The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis

Joshua Hanson; Nguyen H oan Phu; Mahtab U ddin Hasan; Prakaykaew Charunwatthana; Katherine Plewes; Richard J. Maude; Panote Prapansilp; Hugh W F Kingston; Saroj K. Mishra; Sanjib Mohanty; Ric N. Price; M. Abul Faiz; Arjen M. Dondorp; Nicholas J White; Tran T inh Hien; Nicholas P J Day

doi:10.1186/s12916-015-0324-5

The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis

Joshua Hanson, Nguyen H oan Phu, Mahtab U ddin Hasan, Prakaykaew Charunwatthana, Katherine Plewes, Richard J. Maude, Panote Prapansilp, Hugh W F Kingston, Saroj K. Mishra, Sanjib Mohanty, Ric N. Price, M. Abul Faiz, Arjen M. Dondorp, Nicholas J White, Tran T inh Hien, Nicholas P J Day

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Abstract

Background: Thrombocytopenia is a common finding in adults with severe falciparum malaria, but its clinical and prognostic utility is incompletely defined.

Methods: Clinical and laboratory data from 647 adults with severe falciparum malaria were analysed retrospectively to determine the relationship between a patient's platelet count on admission to hospital and their subsequent clinical course.

Results: On admission, 614 patients (94.9%) were thrombocytopenic (platelet count <150 × 10(9)/L) and 328 (50.7%) had a platelet count <50 × 10(9)/L. The admission platelet count was inversely correlated with parasite biomass (estimated from plasma PfHRP2 concentrations, rs = -0.28, P = 0.003), the degree of microvascular sequestration (measured with orthogonal polarizing spectral imaging, rs = -0.31, P = 0.001) and disease severity (the number of World Health Organization severity criteria satisfied by the patient, rs = -0.21, P <0.001). Platelet counts were lower on admission in the patients who died (median: 30 (interquartile range 22 to 52) × 10(9)/L versus 50 (34 to 78) × 10(9)/L in survivors; P <0.001), but did not predict outcome independently from other established laboratory and clinical prognostic indices. The 39 patients (6%) with profound thrombocytopenia (platelet count <20 × 10(9)/L) were more likely to die (odds ratio: 5.00, 95% confidence interval: 2.56 to 9.75) than patients with higher platelet counts, but these high-risk patients could be identified more rapidly with simple bedside clinical assessment. The admission platelet count did not reliably identify the 50 patients (7.7%) with major bleeding during the study.

Conclusions: Thrombocytopenia is a marker of disease severity in adults with falciparum malaria, but has limited utility in prognostication, triage and management.

Original language	English
Article number	97
Pages (from-to)	1-9
Number of pages	9
Journal	BMC Medicine
Volume	13
DOIs	https://doi.org/10.1186/s12916-015-0324-5
Publication status	Published - 24 Apr 2015

Bibliographical note

This work was supported by the Wellcome Trust of Great Britain and the National Health and Medical Research Council of Australia. Neither funding body played any role in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the review for publication.

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Hanson, J., Phu, N. H. O., Hasan, M. U. D., Charunwatthana, P., Plewes, K., Maude, R. J., Prapansilp, P., Kingston, H. W. F., Mishra, S. K., Mohanty, S., Price, R. N., Faiz, M. A., Dondorp, A. M., White, N. J., Hien, T. T. I., & Day, N. P. J. (2015). The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis. BMC Medicine, 13, 1-9. Article 97. https://doi.org/10.1186/s12916-015-0324-5

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abstract = "Background: Thrombocytopenia is a common finding in adults with severe falciparum malaria, but its clinical and prognostic utility is incompletely defined.Methods: Clinical and laboratory data from 647 adults with severe falciparum malaria were analysed retrospectively to determine the relationship between a patient's platelet count on admission to hospital and their subsequent clinical course.Results: On admission, 614 patients (94.9%) were thrombocytopenic (platelet count <150 × 10(9)/L) and 328 (50.7%) had a platelet count <50 × 10(9)/L. The admission platelet count was inversely correlated with parasite biomass (estimated from plasma PfHRP2 concentrations, rs = -0.28, P = 0.003), the degree of microvascular sequestration (measured with orthogonal polarizing spectral imaging, rs = -0.31, P = 0.001) and disease severity (the number of World Health Organization severity criteria satisfied by the patient, rs = -0.21, P <0.001). Platelet counts were lower on admission in the patients who died (median: 30 (interquartile range 22 to 52) × 10(9)/L versus 50 (34 to 78) × 10(9)/L in survivors; P <0.001), but did not predict outcome independently from other established laboratory and clinical prognostic indices. The 39 patients (6%) with profound thrombocytopenia (platelet count <20 × 10(9)/L) were more likely to die (odds ratio: 5.00, 95% confidence interval: 2.56 to 9.75) than patients with higher platelet counts, but these high-risk patients could be identified more rapidly with simple bedside clinical assessment. The admission platelet count did not reliably identify the 50 patients (7.7%) with major bleeding during the study.Conclusions: Thrombocytopenia is a marker of disease severity in adults with falciparum malaria, but has limited utility in prognostication, triage and management.",

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author = "Joshua Hanson and Phu, {Nguyen H oan} and Hasan, {Mahtab U ddin} and Prakaykaew Charunwatthana and Katherine Plewes and Maude, {Richard J.} and Panote Prapansilp and Kingston, {Hugh W F} and Mishra, {Saroj K.} and Sanjib Mohanty and Price, {Ric N.} and Faiz, {M. Abul} and Dondorp, {Arjen M.} and White, {Nicholas J} and Hien, {Tran T inh} and Day, {Nicholas P J}",

note = "This work was supported by the Wellcome Trust of Great Britain and the National Health and Medical Research Council of Australia. Neither funding body played any role in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the review for publication.",

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doi = "10.1186/s12916-015-0324-5",

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Hanson, J, Phu, NHO, Hasan, MUD, Charunwatthana, P, Plewes, K, Maude, RJ, Prapansilp, P, Kingston, HWF, Mishra, SK, Mohanty, S, Price, RN, Faiz, MA, Dondorp, AM, White, NJ, Hien, TTI & Day, NPJ 2015, 'The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis', BMC Medicine, vol. 13, 97, pp. 1-9. https://doi.org/10.1186/s12916-015-0324-5

TY - JOUR

T1 - The clinical implications of thrombocytopenia in adults with severe falciparum malaria

T2 - a retrospective analysis

AU - Hanson, Joshua

AU - Phu, Nguyen H oan

AU - Hasan, Mahtab U ddin

AU - Charunwatthana, Prakaykaew

AU - Plewes, Katherine

AU - Maude, Richard J.

AU - Prapansilp, Panote

AU - Kingston, Hugh W F

AU - Mishra, Saroj K.

AU - Mohanty, Sanjib

AU - Price, Ric N.

AU - Faiz, M. Abul

AU - Dondorp, Arjen M.

AU - White, Nicholas J

AU - Hien, Tran T inh

AU - Day, Nicholas P J

N1 - This work was supported by the Wellcome Trust of Great Britain and the National Health and Medical Research Council of Australia. Neither funding body played any role in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the review for publication.

PY - 2015/4/24

Y1 - 2015/4/24

N2 - Background: Thrombocytopenia is a common finding in adults with severe falciparum malaria, but its clinical and prognostic utility is incompletely defined.Methods: Clinical and laboratory data from 647 adults with severe falciparum malaria were analysed retrospectively to determine the relationship between a patient's platelet count on admission to hospital and their subsequent clinical course.Results: On admission, 614 patients (94.9%) were thrombocytopenic (platelet count <150 × 10(9)/L) and 328 (50.7%) had a platelet count <50 × 10(9)/L. The admission platelet count was inversely correlated with parasite biomass (estimated from plasma PfHRP2 concentrations, rs = -0.28, P = 0.003), the degree of microvascular sequestration (measured with orthogonal polarizing spectral imaging, rs = -0.31, P = 0.001) and disease severity (the number of World Health Organization severity criteria satisfied by the patient, rs = -0.21, P <0.001). Platelet counts were lower on admission in the patients who died (median: 30 (interquartile range 22 to 52) × 10(9)/L versus 50 (34 to 78) × 10(9)/L in survivors; P <0.001), but did not predict outcome independently from other established laboratory and clinical prognostic indices. The 39 patients (6%) with profound thrombocytopenia (platelet count <20 × 10(9)/L) were more likely to die (odds ratio: 5.00, 95% confidence interval: 2.56 to 9.75) than patients with higher platelet counts, but these high-risk patients could be identified more rapidly with simple bedside clinical assessment. The admission platelet count did not reliably identify the 50 patients (7.7%) with major bleeding during the study.Conclusions: Thrombocytopenia is a marker of disease severity in adults with falciparum malaria, but has limited utility in prognostication, triage and management.

AB - Background: Thrombocytopenia is a common finding in adults with severe falciparum malaria, but its clinical and prognostic utility is incompletely defined.Methods: Clinical and laboratory data from 647 adults with severe falciparum malaria were analysed retrospectively to determine the relationship between a patient's platelet count on admission to hospital and their subsequent clinical course.Results: On admission, 614 patients (94.9%) were thrombocytopenic (platelet count <150 × 10(9)/L) and 328 (50.7%) had a platelet count <50 × 10(9)/L. The admission platelet count was inversely correlated with parasite biomass (estimated from plasma PfHRP2 concentrations, rs = -0.28, P = 0.003), the degree of microvascular sequestration (measured with orthogonal polarizing spectral imaging, rs = -0.31, P = 0.001) and disease severity (the number of World Health Organization severity criteria satisfied by the patient, rs = -0.21, P <0.001). Platelet counts were lower on admission in the patients who died (median: 30 (interquartile range 22 to 52) × 10(9)/L versus 50 (34 to 78) × 10(9)/L in survivors; P <0.001), but did not predict outcome independently from other established laboratory and clinical prognostic indices. The 39 patients (6%) with profound thrombocytopenia (platelet count <20 × 10(9)/L) were more likely to die (odds ratio: 5.00, 95% confidence interval: 2.56 to 9.75) than patients with higher platelet counts, but these high-risk patients could be identified more rapidly with simple bedside clinical assessment. The admission platelet count did not reliably identify the 50 patients (7.7%) with major bleeding during the study.Conclusions: Thrombocytopenia is a marker of disease severity in adults with falciparum malaria, but has limited utility in prognostication, triage and management.

KW - artemether

KW - bilirubin

KW - creatinine

KW - lactic acid

KW - quinine

KW - microorganism protein

KW - Plasmodium falciparum histidine rich protein 2

KW - unclassified drug

KW - adult

KW - Article

KW - Bangladeshi

KW - bilirubin blood level

KW - bleeding

KW - blood transfusion

KW - creatinine blood level

KW - disease course

KW - disease severity

KW - female

KW - hematocrit

KW - high risk patient

KW - human

KW - Indian

KW - lactate blood level

KW - major clinical study

KW - malaria falciparum

KW - male

KW - mortality

KW - nonhuman

KW - parasite load

KW - Plasmodium falciparum

KW - prognostic assessment

KW - randomized controlled trial (topic)

KW - retrospective study

KW - thrombocyte count

KW - thrombocyte volume

KW - thrombocytopenia

KW - Vietnamese

KW - world health organization

KW - blood analysis

KW - clinical assessment

KW - disease marker

KW - gastrointestinal hemorrhage

KW - hospital admission

KW - prognosis

KW - survival

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U2 - 10.1186/s12916-015-0324-5

DO - 10.1186/s12916-015-0324-5

M3 - Article

C2 - 25907925

SN - 1741-7015

VL - 13

SP - 1

EP - 9

JO - BMC Medicine

JF - BMC Medicine

M1 - 97

ER -

The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis

Abstract

Bibliographical note

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