malaria is a disease of global importance . the world health organization ( who ) has reported a worldwide annual incidence of 247 million cases and malarial mortality of one million per year .
infection with plasmodium falciparum ( p. falciparum ) is known to cause thrombocytopenia and severe malaria but severe cases in plasmodium vivax ( p. vivax ) malaria patients have been reported in the last decade .
with implementation of molecular diagnosis , it became evident that p. vivax monoinfection could also be involved in multiple organ dysfunction and severe life - threatening disease as seen in p. falciparum infection [ 2 , 3 ] .
many explanations have also been proposed for severe manifestations in vivax malaria like adherence of platelets stimulated by tumor necrosis factor ( tnf ) to endothelium ; bridges formed by platelets between rbcs and endothelial cells as in falciparum malaria   and stimulation of platelets by parasitised rbcs triggering apoptosis in endothelial cells pretreated with tnf in a pathway mediated by tumor growth factor- ( tgf- ) 1 .
recent evidence showing p. vivax infected rbcs adhering to lung endothelial cells and to the placental tissue ex vivo indicates that , in vivax malaria , mechanisms similar to those associated with falciparum malaria severity may be involved .
all the complications seen in falciparum malaria are now reported with vivax also [ 810 ] .
a study on pediatric population from bikaner in northwest india reported a high proportion ( 63.1% ) of severe malaria contributed by p. vivax monoinfection .
they reported all severe manifestations in vivax malaria in children including severe anemia , thrombocytopenia , cerebral malaria , acute respiratory distress syndrome ( ards ) , hepatic dysfunction , renal dysfunction , and abnormal bleeding .
they reported thrombocytopenia in 61.5% children and bleeding symptoms in 10.8% cases . a study from venezuela reported thrombocytopenia in 58.9% children with p. vivax malaria , with 25.6% requiring platelet transfusions .
thus , although many studies regarding thrombocytopenia in p. vivax malaria are available , most of them were done on pediatric population or included children also .
there is lack of studies assessing thrombocytopenia and severity in p. vivax exclusively in adults .
hence , we carried out this study to find out the status of thrombocytopenia in p. vivax in adult population and find if it has any association with severity .
the patients with falciparum infection either alone or in combination with vivax or who did not give written informed consent were excluded . the patients with underlying disease which may cause similar complications like dengue and sepsis were also excluded .
all patients were subject to the routine laboratory investigations like hematological profile ( complete blood count with platelet count ) , urine routine microscopy , renal function test , serum electrolytes , liver function test , blood sugar levels , and chest x - ray .
ultrasonography was also done to study the size and echo texture of the liver and gall bladder , intrahepatic or extrahepatic bile duct dilatation , and signs of portal hypertension .
other special investigations like ct scan of head and arterial blood gas analysis ( abg ) were done when indicated .
respiratory distress was defined as oxygen saturation less than 94% at room air or deep breathing ( acidotic breathing ) or a rapid respiratory rate ( > 32/min ) .
the patients were then categorized into two groups according to platelet count ( less than 1  lac / cumm and more than 1  lac / cumm ) for further analysis .
data was analysed for comparing hematological profile , clinical presentation , complications , and outcome in the two groups .
a total of 120 patients diagnosed on peripheral smear with malaria were enrolled for the study .
20 were excluded for various reasons ( p. falciparum monoinfection or mixed p. vivax and p. falciparum infection or coinfection with dengue or associated sepsis ) .
, total 100 patients with p. vivax monoinfection were included in the study . the age of included patients ranged from 18 to 50 years .
average platelet count amongst them was 1,18,651  1,01,937/cumm and mean hemoglobin was 10.69  2.35  mg% .
the patients were divided into two groups based on platelet count ( < 1  lac / cumm and > 1  lac / cumm ) for further analysis .
gastrointestinal symptoms ( nausea , vomiting ) , shortness of breath , and cns symptoms ( headache , altered sensorium , and loss of consciousness ) were more common in < 1  lac / cumm group whereas upper respiratory tract symptoms ( dry cough , running nose , and sore throat ) were more common in > 1  lac / cumm group ( table 2 ) .
icterus , tachypnoea , and petechiae were seen in 21.42% , 7.14% , and 2.38% patients , respectively , in the < 1  lac / cumm group whereas none was seen in the > 1  lac / cumm group . on lab investigation ( table 3 )
there was a statistically significant difference in platelet count , serum bilirubin , blood urea , and serum creatinine between the two groups .
in the < 1  lac / cumm group , 15 ( 35.7% ) had serum creatinine > 1.4  mg / dl ( or 8.5 ) , 11 ( 26.19% ) had sgpt > 35  iu ( or 6.3 ) , 14 ( 33.35 ) had serum bilirubin > 1.2  mg / dl ( or 4.28 ) , and 8 ( 19.04% ) had blood urea > 40  mg / dl ( or 2.3 ) .
similarly , 7.14% , 11.90% , and 14.28% had ards , hepatomegaly , and splenomegaly , respectively , in the < 1  lac / cumm group but they were not observed in the other group .
odds ratio ( or ) of hemoglobin < 8  gm / dl between the two groups was 1.14 . in < 1 
lac / cumm group , 2 ( 4.76% ) patients required blood or platelet transfusion and 3 ( 7.14% ) required inotropes and ventilatory support .
they were not required in any patient in the > 1  lac / cumm group .
one patient expired in the < 1  lac / cumm group ; however , no mortality was seen in the other group .
malaria is a disease that affects almost all blood components . the essential pathological feature of severe falciparum malaria is sequestration of erythrocytes in the deep vascular beds of vital organs leading to cerebral malaria , renal failure , hepatic dysfunction , or ards .
hemolysis , reduced cell deformity of parasitized and nonparasitized erythrocytes , increased splenic clearance , reduced platelet production and survival , and increased splenic uptake of platelets cause severe anemia and thrombocytopenia leading to bleeding diathesis . initially thrombocytopenia was thought to be a feature of p. falciparum . since the beginning of the 1970s , reports of similar degree of thrombocytopenia in p. vivax and p. falciparum infections started coming in .
most of the major publications related to frequency of thrombocytopenia in p. vivax malaria were published in the late 1990s , probably due to the surge in the availability of automated machines . around the same time
, reports of severe , complicated malaria with p. vivax infection also started being published ; but regardless of being described as a complication by who , thrombocytopenia is not considered to be a severity criterion by itself   due to the inability to cause death per se .
many studies have shown a wide range of thrombocytopenia and severity in p. vivax malaria but they had distinct selection criteria of the enrolled patients or included only pediatric patients [ 9 , 14 ] .
no study has reported any major bleeding or complication or mortality resulting from even severe thrombocytopenia ( platelet count under 50,000/l ) [ 15 , 16 ] .
only few studies have so far reported mortality from p. vivax infection ; some have reported multiple complications , but none of these studied adult population exclusively [ 1720 ] .
some studies have reported a negative correlation , while many studies in brazil confirmed a direct positive correlation [ 15 , 16 ] .
another recent study reported no relation between platelet count and peripheral parasitemia in p. vivax monoinfection .
although some studies have reported association of thrombocytopenia with severe malaria [ 23 , 24 ] , most of these included pediatric age group also with adults and did not exclude the other endemic causes of thrombocytopenia . in another study , out of the 17 patients affected by any of the who malaria severity criteria with confirmed monoinfection , 14 presented with thrombocytopenia , suggesting that this hematological complication can be explored as a marker of severity for p. vivax .
tanwar et al . in 2012 reported significant association of severe malaria with platelet count < 2  lac / cumm in children .
kochar et al . in 2009 studied adult patients and reported all complications in patients with plasmodium vivax malaria .
thus , there has been a lack of studies on thrombocytopenia in p. vivax malaria in adults .
most have included both adult and pediatric populations and have not excluded the other causes of thrombocytopenia . also , there is no study which has assessed the association of thrombocytopenia with severity in p. vivax malaria in adults .
we excluded p. falciparum , dengue positive as well as sepsis patients as these are the major causes of thrombocytopenia in our region .
we observed both sequestration - related and nonsequestration - related complications ( including abnormal bleeding , cerebral malaria , renal failure , circulatory collapse , ards , and jaundice ) in our study population .
these were significantly more common in patients with platelet count < 1  lakh / cumm .
ards and need of blood or platelet transfusion and inotropes as well as mechanical ventilation were also seen in platelet count < 1  lac / cumm group .
thus , this study highlights the fact that all complications of p. falciparum can be seen with p. vivax and that the parameter of platelet count < 1  lac / cumm may be used as a marker of severity and increased chances of complications .
the trend of disease with p. vivax malaria is changing . similar incidence of thrombocytopenia is now seen in vivax and falciparum malaria patients . all complications seen in falciparum positive cases are being seen in vivax positive cases also .
thrombocytopenia may not be a cause of mortality by itself , but it can be a marker of increased severity and need of aggressive management . there is a need to reexamine the clinical spectrum and severity of p. vivax malaria especially in the light of thrombocytopenia .
we also recommend formulation of separate guidelines for management of p. vivax with platelet count < 1  lac / cumm looking at the severity profile of such patients .
 
 introduction . 
 thrombocytopenia is frequently noticed with p. falciparum malaria but is less reported and studied with p. vivax . 
 materials and methods . 
 the study was conducted in the department of medicine , sbks mi & rc , pipariya . 
 we included patients who were diagnosed with vivax malaria . 
 the data regarding their clinical and hematological profile was collected and analysed . result . 
 a total of 66 patients were included . 
 42 ( 63% ) had platelet count < 100000/mm3 . 
 mean platelet count was 1,18,650 , range being 8000/mm36,10,000/mm3 . amongst those with thrombocytopenia , 16 ( 38.09% ) 
 had anemia , 14 ( 33.33% ) had serum creatinine > 1.2  gm / dl , 15 ( 35.71% ) had jaundice ( s. bilirubin > 1.2 ) , 2 ( 4.76% ) had altered sensorium , 6 ( 14.28% ) had ards , 2 needed ventilator support , and 1 expired . 
 amongst those with normal platelet count , 5 ( 20.83% ) had anemia and 1 had jaundice whereas none had elevated s. creatinine , altered sensorium , or lung involvement . 
 conclusion . 
 thrombocytopenia is now being seen more commonly with vivax malaria . 
 patients with platelet count < 1  lac / cumm have more severe disease . 
1. Introduction
2. Methodology
3. Result
4. Discussion
5. Conclusion