Serum ferritin and hematological feature among malaria patients in Assam

Introduction: Assam is considered as a vulnerable state for malarial infection. Malarial patient exhibit several divergent values in their blood cell parameter as well as changes in concentration of normal serum ferritin level. The study was intended to observe the concentration of serum ferritin level and estimation of hematological feature among malaria patients in Assam. Materials and Methods: During the period from August 2012 to January 2013, a total of 77 blood samples have been collected from 77 individuals suspected with malaria from different malaria endemic districts of Assam. Results: A total of 36 cases were found to be malaria positive of which 25 were symptomatic and 11 were asymptomatic. Overall the percentage of parasitaemia was found 0.1-15%. Distribution of malaria cases was observed in all age groups and both the sexes. Hematological values among the malaria positive patients revealed that about 89% were having anaemia, 66.67% with Thrombocytopenia and 47% Lymphocytopenia. Iron deficiency anaemia was recorded in 63.87% of the patients. Other haematological status includes 30.56% individual with Granulocytosis and 50.00% subjects with low Mean platelet volume etc. Results also showed that the serum ferritin level in the malaria positive population ranged in from 70 ng/ml to 300 ng/ml, with a mean value of 114 ng/ml. Conclusion: In our study, hematological abnormality and low serum ferritin level is observed as an imperative marker for identification of malaria patients.

Keywords: Malaria, polymerase chain reaction, SD Bioline malaria Pv/Plasmodium falciparum test

Malaria is a major global public health problem all over the world including India. Northeastern region of India has experienced several outbreaks of malaria. ^[1],[2] There are five species of malaria parasite of which Plasmodium falciparum (Pf) species is mostly predominance, and it was affirmed as fatal. A Pf positive patient exhibit several divergent value in their blood cell parameter. Blood is the most easily accessible diagnostic tissue. Changes in hematological parameters are likely to be influenced by any disease condition which affects the hemopoetic physiology at any level. This is likely to happen with an endemic disease such as malaria that affects the host homeostasis at various fronts resulting in a myriad of clinical presentation. Hematological changes are some of the most common complications in malaria, and they play a major role in malaria pathology. These changes involve the major cell lines such as red blood cells, leucocytes and thrombocyte. When used in combination with other clinical and microscopy, these parameters could improve malaria diagnosis in sub-patent cases. However, a few previous studies revealed that there was no significant difference in hematological parameters between malaria positive and negative patients. ^[3] However, according to several studies thrombocytopenia and low leukocyte count may be used as a probable indicator for malaria in endemic countries. Higher mean platelet volume (MPV) and platelet distribution width (PDW) also show considerable sensitivity for malarial infection. ^[4]

It was also brought into being that malaria may be associated with complications that may be avoided by early diagnosis and treatment. Microscopic diagnosis showing presence of malarial parasites is needed for confirmation that at times may be unreliable and requires technical expertise. The present study was conducted to analyze the hematological parameters including platelet indices that can give initial hint for malarial infection and therefore prompt the laboratory physician for active search of the parasite microscopically.

On the other hand, alteration in normal ferritin level was observed in subjects with malaria parasitemia. There was a negative correlation between ferritin concentration and malaria density while the serum ferritin levels increased with increasing malaria antibodies. High concentrations of ferritin are found in the cytoplasm of the reticuloendothelial system, the liver, spleen and bone marrow. High ferritin levels may indicate iron overload without apparent liver damage, as may be noted in the early stages of idiopathic hemochromatosis. Ferritin levels in serum have also been used to evaluate clinical conditions not related to iron storage, including inflammation, chronic liver disease, and malignancy. ^[5]

Keeping these views in mind a study has been anticipated with the following objectives:

1. Hematological parameters among the malaria positive and healthy control subjects,
2. Severity of malaria depending on the percentage of parasitemia in symptomatic versus asymptomatic patients and
3. Level of serum ferritin among the malaria positive and healthy control subjects.

Study area

The work has been initiated in the month of August, 2012. During the period from August 2012 to January 2013, a total of 77 blood samples have been collected from 77 individuals suspected with malaria from different malaria endemic districts (Dibrugarh, NC Hills, Karbi Anglong and Chirang) of Assam.

Initially, 20 μl of blood samples were collected by finger prick from patients having fever. Diagnosis of malaria was done by immunochromatographic test methods using commercial kits preferably SD Bioline malaria antigen kit in the field followed by microscopic and polymerase chain reaction (PCR) examination in the laboratory [Figure 1] and [Figure 2]. If the suspected patients are found malaria positive in the commercial malaria diagnosis kits during field then, 3-5 ml of venous blood samples were collected from suspected malaria patients. A thin and thick blood smear was prepared for microscopic examination. A Severity of malaria (percentage of parasitemia) was determined by the microscopic slide. The hematological parameters were estimated by using hematological cell counter (Sysmex, Germany) from whole blood. Serum separated from plain vials was used for estimation of ferritin by using ferritin Elisa method. Clinical and demographic history of the patients was also recorded in a predesigned standard proforma.

Out of 77 collected blood samples from malaria suspected patients, a total of 36 cases were found malaria positive. Among these positive cases 25 nos were symptomatic patients, and 11 nos were asymptomatic patients. Distribution of malaria cases was observed in all age groups and both the sexes.

Out of 36 malaria positive cases 91.67% were Pf positive. Only one Plasmodium vivax (Pv) positive case and two numbers of mixed infections were detected in laboratory examination [Table 1]. The percentage of malaria positive cases were higher in Karbi Anglong where 80% of the suspected malaria cases were showed positive results [Table 2].

Hematological parameters among the healthy controls revealed that 53.67% had anemia, 43.90% had leukocytopenia, thrombocytosis and iron deficiency anemia [Table 3]. Hematological parameters of the malaria positive patients indicate that, about 89.00% were having anemia, 66.67% were with thrombocytopenia, 63.87% were with iron deficiency anemia, 50.00% were having low MPV, 47.00% were with lymphocytopenia and 44.44% were with high PDW. It was also found that the percentages of these hematological parameters are nearly approximate among both symptomatic and asymptomatic malaria positive patients [Table 4].

About 68.00% of malaria positive symptomatic patients showed 2-6% of parasitemia. Whereas, high level of parasitemia was found in only 9.09% of malaria positive asymptomatic patients [Figure 3] and [Table 5].

Serum ferritin level in the malaria positive population ranged in from 70 to 300 ng/ml, with a mean value of 114 ng/ml. In our study, we could ascribe no differences in serum ferritin levels to gender. But low level of ferritin was higher in symptomatic malaria positive patients and in healthy control subjects higher level of ferritin was strong-minded [Table 6] and [Table 7].

This study confirms that hematological abnormalities considered hallmark of malaria infection. This is probably due to the higher levels of parasitemia found in these patients. The abnormalities previously reported include changes in hemoglobin, leucocyte count, platelet abnormalities resulting in defective thromboplastin, and disseminated intravascular coagulation (DIC). ^[6],[7],[8] In this study changes in other hematological parameter like thrombocyte, lymphocyte monocyte and granulocyte was also brought into being.

Many studies revealed that the anemia is one of the most common complications in malaria. ^[9] Our present study also supports the hypothesis. It was also observed in the present study that leukocyte count was significantly lower in healthy controls comparison to count for malarial infection [Table 3]. This is in resemblance to the previous study which concluded that leukocyte count was not predictive for malaria infection. ^[10] However, is in the likeness to a previous study that reported low monocyte count being associated with severe malaria and an adverse outcome. ^[11]

Thrombocytopenia occurred in 67% of malaria cases and was inversely related to parasite density [Table 3]. These observations imply that thrombocytopenia may be a marker of parasite burden and disease severity. Thrombocytopenia seems to occur through peripheral destruction, ^[11] excessive removal of platelets by splenic pooling ^[12],[13] as well as platelet consumption by the process of DIC. ^[14] The increase percentages of low platelet volume among malaria positive patients are possibly due to the cytokine interference of megakaryopoiesis. ^[15] Significantly more samples in the parasitemic group had high PDW suggesting that the aggregation was associated with malaria.

In our study, it was seen that the serum ferritin levels are decreased in malaria positive patients when compared to healthy controls. We do not know the defined mechanism for this consequence. However, several studies reported an increased serum transferrin receptor concentration and decreased serum ferritin in persons with symptomatic and mildly symptomatic falciparum malaria. ^{[16],[17],[18],[19]} Furthermore, acute erythropoietin deficiency ^[20] or suppression of marrow response to erythropoietin could lead to decreased erythropoiesis and thus low serum ferritin concentrations.

Patient infected with Pf malaria exhibited important changes in some hematological parameters with low thrombocyte count and hemoglobin concentration being the two most important predictors of malaria infection in patients in our study area. There was a negative correlation between serum ferritin levels and malaria positivity.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.145001

[Figure 1], [Figure 2], [Figure 3]

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]