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Bleeding and coagulation abnormalities are seen in less than 5% of
patients with severe falciparum malaria. It can be due to thrombocytopenia and/or
disseminated intravascular coagulation.
Mature parasitised red cells and cytokines activate the coagulation
cascade. Accelerated cogulation cascade, consumpton of antithrombin III, increased
concentration of FDP and increased splenic clearance of platelets contribute to the
coagulopathy and thrombocytopenia in malaria. Hypofibrinogenemia due to DIC occurs in 5%
of patients.
Thrombocytopenia is commonly seen
in severe falciparum malaria. It is presumed to be due to increased consumption of the
platelets in the periphery, may be in the spleen. Bone marrow shows appropriate
megakaryocyte response. However, bleeding due to thrombocytopenia is very rare in malaria.
Corticosteroids are not indicated. However, if thrombocytopenia is severe, platelet
transfusion may be considered. Generally, the platelet count returns to normal with the
completion of antimalarial chemotherapy.
Disseminated intravascular coagulation
is seen in less than 5% of patients with severe falciparum malaria. It tends to be more
common in patients with cerebral malaria, pregnancy and secondary bacterial infections.
D.I.C. in turn may aggravate the other complications of malaria like cerebral malaria,
renal failure, pulmonary oedema and anemia (due to bleeding). Since it is rare, routine
use of drugs like heparin may cause more harm than good and should be avoided. Prolonged
prothrombin and partial thromboplastin time suggests the possibility of D.I.C. which can
be confirmed by measuring plasma concentrations of fibrinogen and fibrin degradation
products. D.I.C. in malaria has to be differentiated from that caused by many other
conditions like heat stroke, viral haemorrhagic fevers, snake bites, immune complex
disorders and shock. Treatment involves administration of fresh whole blood or fresh
frozen plasma and injection of Vitamin K 10 mg intravenously. If there is fear of fluid
overload, then exchange transfusion with fresh blood can be tried. Drugs that may cause
gastrointestinal bleeding (aspirin, other NSAIDs and steroids) are better avoided in
patients with severe malaria.
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