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Anemia is a common manifestation of all types of malaria. It is
more common and poses more problems in pregnancy and children. In developing countries of
the tropics, pre-existing anemia, most commonly due to malnutrition and helminthiasis,
compounds the problem.
In
falciparum malaria, anemia can develop rapidly due to profound hemolysis. The degree of
anemia correlates with parasitemia and schizontemia. It is also associated with high serum
bilirubin and creatinine levels. Pregnancy, secondary bacterial infections and bleeding
disorders like disseminated intravascular coagulation can aggravate the anemia. Children
may have severe anemia even with low parasitemia and in such cases the
reticuloendothelial cells exhibit abundant malarial pigments.
Anemia in malaria is multifactorial. The
causes include obligatory destruction of red cells at merogony, accelerated destruction of
non-parasitised red cells (major contributor in anemia of severe malaria), bone marrow
dysfunction that can persist for weeks, shortened red cell survival and increased splenic
clearance. Massive gastrointestinal haemorrhage can also contribute to the anemia of
malaria.
See
Pathology
Patients with anemia can present with
tiredness, prostration, breathlessness or even severe left ventricular failure and
pulmonary oedema.
In pregnancy, anemia can cause premature
labour, still birth and high perinatal and maternal mortality.
Anemia and fever tend to increase the
cardiac output and this combination can prove fatal for patients with pre-existing cardiac
disease.
A hemoglobin level of less than 7.1g%
(4.4 mmol/l) should serve as a warning for impending crisis. Hemoglobin of less than 5g%
(3.1 mmol/l) is an indication for transfusion of packed cells.
Management
See Treatment of Severe P.
falciparum malaria
If the hematocrit falls below 20%, blood
transfusion may be needed. Fresh blood may in addition provide clotting factors. If fluid
overload is a problem (e.g. pregnancy), it is preferable to transfuse packed red cells.
Transfusion should be carefully monitored and central venous pressure should be assessed
to avoid fluid overload and pulmonary oedema. 20 mg of Injection Furoscemide can be given
as a diuretic to reduce the circulatory load. Repeated transfusions may be necessary in
cases of severe parasitemia and profound hemolysis.
Iron and folic acid supplementation
should be given, particularly for pregnant women.
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