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.
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.
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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