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.

Pancytopenia

1. Acute Leukemia (ALL, AML, Myelodysplastic Syndrome) and Aplastic Anemia are the most prevalent causes of pancytopenia.
2. Megaloblastic Anemia is also high on the list.
3. Many drugs can cause bone marrow suppression as well.
4. Sepsis naturally can cause it also.
5. Infections can also just lead to bone marrow suppression.
6. Viral infections (ex, parvovirus, HHV-8) and bacterial infections.
7. Systemic parasitic infections (ex. Leishmaniasis, toxo, babesiosis, strongyloidiasis, and Malaria) can also cause it.
8. Hemophagocytosis – a Rare cause of pancytopenia
9. Can be due to infections or malignancies.
10. Also can be familial.

Malaria

1. Caused by 4 species

   1. P. falciparum is most severe type.
   2. P. vivax ( most prevalent worldwide), P. Ovale, and P. Malariae are the others.
   3. P. vivax and P. Ovale can remain dormant and cause relapses.

2. Presentations and Findings.

   1. All four species can cause similar presentations
   2. Anemia is the major and most common hematologic finding.
   3. Other hematologic changes that can be seen include:
      1. Leukocytosis
      2. Monocytosis
      3. Neutropenia
      4. Thrombocytopenia
      5. Pancytopenia (more commonly due to P. falciparum, but P. vivax has been shown to cause it as well).
      6. Hemophagocytosis (rare to see)
   4.  Initial presentation can be misleading and lead to misdiagnosis in the ED.
      1. Fever, chills, vomiting, anorexia, malaise and headache are commonly seen.
         1. Of note, the patient I saw had mild headache, vomiting and diarrhea with some mild abdominal pain… with a very reassuring exam.
      2. History of travel (particularly to endemic areas) is paramount to obtain and heighten your suspicion for malaria.
         1. Be careful: Travel history plus vomiting, diarrhea, anorexia, and abdominal pain may lead you to diagnosis Travelers Diarrhea.

3. Complications

   1. P. falciparum leads to the most complications and deaths.
   2. Cerebral malaria
      1. Potentially lethal if not treated.
      2. Change in mental status
      3. Seizures
      4. Focal neurologic findings
   3. Kidney failure
   4. Severe hypoglycemia
   5. Pulmonary edema
   6. Speticemia
   7. Shock

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.