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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 41-46

Effect of Malaria on Biochemical and Hematological Parameters: A Hospital-based Case–Control Study


Chief Entomologist, GHMC, Hyderabad, Telangana, India

Date of Submission04-May-2021
Date of Decision05-Dec-2021
Date of Acceptance14-Feb-2022
Date of Web Publication28-Jul-2022

Correspondence Address:
Rambabu Ayyadevara
No. 10-3-146, Flat No: G2, Sai Amrutha Nilayam Apts, Back Side of Busdepot, Khammam - 507 001, Telangana State
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_35_21

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  Abstract 


Background: Alterations in biochemical and hematological are found to be dependent on type of parasite of malaria, endemicity of the area, various demographic factors, and nutritional status of the person, immunity to the malaria, and presence or absence of hemoglobinopathies. Hence, if these parameters are monitored during clinical illness of malaria, they are of great importance to the treating physician to take a decision on prognosis and further management of the cases. They can even assess the severity of the malaria based on changes in these biochemical and hematological parameters.
Objective: To study the effect of malaria on biochemical and hematological parameters.
Methods: During the study period, 40 confirmed cases of malaria and 10 negative controls were investigated. Their hematological, biochemical, and liver parameters and electrolytes were compared. Unpaired t-test and analysis of variance were applied to study the intergroup comparisons.
Results: Hemoglobin, red blood cells, platelets, lymphocytes, basophils, and monocytes were significantly decreased in cases, but neutrophils were significantly more in cases (P < 0.05). Sodium, potassium, and chlorides were significantly decreased in cases (P < 0.05). Creatinine, total cholesterol, total bilirubin, and direct bilirubin were significantly increased in cases (P < 0.05). Serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, and alkaline phosphatase were significantly increased in cases, but total proteins and albumin were significantly decreased in cases (P < 0.05).
Conclusion: Malaria had a significant impact on biochemical, liver, hematological parameters, and electrolytes. Hence, they should be regularly monitored in all admitted cases of malaria, which will help the treating physician to take appropriate decision on clinical management of the disease.

Keywords: Biochemical changes, effect, hemoglobin, liver, platelets


How to cite this article:
Ayyadevara R. Effect of Malaria on Biochemical and Hematological Parameters: A Hospital-based Case–Control Study. MRIMS J Health Sci 2022;10:41-6

How to cite this URL:
Ayyadevara R. Effect of Malaria on Biochemical and Hematological Parameters: A Hospital-based Case–Control Study. MRIMS J Health Sci [serial online] 2022 [cited 2022 Aug 18];10:41-6. Available from: http://www.mrimsjournal.com/text.asp?2022/10/3/41/352626




  Introduction Top


In the tropical countries, malaria is the most common. It is associated with increase in mortality and morbidity in people. It has been estimated by the World Health Organization (WHO) that globally 216 cases occurred in 2016. Seven percentage of these cases were from South-East Asia Region of the WHO. Out of four species of malaria, Plasmodium vivax and Plasmodium falciparum are the most commonly affecting species, of which P. falciparum is commonly found in Sub-Saharan Africa and P. vivax is common in South-East Asia Region of the WHO. The death is comparatively more in severe cases as well as among those cases where the biochemical and hematological parameters get altered. These deaths were found to be associated with complications due to malaria.[1]

Malaria in the patients alters their hematological parameters. These effects depend on the species of the parasite and also on the patient characteristics such as age and sex. In case an anemic patient develops malaria, it leads to severe problems in such cases and it leads to complications. The common hematological changes that are found in malaria cases are anemia, neutrophilia, thrombocytopenia, eosinophilia, and leukopenia.[2]

In cases of malaria, a positive association was found between eosinophilia and inflammatory markers. This has led to the conclusion that in acute cases, eosinophilia gets initiated due to interaction with inflammatory markers or the activation of the T cells. In infection due to P. vivax and P. falciparum, thrombocytopenia is a common finding. More severe the disease, more chances of hematological alterations were observed. Level of thrombocytopenia has been found to be associated with prognosis in malaria cases, especially in falciparum cases.[3]

The common effects of malaria on biochemical parameters include increased bilirubin levels, increase in the enzymes of the liver, and increase in the serum creatinine levels. These biochemical parameter alterations were found to be associated with increased complications in malaria cases. Acute malaria is associated with injury to the liver as there is evidence of increase in the enzymes of the liver in acute cases. There is a direct relationship between parasitic load in the blood and abnormalities of renal markers like urea and creatinine. All these alterations in the parameters are associated with bad prognosis and outcome.[4]

Blood circulates in the blood vessels. It is made up of cells and plasma. The plasma composition is similar to the fluid in the intracellular spaces.[5] Usually, under the normal circumstances, the physiochemical properties of blood tend to remain constant with some normal range fluctuations are common. However, certain conditions can alter it like cancer, malnutrition, and infections including parasitic infections. Malaria infection also alters the biochemical and hematologic aspects of the blood.[6]

These alterations are found to be dependent on type of parasite of malaria, endemicity of the area, various demographic factors, and nutritional status of the person, immunity to the malaria, and presence or absence of hemoglobinopathies. Hence, if these parameters are monitored during clinical illness of malaria, they are of great importance to the treating physician to take a decision on prognosis and further management of the cases. They can even assess the severity of the malaria based on changes in these biochemical and hematological parameters.[7]

Hence, the present study was undertaken to study the effect of malaria on biochemical and hematological parameters.

METHODS

Study design

Case–control study.

Settings

Government Hospital, Vijayawada.

Study period

From January 2011 to December 2011.

Sample size

Forty positive confirmed cases of malaria willing to participate in the study and 10 confirmed cases of nonmalaria (selected as controls) were enrolled to study the effect of malaria on various parameters such as biochemical and hematological.

Sampling technique

Convenient sampling technique was used.

Inclusion criteria

  1. All cases of all age groups of either gender reporting to Government Hospital, Vijayawada, for malaria smear testing
  2. Willing to participate in the present study.


Exclusion criteria

  1. With severe comorbid conditions
  2. Not willing.


Ethical issues

Institution ethics committee permission was obtained. Written informed consent was taken from all the study participants (n = 50).


  Methodology Top


Willing and eligible positive cases of malaria and negative cases of malaria were contacted during the study period. They were explained about the blood tests to be done to study the impact of malaria on various parameters. If they were willing to undergo the study, written informed consent was taken and they were included. Such 40 cases and 10 controls agreed to participate in the study.

Identification of malaria parasite

The presence of malarial infection identification was by CARD method.

Principle

Advantage Malaria PAN + Pf Card method is an immunoassay based on the sandwich principle. The conjugate contains colloidal gold conjugated to Pf-specific monoclonal anti histidine-rich protein 2 (HRP-2) antibody and monoclonal antipan-specific pLDH antibody. The test uses monoclonal anti-Pf. HRP-2 antibody (test line F) and monoclonal antipan-specific pLDH antibody (test line P) immobilized on a nitrocellulose strip. The test sample is added to the device (WHO, 2000). On addition of assay buffer, the red blood cells (RBC) get lysed. If the sample contains P. falciparum or P. vivax/Plasmodium malariae/Plasmodium ovale, the colloidal gold conjugates complex the Pf-specific HRP-2/Pan-specific pLDH in the lysed sample. This complex migrates through the nitrocellulose strip by capillary action. When the complex meets the line of the corresponding immobilized antibody, the complex is trapped forming a purplish pink band, which confirms a reactive test result. Absence of a colored band in the test region indicates a negative test result. A procedural control is present as an additional line of antimouse antibody has been immobilized on the strip as control. Materials required to perform the test are Advantage Malaria PAN + Pf Card, Assay Buffer, Sample Dropper, and Instruction Manual.

Specimen collection

The whole blood was collected by venipuncture into a clean and dry container with anticoagulant. Fresh samples were preferred. Even a fresh finger samples can also be used. Clotted and hemolyzed samples should not be used.

Procedure

Advantage Malaria PAN + Pf Card kit and sample should be at room temperature before testing. The foil pouch on the test card was removed. Patient's name and identification number was labeled on the test card. 5 μL anticoagulated whole blood was added on to the sample well “A” in the test card using a micropipette. Then, the assay buffer was added in the buffer well “B”. The test card was allowed to complete the reaction in 20 min. Now, the results may be read as three types. Appearance of three purplish pink colored lines, one each in Pf region (F), Pan region (P), and control region, indicates that the sample is reactive for P. falciparum or P. vivax/P. malariae/P. ovale. Appearance of two purplish pink colored lines, one each in P and C region, indicates that the sample is reactive for P. vivax/P. malariae/P. ovale. Appearance of two purplish pink colored lines, one each in F and C region, indicates that the sample is reactive for P. falciparum only.

Estimation of random blood sugar was done by glucose oxidase method; estimation of alkaline phosphatase, alanine aminotransferase (ALT). Aspartate aminotransferase (AST), total protein, albumin, cholesterol, urea by modified berthlot's method, creatinine, bilirubin were carried out as per the standard protocol and guidelines.

RBC count, hemoglobin content (Hb), hematocrit (HCT), WBC count, absolute and relative counts of WBC populations: lymphocytes, monocytes, Neutrophils, eosinopils and basophils platelets - PLT count. For the measurement of the above mentioned parameters, laser scatter technology combined with chemical dye method and flow cytometry were used. Mindray Haematology Analyser (Mindray BC-2300, Guangzhou Shihai Medical Equipment Co., Ltd, China).

Statistical analysis

The mean values (with + 2 standard deviation) were used to describe the variables in the study. For comparison of mean values in the two groups, t-test was used. For comparison of mean values in more than two groups, analysis of variance was used and f value was calculated. P < 0.05 was considered statistically significant.


  Results Top


[Table 1] shows comparison of various parameters in control and malarial subjects. Among hematological parameters, hemoglobin, RBC, platelets, lymphocytes, basophils, and monocytes were significantly decreased in cases compared to controls (P < 0.05). However, neutrophils were significantly more in cases compared to controls (P > 0.05). With regard to electrolyte parameters, all of these, viz., sodium, potassium, and chlorides, were significantly decreased in cases compared to controls (P < 0.05). In terms of biochemical parameters, creatinine, total cholesterol, total bilirubin, and direct bilirubin were significantly increased in cases compared to controls (P < 0.05). With regard to liver parameters, serum glutamic pyruvic transaminase (SGPT), serum glutamic oxaloacetic transaminase (SGOT), and ALP were significantly increased in cases compared to controls (P < 0.05). However, total proteins and albumin were significantly decreased in cases compared to controls (P < 0.05).
Table 1: Effect of malaria on various parameters

Click here to view


[Table 2] shows comparison of various parameters, malarial species wise. Among all the parameters studied, total proteins were found to be significantly decreased in cases with falciparum malaria compared to vivax malaria and mixed infection. Hemoglobin was significantly less in cases with mixed infection compared to vivax and falciparum cases. Platelets were significantly reduced in cases with falciparum malaria compared to vivax malaria cases and mixed infection cases.
Table 2: Comparison of various parameters malarial species wise

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  Discussion Top


In the present study among haematological parameters, haemoglobin, RBC, Platelets, lymphocytes, basophils and monocytes were significantly decreased in cases compared to controls (P < 0.05). But neutrophils were significantly more in cases compared to controls (P > 0.05). With regard to electrolyte parameters, all of these viz. Sodium, potassium and chlorides were significantly decreased in cases compared to controls (P < 0.05). In terms of biochemical parameters, creatinine, total cholesterol, total bilirubin and direct bilirubin were significantly increased in cases compared to controls (P < 0.05). With regard to liver parameters, SGPT, SGOT, ALP was significantly increased in cases compared to controls (P < 0.05). But total proteins and albumin were significantly decreased in cases compared to controls (P < 0.05). Among all the parameters studied, total proteins were found to be significantly decreased in cases with falciparum malaria compared to vivax malaria and mixed infection. Haemoglobin was significantly less in cases with mixed infection compared to vivax and falciparum cases. Platelets were significantly reduced in cases with falciparum malaria compared to vivax malaria cases and mixed infection cases.

Das S et al[8] carried out a case control study among 69 cases of malaria and 69 healthy controls. They noted that there were significant alterations in the levels of hemoglobin, count of red blood cells and levels of hematocrit. We also found that the levels of hemoglobin, count of red blood cells were significantly decreased in cases compared to controls. There was marked decrease in the white blood cells count and neutrophils count and we also observed the similar results. Thrombocytopenia was also seen and in the present study also we found significant thrombocytopenia in malaria cases compared to the controls. The author noted that there was significant increase in the enzymes of liver and bilirubin and we also observed that same. The author concluded that these parameters indicate the prognosis of the disease and recommended that the complications of malaria could be prevented if these markers are studied in the malaria cases.

Singh G et al[9] studied retrospectively the effect of parasite infection of malaria on liver and renal parameters. They compared 30 samples of vivax malaria with 30 samples of falciparum malaria. They observed that falciparum malaria was more affecting these parameters than the vivax malaria. In the present study we found that only total proteins were significantly reduced in falciparum malaria compared to vivax infection and mixed infection.

Kotepui M et al[10] compared biochemical parameters of 703 malaria cases and 4282 controls. They noted that count of red blood cells, level of hemoglobin, count of platelets, and other hematological parameters were significantly decreased in cases compared to the controls which are similar to the observation of the present study. They also noted that there was significant increase in the mean corpuscular volume, monocyte-lymphocyte ratio; Mean corpuscular haemoglobin concentration etc. among the cases compared tithe controls. We did not study this aspect. They also found that patients with platelet value of less than 1.5 lakh/microliter were more likely to have the malaria. They concluded that malaria affects the hematological parameters significantly and can be used as predictors of malaria infection. They felt that these parameters could help improve the management and diagnosis of malaria.

Adamu J et al[11] carried out a case control study among 231 malaria confirmed cases and 50 healthy controls matched for age. They found that the hemoglobin was significantly reduced in malaria cases compared to the controls which we also found in the present study. Neutrophils were also found to be significantly reduced in cases than controls. Lipid levels did not differ significantly when it was compared between pregnant and non pregnant women.

Elbadawi NE et al[12] carried out a case control in Sudan study to see effect of malaria on biochemical parameters among the 150 pregnant women as cases and 50 pregnant women without malaria as controls. They observed that urea, creatinine and potassium and sodium were significantly reduced in malaria cases compared to controls. Out study did not include pregnant women but also found similar results.

Al-Salahy M et al[13] investigated changes in the enzymes of liver and hematological parameters due to Plasmodium falciparum malaria among 67 such cases. They found that parasitemia was associated with decreased levels of hemoglobin, decrease in hematocrit when compared to healthy subjects which is similar to the findings of the present study.


  Conclusion Top


Malaria affected haematological parameters, electrolyte parameters, biochemical parameters, liver parameters, and total proteins and albumin significantly. Mixed infection was associated with thrombocytopenia. Hence careful monitoring of these parameters in malaria cases of utmost importance. Hence they should be regularly monitored in all admitted cases of malaria which will help the treating physician to take appropriate decision on clinical management of the disease.



 
  References Top

1.
World Health Organization. World Malaria Report. Geneva: World Health Organization; 2018. Available from: https://apps.who.int/iris/bitstream/handle/10665/275867/9789241565653-eng.pdf?ua=1. [Last accessed on 2019 Dec 26].  Back to cited text no. 1
    
2.
Das BP, Ganguly R, Khuntia HK, Bal M, Ranjit M. Hematological changes in severe P. falciparum malaria. Int J Curr Microbiol Appl Sci 2017;6:1733-9.  Back to cited text no. 2
    
3.
D'souza JJ, Jayaprakash C, D'souza P, Abraham S, Suresh S, Shrinath M. Comparative hematological changes in malarial infection by P. vivax and P. falciparum: Observations from the endemic region of Mangalore, India. Int J Appl Res 2017;3:179-83.  Back to cited text no. 3
    
4.
Sharma M, Nand N, Kumar H, Suman L. Evaluation of liver functions in falciparum malaria. JIMSA 2012;25:229-30.  Back to cited text no. 4
    
5.
Chidoka CP, Tochukwu OR. Hematologic and biochemical indices of Plasmodium falciparum infected inhabitants of Owerri, Imo State, Nigeria. J Med Lab Diagn 2013;4:38-44.  Back to cited text no. 5
    
6.
Chandra S, Chandra H. Role of haematological parameters as an indicator of acute malarial infection in Uttarakhand state of India. Mediterr J Hematol Infect Dis 2013;5:e2013009.  Back to cited text no. 6
    
7.
World Health Organization (WHO) Report. Severe falciparum malaria. Trans R Soc Trop Med Hyg 2000;94:1-90.  Back to cited text no. 7
    
8.
Das S, Rajkumari N, Chinnakali P. A comparative study assessing the effect of haematological and biochemical parameters on the pathogenesis of malaria. J Parasit Dis 2019;43:633-7.  Back to cited text no. 8
    
9.
Singh G, Urhekar D, Singh R, Maheshwari U, Samant P. Alteration in biochemical parameters in malaria patients. Plasmodium falciparum vs. Plasmodium vivax. J Microbiol Antimicrob Agents 2015;1:13-5.  Back to cited text no. 9
    
10.
Kotepui M, Phunphuech B, Phiwklam N, Chupeerach C, Duangmano S. Effect of malarial infection on haematological parameters in population near Thailand-Myanmar border. Malar J 2014;13:218.  Back to cited text no. 10
    
11.
Adamu J, Jigam AA. Effects of malaria infection on some hematological and biochemical parameters in the general population and pregnant malaria patients attending two district hospital in Niger state. Niger Glob J Infect Dis Clin Res 2019;5:1-5.  Back to cited text no. 11
    
12.
Elbadawi NE, Ibrahim EK, Ismael M, Ahmed EG, Adam AO, Khalid FA, et al. The effect of malaria on biochemical renal function parameters in Sudanese pregnant women. J Cell Biol Biochem Res 2013;1:4-7.  Back to cited text no. 12
    
13.
Al-Salahy M, Shnawa B, Abed G, Mandour A, Al-Ezzi A. Parasitaemia and its relation to hematological parameters and liver function among patients malaria in Abs, Hajjah, Northwest Yemen. Interdiscip Perspect Infect Dis 2016;2016:5954394.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2]



 

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