Splenomegaly in malaria patients
in a tertiary care institute: A study from central India
Soni P.1, Jalaly T.2
1Dr. Pradip Soni, Associate Professor, 2Dr. Tariq Jalaly, Professor,
both authors are affiliated with Department of Medicine, Chirayu
Medical College and Hospital Bhopal, M.P. India.
Corresponding Author:
Dr. Tariq Jalaly, Professor, Department of Medicine, Chirayu Medical
College and Hospital Bhopal, M.P. India. Email:
tariqjalaly@gmail.com
Abstract
Introduction:
The spleen is 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 area. Material and Methods:
The study was conducted in the department of Medicine, Chirayu medical
college and hospital Bhopal. All patients of age equal or greater than
15 years presenting with the fever and had positive peripheral smear
for malaria parasite were included in my study. Results: 81% (n=21)
patients of asexual stage had enlarged spleen where as 19% (n=5)
patients of sexual stage had enlarge spleen. There is significant
association of splenomegaly with asexual stage. All cases have
splenomegaly in mixed species, 41.60% (n=20) splenomegaly seen in P.
falciparum species and only 20% splenomegaly seen in P. vivax species. Conclusion: Though
clinical examination is one of the good method to detect splenomegaly
USG examination is superior as its sensitivity and specificity is
higher than clinical examination. Hence it is recommended that
splenomegaly be detected by USG examination in cases of malaria.
Keywords:
Splenomegaly, Malaria, P. Falciparum, P. vivax
Manuscript received:
16th February 2018,
Reviewed: 26th February 2018
Author Corrected:
5th March 2018, Accepted
for Publication: 12th March 2018
Introduction
Spleen has an important role in defense mechanism against malarial
infection. As the body’s largest lymphoid organ, the spleen
has a variety of immunologic functions including as a sieve for the
blood removing blood cells, microorganisms, and immune complexes.
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 area [1].
The spleen enlargement in an individual occurs if he experiences
parasitemia for a period exceeding two weeks. Thereafter the degree of
spleen enlargement depends upon the duration of exposure and severity
of parasitemia [2].
As the endemicity increases, the average enlargement of the spleen is
considered to be greater. Some renowned malariologists have even
considered spleen examination superior to the blood examination.
Splenomegaly thus becomes extremely important in reaching a diagnosis
in all cases of questionable malaria, especially the ones presenting
atypically [3].
The objective of this study was to find out the relationship between
Splenomegaly and malaria patients attending OPD of medicine department
of Chirayu Medical College and Hospital, Bhopal, M.P.
Material
and Methods
It was a cross sectional study, patients were selected from Medicine
OPD and indoor wards of Department of Medicine, Chirayu medical college
and hospital Bhopal. All patients of age equal or greater than 15 years
presenting with the fever and had positive peripheral smear for malaria
parasite were included in my study. All the patients who had fever and
splenomegaly due to other tropical disease were excluded from the
study.
Procedure:
Each case was subjected to detailed interrogation and through clinical,
including personal history. Thick and thin film were prepared and
stained by JSB staining. Ultra-sonography was done by Shimadzu
(SOU-500) and L & T selectra machine with 3.5 MHz sector curved
array probe. Subcostal, intracostal and sagittal scan of the spleen
were done with patients lying on his or her right side or supine
position.
Results
Table No.-1: Age wise
distribution of splenomegaly
|
Age Group
|
USG Examination
|
Total
|
|
Normal
|
Enlarged
|
%
|
|
15-20
|
23
|
18
|
69.24
|
41
|
|
31-40
|
8
|
7
|
26.92
|
15
|
|
41-50
|
7
|
0
|
0
|
7
|
|
61-60
|
4
|
0
|
0
|
4
|
|
61-70
|
2
|
1
|
3.84
|
3
|
|
Total
|
44
|
26
|
100
|
70
|
This table shows maximum no. of enlarged spleen found in group 15-30
years 69.24% (n=41). No enlarged spleen is found in 41-60 years age
group of patients. There is a significant decreasing trend of
splenomegaly in older age group.
Table No.-2: Malaria
parasite: stage wise distribution of splenomegaly
|
Species
|
Spleen Enlarge
|
Total
|
|
Asexual Stage
|
Sexual Stage
|
|
Mixed
|
1
|
1
|
43
|
|
PV
|
17
|
3
|
27
|
|
PV
|
3
|
1
|
70
|
|
Total
|
21
|
5
|
26
|
|
%
|
81
|
19
|
100
|
This table shows 81% (n=21) patients of asexual stage had enlarged
spleen where as 19% (n=5) patients of sexual stage had enlarge spleen.
There is significant association of splenomegaly with asexual stage.
Table No.-3: Malaria
parasite species age wise distribution of splenomegaly
|
MP Species
|
USG Examination
|
Total
|
|
Normal
|
Enlarged
|
%
|
|
Mixed
|
0
|
2
|
100
|
2
|
|
PF
|
28
|
20
|
41.66
|
48
|
|
PV
|
16
|
4
|
20
|
20
|
This table shows that all cases of mixed species has splenomegaly,
41.60% (n=20) splenomegaly seen in P. falciparum species and only 20%
splenomegaly seen in P. vivax species.
Discussion
In the present study, the maximum number of patients having
splenomegaly is 69.24% in the 15-30 years age group. A significantly
decreasing trend of splenomegaly in older age group was found.
Size of splenic enlargement in children after the age of 8 to 10 years
is affected by development of immunity which reduces parasite density
in the peripheral blood and in holoendemic area adult do not show
splenic enlargement.3 Sanjib Mohanty et al also found in their study
that splenomegaly occurred more frequently in children 76% v/s 61% in
adult. So, this study supports our study [4].
In the present study splenomegaly was found mostly {81% patients) in
asexual stage (acute infection) of malaria parasite, while only 19%
patients with splenomegaly had sexual stage. So there is a significant
co-relation of splenomegaly with asexual stage.This may be due to the
fact that most of our patients had P falciparum infection. In P
falciparum infection heavy parasitemia is more common, so increased
clearance of parasitized and non-parasitized erythrocytes occurs in the
presence of splenomegaly [5].
White MS et al in 1986 have reported splenomegaly in 53% cases of acute
attack of uncomplicated malaria [6].
In present study 100% patients of mixed species infection had
splenomegaly. In P falciparum infection 41.66% patients and in P vivax
infection 20% patients had splenomegaly. So splenomegaly is probably
more common in mixed infection than isolated infection.
D. R. Ohalohan also found splenomegaly in 33% patients in mixed
infection, 16% in P, falciparum infection and 9% in P vivax infection
in their study [7]. Strickland GT at al found in their study that
larger the spleen more likely a P. falciparum infection, whereas P
vivax was more commonly associated with minimal spleen enlargement [8].
Hazra BR et al found splenomegaly in 40% cases with P falciparum
infection and only in 18, 18% cases of P vivax infection [9].
Generally, spleen enlarges more in P. falciparum infection due to
phagocytosis of parasitized RBC and their accumulation in spleen for
clearance. We observed splenomegaly in 41% of P. falciparum and 20% of
P. vivax patients. An almost similar enlargement of around 39-45% was
observed P. falciparum patients of Saudi Arabia [10,11]. However, much
higher rate of splenomegaly (71%) was recorded in falciparum malaria
from the other parts of India [12]. This change might be due to
differences in the immune status of patients from different malaria
transmission regions.
Conclusion
There are various parameters in the clinical examination; of which
splenomegaly is one of them and this is directly related with severity
of malaria. Though clinical examination is one of the good method to
detect splenomegaly USG examination is superior as its sensitivity and
specificity is higher than clinical examination. Hence it is
recommended that splenomegaly be detected by USG examination in cases
of malaria. To prevent further complications in malaria, it is
suggested that both P. falciparum and P. vivax infections must be
treated with the most effective antimalarials, preferably combined
therapy aiming at different biochemical targets.
Funding:
Nil, Conflict of
interest: None initiated
Permission from IRB:
Yes
References
1. Bruce-Chwatt LJ. Essential Malariology, 2nd ed. London,
William Heinemann Medical Books Ltd, 1978:72-8.
2. Sharma RS, Sharma GK, Dhillon G.P.S., Measurement of
malaria. Epidemiology & control of malaria in India NPEM 1998;
Govt of India, Ministry of Health & Family Welfare, National
Malaria Eradication Programme, Directorate General of Health Services,
Delhi 54; 101-117.
3. Mashaal HAH. Splenomegaly in Malaria. Ind J Malariol 1986;
23:1-18. [PubMed]
4. Mohanty S., Saroj K., Mishra SP, Jayakrushna P., Bhabani
SD. Complications and mortality patterns due to Plasmodium falciparum
malaria in hospitalized adults and children, Orissa, India. Trans. R
Soc. Trop, Med. Hyg. (2003).
5. Looareesuwan S, et al. 1987 Dynamic alteration in splenic
function during Acute falciparum malaria N Engl J Med 317:675-679. [PubMed]
6. White NJ, Warrell DA, Chanthavanich P, et al. Severe
hypoglycemia and hyperinsulinemia in falciparum malaria. N Engl J Med
1983, 309:61-66.
7. O'Holohan D.R. Clinical and laboratory presentation of
malaria: An analysis of one thousand subjects with malaria
parasitaemra. The J. of Trop Med Hyg, Sep. 1976;191-196. [PubMed]
8. Strickland GT, Fox E, Hadi H. Malaria and splenomegaly in
the Punjab. Trans R Soc Trap Med Hyg. 1988;62(5):667-70. [PubMed]
9. Hazra BR, Chowdhury RS, Saha SKP Ghost MB, Mazumber AK.
Changing scenario of malaria, a study at Calcutta. • Indian J
Malarial 1998 Jun;35(2):111-6.
10. Banzal S, Ayoola FA, El Sammani FE, Rahim SI, Subramanium P, Gadour
MOE, Jain AK. The clinical pattern and complications of severe malaria
in the Jazan region of Saudi Arabia. Ann Saudi Med. 1999;
1:378–380.
11. Malik GM, Seidi O, El-Taher AM, Mohammad AS. Clinical
aspects of malaria in the Asir region, Saudi Arabia. Ann Saudi Med.
1998;18:15–17. [PubMed]
12. Kochar DK, Kaswan K, Kochar SK, Sirohi P, Pal M, Kochar A,
Agrawal RP, Das A. A comparative study of regression of jaundice in
patients of malaria and acute viral hepatitis. J Vector Borne Dis.
2006;43:123–129.
How to cite this article?
Soni P, Jalaly T. Splenomegaly in malaria patients in a tertiary care
institute: A study from central India. Int J Med Res Rev 2018;6
(03):182-185. doi:10.17511/ijmrr. 2018.i03.08.