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).
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.
|
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).
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.
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.
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.
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).
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.
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