
Study Period
August 2018 to October 2018.
Study Design
This was a cross-sectional descriptive study.
Inclusion Criteria
The laboratory conrmed that smear-positive malaria
cases from August 2018 to October 2018 were included
in this study.
Exclusion Criteria
NIL.
Sample Size
The sample size was 480 cases.
Control(s)
Not required.
Methods of Collection of Data
All malaria positive cases were analyzed. Routine
laboratory work, thin, and thick blood films were
prepared and examined for dening the species involved.
The thin and the thick smears were made on the same
slide and stained with Giemsa stain. A minimum of 200
elds (oil immersion) were assessed to label a negative
smear.
Hematological prole by a three-part cell counter was
performed in all patients. Anemia and thrombocytopenia
were labeled when hemoglobin was <11.0 g%, and platelet
counts were <1.5 lakh/mm3, respectively. Leukopenia and
leukocytosis were labeled when the total WBC count was
<4.0 × 103/mm3 and >11.0 × 103/mm3, respectively.
Blood lm examination was also performed in all patients,
and they were classied according to the morphologic
type of anemia in the following category: Normocytic
normochromic, normocytic hypochromic, microcytic
hypochromic, and dimorphic (normocytic to macrocytic
and microcytic to macrocytic).
Statistical Analysis
Qualitative data are presented as frequencies and percentages.
All the data were analyzed using Microsoft Excel 2013.
RESULTS
The present study was carried out in the Department of
Pathology at Tertiary Health Care Center of South Gujarat
from August 2018 to October 2018. A total of 480 smear-
positive malaria cases were analyzed, and hematological
parameters were studied.
Out of 480 malaria positive cases, P. vivax was the most
common observed species in our study accounting for
370 cases (77%) followed by P. falciparum accounting
for 106 cases (22%) followed by 4 (1%) cases of mixed
infection [Table 1].
Most of the cases were seen in the age group of 21–40
years (50%) with the highest prevalence between the age
group of 21 and 30 years (32.5%). There were 28.2% of
cases that were below the age of 20 years. Youngest case

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was 6 months old, and the oldest case was 75 years old and
both cases were having P. vivax infection [Table 2].
There were 312 cases of males (65%) and 168 cases of
females (35%). In our study, male:female ratio was 1.8:1
[Table 3].
Anemia was seen in 255 (53.1%) cases. Out of which, 196
(76.9%) cases were of P. vivax, and 56 (21.9%) cases were
of P. falciparum and 3 (1.2%) cases were of mixed infection
[Table 4].
Blood picture was normocytic normochromic in 224
(46.6%) cases, which was the most common nding in the
study followed by a microcytic hypochromic picture in 102
(21.2%) cases followed by normocytic hypochromic picture
in 65 (13.5%) cases [Table 5].
Out of 480 cases, 138 (28.75%) cases showed hematological
features of leukopenia and 25 (5.2%) cases were having
leukocytosis. Out of 138 leukopenia cases, 90 cases (65.2%)
were having P. vivax infection, and 48 cases (34.8%) were
having P. falciparum infection. Out of 25 leukocytosis cases,
20 cases (80%) were having P. vivax infection, two cases
(8%) were having P. falciparum infection, and three cases
(12%) were having mixed infection [Table 6].
Out of total of 480 cases, the majority – 406 cases (84.58%)
were having thrombocytopenia. Out of which, 308 cases
(75.86%) were affected by P. vivax, 94 cases (23.15%)
were affected by P. falciparum, and four cases (0.98%) were
affected by mixed infection [Table 7].
DISCUSSION
Malaria is transmitted by the female anopheles mosquito,
which causes clinical illness and pathological changes
in various body organs with the parasites invading and
multiplying in the circulating red blood cells. Malaria causes
Table 1: Total malaria positive cases
Total case Plasmodium vivax Plasmodium falciparum Mixed infection
Number of cases Percentage Number of cases Percentage Number of cases Percentage
480 370 77 106 22 4 1
Table 2: Age-wise distribution of malaria
Age group
(years)
Plasmodium vivax Plasmodium falciparum Mixed infection Total
Number of
cases
Percentage Number of
cases
Percentage Number of
cases
Percentage Number of
cases
Percentage
0–10 61 16.4 09 8.5 00 00 70 14.6
11–20 53 14.4 12 11.3 00 00 65 13.6
21–30 126 34.0 28 26.4 2 50 156 32.5
31–40 62 16.7 22 20.8 00 00 84 17.5
41–50 33 8.9 20 18.9 00 00 53 11.0
51–60 26 7.1 13 12.3 2 50 41 8.5
61–70 8 2.1 02 1.8 00 00 10 2.1
71–80 1 0.4 00 00 00 00 01 0.2
Total 370 100 106 100 4 100 480 100
Table 3: Sex-wise distribution of malaria
Sex Plasmodium vivax Plasmodium falciparum Mixed infection Total
Number of
cases
Percentage Number of
cases
Percentage Number of
cases
Percentage Number of
cases
Percentage
Male 233 63.0 78 73.6 1 25 312 65
Female 137 37.0 28 26.4 3 75 168 35
Total 370 100 106 100 4 100 480 100
Table 4: Anemia in malaria cases (hemoglobin <11 g%)
Total case Plasmodium vivax Plasmodium falciparum Mixed infection
Number of cases Percentage Number of cases Percentage Number of cases Percentage
255 196 76.9 56 21.9 03 1.2

Shah, et al.: Study of Hematological Alterations in Malaria
111111 International Journal of Scientic Study | July 2020 | Vol 8 | Issue 4
numerous hematological alterations, of which anemia and
thrombocytopenia are the most important.[4]
The results of the present study and its correlation with
other studies are discussed as follows: [Table 8].
The most common species of malaria in the present
study was P. vivax (77%) followed by P. falciparum (22%).
Findings are compatible with studies done by Jadhav et al.[5]
and Ca et al.[3] However, Bashawri et al.[6] reported higher
falciparum prevalence and Jairajpuri et al.[7] reported a
higher prevalence of mixed infection (47.1%).
P. falciparum is associated with serious complications such
as severe anemia, malarial hepatitis, and renal failure; hence,
P. falciparum infection on suspicion of complication should
be further evaluated.
Mixed infections behave like falciparum malaria, but its
incidence and severity are less than severe P. falciparum
malaria. In mixed infection, P. vivax malaria has a protective
role against the severity of falciparum malaria.
In the present study, 50% of cases were in the age group
between 21 and 40 years and were found to be similar
with the studies done by Agrawal et al.,[8] in which 75% of
cases were in the age group between 21 and 40 years and
Jairajpuri et al.,[7] in which 46% of cases were in the age
group between 20 and 30 years.
Children aged under 5 years are the most vulnerable group
affected by malaria. In 2017, they accounted for 61% of
all malaria deaths worldwide.[1] Malaria can affect any
age group. However, most studies show more adults as
compared to children. The adult age group is more affected
due to their greater mobility and greater risk of exposure
due to more outdoor activity.[3]
The present study had 65% male patients as compared to
35% female patients. Other studies with comparable results
include Surve et al.[4] with 57% males, Jadhav et al.[5] with 58.3%
males, Erhart et al.[9] with 69% males, Bashawri et al.[6] with
75.9% males, Agrawal et al.[8] with 58.5% males, and Saha
and Das[2] with 55.4% males.
Anemia was present in 53.1% of cases in our study. Other
studies with comparable results include Igbeneghu and
Odaibo[10] with 63.5% cases of anemia, Ca et al.[3] with 63%
cases of anemia, Kashinkunti and Alevoor[11] with 69%
cases of anemia, Sharma[12] with 86.7% cases of anemia,
and Bhawna et al.[13] with 65.5% of cases of anemia.
There is a wide variation in anemia due to malaria infection
depending on the geographical location of the study.
Report of the year 2017 includes a section on malaria-
related anemia, a condition that, left untreated, can result
in death, especially among vulnerable populations such as
pregnant women and children aged under 5 years. Recent
years have seen a decline in awareness of the burden of
malaria-associated anemia.[1]
Anemia was normocytic-normochromic in the majority
(46.6%) of cases, which is concordant with other studies
done by Bhawna et al.,[13] Bashawri et al.,[6] and Facer.[14]
However, the microcytic hypochromic picture was seen in
21.2% cases, results are similar to other studies.[6,13,15] This
is due to the geographical location of the study, where
patients have Iron and Folate deciency due to inadequate
dietary intake, along with parasitic and bacterial infections
which themselves cause a signicant amount of anemia.
Hence, practically it becomes difcult to determine the
extent to which malaria alone contributes to the anemia.
Table 6: Leukopenia and leukocytosis in malaria cases
TC Plasmodium vivax Plasmodium falciparum Mixed infection Total
Number of
cases
Percentage Number of
cases
Percentage Number of
cases
Percentage Number of
cases
Percentage
Leukopenia 90 65.2 48 34.8 00 00 138 28.75
Leukocytosis 20 80 2 8 3 12 25 5.2
Table 7: Thrombocytopenia in malaria cases
Total case Plasmodium vivax Plasmodium falciparum Mixed Infection
Number of cases Percentage Number of cases Percentage Number of cases Percentage
406 308 75.86 94 23.15% 04 0.98
Table 5: Type of blood picture in malaria cases
Type of blood picture Number of
cases
Percentage
Normocytic normocromic 224 46.6
Normocytic hypochromic 65 13.5
Microcytic hypochromic 102 21.2
Dimorphic (normocytic to macrocytic) 42 8.8
Dimorphic (microcytic to macrocytic) 47 9.9

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112112International Journal of Scientic Study | July 2020 | Vol 8 | Issue 4
We observed normal WBC count in 66.05% of the
patients and leukopenia in 28.75% patients, leukocytosis
(5.2%) was seen rarely in some cases. Leukopenia was
present more frequently in P. vivax – infected patients
(65.21%) than in P. falciparum – infected patients (34.78%)
in our study.
Leukopenia was observed in a study done by Surve et al.[4]
(18%), Bashawri et al.,[6] (13.3%), and Agrawal et al.[8] (26%).
Leukocytosis was observed in a study done by Kashinkunti
and Alevoor[11] (11%), Agrawal et al.[8] (9%), Sharma[12]
(13.3%), Biswas et al.[16] (12.2%), Surve et al.[4] (10%), and
Bashawri et al.[6] (7.2%).
The results of leukopenia and leukocytosis in the present
study were in concordance with other studies.
The reduction in circulating platelet count is consistently
reported in the different types of malaria. In the
present study, the percentage of patients showing
thrombocytopenia was 75.86% in the case of vivax
malaria and 23.15% in the case of falciparum malaria.
The percentage of cases showing thrombocytopenia
in falciparum infections and vivax infections varies in
different studies. Studies conducted by Bashawri et al.[6] and
Jadhav et al.[5] had thrombocytopenia more in vivax as in the
present study, while in a study conducted by Erhart et al.,[9]
thrombocytopenia is more in cases of falciparum malaria.
Thrombocytopenia is a common nding in cases of malaria,
both vivax and falciparum, as shown by most of the studies
conducted. In the present study, thrombocytopenia was
seen in 84.58% of all malaria cases. Results are comparable
with other studies, as shown in Table 9.
Patients who develop thrombocytopenia in malaria cases
are seldom bleed whatever the grade of thrombocytopenia.
The cause of thrombocytopenia in malaria cases is poorly
understood; however, the researcher has proposed the
following mechanisms as the cause of thrombocytopenia
in malaria cases:[2]
• Decreased thrombopoiesis, however, bone marrow
examination shows normal or increased number of
megakaryocytes
• Peripheral destruction of platelets
• Sequestration of platelets in the spleen
• Some scientists have found disseminate intravascular
coagulation (DIC) as a cause of thrombocytopenia;
however, other scientists did not found DIC as a cause
of thrombocytopenia.
According to Kumar et al.,[17] not only decreased platelet
count occurs in malaria patients but also platelet dysfunction
commonly encountered. According to them, two types
of platelet dysfunction occur – platelet hyperactivity and
platelet hypoactivity. Hyperactivity results from various
aggravating agents such as immune complexes, platelet
surface contact with infected RBCs, and damage to
endothelial cells. Injured platelet undergoes intravascular
hemolysis and releases cellular contents of the platelets that
activate intrinsic coagulation cascade, as contributed to DIC.
The hyperactive platelets may enhance hemostatic responses
and, that is, why bleeding episodes are very rare in acute
malarial infections, despite signicant thrombocytopenia.
CONCLUSIONS
Malaria is one of the most common infections in the
Indian subcontinent. Malaria affects mostly adults with male
predominance. P. vivax is more common than P. falciparum and
mixed infection. Complications associated with P. falciparum and
mixed infection should be evaluated and the use of antibiotics
along with antimalarial agents shows a better response.
The malarial infection causes various hematological and
biochemical changes. Anemia and thrombocytopenia
of varying severity are the most frequently observed
hematological ndings.
Depending on the geographical location of the study,
discrimination of anemia, whether it is due to malaria or
iron/FA deciency, is difcult. However, severe anemia
Table 8: Comparative analysis of different malarial
species
Study Plasmodium
vivax (%)
Plasmodium
falciparum (%)
Mixed (%)
Present study 77 22 1
Jadhav et al.[5] 62.17 37.69 0.04
Ca et al.[3] 60 30 10
Surve et al.[4] 55 45 -
Erhart et al.[9] 59 38 2
Jairajpuri et al.[7] 51.6 1.1 47.1
Bashawri et al.[6] 39 54.1 2.33
Table 9: Frequency of thrombocytopenia in
different studies
Study Incidence of thrombocytopenia (%)
Present study 84.58
Agrawal et al.[8] 85.5
Horstmann et al.[18] 85
Saha and Das[2] 82.43
Akhtar et al.[19] 71.06
Sharma[12] 70
Richards et al.[20] 67
Gill et al.[21] 63.33

Shah, et al.: Study of Hematological Alterations in Malaria
113113 International Journal of Scientic Study | July 2020 | Vol 8 | Issue 4
is a poor prognostic factor, and malaria-related anemia, if
left untreated, can cause a death, especially in women of
reproductive age, pregnancy and children under 5 years.
Thrombocytopenia is another most commonly observed
nding in malaria cases; however, bleeding manifestations
are uncommon. In a patient with febrile illness, observation
of thrombocytopenia warrants careful search for malaria
parasite. The use of antimalarial agents, along with platelet
transfusion in such patients, can lower the complications
associated with it.
Various hematological ndings can help in early diagnosis
of malaria which is essential for timely and appropriate
treatment which can limit the morbidity and prevent further
complications.
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How to cite this article: Shah P, Nishal A, Gamit S, Patel A, Sheth S. Study of Hematological Alterations in Malaria at a Tertiary Health
Care Center of South Gujarat, India. Int J Sci Stud 2020;8(4):108-113.
Source of Support: Nil, Conicts of Interest: None declared.