The Correction Between Parasitemia And Spleen Size In Children With Falciparum Malaria
The Correction Between Parasitemia And
Spleen Size In Children With Falciparum Malaria
Syahril Pasaribu
Chairuddin P. Lubis
Department Of Child Health
Medical School
University of Sumatera Utara.
Objective : To find out the correlation between parasitemia and spleen size in falciparum
malaria children.
Methods : The study was conducted in 5 villages in the district of Mandailing Natal,
North Sumatera Province, Indonesia. Subjects were children who visited to the Health
Center with the complaints of fever, shivering, pale, jaundice, diarrhea and headache.
Diagnosis was made by using thin and thick blood smear of Giemsa's method and
Hackett's method was done as a tool for spleen size. Data had been analyzed by ANOVA
(SPSS Version 10.5).
Results : From 152 patients, 60 (39.5%) was falciparum malaria, 83 (54.5%) was vivax
malaria and 9 (6.0%) was mixed infection (plasmodium falciparum + plasmodium vivax).
The youngest patient of falciparum malaria was 6 month old. Splenomegaly had been
found in 27 cases, Hackett 1 in 9 (33.3%) ; Hackett 2 in 11 (40.7%) cases and Hackett 3
in 7 (26.0%) cases. Mean parasites count in splenomegaly patients were higher than
normal spleen size patients. We found that the correlation between parasitemia and
spleen size, especially there was significant correlation between Ho and H3.
Conclusion : There was correlation between parasitemia and spleen size in children with
falciparum malaria.
Key words : falciparum malaria, parasitemia, splenomegaly
Introduction
Malaria is a life-threatening parasitic disease transmitted by mosquitoes. Today
approximately 40% of the world's population, mostly those living in the world's poorest
countries is a risk of malaria. The disease was once more widespread but it was
successfully eliminated from many countries with temperate climates during the mid 20th
century. Today malaria is found throughout the tropical and sub-tropical regions of the
world and causes more than 300 million acute illnesses at least one million deaths
annually 1.
Malaria still remains a major problem in many parts of the world, including
Indonesia. The mortality of malaria in Java and Bali were 1-2 person per 1000 population
in 1983, and 10 fold in other islands of Indonesia2.
1
e-USU Repository © 2004 Universitas Sumatera Utara
There is a semi-quantitative relationship between the magnitude of the
parasitemia and the risk of death, especially among non-immune expatriates with
Plamodium falciparum infection. Parasites in blood more than 100.000/microlitre were
associated with severe infection3.
Spleen is an important organ in immunity to malaria infection. As the body's
largest lymphoid organ, the spleen has a variety of immunology functions, such as sieve
for the blood, removing blood cells, microorganisms and immune complexes. Red blood
cells (RBC) that contain inclusions, after circulating through the splenic microvasculature, may be returned to the blood stream after remodeling (pitting)4. Taylor had
written about the increasing of antibody titer and level of Immunoglobulin M in chronic
malaria with massive splenomegaly5. The spleen was always affected in person suffered
from malaria. The palpable spleen is one of the main clinical symptoms. History of fever,
anemia and splenomegaly are predicting symptoms for clinical diagnosis of malaria
infection in endemic area6. The spleen is enlarged in a first attack or after several attacks
in a duration of time7 Red blood cells that contain merozoites will induced humoral and
cellular immune responses, results in phagocytic effect towards the parasites infected
cells, pigment and remain cells of histiocytes and macrophages from reticulo-endothelial,
particularly spleen8. The main changes were congestion, but later spleen becomes dark
result from the accumulation of pigment in parasitized cells in the capillaries and loci of
necrosis in the splenic pulp 6,9.
The objective of this study is to describe the correlation between parasitemia and
spleen size in falciparum malaria children.
Materials and Methods
A cross sectional study was conducted in 5 villages, Mandailing-Natal (Madina)
District, North Sumatera Province, Indonesia during the period of April 9th - 19th , 2001.
The inclusion criteria were fever, pale, diarrhea, headache and jaundice. Patients who had
got anti-malarial drugs one week before study were excluded.
Blood examination for counting the parasites was performed by taking a drop of
blood from finger or toe in infants. Thick blood smear was used for detecting parasites
and thin blood smear for identification of malaria parasites. The spleen enlargement was
determined by Hackett'& method6 :
Class of Spleen
0
1
2
3
4
5
Description
Normal spleen not palpable even in deep inspiration .
Spleen palpable below the costal margin usually on deep inspiration.
Spleen palpable below the costal margin, but not projected beyond a
horizontal line half way between the costal margin and the umbilicus
measured along a line dropped vertically from left nipple.
Spleen with lowest palpable point projected more than half way to the
umbilicus but not below a line drawn horizontally through it.
Spleen with lowest palpable point below the umbilical level but not
projected beyond a horizontal line situated half way between the
umbilicus and the symphysis pubis.
Spleen with the lowest point palpable beyond the lower limit of class 4.
2
e-USU Repository © 2004 Universitas Sumatera Utara
Data was analyzed by using the computer program of SPSS version 10.5
Correlation between parasitemia and spleen size was assesed by ANOVA.
Results
From 152 patients, 60 (39.5%) was falciparum malaria, 83 (54.5%) was vivax
malaria and 9 (6.0%) was mixed infection (Plasmodium falciparum with Plasmodium
vivax). Sixty patients were enrolled in this study The youngest patient was 6 month old
and the oldest was 13 year old. There were 33 (55%) boys and 27 (45%) girls. The
highest proportion was the age group of > 5 - 10 year old (37%) (table 1).
Age (Years)
0–1
>1–5
> 5 – 10
> 10
Total
Table 1
Sex
Boys (%)
Girls (%)
4
4
11
9
12
10
6
4
33 (55)
27 (45)
Total (%)
8 (13)
20 (33)
22 (37)
10 (17)
60 (100
From history, the most clinical symptoms were fever (97%), pale (80%), headache
(55%), diarrhea (42%), and jaundice (13%) respectively. On physical examination we
found that 27 patients had splenomegaly.
Clinical manifestation of falciparum malaria patients
Symptoms/Physical Examination
Total N (60)
Symptoms :
Fever
58
Pale
48
Jaundice
8
Diarrhea
25
Headache
33
97
80
13
42
55
Physical examintation :
Fever
Pale
Jaundice
Splenomegaly
H0
H1
H2
H3
58
48
8
27
33
9
11
7
97
80
13
45
55
15
18
12
Hepatomegaly
10
17
%
3
e-USU Repository © 2004 Universitas Sumatera Utara
The mean parasitemia was highest in the age group of > 10 years old (6463.60 +
10.662.23), but statistical analysis showed no significant correlation between mean
parasite count and age groups (figure 1)
Figure 1. The correlation of mean parasite count with age groups
The mean parasite count in patients with splenomegaly was higher than without
splenomegaly. There was clinically different in mean parasite count between H0, H1, H2
and H3. There was significant correlation in mean parasite count between Ho and H3
(figure 2).
Figure 2. The correlation between mean parasites count and spleen size
4
e-USU Repository © 2004 Universitas Sumatera Utara
Discussion
We found that there was splenomegaly in 27 patients (45%). This result as same
as Annobil in Saudi Arabia 10. Hepatomegaly was found only in 10 cases (17%).
Sowunmi found that hepatomegaly was more common than splenomegaly and was
significantly more frequent in younger than in older children. He found that there was no
correlation between liver and parasite densit11. In our study, 9 of 10 malaria cases with
hepatomegaly less than 5 year old, and parasite rate around 120 - 14.800/µL. During the
acute infection, Kupffer cells may increase in both number and size. They contain
hemozoin, parasites, parasitized and unparasitized erythrocytes 5,6.
In this study, we found that no correlation between mean parasite count and age
groups (p>0.05), but in clinically parasitemia will increase according to age groups.
Normal spleen function is an important host factor because of both the
immunologic and filtering functions of the spleen. The spleen always affected in malaria.
The palpable enlargement of this organ is one the main clinical symptoms. The
main change is that of congestion, but later the spleen becomes dark from the
accumulation of pigment in parasitized cells in the capillaries and sinusoid6. Spleen
enlargement in malaria related to the lysis of erythrocytes that infected by merozoit, and
will induce immune responses include spleen as a part of RES (reticulo-endothelial
system), and enlargement of spleen as a consequency 12. From this study we found that
there was correlation between mean parasite count and spleen size (p
Spleen Size In Children With Falciparum Malaria
Syahril Pasaribu
Chairuddin P. Lubis
Department Of Child Health
Medical School
University of Sumatera Utara.
Objective : To find out the correlation between parasitemia and spleen size in falciparum
malaria children.
Methods : The study was conducted in 5 villages in the district of Mandailing Natal,
North Sumatera Province, Indonesia. Subjects were children who visited to the Health
Center with the complaints of fever, shivering, pale, jaundice, diarrhea and headache.
Diagnosis was made by using thin and thick blood smear of Giemsa's method and
Hackett's method was done as a tool for spleen size. Data had been analyzed by ANOVA
(SPSS Version 10.5).
Results : From 152 patients, 60 (39.5%) was falciparum malaria, 83 (54.5%) was vivax
malaria and 9 (6.0%) was mixed infection (plasmodium falciparum + plasmodium vivax).
The youngest patient of falciparum malaria was 6 month old. Splenomegaly had been
found in 27 cases, Hackett 1 in 9 (33.3%) ; Hackett 2 in 11 (40.7%) cases and Hackett 3
in 7 (26.0%) cases. Mean parasites count in splenomegaly patients were higher than
normal spleen size patients. We found that the correlation between parasitemia and
spleen size, especially there was significant correlation between Ho and H3.
Conclusion : There was correlation between parasitemia and spleen size in children with
falciparum malaria.
Key words : falciparum malaria, parasitemia, splenomegaly
Introduction
Malaria is a life-threatening parasitic disease transmitted by mosquitoes. Today
approximately 40% of the world's population, mostly those living in the world's poorest
countries is a risk of malaria. The disease was once more widespread but it was
successfully eliminated from many countries with temperate climates during the mid 20th
century. Today malaria is found throughout the tropical and sub-tropical regions of the
world and causes more than 300 million acute illnesses at least one million deaths
annually 1.
Malaria still remains a major problem in many parts of the world, including
Indonesia. The mortality of malaria in Java and Bali were 1-2 person per 1000 population
in 1983, and 10 fold in other islands of Indonesia2.
1
e-USU Repository © 2004 Universitas Sumatera Utara
There is a semi-quantitative relationship between the magnitude of the
parasitemia and the risk of death, especially among non-immune expatriates with
Plamodium falciparum infection. Parasites in blood more than 100.000/microlitre were
associated with severe infection3.
Spleen is an important organ in immunity to malaria infection. As the body's
largest lymphoid organ, the spleen has a variety of immunology functions, such as sieve
for the blood, removing blood cells, microorganisms and immune complexes. Red blood
cells (RBC) that contain inclusions, after circulating through the splenic microvasculature, may be returned to the blood stream after remodeling (pitting)4. Taylor had
written about the increasing of antibody titer and level of Immunoglobulin M in chronic
malaria with massive splenomegaly5. The spleen was always affected in person suffered
from malaria. The palpable spleen is one of the main clinical symptoms. History of fever,
anemia and splenomegaly are predicting symptoms for clinical diagnosis of malaria
infection in endemic area6. The spleen is enlarged in a first attack or after several attacks
in a duration of time7 Red blood cells that contain merozoites will induced humoral and
cellular immune responses, results in phagocytic effect towards the parasites infected
cells, pigment and remain cells of histiocytes and macrophages from reticulo-endothelial,
particularly spleen8. The main changes were congestion, but later spleen becomes dark
result from the accumulation of pigment in parasitized cells in the capillaries and loci of
necrosis in the splenic pulp 6,9.
The objective of this study is to describe the correlation between parasitemia and
spleen size in falciparum malaria children.
Materials and Methods
A cross sectional study was conducted in 5 villages, Mandailing-Natal (Madina)
District, North Sumatera Province, Indonesia during the period of April 9th - 19th , 2001.
The inclusion criteria were fever, pale, diarrhea, headache and jaundice. Patients who had
got anti-malarial drugs one week before study were excluded.
Blood examination for counting the parasites was performed by taking a drop of
blood from finger or toe in infants. Thick blood smear was used for detecting parasites
and thin blood smear for identification of malaria parasites. The spleen enlargement was
determined by Hackett'& method6 :
Class of Spleen
0
1
2
3
4
5
Description
Normal spleen not palpable even in deep inspiration .
Spleen palpable below the costal margin usually on deep inspiration.
Spleen palpable below the costal margin, but not projected beyond a
horizontal line half way between the costal margin and the umbilicus
measured along a line dropped vertically from left nipple.
Spleen with lowest palpable point projected more than half way to the
umbilicus but not below a line drawn horizontally through it.
Spleen with lowest palpable point below the umbilical level but not
projected beyond a horizontal line situated half way between the
umbilicus and the symphysis pubis.
Spleen with the lowest point palpable beyond the lower limit of class 4.
2
e-USU Repository © 2004 Universitas Sumatera Utara
Data was analyzed by using the computer program of SPSS version 10.5
Correlation between parasitemia and spleen size was assesed by ANOVA.
Results
From 152 patients, 60 (39.5%) was falciparum malaria, 83 (54.5%) was vivax
malaria and 9 (6.0%) was mixed infection (Plasmodium falciparum with Plasmodium
vivax). Sixty patients were enrolled in this study The youngest patient was 6 month old
and the oldest was 13 year old. There were 33 (55%) boys and 27 (45%) girls. The
highest proportion was the age group of > 5 - 10 year old (37%) (table 1).
Age (Years)
0–1
>1–5
> 5 – 10
> 10
Total
Table 1
Sex
Boys (%)
Girls (%)
4
4
11
9
12
10
6
4
33 (55)
27 (45)
Total (%)
8 (13)
20 (33)
22 (37)
10 (17)
60 (100
From history, the most clinical symptoms were fever (97%), pale (80%), headache
(55%), diarrhea (42%), and jaundice (13%) respectively. On physical examination we
found that 27 patients had splenomegaly.
Clinical manifestation of falciparum malaria patients
Symptoms/Physical Examination
Total N (60)
Symptoms :
Fever
58
Pale
48
Jaundice
8
Diarrhea
25
Headache
33
97
80
13
42
55
Physical examintation :
Fever
Pale
Jaundice
Splenomegaly
H0
H1
H2
H3
58
48
8
27
33
9
11
7
97
80
13
45
55
15
18
12
Hepatomegaly
10
17
%
3
e-USU Repository © 2004 Universitas Sumatera Utara
The mean parasitemia was highest in the age group of > 10 years old (6463.60 +
10.662.23), but statistical analysis showed no significant correlation between mean
parasite count and age groups (figure 1)
Figure 1. The correlation of mean parasite count with age groups
The mean parasite count in patients with splenomegaly was higher than without
splenomegaly. There was clinically different in mean parasite count between H0, H1, H2
and H3. There was significant correlation in mean parasite count between Ho and H3
(figure 2).
Figure 2. The correlation between mean parasites count and spleen size
4
e-USU Repository © 2004 Universitas Sumatera Utara
Discussion
We found that there was splenomegaly in 27 patients (45%). This result as same
as Annobil in Saudi Arabia 10. Hepatomegaly was found only in 10 cases (17%).
Sowunmi found that hepatomegaly was more common than splenomegaly and was
significantly more frequent in younger than in older children. He found that there was no
correlation between liver and parasite densit11. In our study, 9 of 10 malaria cases with
hepatomegaly less than 5 year old, and parasite rate around 120 - 14.800/µL. During the
acute infection, Kupffer cells may increase in both number and size. They contain
hemozoin, parasites, parasitized and unparasitized erythrocytes 5,6.
In this study, we found that no correlation between mean parasite count and age
groups (p>0.05), but in clinically parasitemia will increase according to age groups.
Normal spleen function is an important host factor because of both the
immunologic and filtering functions of the spleen. The spleen always affected in malaria.
The palpable enlargement of this organ is one the main clinical symptoms. The
main change is that of congestion, but later the spleen becomes dark from the
accumulation of pigment in parasitized cells in the capillaries and sinusoid6. Spleen
enlargement in malaria related to the lysis of erythrocytes that infected by merozoit, and
will induce immune responses include spleen as a part of RES (reticulo-endothelial
system), and enlargement of spleen as a consequency 12. From this study we found that
there was correlation between mean parasite count and spleen size (p