Refractory pancytopenia and megaloblastic anemia due to falciparum malaria

Cranial fluctuating asymmetry and its relationship with non-specific physiological stress indicators in a contemporary South African cadaveric skeletal sample

OBJECTIVES

Biological anthropologists frequently explore skeletal asymmetry, together with population health and disease. Given the conflicting findings in existing literature, this study aimed to clarify whether an association exists in a South African sample.

MATERIALS

Dry bone and cranial micro-focus X-ray Computed Tomography (micro-XCT) scans of 115 South African individuals were assessed.

METHODS

Fluctuating asymmetry (FA) indices were calculated from interlandmark distances, and the frequency of four types of non-specific signs of physiological stress were documented to explore the relationship between FA and disease.

RESULTS

Black South Africans did not exhibit a high FA index; however, they had the highest prevalence of non-specific signs of physiological stress. However, no significant correlations were detected between FA indices and pathological lesions.

CONCLUSION

No correlation was observed between FA and populations from different socio-economic backgrounds. However, individuals of lower socio-economic status (SES) demonstrated a greater prevalence of non-specific signs of physiological stress.

SIGNIFICANCE

This research suggests that skeletal indicators of stress may be a suitable biological marker for assessing differences in SES among population groups, while indicating that levels of cranial FA is an inadequate biological marker.

LIMITATIONS

Possible limitations may include measurement error, and the lack of information on the life history and medical records of individuals in this sample.

SUGGESTIONS FOR FURTHER RESEARCH

Future research should include a larger sample with more South African groups, and should evaluate the potential association among age, FA, and expression of skeletal markers of disease.

REFRACTORY ANEMIA AND PANCYTOPENIA AS PRESENTATIONS OF FALCIPARUM MALARIA IN POPULATION OF KHYBER PAKHTUNKHWA, PAKISTAN

Background: Falciparum malaria is a common disease in our area. Apart from its classical presentation, at times it may present with refractory anemia or pancytopenia. The aim of this study was to determine the refractory anemia and pancytopenia as complications of falciparum malaria and apart from peripheral blood smears the significance of rapid antigen tests and bone marrow examination in the diagnosis of falciparum malaria. Material & Methods: The descriptive study included 200 consecutive cases of fever and refractory anemia or pancytopenia from 2011 to 2014. Stratification of patients according to the clinical scenario included Group-A having fever with refractory anemia and Group-B with fever and pancytopenia. A detailed history, thorough clinical examination, and pertinent laboratory tests were performed. All patients were treated with antimalarial drugs and followed-up for eight weeks. The pre and post treatment hematologic parameters were compared. Results: Among the 200 patients, 85 were males and 115 females. The age ranged from 15 to 55 years. Stratification of patients on clinical scenario revealed 175(87.5%) patients with fever and refractory anemia (Group-A). Among these, 125(62.5%) patients were reported smear positive for P. falciparum. In the remaining 50 smear negative patients rapid antigen tests were performed and all were reported positive. In 25 patients of Group B with fever and pancytopenia, the peripheral smear for malaria was positive only in 5 patients. In the remaining 20 cases both the peripheral blood smears and rapid antigen tests were reported negative. Bone marrow examination was planned to confirm the bone marrow suppression as the cause of peripheral pancytopenia, to exclude leukemia and to identify P. falciparum. The bone marrow examination revealed P. falciparum in all these cases. All the patients had a dramatic response to treatment with antimalarials in terms of disappearance of fever and correction of anemia and bone marrow rescue with reversal of pancytopenia to normal counts. Conclusion: Plasmodium falciparum should be considered in all cases of prolonged fever with refractory anemia or pancytopenia in malaria endemic areas, even with negative smear and rapid antigen tests. Bone examination is mandatory for the diagnosis in such cases. There is dramatic response of such patients to treatment with antimalarial drugs and hematinics.

Haemophagocytic lymphohistiocytosis: a cause of unresponsive malaria in a 5-year-old girl

A 5-year-old immunocompetent girl presented with fever, jaundice, hepatosplenomegaly and pancytopenia. The peripheral blood smear demonstrated mixed malaria infection (Plasmodium vivax and Plasmodium falciparum). Fever was persistent despite antimalarials in the absence of any coexisting bacterial or viral infection. Laboratory findings included cytopaenia, hyperbilirubinaemia, hyperferritinaemia, hypertriglyceridaemia, hyponatraemia, deranged partial thromboplastin time, decreasing ESR and megaloblastic changes on bone marrow aspiration. A final diagnosis of haemophagocytic lymphohistiocytosis (HLH) with megaloblastic anaemia associated with severe mixed malaria was made. There was a dramatic response to corticosteroid treatment with improvement in her clinical condition. This report endorses the use of corticosteroids in malaria-associated HLH whenever there is no clinical improvement with antimalarials alone.