analysis findings of malaria patients attending tertiary care

ORIGINAL ARTICLE Urine analysis findings of malaria patients attending tertiary care hospital of North Gujarat

Amarramkrishna Shah1*, Nimisha Devendrakumar Shethwala2, Tejas AjitBhai Shah3

1Associate Professor Department of Pathology, 2Associate Professor Department of Microbiology, 3Assistant Professor, Department of community medicine, GMERS Medical College, Himmatnagar,

ABSTRACT BACKGROUND: Vector borne diseases are emerging health problems in developing countries. Among all of vector borne diseases, malaria remains at the top especially during rainy seasons. Plasmodium vivax and plasmodium falciparum are commonly found among all malarial illnesses. As such blood films are used for diagnosing malarial cases, urine abnormality also found among them. Present study carried out for identification of urinary abnormalities observed among malaria cases. OBJECTIVES: 1. To study abnormal urine analysis findings in patient with malaria. 2. To correlate severity of malaria with urine abnormal findings. MATERIALS AND METHOD: A cross sectional study was conducted among the indoor and outdoor patient of teaching hospital of north Gujarat during month of August and September. Out of total 880 cases of fever, 443 (285 males and 158 females) diagnosed having malaria were included in the study. 50 healthy individuals without malaria parasite on both thick and thin smear were taken as control group. 10 ml mid stream urine sample was collected from each cases and control. Urine samples were analyzed as per standard operating procedure using multi colour reagent strips. RESULT: All urine parameters were abnormal in malaria positive patient as compared to malaria negative control. Urine , urobilinogen, blood, protein and leucocyte were significantly abnormal in P.falciparum as compared to P.vivax infection. Although irrespective of malaria species, urine parameter abnormalities increase with malaria parasitaemia, only in P. falciparum infection urinary bilirubin and urobilinogen were significantly abnormal at higher malaria parasite index. CONCLUSION: Although urinalysis is not an alternative diagnostic tool for malaria infection, urinary abnormalities, such as bilirubinuria, urobilinogenuria, and haematuria may help in identifying patients with severe malaria parasitaemia, especially the falciparum malaria.

Keywords: Urine analysis, Malaria, Bilirubinuria, , Urobilinogenemia

INTRODUCTION High mortality is seen in P. falciparum Malaria is a disease spread by mosquito because P. vivax, P. ovale, and P. malaria and caused by parasite of plasmodium cause relatively mild form of malaria.1 species.1 Malaria is major health problem Hematology parameter and Urine findings more affecting developing nation and are most important test for diagnosis of about 500 million people particularly malaria.6 Renal failure is a feature of children and young woman2. Malaria has blackwater fever, where hemoglobin from a negative effect on economy of nation.3,4 lysed red blood cells leaks into the urine.7 Migration of people affected with malaria Various research articles have shown that also spread infection in developed nation. urine tests for and proteinuria There are four species of malaria identified are indicator for severe renal disease.8 e.g. P.falciparum, P.vivax, P.malaria, Renal failure do occurs in patient with P. P.Ovale.5 However in India, P.Vivax and falciparum malaria but the mortality in P.falciparum are most common species these cases are very high.2 Present study is responsible for malaria. carried out to find urine abnormalities in patients with malaria infection. *Corresponding Author: MATERIAL & METHODS Dr. Amarramkrishna Shah A cross sectional study was conducted 101,A Block Staff Quarter, among the indoor and outdoor patient of Gmers Medical College, teaching hospital of north Gujarat. As such Himmatnagar malaria remains endemic in all seasons but Contact No: 9909927725 peak in the cases are observed during Email: [email protected] month of July to September. All the 14 Int J Res Med. 2016; 5(4); 14-17 e ISSN:2320-2742 p ISSN: 2320-2734

Urine analysis findings of malaria patients attending tertiary care patients with complain of fever who Differences in abnormal urine attended the clinics in these months were parameter according to species are screened for malaria. shown in Figure 2. Immunochromatography was done for Figure 2: Urine abnormalities among P rapid screening of patient. Patients who falciparum and P vivax cases tested positive were again checked by thin 100 90 and thick smear stained by giemsa stain. 80 P.FALCIPARU 70 M 60 Parasitemia was calculated as per WHO 50 P.VIVAX 40 9 30 standard method. Total 880 patients of 20 10 fever have attended the clinics. Out of 0 them 443 (285 males and 158 females) FREQUENCY % diagnosed having malaria were included for the study. Patients were categorized Urine Abnormality into grade 1 to 4 on the basis of parasite It was observed that Urine bilirubin, density. 50 healthy individuals without urobilinogen, blood, protein and malaria parasite on both thick and thin leucocyte were significantly abnormal smear were taken as control group. 10 ml among P.falciparum as compared to mid stream urine sample was collected P.vivax infection. Irrespective of from each cases and control. Urine malaria species, urine parameter samples were analyzed as per standard abnormalities increase with malaria operating procedure using multi colour parasitaemia. reagent strips. Urine protein, bilirubin, Figure 3: Comparison of urine urobilinogen, blood and leukocyte abnormalities with various grade esterase were considered positive on and species of malaria infection colour change. Data entry and analysis was 100 90 carried out using trial MS Excel. 80 70 60 RESULTS 50 Bilirubin 40 Distribution of malaria in patients 30 Urobilinogen 20 10 according to species and sex difference is 0 Blood

depicted in Leucocyte % Frequency % Table 1: Gender wise distribution of Protein malaria subjects and control Subject Male Female Total P.Falciparum 101 55 156 In P. falciparum infection, urinary P.Vivax 184 103 287 bilirubin and urobilinogen were Control 28 22 50 Urine examination of 50 normal significantly abnormal at higher persons is taken as control. Out of 443 malaria parasite index. malaria positive individuals, 156 were DISCUSSION found positive for P. falciparum and The present study has observed 287 were having P.vivax infection. All significantly higher urinary bilirubin urine parameters were abnormal in and urobilinogen in malarial patients in malaria positive patient as compared to comparison to healthy person. Patients malaria negative control. infected with P. falciparum malaria excreted significantly higher bilirubin, Figure 1: Comparison of urine urobilinogen, blood and protein as abnormality between control and compared with patients infected with subject 100 P.vivax malaria, with abnormalities 90 80 70 increasing with higher parasite index, 60 Malaria 50 Negative 40 30 particularly in P. falciparum infection. 20 10 Malaria 0 Positive In the present study, significantly higher incidence of urinary bilirubin

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Urine analysis findings of malaria patients attending tertiary care was observed in comparison to Haematuria and proteinuria in malaria controls. These findings suggest either patients have been observed with hepatic involvement or haemolysis. immune complex nephritis.13 Abnormal Moreover, the significantly higher function of kidney in malaria patients, incidence of urinary bilirubin, have been attributed to increased urobilinogen, blood, and protein in capillary permeability14 or impairment patients infected with P. falciparum in in electrolyte and fluid balance.15 comparison to patients infected with CONCLUSION P.Vivax malaria indicates that Although urinalysis is not an falciparum malaria may lead to liver alternative diagnostic tool for malaria disorder and severe jaundice in malarial infection, urinary abnormalities, such patients. According to Ahsan et al [9], as bilirubinuria, urobilinogenuria, jaundice is the leading clinical proteinuria and haematuria may help in presentation of complicated falciparum identifying patients with severe malaria malaria. In patients with a history of parasitaemia, especially the falciparum fever and conjugated malaria. These preliminary findings hyperbilirubinaemia, falciparum may be of value in the management of malaria should be suspected in spite of malaria patients by clinician in negative blood films.9 Involvement of developing countries. liver in malaria occurs with histo- REFERENCE pathological changes and altered liver 1. WHO "Malaria Fact sheet": function test.10,11 Estimation of serum www.who.int/media bilirubin and liver enzymes were not centre/factsheets/fs094/en/ Last part of the present study. Although the accessed 11 August 2016. 2. Mishra SK, Mohapatra S, Mohanty S, presence of bilirubin in urine suggest Peter NC, Mohapatra DN. Acute renal that it is of the conjugated type and failure in falciparum malaria. J India conjugated hyperbilirubinaemia in Acad Clini Med 2002; 3(2): 141–7. malarial subjects is evident as 3. Gollin D, Zimmermann C (August compared to the controls. Also it was 2007). Malaria: Disease Impacts and very high in patients with P. falciparum Long-Run Income Differences (PDF) infection as compared to P.vivax (Report). Institute for the Study of malaria infection. Jaundice in malaria Labor. infection is caused by mainly 4. Worrall E, Basu S, Hanson K (2005). intravascular haemolysis of infected "Is malaria a disease of poverty? A red blood cells, haemolysis of non review of the literature". Tropical infected red blood cells and micro- Health and Medicine 10 (10): 1047– 59. doi:10.1111/j.1365- angiopathic haemolysis associated with 3156.2005.01476.x. PMID 16185240. disseminated intravascular coagulation 5. Wright JW. Community malaria. BMJ (DIC), liver dysfunction, 2004; 4: 49–54. haemoglobinopathies, drug induced 6. Haber MH. Piesse prophesy: a brief haemolysis,G-6-PD deficiency, etc. history of urine analysis. Clin Lab Med Abnormal urine analysis findings such 1988; 8: 415–30. as haematuria and proteinuria in P. 7. Bartoloni A, Zammarchi L (2012). falciparum infection as compared to "Clinical aspects of uncomplicated and P.Vivax malaria in the present study is severe malaria". Mediterranean Journal comparable with the findings of other of Hematology and Infectious Diseases researchers.4,12 Renal impairment in 4 (1): e2012026. malaria infection is more commonly doi:10.4084/MJHID.2012.026. PMC 3375727. PMID 22708041. seen in falciparum infection.

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