Thrombocytopenia in malaria--correlation with type and severity of malaria.

AIM OF THE STUDY: Malaria is a major health problem in the tropics with increased morbidity and mortality. Thrombocytopenia is a common finding in malaria. Although a reliable diagnostic marker, prognostic implications could vary in the two types of malaria. This study was undertaken to correlate the presence and severity of thrombocytopenia with the type of malaria. DESIGN: A total of 1565 subjects were included in the study and identified positive for malaria parasites on peripheral smear examination with conventional microscopy. Platelet count was done on a fully automated, quantitative, hematology Coulter analyser. RESULTS: Normal platelet count was noted in 21.6% cases. The mean platelet count in vivax malaria (n=973) was 1,15,390/microl (SD 64,580) with a range of 8000-5,73,000/microl, as against falciparum malaria (n=590) where the mean platelet count was 100,900/microl (SD 75,437) with a range of 2000-497,000/microl (Pearson coefficient 8.825, p < 0.0001). Platelet count < 20,000/microl was noted in only 1.5% cases in vivax malaria as against 8.5% cases of falciparum malaria, and none of the subjects with vivax malaria had a platelet count less than 5000/microl. CONCLUSION: Although absence of thrombocytopenia is uncommon in malaria, its presence is not a distinguishing feature between the two types. Thrombocytopenia less than 20,000/microl can occur in P. vivax malaria although statistically more common with P. falciparum malaria. The above findings can have therapeutic implications in context of avoiding unnecessary platelet infusions with the relatively more benign course in P. vivax malaria.

Apolipoproteins: correlation with carotid intimamedia thickness and coronary artery disease.

BACKGROUND: Lower levels of plasma apolipoprotein AI (Apo A-I) and higher levels of ApoB, and the ratio of ApoB to ApoA-I are considered to be independent risk factors for coronary heart disease, and may assume importance in the definite subset of Indian patients with normal levels of traditional lipid risk factors and an early-onset of coronary artery disease (CAD). Carotid intima-media thickness is considered as a marker of atherosclerosis and in prediction of clinical coronary events and coronary artery disease. With increasing interest in the role of non-traditional lipid risk factors in CAD and few studies reported in Indian subjects, we undertook this study to correlate the apolipoprotein levels with CAD and their impact on arterial thickening utilizing the carotid intima-media thickness as a surrogate marker. METHODS AND RESULTS: Traditional lipid profile, apolipoprotein A-I and B and carotid artery Intima-media thickness (IMT) with a B-mode scan were measured in 309 patients recruited for the study (age group 36-64 years), which included 193 males and 116 females. Mean of maximal IMT exceeding 0.8 mm at the far wall of common carotid artery, excluding plaques, was selected as the higher values for comparison. One hundred and twenty two subjects had evidence for CAD as diagnosed by documented hospitalization with myocardial infarction or acute coronary syndrome, coronary angiography when feasible or noninvasive cardiac evaluation. Prevalence of subjects with increased IMT was higher among subjects with an apolipoprotein B: apolipoprotein A-I ratio exceeding one compared to those with a ratio less than one (30.6% vs 16.5%, p = 0.005). Prevalence of CAD was significantly higher among subjects with apolipoprotein B: apolipoprotein A-I ratio exceeding one as compared to those with a ratio less than one (53.7% vs 30.3%, p = 0.0002). Subjects with apolipoprotein B: apolipoprotein A-I ratio exceeding one and carotid IMT more than 0.8 mm had a 2.7-fold prevalence for CAD as against those with a ratio less than one and IMT less than 0.8 mm. On multivariate logistic regression analysis, apolipoprotein B: apolipoprotein A-I ratio exceeding one was significantly associated with increased IMT (odds ratio 2.27) and CAD (odds ratio 2.50) even after inclusion of sex, smoking, body mass index, total cholesterol, LDL-cholesterol, HDL-cholesterol, total cholesterol:HDL-cholesterol ratio and serum triglycerides into the model. CONCLUSIONS: We conclude that apolipoprotein B to A-I ratio shows a strong association with carotid intimal medial thickening and coronary artery disease in this Western Indian population and may play an important role is assessment of coronary risk in addition to traditional coronary risk factors.

Prognostic implications of white cell differential count and white cell morphology in Malaria.

BACKGROUND: Malaria is of immense importance amongst the tropical diseases in India. There is a need to develop newer diagnostic aids and research is necessary to identify new prognostic markers for prediction of the course and complications. AIMS: To evaluate the white cell differential count and morphology in Plasmodium vivax and Plasmodium falciparum malaria and study their prognostic utility. SUBJECTS AND METHODS: Two hundred and sixty-four adult patients in the age range of 20 to 65 years presenting to the hospital over a period of 4 months with clinical features of malaria and a positive peripheral smear examination were studied. RESULTS: No statistically significant difference was noted in the white blood cell (WBC) count and neutrophil count in P.vivax versus P. falciparum malaria. Band cells were more frequently noted in P. falciparum malaria than in P.vivax malaria (p < 0.0001). Toxic granulation of the neutrophils was noted in 9.5% of the patients and exclusively in P. falciparum malaria. Presence of toxic granulation of the polymorphs in subjects with P. falciparum malaria was significantly associated with anaemia (p=0.019), jaundice, cerebral involvement, adult respiratory distress syndromes, renal dysfunction and death (p < 0.0001 for all these parameters). CONCLUSION: Band cells were seen in P. vivax and P. falciparum malaria, although in higher numbers in P. falciparum malaria. Toxic granulation of the neutrophils was noted only in the presence of P. falciparum malaria in this study and correlated with severity.

Association of microalbuminuria with carotid intima-media thickness and coronary artery disease--a cross-sectional study in Western India.

OBJECTIVE: Microalbuminuria, a slightly elevated albumin excretion in the urine, is considered a novel atherosclerotic risk factor, both in diabetics subjects and in general population. Carotid intima-media thickness assessed non-invasively by a B-mode ultrasound has been recently shown to be an early marker for atherosclerosis. This study aims at determining the role of microalbuminuria as an atherosclerotic risk factor and its association with coronary artery disease. METHODS: We measured the urine microalbumin excretion and carotid intima-media thickness (IMT) in 301 subjects, with or without evidence for coronary artery disease (CAD). Microalbuminuria was diagnosed if urinary excretion of albumin exceeded 20 microgm/ml. RESULTS: Of the 301 subjects (age group--30-80 years) recruited for the study, 194 were males, 107 females. One hundred amd eighteen subjects had evidence of CAD as diagnosed by documented hospitalization with myocardial infarction or acute coronary syndrome, coronary angiography when feasible or non-invasive cardiac evaluation. One hundred and sixty three subjects had diabetes mellitus. Microalbuminuria was detected in 74 subjects (24.6%). Prevalence of subjects with increased IMT was higher among subjects with microalbuminuria compared to normoalbuminuria (42% vs 21.4%, p < 0.003). Prevalence of CAD was significantly higher among diabetic subjects with microalbuminuria compared to those with normoalbuminuria (Diabetic subjects: 58% vs 31.9%, p = 0.002, Non-diabetic subjects: 41.7% vs 37.7%, p = 0.718). Multivariate logistic regression analysis using carotid intimal medial thickness as a dependent variable revealed a statistically significant association with microalbuminuria in diabetic subjects (p = 0.027). CONCLUSION: We conclude that microalbuminuria shows a strong association with increased carotid intimal medial thickening and coronary artery disease in diabetic subjects in this Western Indian population.

Carotid intima-media thickness as an independent predictor of coronary artery disease.

BACKGROUND: A noninvasive technique of measuring carotid artery intima-media thickness has recently generated considerable interest as a marker of atherosclerosis and in the prediction of clinical coronary events and coronary artery disease. The present study evaluated the association of carotid artery intima-media thickness in the prediction of coronary artery disease in a western Indian population. METHODS AND RESULTS: Carotid artery intima-media thickness was measured with a B-mode scan in an ongoing study of 266 patients, who were further subdivided into 4 subgroups: those with non-insulin dependent diabetes mellitus; hypertension; diabetes mellitus with hypertension; and those without diabetes or hypertension (labeled as controls). The maximal intima-media thickness greater than 0.8 mm at the far wall of the common carotid artery, excluding raised lesions and plaques, was selected as the highest value for comparison. The subgroups were further divided into those with and without apparent coronary artery disease. A statistically significant intima-media thickness greater than 0.8 mm was observed in 59.2% of the subjects with coronary artery disease as against 40.8% in those without the disease on univariate analysis. A higher incidence of intima-media thickness of more than 0.8 mm was observed in all subgroups with coronary artery disease as against those without the disease, which was most marked in the hypertensive group (22.2% v. 3.6%) and contributed to the increased arterial thickness in diabetics with concomitant hypertension. Multivariate regression analysis revealed carotid artery intima-media thickness to be associated with coronary artery disease with an odds ratio of 2.40. CONCLUSIONS: Carotid artery intima-media thickness is a simple, noninvasive and reproducible clinical tool to evaluate atherosclerosis and predict coronary artery disease in Indian subjects. Prospective studies in a larger number of subjects, particularly in those undergoing coronary angiography, will help in establishing the role of this technique.