Rajiv Gandhi University of Health Sciences, Karnataka s48

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 / Name of the candidate and address ( in block letters) / : / Dr. RAHUL NIMMAKAYALA
DEPARTMENT OF GENERAL MEDICINE
MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA - 585105
Permanent address / : / Dr. RAHUL NIMMAKAYALA
S/O DR. N. BALAIAH, SRI GANESH NURSING HOME, OPP. SBH, NEW PALONCHA KHAMMAM DISTRICT:
(AP) - 507115
2 / Name of the institution / : / H.K.E. SOCIETY’S MAHADEVAPPA
RAMPURE MEDICAL COLLEGE,
GULBARGA – 585105
3 / Course of study and subjects / : / (M.D) General Medicine
4 / Date of admission to the course / : / 1st JUNE 2008
5 / Title of Topic / : / Study of platelet count in malaria patients and the correlation between the presence and severity of platelet count with type of malaria.
6 / Brief Resume of the intended work
6.1 / Need for the study
Malaria is a global health problem with an annual incidence of 300 million people with one million deaths2. Malaria is one of the most prevalent human infection world wide .over 40% of world population lives in malaria endemic areas including Southeast Asia, India, Pakistan, Central and South America3.Malaria is one of the most important parasitic diseases of humans with prevalence in 103 countries. Malaria remains today as it has been for centuries-a heavy burden on tropical countries like India12. Malaria remains today one of the major health problems in the tropics with increased mortality and morbidity1.
Hematological abnormalities have been observed in patients with malaria with thrombocytopenia and anaemia being the most common3. Studies showed that thrombocytopenia as an early indicator for acute malaria; A finding that is frequent and present even before anaemia and spleenomegaly sets in5. Studies showed that the low platelet count emerged as a strongest predictor of malaria8.
In any patient with fever and recent travel history, platelet count is an important clue to the diagnosis of malaria9. The presence of thrombocytopenia in a patient with acute febrile illness increases the probability of malarial infection this may be used in addition to the clinical and microscopic parameters to heighten the suspicion of this disease8.
Thrombocytopenia often accompanies malaria and is usually mild to moderate and rarely symptomatic2. The major complications of the severe malaria include cerebral malaria, pulmonary odema,acute renal failure, severe anaemia, bleeding, hypoglycemia and acidosis11. Although a diagnostic marker the prognostic implications may vary in the two types of malaria mainly p.vivax and p.falciparum since these two are the common species associated with malarial infection.
Gulbarga is an endemic area for malaria, so this study was taken to study the platelet count in malaria and to correlate the presence and severity of platelet count with the type of malaria.
6.2 / Review of Literature
Jadhav UM, Patkar VS, Kadam NN [2004]. Studied in 1565 subjects who were identified as positive for malarial parasite on peripheral smear and concluded that absence of thrombocytopenia is uncommon in malaria, its presence is not a distinguishing feature between the two types. Severe thrombocytopenia can occur in both but more in plasmodium falciparum1.
Sheraz Jamal Khan, Fazal Raheem Khan, Sameena Zahid et al [2008] In their study,out of 947 patients, they concluded that significant thrombocytopenia was seen in more than half of their patients with malaria, more so in vivax type contrary to the belief that thrombocytopenia is very common in p.falciparum2.
Abdul Rauf Memon, Salahuddin Afsar [2006]. In their study, out of 128 patients subjected for malaria testing,60 patients had a positive peripheral smear and concluded that mild to severe thrombocytopenia was observed in hospitalized patients, in which plasmodium falciparum was found to be the most common3.
Horstmann RD, Dietrich M, Rasche H et al [1981]. In their study platelet counts were investigated in 26 patients with plasmodium falciparum and 39 patients with plasmodium vivax and concluded that thrombocytopenia is a common feature in human malaria and in all the patients the platelet count rose to threefold the initial values within the clearance of parasite4.
A Kumar, Sashirekha [2006]. Studied in 27 cases of acute vivax malaria out of which 24 cases had thrombocytopenia, platelet counts reverted to normal on treatment and concluded the importance of thrombocytopenia as an early indicator for acute vivax malaria5.
Krishnan, Anand MD, Karnad et al [2003]. In their study, out of 301 patients of falciparum malaria, they noticed that severe thrombocytopenia occurred in 114 patients [among them 7 required platelet transfusion] and 19 patients had thrombocytopenia and disseminated intravascular coagulation and concluded that malaria is an important cause of multi organ failure in India. Mortality rate is fewer when one or few organs are involved when compared to two or more organs involved6.
Laura M. Erhart, Kritsanai Yingyuen, Niphon Chuanak et al [2004]. This study examines the haematological profiles of persons with acute p.falciparum or p.vivax infection in comparison with febrile, non-parasitemic persons reported to malaria clinics.979 subjects were malaria negative,414 were infected with p.falciparum and 646 were infected with p.vivax. they concluded that platelet count < 1,50,000/mm3 were 12-15 times likely to have malaria than persons with platelet count >1,50,000 and identified that thrombocytopenia as an key indicator of malaria in these febrile patients7.
Lathia TB, Joshi R [2004]. A total of 184 patients were included in their study and 70 had a positive peripheral smear for malarial parasite and found that thrombocytopenia alone was a predictor for malaria and in combination with anaemia was the next best parameter. They concluded that thrombocytopenia in a patient with acute febrile illness increases the probability of malarial infection8.
Patel Umang, Gandhi Gaurang, Friedman Sandor et al [2004].Their study evaluated the role of platelet count for predicting malarial infection in patients with fever who traveled to a malaria endemic area. They concluded that in any patient with fever and recent travel history, platelet count is an important clue and should increase the suspicion of malaria and lead to performance of more specific tests9.
Beale Pj, Cormack JD, Oldrey TBN et al [1972]. In their study, out of 33 cases of naturally occurring human malaria 32 were found to have significant thrombocytopenia, only 1 patient showed bleeding .The lowest platelet counts were found between the day of diagnosis and the fourth day of treatment, thereafter they returned to normal values10.
Andrej Trampuz, Matjaz Jereb, Rajesh M Prabhu et al [2003]. In their study they concluded that malaria should be included in the differential diagnosis of every febrile illness in a person with a history of travel to endemic area. Delay in the recognition and treatment would increase the morbidity and mortality. Any of the complications can develop rapidly and progress to death within hours or days11.
Dharmesh Kumar N Patel, Pradeep P, Surti MM et al [2003]. Concluded that complicated malaria is more commonly caused by falciparum malaria and is rarely caused by other malarial parasites12.
6.3 / Objectives of the study
1.  To study the platelet count in malaria patients getting admitted in B.T.G.H.
2.  To correlate the platelet count with type of malaria.
3.  To correlate the severity of platelet count with type of malaria.
4.  To determine whether initial platelet count is an independent prognostic marker for severity of malaria.
7 / Materials and methods
7.1 / Source of data
All subjects aged >16 years of either sex attending and getting admitted in B.T.G.H, Gulbarga attached to M.R.M.C between November-2008 to April-2010.
7.2 / Methods of collection of data ( including sampling procedure, if any)
Identify subjects at risk by taking proper history [fever, chills, loss of consciousness, bleeding from gums and nose, convulsions,],checking vitals[blood pressure, pulse rate]clinical examination [spleenomegaly, hepatomegaly] and laboratory investigations mainly Rapid optimal test[ROT] and Peripheral smear for type of parasite, and Platelet count.
For mild thrombocytopenia – 50,000/mm3- 1,50,000/mm3
Moderate thrombocytopenia – 20,000/mm3-50,000/mm3
Severe thrombocytopenia - < 20,000/mm3 are taken into consideration.
Inclusion Criteria
All patients of >16 years of age and either sex with plasmodium positive species identified by slide positivity and Rapid optimal test [ROT] getting admitted in B.T.G.H attached to M.R.M.C, Gulbarga.
Exclusion Criteria
1.  Clinical diagnosis of malaria without slide positivity and rapid optimal test [ROT].
2.  Patients who received partial treatment outside the B.T.G.H and referred later to this hospital
3.  Platelet count done after starting treatment.
4.  Known HIV positive patients.
5.  Known thrombocytopenic or platelet disorders.
6.  Known case of chronic renal failure.
7.  Known case of chronic liver disease.
8.  Drugs causing thrombocytopenia.[phenytoin,digoxin,octreotide,etc]
Sample Size
Approximately 100 patients
7.3 / Does the study require any investigation or intervention to be conducted on patients or other humans or animals? if so please describe briefly
Yes
Peripheral smear for type of malarial parasite
Rapid optimal test
Platelet count.
Complete blood picture
Urine routine and microscopy
Liver function tests
Renal profile
Random blood sugar
Bleeding time
Clotting time
Prothrombin time
Chest-x ray[if required]
Arterial blood gas analysis[if required]
7.4 / Has ethical clearance been obtained from your institution in case of 7.3 ?
Yes. Ethical clearance has been obtained from “Ethical clearance committee” of the institution.
8 / List of References
1.  Jadhav UM, Patkar VS, Kadam NN. Thrombocytopenia In Malaria – Correlation with type and Severity of Malaria. Journal Association of Physicians of India—aug-2004;vol-52;pages 615-618.
2.  Sheraz Jamal Khan, Fazal Raheem Khan, Sameena Zahid Muhammad Usman. Malaria can lead to thrombocytopenia-Rawal Medical Journal- July-Dec-2008;vol-33:number-2;pages 183-186.
3.  Abdul Rauf Memon, Salahuddin Afsar. Thrombocytopenia in hospitalized malaria patients-Pakistan Journal of Medical Sciences - April-June 2006;Vol-22:Number-2;pages 141-143.
4.  Horstman RD, Dietrich M, Rasche H and Bienzle U. Malaria Induced Thrombocytopenia-Annals of Hematology, March-1981;Vol-42;Number-3;pages157-164.
5.  Kumar A, Shashirekha. Thrombocytopenia an indicator of acute vivax malaria-Indian Journal of Pathology and Microbiology, 2006; vol-49: Issue-4; pages 505-508.
6.  Krishnan, Anand MD, Karnad, Dilip R md - Severe falciparum malaria: an important cause of multiple organ failure in Indian intensive care unit patients-critical care Medicine, September-2003; 31[9]:2278-2284.
7.  Laura M. Erhart, Kritsanai Yingyuen, Niphon Chuanak, Nilawan Buathong; Anintita Laoboonchai, Scott Miller R, Steven R. Meshnick, Robert A. Gasserjr and Chansuda Wongsrichanalai – hematologic and clinical indices of malaria in a semi-immune population of western Thailand-American journal of tropical medicine hygiene 2004;70[1]:pages 8-14.
8.  Lathia TB, Joshi R. Can hematological parameters discriminate malaria from non-malarious acute febrile illness in the tropics-Indian Journal of Medical Sciences. 2004; vol-58: Issue-6; pages 239-244.
9.  Patel Umang, Gandhi Gaurang, Friedman Sandor, Niranjan Selvanayagam. Thrombocytopenia in malaria. Journal of National Medical Association, 2004; vol-96: Number-9, pages 1212-1214.
10.  Beale PJ, cormack JD, oldrey TBN. Thrombocytopenia in Malaria with Immunoglobulin [IGM] Changes-British Medical Journal, 1972; Vol-1: Pages 345-349.
11.  Andrej Trampuz, Matjaz Jereb, Rajesh M Prabhu and Igor Muzlovic. Clinical Review: Severe Malaria-Critical Care. 2003; Vol-7: Pages 315-323.
12.  Dharmesh Kumar N Patel, Pradeep P, Surti MM, Agarwal SB. Clinical Manifestations of Complicated Malaria An Overview-Journal, Indian academy of clinical medicine oct-dec-2003; vol-4: Number-4, pages 323-331.
9 / Signature of Candidate
10 / Remarks of guide / Malaria is rampant in Gulbarga district and in particular Falciparum malaria. The platelet count levels in malaria is an important predictor in noting the type of malaria and in the prognosis. Hence the present study is under taken.
11 / 11.1 / Name and designation of the Guide / Dr. V.H KUMARSWAMY
MD (General Medicine)
PROFESSOR,
DEPARTMENT OF MEDICINE,
M.R. MEDICAL COLLEGE, GULBARGA
11.2 / Signature
11.3 / Co- guide (if any)
11.4 / Signature
11.5 / Head of the Department / Dr. G. VEERANNA
MD.,D.M. Cardiology
PROFESSOR AND HOD
DEPARTMENT OF MEDICINE
M.R.MEDICAL COLLEGE, GULBARGA
11.6 / Signature
12 / 12.1 / Remarks of the Chairman and Principal
12.2 / Signature