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Platelet counts at Kamuzu Central Hospital in Lilongwe, Malawi.

 

Yohannie Mlombe, Francis Kachedwa, Collins Mitambo, John Chisi.

 

Department Of Haematology, College Of Medicine, University Of Malawi

 

Corresponding author: YB Mlombe, Haematology Department, College Of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi. Email: yohanniemlombe@googlemail.com

 

Afr J Haematol  Oncol  2011;2(1):166-175 

 

ABSTRACT

 

It is not clear as to what the prevalence of quantitative abnormalities of platelets is in Malawian hospitals as full blood counts are not routinely available.

 

Both thrombocytosis and thrombocytopenia may be fatal. We therefore carried out a retrospective  analysis of platelet counts of 1,297 randomly selected case notes of in-patients presenting to Kamuzu Central Hospital (KCH) in Lilongwe in the period 2005-2009. Platelet counts were graded into unknown, normal, mild thrombocytopenia, moderate thrombocytopenia, severe thrombocytopenia and increased counts.

 

The overall prevalence of thrombocytopenia was found to be 26% and that of thrombocytosis to be 5% but a relatively high percentage of patients (36%) had unknown platelet counts. Malaria patients formed the highest percentage of those with severe thrombocytopenia followed by sepsis then tuberculosis, pneumonia, epistaxis, anaemia, bleeding, and Kaposi's sarcoma.  Among the study patients who died, those with severe thrombocytopenia were the highest percentage (25.8%) compared to all the other platelet count grades. A prospective study is required to assess the cost effectiveness of not doing routine full blood counts. Not obtaining routine platelet counts might be contributing to mortality in our patient population.

 

 

Keywords: Thrombocytopenia; Thrombocytosis; Malaria; Platelet count; Malawi

 

 

INTRODUCTION

 

It is not clear as to what the prevalence of quantitative abnormalities of platelets is in Malawian hospitals as full blood counts are not routinely available.

 

Thrombocytosis may lead to fatal thrombosis.1  Severe thrombocytopenia may lead to fatal haemorrhage. Thrombocytosis can also rarely present with bleeding which is often not serious unless associated with other conditions like acquired von Willebrand disease 2 and high doses of anti-platelet therapy. 3

 

We retrospectively  analysed platelet counts of 1,297 randomly selected case notes of in-patients presenting to Kamuzu Central Hospital (KCH) in Lilongwe in the period 2005-2009. KCH is the main referral hospital in the central region of Malawi. Platelet counts were graded as unknown, normal (150-450 x 109/L), mild thrombocytopenia (100-149 x 109/L), moderate thrombocytopenia (50-99 x 109/L), severe thrombocytopenia (< 50 x 109/L) 4 and thrombocytosis (>450 x 109/L). The study was approved by the College Of Medicine Research and Ethics Committee (COMREC) in Blantyre and permission was granted to carry out the study at KCH by the hospital administration. There was no direct patient contact and no patient identifying details were recorded. Data analysis to obtain descriptive statistics was done using the statistical package SPSS (11.5.1 for Windows; SPSS Inc., Chicago, Illinois, USA).

 

 

FINDINGS AND DISCUSSION

 

There were 462 males ( 35.6%) and 835 females (64.4%). The mean age of the population was 28.9 (SD 19.3). The lowest age recorded was 7 days while the highest was 88 years.

 

The patients were evenly distributed among the major departments as follows: Surgery, 348 (26.8%); Internal Medicine, 342 (26.4%); Obstetrics and gynaecology, 319 (24.6%) and Paediatrics, 288 (22.2%). Except for Internal Medicine Department (in 2005) and Paediatric Department (in 2005 and 2006), where between 30 and 50 patients were studied per year, the number of patients studied per department per year was between 60 and 90 (Figure 1).

 

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Figure 1. Int Med, Internal Medicine; OBGY, Obstetrics and gynaecology. Except for Internal Medicine Department (in 2005) and Paediatric Department (in 2005 and 2006), where between 30 and 50 patients were studied per year, the number of patients studied per department per year was between 60 and 90.

 

               

In terms of catchment area, 37.3% came from Lilongwe Urban, 29.5% from Lilongwe Rural, 26.2% were referrals from other districts within the central region, 4.5% were referred from other regions and 2.5% their sources were unknown.

 

Overall the patients studied had 132 different diagnoses and 40.5% of these diagnoses (53) were single diagnoses (Table 1). The commonest five conditions were: malaria (13.0%), sepsis (8.3%), abortion (6.2%), pneumonia (5.3%) and tuberculosis (TB) (3.5%). Two patients had a diagnosis of thrombocytopenia. No patient was diagnosed with thrombocytosis. HIV status was unknown in the majority of the patients (979, 75.5%). Of the rest whose HIV status was known, 68.2% (217) were HIV positive. Of those who were HIV positive 19.4% (42) were on HAART.

 

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Table 1. Study patients diagnoses in descending order of frequency

 

 

Many of the patients (36%) had normal platelet counts but there was an almost equal percentage of patients who had no full blood count result (33%). Similar percentages of patients had mild, moderate and severe thrombocytopenia (9%,9% and 8% of patients respectively, total 26%). Five percent of patients studied had thrombocytosis (Figure 2).

 

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Figure 2. Many of the study patients (36%) had normal platelet counts but there was an almost equal percentage of patients who had no full blood count result (33%). Similar percentages of patients had mild, moderate and severe thrombocytopenia (9%,9% and 8% of patients respectively, total 26%). Five percent of patients studied had thrombocytosis

 

 

 

Malaria patients formed the highest percentage of those with severe thrombocytopenia followed by sepsis (Figure 3) then TB, pneumonia, epistaxis, anaemia, bleeding, and Kaposi's sarcoma. In total, five study patients presented with epistaxis and they all had full blood count results. Four of them had severe thrombocytopenia and the fifth patient had normal platelet count. Two patients were diagnosed with thrombocytopenia. They both had severe thrombocytopenia. No diagnosis of thrombocytosis or thrombocythaemia was made. In descending order, thrombocytosis was prominent in gastroenteritis, pneumonia, sepsis and malaria (Figure 3). As the study patients were randomly picked from their respective departments and as there was a tendency to pick equal numbers of patients from each department, this study can not make any inference to the prevalence of quantitative platelet disorders at the study site. Despite this, however, the study provides a useful indicator of the kind of conditions that present to Kamuzu Central Hospital. It is thus noteworthy that diagnoses of thrombocytopenia were almost negligible despite a high prevalence of HIV among our patients. HIV has a strong association with thrombocytopenia. The five patients with thrombocytosis appear to have had reactive thrombocytosis rather than essential thrombocythaemia as they had other known diagnoses.

 

 

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Figure 3. A 100% stacked line graph showing that malaria patients formed the highest percentage of those with severe thrombocytopenia followed by sepsis then tuberculosis, pneumonia, epistaxis, anaemia, bleeding, and Kaposi's sarcoma. In descending order, thrombocytosis was prominent in gastroenteritis, pneumonia, sepsis and malaria.

 

 

In terms of HIV status and platelet counts, the patients on HAART had the highest percentage (26.2%) of severe thrombocytopenia (Table 2) but it was also the group with the least percentage of (2.4%) unknown platelet counts. 

 

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Table 2. HIV status and platelet count grades

 

 

The majority of patients who received platelets had severe thrombocytopenia (Table 3). One received platelet transfusion with a normal platelet count. This was a 22 year old male patient who presented to the surgical department with an acute abdomen.

 

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Table 3. Management modality and platelet count grades

 

 

Among the study patients who died, those with severe thrombocytopenia were the highest percentage (25.8%) compared to all the other platelet count grades (Table 4).

 

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Table 4. Outcome and platelet count grades

 

 

Many of the common medical conditions in our region such as malaria, bacterial infections and tuberculosis presented with platelet count abnormalities. It is well known that malaria has a strong association with thrombocytopenia. 5-6 These associations suggest that routine platelet counts in all our patients would be useful. The fact that HIV positive patients on HAART were the category with the highest percentage of severe thrombocytopenia appears to be counterintuitive as one would expect HIV positive patients not on HAART to have a higher proportion of patients with severe thrombocytopenia than those on HAART. But then the former group had the least number of unknown platelet counts suggesting that HIV positive patients are more likely to have full blood count results and this would explain the higher numbers of severe thrombocytopenia in this group. A study done in Haiti suggested that routine platelet counts are not cost effective in HIV positive patients who are on HAART. 7 However that study noted that the cost effectiveness of routine haematological profiles in this patient population would depend on the national ARV drug regimen used and the spectrum of other comorbidities.

 

It is worrisome that the highest percentage of the patients who died had severe thrombocytopenia compared to the rest of the platelet count grades. It is not clear whether this means that patients with severe disease have severe thrombocytopenia or whether the severe thrombocytopenia contributed to the deaths. In children with malaria, the presence of thrombocytopenia has been shown to be indicative of poor prognosis irrespective of clinical condition. 8

 

Not obtaining routine platelet counts might be contributing to mortality in our patient population. A prospective study is required to assess the cost effectiveness of not doing routine full blood counts so that perceived savings of this approach are analysed in the context of their adverse effects.

 

ACKNOWLEDGEMENT

 

We are grateful to Dr L. Kalilani, Dr F. Saidi, Dr P. Mpesi and Health Research Capacity Strengthening Initiative (HRCSI)  for their contributions to this study.

 

 

FOOTNOTES

 

Contributors: JC, FK and CM were responsible for the conception and design of study protocol, they collected and analysed data and approved the final version. YM analysed data and wrote the report.

 

Conflicts of interest: The authors declare no competing conflicts of interest.

 

REFERENCES

 

1.      Pearson TC, Bareford D, Craig J et al. The management of ‘low-risk’ and ‘intermediate-risk’ patients with primary thrombocythaemia MPD (UK) Study Group. British Journal of Haematology. 1999;106:833–834.

2.      Budde U, Schaefer G, Mueller N et al. Acquired von Willebrand’s disease in the myeloproliferative syndrome. Blood. 1984;64:981–985.

3.      Tartaglia AP, Goldberg JD, Berk PD et al. Adverse effects of antiaggregating platelet therapy in the treatment of polycythemia vera. Seminars in Hematology. 1986;23:172–176.

4.      Bonifacio L, Petrova A, Nanjundaswamy S, Mehta R. Thrombocytopenia related neonatal outcomes in preterms. Indian Journal of paediatrics. 2007;74(3):269-274.

5.      Ladhani S, Lowe B, Cole AO, Kowuondo K, Newton CR. Changes in white blood cells and platelets in children with falciparum malaria: relationship to disease outcome. Br J Haematol 2002;119:839-47.

6.      Patel U, Gandhi G, Friedman S, Niranjan S. Thrombocytopenia in malaria. J Natl Med Assoc 2004;96:1212-4.

7.      Koenig SP,  Schackman BR, Riviere C et al. Clinical Impact and Cost of Monitoring for Asymptomatic Laboratory Abnormalities among Patients Receiving Antiretroviral Therapy in a Resource-Poor Setting. Clin Infect Dis. 2010;51(5): 600–608.

8.      Gerardin P, Rosier C, Ka AS, Jouvencel P, Brousse V, Imbert P. Prognostic value of thrombocytopenia in African children with falciparum malaria. Am J Trop Med Hyg. 2002;66:686-91.

 

 

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