Original Article

Malarial Hepatitis
DK Kochar*, P Singh**, Priya Agarwal**, SK Kochar***, R Pokharna****, PK Sareen+

Abstract
Aims and Objective: To study the clinical, biochemical and histopathological changes in the liver of patients of Plasmodium falciparum malaria with jaundice. Material and Method: This study was conducted on 50 PBF confirmed cases of Plasmodium falciparum malaria with jaundice. Detailed history, clinical examination, biochemical parameters for liver function test and blood for hepatitis B and C was done in all patients. Liver biopsy was done for detailed histopathological examination in all the 20 patients having serum bilirubin between 3 to 10 mg%. All patients were treated by IV / oral quinine using standard regimen. Results: Age of the patient was ranging from 15-45 years. All patients had jaundice, 70% had pallor, 56% had splenomegaly, 48% had hepatomegaly and 24% of cases had coma. Based on serum bilirubin level, the patients were categorized in group A (18 patients, serum bilirubin < 3mg%), in group B (20 patients, serum bilirubin 3-10 mg%) and in group C (12 patients, serum bilirubin >10 mg%). Histopathological examination done in all the 20 patients of group B, showed evidence of swollen hepatocytes (100%), malarial pigment deposition (75%), inflammatory infiltrates (60%), congestion of hepatocyte (50%) alongwith centrizonal necrosis in 25% of cases. Conclusion: The evidence of predominant conjugated hyperbilirubinemia, increased levels of AST and ALT along with evidence of hepatocellular necrosis in histopathological examination are strong evidence of gross hepatocytic dysfunction in patients of Plasmodium falciparum malaria with jaundice. Therefore the term malarial hepatitis should not be taken as a misnomer.

INTRODUCITON
alaria is one of the most widespread diseases in the world occurring between 60N and 40S. It is endemic in 91 countries with about 40% of world population at risk of acquiring the infection. Each year there are 300-500 million cases of malaria and 1.5-2.7 million deaths. The predominant cause of mortality in these patients is due to severe malaria. According to WHO the term severe malaria is defined as the presence of one or more complication in a patient having asexual parasitaemia of P. falciparum in the peripheral blood smear.1 Presence of jaundice and renal failure are observed more commonly in recent years in the patients of Plasmodium falciparum malaria in Thailand and Vietnam.2 Jaundice is the commonest sign of hepatic dysfunction in P. falciparum malaria, although tender hepatomegaly is the most common

clinical finding in these patients. Alteration in liver function has also been observed by many earlier workers, in India as well as other part of Asia hence the present study was designed to evaluate the clinical biochemical and histopathological changes in liver in patients with PF malaria with jaundice.3,4

MATERIAL AND METHODS

The present prospective study was conducted on 50 consecutively admitted patients of malaria confirmed by demonstration of asexual forms of Plasmodium falciparum in the peripheral smear alongwith jaundice. All patients were admitted in the classified malaria ward of this tertiary care hospital situated at Bikaner (Northwest India) during 199899. It included adult patients of both sexes and different ages after obtaining the formal consent from the patient or relatives. Patients having negative peripheral blood smear for PF or having only vivax infection were not included in the study. All these patients of Plasmodium falciparum malaria with jaundice were evaluated clinically for history of fever, headache, altered sensorium, urinary output, vomiting, convulsions, pallor, icterus, hepatosplenomegaly and coma. Other causes of liver dysfunction like various drugs or toxin
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*Professor; **Senior Registrar, ****Associate Professor, Department of Medicine; ***Assistant Professor, Department of Gastroenterology; +Associate Professor, Department of Pathology, SP Medical College, Bikaner 334001. Received : 31.1.2002; Revised : 3.4.2003; Re-revised : 18.7.2003; Accepted : 7.10.2003

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induced hepatitis, cirrhosis of liver, hepatocellular carcinoma or unexplained hepatomegaly were excluded by appropriate investigations. The laboratory investigations done in all the patients included blood for Hb, TLC, DLC, ESR, detailed morphology of PBF, platelet count, BT, CT, sugar, urea and S. electrolytes. Urine examination was done for urobilinogen, bile pigment and bile salt. Liver function was evaluated by determining the levels of S. bilirubin both conjugated and unconjugated, AST and ALT, S. protein, and prothrombin time (PT). Blood for hepatitis B and C was done in all the patient to rule out possibility of concomitant viral hepatitis. Specific laboratory evaluation was done to define other complications in individual patients. A formal consent of hospital ethical committee was obtained for the clinical & histopathological study on these patients. Liver biopsy was done by gun shot method through micro invasive needle using transthorasic approach in ninth or tenth intercostal space in the mid-axillary line after infiltrating 1% xylocaine in all the twenty patients of group B after obtaining reports of BT, CT, PT, platelet count and patients consent. The liver tissue was fixed in 1% unbuffered formalin and was stained with hematoxylin and eosin, periodic acid Schiffs, reticulin and von Gieson stain. All patients were treated by IV/oral quinine using standard regimen, whereas specific complications were treated according to the WHO protocol.1 Adequate care was taken for management of hypoglycemia. Chi square test x2 = 1.343 was used to calculate p value which was considered insignificant when the value were > 0.05.

Table 1 : Serum biochemistry in patients classified as A, B, C groups according to serum bilirubin levels (n=50)
Groups A B C > 10 12 5 7

Serum bilirubin (mg%) <3 3-10 No. of patients 18 20 significant hyperbilirubenemia Unconjugated 16 8 Conjugated 2 12 X2 A with B 7.73 p < 0.01 X2 A with C 5.56 p < 0.05 Haemoglobin level < 5gm% 7 6 > 5gm% 11 14 X2 A with B 0.055 p > 0.05 X2 A with C 1.250 p > 0.05 AST level (IU) < 40 17 7 40-100 1 10 > 100 3 X2 A with B 10.242 p < 0.001 X2 A with C 34.820 p < 0.001 ALT levels (IU) < 40 16 7 40-100 2 10 > 100 3 X2 A with B 20.891 p < 0.001 X2 A with C 31.779 p < 0.001 Mortality No. of patients 18 20 Deaths 3 Percentage 15

8 4

1 2 9

1 2 9

12 3 25

OBSERVATIONS
The age of the patients ranged between 15-45 years. Apart from the fever and jaundice, which were present in all the patients, other signs and symptoms were related to individual complication. The important findings were icterus in all patients, pallor in 70%, splenomegaly in 56%, hepatomegaly in 48% while coma was noted in 24% of cases. The other important associated manifestations of severe falciparum malaria were cerebral malaria in 24% cases and renal dysfunction in 10% of the cases. The details of biochemical examination are mentioned in the Table 1. The important histopathological features were the presence of swollen hepatocytes in 100% cases, presence of malarial pigment deposition in 75% cases, portal infiltration by mononuclear cells in 60%, congestion of hepatocytes in 50%, Kupffer cell hyperplasia in 30%, centrizonal necrosis in 25% and fatty change in 10% of cases, (Figs. 1-4 and Table 2).

Table 2: Histopathological changes in liver in patients of Plasmodium falciparum malaria with jaundice (serum bilirubin 3 to 10 mg%, n=20)
Changes in Histopathology Swollen hepatocytes Pigment deposition Portal infiltration Sinusoidal infiltration and dilatation / congestion Kupffer cell hyperplasia Liver cell necrosis Fatty change No. of Patient 20 15 12 10 6 5 2 Percentage 100 75 60 50 30 25 10

DISCUSSION
Hepatic dysfunction in a case of falciparum infection had been recognized since the beginning and various causes have been attributed for the same. According to WHO, the jaundice is one of the important manifestations of severe malaria. The cause of jaundice in a patient of PF malaria is multifactorial and includes (i) intravascular haemolysis due to destruction of parasitised and non-parasitised red blood cells. There is
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also evidence of immune haemolysis involving the adherence of the circulating antigen-antibody complexes to the surface of the erythrocytes (ii) malnutrition, shock, disseminated intravascular coagulation leading to microangiopathic haemolysis and (iii) hepatocyte dysfunction, which may be because of alteration in vascular flow through the organ as parasitised red blood cells adhere to endothelial cells blocking sinusoids and obstructing intrahepatic blood flow. There is evidence of focal hepatocyte necrosis, cholestasis, bile stasis, granulomatous lesion or malarial nodules. The bile stasis is because of impairment of bilirubin transport due to endothelial blockage and disturbance of hepatocyte microvilli.1 Intravascular haemolysis of parasitised and nonparasitised red blood cells has been considered as an important factor for the causation of mild to moderate jaundice
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Fig. 1 : Microphotograph showing multiple small foci of loss of nuclei of hepatocytes (necrosis) the intervening areas show fibroblastic proliferation and inflammatory cell infiltration (H and E x 450).

Fig. 3 : Microphotograph showing small foci of liver cell necrosis, some hepatocytes show clear cytoplasm also (H and E x 450).

Fig. 2 : Microphotograph showing hepatic cords with congested and dilated sinusoids containing numerous red blood cells (H and E x 450).

Fig. 4 : Microphotograph showing a portal triad with predominantly mononuclear cell infiltration in the upper left part of the figure (H and E x 100).

which is predominantly unconjugated and the role of liver in its pathogenesis has always been a subject of debate. Haemolysis alone can never cause severe jaundice or predominantly conjugated hyperbilirubinemia alongwith an increase in liver enzyme levels as seen in many patients of falciparum malaria. Even if bile pigment production reaches to its maximum of 1500 mg daily (6 times normal), serum bilirubin rises only to about 2-3mg%.5 Many workers have proposed the role of hepatocellular damage in patients having hyperbilirubenemia of greater magnitude. Bartelloni (1967) and Glor (1969) have suggested that mild jaundice may result from haemolysis alone, but very high bilirubin concentration indicate hepatocyte dysfunction.6,7 According to WHO, the patients of severe falciparum malaria with jaundice rarely have the serum bilirubin levels of more than 10mg%1 but in this study 24% patients had serum bilirubin levels of > 10mg% and the maximum value was 24 mg%. Earlier similar findings were recorded by many workers from this subcontinant.3,4 Moreover, haemolysis alone can produce predominantly unconjugated hyperbilirubinemia which usually does not exceed more then 10 mg%. In patients having serum bilirubin
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levels of more then 10 mg%, there are more chances of associated hepatocellular injury as compared to the patients having serum bilirubin levels of less then 10 mg%, in whom the haemolysis and disseminated intravascular coagulation may be the important factors. The observation of conjugated hyperbilirubinemia also indicates the role of hepatocytic dysfunction in its causation. It has also been observed that higher serum bilirubin levels are associated with increased incidents of complications and mortality.8 In this study we also observed raised serum enzyme levels in some of these patients and 9 out of 12 patients having serum bilirubin levels of more then 10mg% also had very high levels of serum enzymes. Earlier Chawla et al and Anand et al also had similar observation in the patients of PF malaria.3,4 All these observations of this study and other workers further support the possible role of hepatic dysfunction in the causation of jaundice. In acute falciparum malaria, the liver is enlarged and weighs up to 2.5kg. It is congested and pigmented dark brown. The Kupffer cells are hypertrophied and contain haemozoin pigment.3,9-13 The sinusoids are dilated (Fig. 2) and the portal
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tracts shown infiltration of chronic inflammatory cells3,11,12 (Fig. 4) but the parasites are rarely demonstrable. Additional changes in morphology include steatosis,3,14 focal hepatocyte necrosis15 (Fig. 1) and focal accumulations of histiocytes forming non-specific granulomatous lesion.10 Parasitised red blood cells are seen in Kupffer cells and endothelial cells. Characteristically rectangular, crystalline malarial pigment granules are seen in these cells. The hepatocytes contain lipofuschin and hemosiderin alongwith fat droplets deposition. The space of Disse becomes narrow with loss of microvilli of both the hepatocytes and the bile canaliculi. These last two features have been suggested as the important factors related to hepatic dysfunction and cholestasis. The predominant histopathological changes in malarial liver comprises of a reticulo endothelial response i.e., Kupffer cell hyperplasia, presence of malarial pigment and congestion alongwith minor effects on hepatocytes.16 These changes may be non-specific but the presence of centrizonal necrosis is a strong indicator of hepatic damage. Mishra observed liver cell necrosis in 1 out of 33 patients and considered it as relatively uncommon observation.17 Murthy et al attributed malarial hepatitis to be an important contributory factor for the jaundice.8 Deller et al also reported evidence of malarial hepatitis in patients of Plasmodium falciparum malaria with jaundice. 18 Debrito et al in their study observed focal hepatocyte necrosis and linked it to the causes other than poor nutritional status. 15 Molyneux et al observed centrilobular necrosis in severe malaria and regarded it as ischaemic in origin because of major reduction in splanchnic blood flow induced by heavy Plasmodium falciparum parasitaemia.19 According to Mashaal et al the centrilobular necrosis seen in severe malaria may result from reduction in splanchnic flow.20 The role of tumor necrosis factor in causing hepatocellular damage is controversial. All these observation of different workers are in support of our observation of evidence of hepatocyte necrosis, which is the strongest indicator of hepatocyte injury. Thus, in our opinion the evidence of predominantly conjugated hyperbilirubinemia and increased levels of SGOT, SGPT and LDH levels along with evidence of hepatocellular necrosis in histopathological examination in few patients are strong evidence of gross hepatocytic dysfunction in patients of Plasmodium falciparum malaria with jaundice. Therefore the term malarial hepatitis should not be taken as a misnomer.

1994;45:298-302. 3. 4. Anand AC, Ranji C, Narula AS, Singh W. Malaial hepatitis: a heterogenous syndrome? Natl Med India 1992;5:59-62. Chawla LS, Sidhu G, Sabharwal BD, Bhatia K, Lsood A. Jaundice in Plasmodium falciparum malaria. J Assoc Phys India 1989;376:390-92. Sheilla Sherlock, Dooley. Diseases of the liver and biliary system. 10th Ed. Oxford: Blackwell scientific publication. pp 48. Bartelloni PJ, Sheehy TW, Tigertt WD. Combined therapy for Chloroquine-resistant Plasmodium falciparum infection. Concurrent use of long-acting sulphamethoxine and pyrimethamine. J Am Med Assoc 1967;199:173-77. Glor BA. Falciparum malaria in Vietnam: Clinical manifestations and nursing care requirements. Military Medicine 1969;134:181-91. Murthy GL, Sahay RK, Sreenivas DV, Sundaram C, Shantaram V. Hepatitis in falciparum malarial. Tropical Gastroenterol 1998;19:152-4. Taliaferro WH, Mulligan HW. The histopathology of malaria with special reference to the function and origin of the macrophages in defense. Indian M Res Mem 1937;39:1.

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10. Srichaikul T. A study of Pigmentation and other changes in the liver in malaria. Am J Trop Med Hyg 1959;8:110-18. 11. Ramchandran S, Perera MVF. Jaundice and hepatomegaly in primary malaria. J Trop Med Hyg 1976;79:207-10. 12. Weatherall DJ, Abdalla S. The anaemia of plasmodium falciparum malaria. Brit Med Bull 1980;293:11-3. 13. Murthy MR. A study of histopathological changes in liver in patients of plasmodium falciparum with jaundice. In: A thesis submtittedto Kanpur University, Kanpur (UP) for degree of Doctor of Medicine, 1997. 14. Dash SC, Bhuyan UN, Gupta ALC, Kumar A, Agarwal SK. Falciparum malaria complicating cholestatic jaundice and acute renal failure. J Assoc Phys India 1994;42:101-2. 15. Debrito T, Barone AA, Faria Rm. Human liver biopsy in Plasmodium falciparum and P. vivax malaria. Alight and electron microscopy study. Virchows Arch (A) 1969;348:22029. 16. Sheilla Sherlock, Dooley. Diseases of the liver and biliary system. 10th Ed. Oxford: Blackwell scientific publication. pp 514 17. Mishra SR, Mohanty S, Das BS, Patnain JR, Satpathy SR, Mohanty D, Bose ID. Hepatic changes in Plasmodium falciparum malaria. Indian J Malariol 1992;29:167-71. 18. Deller JJ, Cefarelli PS, Berque S, Buchanan R. Malaria hepatitis. Military Medicine 1962;132:614-620. 19. Molyneux ME, Looarreesuwan, S, Menzie SIS. Reduced hepatic blood flow and intestinal malabsorption in severe falciparum malaria. Am J Trop Med Hyg 1989a; 40:470-76. 20. Mashaal H. Clinical Malariology 1986. Tokyo Seamie Publication No. 48.

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