ACEP ID:

Pediatric Emergency Medicine

Pancytopenia and Malaria

Sean M. Fox, MD
Assistant Professor
Adult and Pediatric Emergency Medicine
Carolinas Medical Center, Charlotte, NC

You may wonder why I continue to write and distribute my beloved PedEM Morsels.  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.

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 complete blood count (CBC) with all cell lines was down.  I told the family my concern for malignancy (which, by the way is what I think you need to do anytime you are considering cancer.  Do not let the family find out that their child has cancer by seeing a doctor with hematology/oncology on the white coat).  Then, to my delight, the peripheral smear was positive for malaria. I’ll take malaria over cancer any day.

Pancytopenia

  • 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 (i.e., parvovirus, HHV-8) and bacterial infections.
    • Systemic parasitic infections (i.e., 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

Malaria

  • Caused by 4 species
    • Plasmodium falciparum is most severe type.
    • Plasmodium vivax (most prevalent worldwide), Plasmodium vivax ovale, and Plasmodium vivax malariae are the other species.
    • P. vivax and P. Ovale can remain dormant and cause relapses.
  • Presentation 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 the following:
      • Leukocytosis
      • Monocytosis,
      • Neutropenia
      • Thrombocytopenia
      • 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 (a very reassuring examination).
    • 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 Traveler’s Diarrhea.
  •   Complications
    • P. falciparum leads to the most complications and deaths.
    • Cerebral malaria
      • Potentially lethal if not treated.
      • Change in mental status
      • Seizures
      • Focal neurologic findings
    • Kidney failure
    • Severe hypoglycemia
    • Pulmonary edema
    • Septicemia
    • Shock

References

1.Kyriacou DN., Spira AM., Talan DA., Mabey DCW.  Emergency Department Presentation and Misdiagnosis of Imported Falciparum Malaria. Ann Emerg Med. 1996 June; 27(6): 696-699.

2.Zvulunov A., Tamary H., Gal N. Pancytopenia resulting from hemophagocytosis in Malaria. Ped Infect Dis J. 2002 Nov; 21(11): 1086-1087.

3.Thapa R., Ranjan R., Patra VS. Chakrabartty S. Childhood Cerebral Vivax Malaria with Pancytopenia. J Ped Hem Onc. 2009 Feb; 31(2): 116-117.

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