Anaemia in acute, Plasmodium falciparum malaria in children from Orissa state, India

The severity of anaemia associated with acute, Plasmodium falciparum malari a and the extent to which haemolysis, bone-marrow suppression, and pre-exis tent iron deficiency contribute to the anaemia were assessed in 102 Indian children aged 2-12 years. Blood haemoglobin (Hb), plasma unconjugated bilir ubin and haptoglobin, serum iron and transferrin concentrations and transfe rrin saturation, red cell morphology and reticulocyte response were investi gated in the patients and in 50 control children. Twenty-three patients wit h severe anaemia (< 70 g Hb/litre) were investigated further, by bone-marro w biopsy followed by iron staining of sections or touch smears of the biops y material. There was evidence of haemolysis in the malaria cases: in the p eripheral blood smears and the significantly higher plasma concentrations o f unconjugated bilirubin, lower plasma concentrations of haptoglobin and lo wer blood concentrations of IIb than those seen in the controls. Haemoglobi n concentration correlated directly with haptoglobin (r = 0.489; P < 0.001) and inversely with unconjugated bilirubin in malaria patients (r = - 0.526 ; P < 0.001) but not in controls (r = -0.140 and -0.061, respectively). Par asitaemia (parasites/mu l) was not significantly correlated with IIb, hapto globin or unconjugated bilirubin. Compared with the earlier samples, follow -up samples from the patients, collected 2 weeks after discharge from hospi tal and antimalarial therapy, showed significant increases in Hb, haematocr it, haptoglobin and decreases in both total and unconjugated bilirubin. The re was evidence of hypercellularity and mild-moderate erythroid hyperplasia , mainly of normoblastic maturation with adequate reticulocyte response, in the bone-marrow samples from the cases of severe anaemia; dyserythropoiesi s was only noticed in one case and no stainable iron was detectable in 17 o f the 23 cases. These observations indicate that haemolysis is the prime ca use of the anaemia seen in acute falciparum malaria, although destruction o f parasitised erythrocytes is not the sole cause of the haemolytic process. Bone-marrow suppression appears to have an insignificant role but pre-exis tent iron deficiency aggravates the severity of the anaemia.