Pancytopenia and Malaria
You may wonder why over the past >3 years I have continued to write and distribute my beloved PedEM Morsels. You consider the fame and fortune that I have amassed and realize that… well, that cannot be it. Certainly knowing that ~500 people are hanging on my every word is a huge ego boost… of course even with that boost, my ego is nothing to boast about. The true reason is… because it is a great way for me to continue to learn more. This week’s Morsel is a prime example: I had no idea that Pancytopenia and Malaria can be associated.
Pancytopenia – it is never a good thing. I was taught that the biggest concern is for a malignancy. Yes, other things can cause it… but cancer is the biggest and baddest. So this week, when I worked up a child for potential malaria (recent travel and persistent fever) I was sad to see the CBC with all cell lines down. I told his family my concern for malignancy (which, by the way is what I think you need to do anytime you are considering cancer… don’t let the family find out that their child has cancer by seeing a MD with hematology/oncology on the white coat). Then, to my delight, the peripheral smear was positive for malaria! Sweet! I’ll take malaria over cancer any day.
- Acute Leukemia (ALL, AML, Myelodysplastic Syndrome) and Aplastic Anemia are the most prevalent causes of pancytopenia.
- Megaloblastic Anemia is also high on the list.
- Many drugs can cause bone marrow suppression as well.
- Sepsis naturally can cause it also.
- Infections can also just lead to bone marrow suppression.
- Viral infections (ex, parvovirus, HHV-8) and bacterial infections.
- Systemic parasitic infections (ex. Leishmaniasis, toxo, babesiosis, strongyloidiasis, and Malaria) can also cause it.
- Hemophagocytosis – a Rare cause of pancytopenia
- Can be due to infections or malignancies.
- Also can be familial.
Caused by 4 species
- P. falciparum is most severe type.
- P. vivax ( most prevalent worldwide), P. Ovale, and P. Malariae are the others.
- P. vivax and P. Ovale can remain dormant and cause relapses.
Presentations and Findings.
- All four species can cause similar presentations
- Anemia is the major and most common hematologic finding.
- Other hematologic changes that can be seen include:
- Pancytopenia (more commonly due to P. falciparum, but P. vivax has been shown to cause it as well).
- Hemophagocytosis (rare to see)
- Initial presentation can be misleading and lead to misdiagnosis in the ED.
- Fever, chills, vomiting, anorexia, malaise and headache are commonly seen.
- Of note, the patient I saw had mild headache, vomiting and diarrhea with some mild abdominal pain… with a very reassuring exam.
- History of travel (particularly to endemic areas) is paramount to obtain and heighten your suspicion for malaria.
- Be careful: Travel history plus vomiting, diarrhea, anorexia, and abdominal pain may lead you to diagnosis Travelers Diarrhea.
- P. falciparum leads to the most complications and deaths.
- Cerebral malaria
- Potentially lethal if not treated.
- Change in mental status
- Focal neurologic findings
- Kidney failure
- Severe hypoglycemia
- Pulmonary edema
Kyriacou DN., Spira AM., Talan DA., Mabey DCW. Emergency Department Presentation and Misdiagnosis of Imported Falciparum Malaria. Annals of Emergency Medicine. 1996 June; 27(6): pp. 696-699.
Zvulunov A., Tamary H., Gal N. Pancytopenia resulting from hemophagocytosis in Malaria. The Pediatric Infectious Disease Journal. 2002 Nov; 21(11): pp. 1086-1087.
Thapa R., Ranjan R., Patra VS. Chakrabartty S. Childhood Cerebral Vivax Malaria with Pancytopenia. Journal of Pediatric Hematology Oncology. 2009 Feb; 31(2): PP. 116-117.