Severe anaemia in Port Moresby. A review of 101 adult Melanesian patients with haemoglobin level of 4G/100 ml or less


Williams, G.; Naraqi, S.

Papua and New Guinea Medical Journal 22(4): 29-36

1979


Causes of anaemia in 101 adult Melanesian patients admitted to Port Moresby General Hospital over a 3-year period with haemoglobin levels of 4.0 gms per 100 ml or less were studied retrospectively. Cases of anaemia due to acute haemmorrage were excluded. Iron deficiency was found in 80, haemolysis in 39, megloblastosis in 26 and anaemia of chronic diseases in 5 patients. Anaemia was secondary to multiple causes in 56 and to a single cause in 45 patients. In the group with multiple causes, a combination of iron deficiency and haemolysis was found in 18, iron deficiency and megaloblastosis in 18, iron deficiency, haemolysis and megaloblastosis in 6 and haemolysis and megaloblastosis in 5 patients. In the group with a single cause, iron deficiency was found in 34, anaemia of chronic diseases in 5, haemolysis in 4 and megaloblastosis in 2 patients. Hookworm infestation and malaria appeared to be the major underlying causes of anaemia in the majority of these patients. Three of 45 patients who had received blood transfusions shortly after admission to the hospital died, while there was only one death in the nontransfused group. It is concluded that: i) severe anaemia in Papua New Guinea is commonly secondary to multiple causes; ii) administration of iron and folic acid as well as treatment for malaria and hookworm is a responsible approach when these patients can not be investigated; and iii) blood transfusion does not appear to be necessary in this group of patients despite a very low haemoglobin level.

SEVERE
ANAEMIA
IN
PORT
MORESBY
A
REVIEW
OF
101
ADULT
MELANESIAN
PATIENTS
WITH
HAEMOGLOBIN
LEVEL
OF
4G/100
ML
OR
LESS
Gerald
Williams*
and
Sirus
Naraqit
Causes
of
anaemia
in
101
adult
Melanesian
patients
admitted
to
Port
Moresby
General
Hospital
over
a
3-year
period
with
haemoglobin
levels
of
4.0
gms
per
100
ml
or
less
were
studied
retrospectively.
Cases
of
anaemia
due
to
acute
haemmorrage
were
excluded.
Iron
deficiency
was
found
in
80,
haemolysis
in
39,
megloblastosis
in
26
and
anaemia
of
chronic
diseases
in
5
patients.
Anaemia
was
secondary
to
multiple
causes
in
56
and
to
a
single
cause
in
45
patients.
In
the
group
with
multiple
causes,
a
combination
of
iron
deficiency
and
haemolysis
was
found
in
18,
iron
deficiency
and
megalo-
blastosis
in
18,
iron
deficiency,
haemolysis
and
megaloblastosis
in
6
and
haemolysis
and
megaloblastosis
in
5
patients.
In
the
group
with
a
single
cause,
iron
deficiency
was
found
in
34,
anaemia
of
chronic
diseases
in
5,
haemolysis
in
4
and
megaloblastosis
in
2
patients.
Hookworm
infestation
and
malaria
appeared
to
be
the
major
underlying
causes
of
anaemia
in
the
maj-
ority
of
these
patients.
Three
of
45
patients
who
had
received
blood
transfusions
shortly
after
admission
to
the
hospital
died,
while
there
was
only
one
death
in
the
non-
transfused
group.
It
is
concluded
that:
i)
severe
anaemia
in
Papua
New
Guinea
is
commonly
secondary
to
multiple
causes;
ii)
administration
of
iron
and
folic
acid
as
well
as
treatment
for
malaria
and
hookworm
is
a
responsible
approach
when
these
patients
can
not
be
investigated;
and
iii)
blood
trans-
fusion
does
not
appear
to
be
necessary
in
this
group
of
patients
despite
a
very
low
haemoglobin
level.
Anaemia
is
one
of
the
most
common
clinical
conditions
encountered
in
Papua
New
Guinea
and
many
investigators
have
done
extensive
studies
on
different
aspects
of
anaemia
in
different
parts
of
this
countryl.
In
practice
not
infrequently
one
comes
across
the
patients
with
extremely
low
haemoglobin
levels.
In
economically
developed
countries
this
degree
of
anaemia
is
usually
seen
in
patients
with
untreatable
conditions
such
as
leukaemia
and
aplastic
anaemia,
and
blood
trans-
fusion
plays
a
major
role
in
their
manage-
*Former
Medical
Registrar,
Port
Moresby
General
Hospital.
tDepartment
of
Clinical
Sciences,
Medical
Faculty,
University
of
Papua
New
Guinea.
Present
address:
Department
of
Medicine,
University
of
Illinois,
P.O.
Box
6998,
Chicago
Ill.
U.S.A.
ment2.
To
explore
the
causes
of
anaemia
in
patients
with
extremely
low
haemo-
globin
levels
in
Papua
New
Guinea
and
to
explore
the
value
of
blood
transfusion
in
the
management
of
these
patients,
the
following
retrospective
study
was
under-
taken.
MATERIALS
AND
METHODS
All
Melanesian
patients
admitted
to
Port
Moresby
General
Hospital
from
August
1975
to
May
1978
with
a
haemo-
globin
level
of
4gms/100
ml
or
less
were
identified.
The
records
of
101
adult
patients
(104
admissions),
whose
anaemia
was
not
the
result
of
acute
examination
as
well
as
peripheral
blood
and
bone
marrow
examinations,
were
reviewed.
The
following
criteria
were
used
for
the
diagnosis
of
different
anaemias2:-
29
Iron
deficiency:
absence
or
severe
reduction
of
strainable
iron
stores
in
the
bone
marrow.
Megaloblastosis:
presence
of
megalo-
blastosis
erythropoiesis
and
giant
meta-
myelocytes
in
the
bone
marrow.
Haemolysis:
increase
in
circulating
reticulocytes
and
presence
of
nucleated
red
cells
and
polychromasia
in
the
peri-
pheral
blood
film
as
well
as
erythro-
blastic
hyperplasia
in
the
bone
marrow.
Table
1.
There
was
no
significant
differ-
ence
between
the
age
or
haemoglobin
levels
of
men
and
women.
In
45
patients
only
a
single
cause
of
anaemia
could
be
identified,
while
56
patients
had
2
or
more
causes
present
(Tables
2
and
3).
Iron
deficiency
was
the
most
common
finding
in
these
patients
followed
by
haemolysis
and
megaloblastosis.
TABLE
1
General
Information
on
101
Melanesian
adult
patients
with
severe
anaemia.
Anaemia
of
chronic
diseases:
absence
of
evidence
for
megaloblastosis
and
haemolysis
as
well
as
usually
normocell-
ular
marrow,
with
normal
or
increased
iron
stores
in
a
patient
with
a
chronic
disorder.
Hypersplenism
was
defined
as
the
presence
of
marked
splenomegaly,
pancytopenia
and
hyperactive
bone
marrow.
Age:
(years)
Range
12
--
68
Mean
30
Sex:
Male
64
Female
47
Geographical
Origin:
Coast
61
(28)*
Inland
25
(14)
Highland
15
(12)
Bone
marrow
was
obtained
by
needle
aspiration
from
the
iliac
crest
and
exam-
ined
by
the
Haematology
Department
with
conventional
methods.
Peripheral
blood
and
bone
marrow
films
were
stained
with
May-Grunwald-Giemsa
for
morphological
examination.
Bone
mar-
row
films
were
also
stained
with
potas-
sium
ferrocyanide
and
hydrochloric
acid
for
assessment
of
iron
stores.
Haemoglo-
bin
levels
were
measured
by
the
oxy-
haemoglobin
method.
Glucose-6-phos-
phate
dehydrogenase
(G6-PD)
deficiency
was
detected
by
a
fluorescent
screening
method.
Zone
electrophoresis
on
cellu-
lose
acetate
strips
was
used
to
detect
abnormal
haemoglobins.
Guaiac
test
and
direct
faecal
smears
were
used
for
detec-
tion
of
occult
blood
and
ova
and
para-
sites
in
the
stools.
RESULTS
All
101
patients
were
Melanesians
from
the
mainland
of
Papua
New
Guinea.
The
age,
sex,
geographical
origin
and
admis-
sion
haemoglobin
levels
are
shown
in
Admission
haemoglobin
(gms/100
ml)
Range
1.4
4
Mean
3.0
*Number
of
males
in
each
group.
TABLE
2
Causes
of
severe
anaemia
in
101
adult
Melanesian
patients.
TYPE
OF
SOLE
ANAEMIA
CAUSE
Iron
MULTIPLE
CAUSES
TOTAL
deficiency
34
46
80
Haemolytic
4
35
39
Megaloblastic
2
24
26
Chronic
diseases
5
0
5
Total
Number
of
Patients
45
56
101
30
TABLE
3
Combination
of
different
causes
of
anaemia
in
,
patients
with
severe
anaemia.
TABLE
4
Causes
of
iron
deficiency
in
80
Melanesian
patients
with
severe
anaemia.
Iron
deficiency
and
haemolysis
28
Iron
deficiency
and
megaloblastois
18
Iron
deficiency,
haemolysis
and
megaloblastosis
6
Megaloblastosis
and
haemolysis
5
Iron
deficiency
Iron
deficiency
was
found
in
80
patients,
and
was
the
most
common
identifiable
cause
in
both
single
and
multiple
cause
cause
groups.
Iron
stores
were
absent
in
67,
and
severely
reduced
in
13
patients.
An
underlying
aetiology
of
iron
deficiency
was
identified
in
only
37
patients
(Table
4).
Thirteen
out
of
15
highlanders
included
in
this
study
had
iron
deficiency.
Hookworm
infestation
was
found
in
72%
(33
out
of
46
tested)
of
patients
with
iron
deficiency,
and
20%
(2
out
of
10
tested)
with
normal
iron
stores.
The
incidence
of
hookworm
infestation
was
found
to
be
34%
in
patients
whose
stools
were
sent
for
ova
and
paarsite
examination
from
different
hospital
wards
(based
on
a
random
study
of
111
patients
seen
in
the
period
of
study).
Findings
related
to
other
nematodes
supported
the
association
of
hookworm
and
iron
deficiency
anaemia
(Table
5).
Only
6
patients
with
hook-
worm
had
eosinophil
counts
greater
than
400/mm3
of
the
peripheral
blood.
Seven
patients
with
iron
deficiency
were
pregnant
and
this
may
have
been
a
contributing
factor
in
the
aetiology
of
their
anaemia.
Of
patients
with
blood
loss
in
stool,
one
had
amoebic
colitis,
one
had
haem-
morrhoids,
one
had
peptic
ulcer
and
one
had
carcinoma
of
the
stomach.
Nine
others
had
barium
meal
studies
with
normal
results.
Barium
enema
showed
no
abnormalities
in
2
of
these
patients.
Hookworm
infestation
33
(46)•
Occult
blood
loss
in
atoll
10
(14)*
Pregnancy
Idiopathic
thrombocytopenic
purpura
1
Unknown
39
Figures
in
parenthesis
indicate
the
number
of
patients
investigated
for
each
factor.
Haemolysis
Table
6
summarizes
the
causes
of
haemolysis
found
in
39
patients.
Hyper-
splenism,
clinically
thought
to
be
due
to
tropical
splenomegaly
syndrome
(TSS),
was
the
most
common
cause
of
haemo-
lysis.
Three
patients
with
TSS
had
positive
malaria
smears;
iron
deficiency
was
present
in
15
and
megaloblastosis
in
3
of
them.
TABLE
6
Causes
of
haemolysis
in
39
Melanesian
patients
with
severe
anaemia.
Hypersplenism
20
Malaria
29
G6—PD
deficiency
3
Unknown
3
Malaria
was
diagnosed
in
19
patients;
10
had
Plasmoaium
falciparum,
2
P.
vivax,
one
P.
malariae,
and
6
mixed
infection
(falciparum
and
uivax),
9
were
iron
deficient,
6
had
megaloblastosis
and
hypersplenism
was
present
in
3
.
G6-PD
deficiency
was
detected
in
3
of
the
17
tested
patients,
all
of
whom
were
though
to
have
hypersplenism
as
well.
Only
one
of
these
had
evidence
of
severe
haemolysis;
2
were
iron
deficient
as
well
and
one
had
megaloblastosis.
Haemoglobin
electrophoresis
was
done
in
7
patients
and
was
normal
in
all.
31
Of
the
4
patients
with
,haemolysis
as
the
diseases
was
found
in
5
patients,
3
with
only
identifiable
cause
of
anaemia,
3
had
acute
myeloblastic
leukaemia
and
,2
with
malaria
and
the
cause
was
not
apparent
chronic
renal
failure,
one
of
whom
had
in
the
fourth.
pulmonary
tuberculosis
as
well.
One
TABLE
5
Nematode
ova
found
in
Melanesian
patients
with
severe
anaemia.
PARASITE
IRON
DEFICIENCY
NORMAL
IRON
STORES
CONTROL
PATIENTS
*
(46)
*
(10)
*
(111)
Hookworm
33
2
35
Thchuris
7
3
24
Ascaris
3
1
4
*
Numbers
in
parenthesis
indicate
the
number
of
patients
in
each
group
with
stool
examination
for
ova
and
parasites.
Megaloblastosis
Megaloblastic
anaemia
was
found
in
26
patients.
Eighteen
patients
had
associ-
ated
iron
deficiency;
serum
B12
and
folic
acids
levels,
measured
in
one
patient,
only
showed
a
low
folic
acid
and
a
normal
B12
level.
Table
7
shows
known
causes
of
megaloblastic
anaemia
which
were
present
in
these
patients.
Of
patients
with
chronic
haemolysis,
6
had
malaria
and
4
had
hypersplenism.
One
of
the
patients
with
hypersplenism
had
G6-
PD
deficiency
as
well.
TABLE
7
Chronic
haernolysis
10
Pregnancy
._
4
Phenytoin
therapy
(long
term)
1
Unknown
16
Anaemia
of
chronic
diseases
Anaemia
of
chronic
or
malignant
patient
with
chronic
renal
failure
had
hypochromic
microcytic
smear.
No
evidence
of
leukaemia
was
found
in
the
peripheral
blood
film
of
one
of
the
leukaemic
patients
at
admission.
Chronic
infections
such
as
tuberculosis
were
notably
rare
in
these
patients.
Pulmonary
tuberculosis
was
found
in
3
patients but
the
anaemia
of
chronic
disease
was
present
in
only
one
of
them.
Peripheral
blood
examination
Leukopenia:
a
white
cell
count
of
less
than
5000
per
cmm
was
found
in
52
patients,
and
was
associated
with
hyper-
splenism
(20
patients),
malaria
(8
patients),
malaria
(8
patients)
or
megalo-
blastosis
(10
patients).
In
14
patients
with
leukopenia,
iron
deficiency
was
the
only
identifiably
cause
of
anaemia.
Eight
of
these
had
splenomegaly
as
well.
Thrombocytopenia:
platelet
counts
were
done
in
13
patients
and
qualitative
assessments
of
platelets
in
peripheral
blood
were
available
for
all
the
others.
Seven
patients
had
low
platelet
counts
Causes
of
Megaloblastosis
in
26
Melanesian
patients
with
severe
anaemia.
32
(ranging
from
15,000
to
150,000
per
cmm).
Three
had
hypersplenism,
one
acute
leukaemia,
one
idiopathic
thromb-
ocytopenic
purpura
and
the
cause
could
not
be
determined
in
the
other
2.
Of
patients
with
qualitative
assessment,
7
patients
had
reduced
platelets.
All
of
these
could
be
accounted
for
by
hyper-
splenism,
megaloblastosis
or
malaria.
Red
cell
morphology:
Table
8
shows
the
reliability
of
the
peripheral
blood
film
examination
for
detection
of
iron
deficiency
in
our
patients.
Only
2
patients
with
iron
deficiency
had
normo-
chronic
normocytic
smears.
Theie
2
had
some
reduction
in
marrow
iron
store
and
were
thought
to
be
early
stages
of
iron
deficiency.
Of
2
patients
with
normal
iron
stores
but
hypochromia,
one
had
anaemia
of
chronic
disease
(tuberculosis
as
well
as
chronic
renal
failure)
and
in
the
other
the
cause(s)
of
hypochronic
microcytic
anaemia
was
not
identified.
Blood
Transfusion
Forty
five
patients
were
transfused
and
56
were
not.
The
number
of
patients
with
haemoglobin
of
less
than
2.5
was
not
markedly
different
in
each
group
(25
and
24).
There
were
3
deaths
in
the
transfused
group
(one
died
of
leukaemia,
one
of
renal
failure
and
one
of
TSS
and
severe
haemolysis)
and
one
in
the
non-transfused
group
(of
renal
failure).
DISCUSSION
Severe
anaemia
was
due
to
more
than
one
cause
in
the
majority
of
our
patients.
Iron
deficiency
was
a
factor
in
80%
of
the
patients
and
was
common
both
as
a
single-cause
anaemia.
Although
haemo-
lysis
and
megaloblastosis
were
commonly
found,
they
rarely
caused
severe
anaemia
in
the
absence
of
iron
deficiency
or
other
factors.
TABLE
8
Relationship
between
red
cell
morphelogy
and
marrow
iron
stores
in
101
Melanesian
patients
with
severe
anaemia.
Red
cell
morphology
No.
of
patients
Iron
deficiency
Normal
iron
stores
Hypochromic
Microcytic
80
79
2
Normochromic
Normocytic
21
2
19
Table
9
shows
the
value
of
peripheral
blood
films
in
the
diagnosis
of
megalo-
blastosis.
Seventeen
out
of
26
had
one
or
more
peripheral
changes
typical
of
megaloblastic
anaemia.
Of
9
patients
with
megaloblastic
marrow
and
non-
macrocytic
smears,
7
had
associated
iron
deficiency
and
one
had
chronic
renal
failure.
These
associated
factors
may
have
masked
the
typical
findings.
Four
patients
with
no
megaloblastic
changes
in
the
marrow
had
macrocytes
in
the
peripheral
blood
film.
All
of
these
had
iron
deficiency.
It
is
possible
that
mild
megaloblastosis
in
marrow
had
been
masked
by
severe
iron
deficiency.
The
high
incidence
of
iron
deficiency
corresponds
with
previous
investigations
showing
that
iron
deficiency
is
the
commonest
cause
of
anaemia
in
coastal
Papua
New
Guinea3,
4
,
5
.
Highlanders,
whose
haemoglobin
on
average
is
higher
than
that
of
coastal
people,
have
been
found
to
have
a
similar
incidence
of
anaemia
when
living
at
the
coasts
,
7
.
In
this
study
the
incidence
of
iron
deficiency
in
highlanders
with
severe
anaemia
was
the
same
as
in
their
coastal
counterparts.
The
commonest
cause
of
iron
deficiency
in
this
study
was
hookworm
infestation.
Anaemia
has
been
shown
to
33
TABLE
9
Relationship
between
blood
cell
morphology
and
marrow
megaloblastosis
in
101
Melanesian
patients
with
severe
anaemia.
Blood
cell
Morphology
Number
of
paitents
Megaloblastic
Anaemia
Non-Megaloblastic
Anaemia
Macrocytosis
10
6
4
Hypersegmented
neutrophils
7
7
0
Both
4
4
0
Neither
80
9
71
be
related
to
hookworm
infestation
in
many
parts
of
the
world
but
this
ship
has
not
been
clearly
proven8,
9
.
Although
hookworm
lood
has
been
shown
to
be
light
in
Papua
New
Guinea,
and
the
worm
most
commonly
found
in
Nector
ameri-
canus10,
a
positive
correlation
has
been
found
between
the
haemoglobin
level
and
the
degree
of
hook
worm
infestation
in
both
highland
and
coastal
people
,
11
.
In
this
study,
the
rate
of
72%
of
hookworm
infestation
found
in
the
patients
with
iron
deficiency
anaemia
was
more
than
twice
that
in
total
hospital
patients
(34%)
and
3
times
higher
than
that
of
patients
with
anaemia
with
normal
iron
stores.
These
findings
suggest
that
hookworm
infestation
contributed
to
the
iron-
deficiency
anaemia
in
these
patients.
The
lack
of
eosinophilia
in
relation
to
hook-
worm
infection,
noted
in
the
patients
in
this
series,
has
been
reported
previously.
8,10
The
presence
of
occult
blood
in
the
stools
in
some
of
the
iron-deficient
patients
may
have
resulted
from
undetect-
ed
gastrointestinal
lesions,
though
occult
blood
may
be
found
in
the
stools
as
a
result
of
hookworm
infestation
as
well.9
The role
-
of
diet
could
not
be
assessed
from
the
records
of
patients
in
this
study
Other
investigators
have
estimated
a
normal
dietary
iron
intake
in
coastal
non-urban
areas
(dietary
intake
of
12-20
mg/day
for
adults)
4
,
7
.
However,
normal
dietary
iron
will
not
protect
against
iron
deficiency
in
subjects
with
heavy
hook-
worm
infestation
or
with
'
increased
requirements.
The
role
of
excessive
menstrual
blood
loss
could
not
be
assessed
from
the
records
of
our
patients
but
pregnancy
may
have
been
an
import-
ant
factor
in
some
patients.
Megaloblastic
anaemia
in
this
series
was
often
not
severe
enough
to
be
the
sole
cause
of
anaemia.
Though
serum
folic
acid
levels
were
not
available,
the
patients
frequently
had
associated
factors
known
to
predispose
to
folic
acid
deficiency
such
as
pregnancy,
hyper-
splenism
and
malaria,
all
of
which
increase
the
folate
requirement.
In
Papua
New
Guinea
folic
acid
deficiency
has
been
found
to
be
associated
with
megalo-
blastic
anaemia
much
more
commonly
than
B12
deficiency4,12,15
.
There
was
no
case
of
pernicious
anaemia
in
our
patients.
Haemolytic
anaemias
were
caused
by
hypersplenism
and
malaria
in
the
majority
of
cases.
The
frequency
of
malaria
detected
in
this
series
may
have
been
reduced
by
therapy
prior
to
hospital
admission.
Malaria
is
an
important
cause
of
anaemia
in
Papua
New
Guinea
and
significant
improvement
in
haemoglobin
levels
following
control
of
malaria
have
been
demonstrated
16
.
It
may
also
account
for
the
majority
of
cases
of
hypersplenism
(which
in
Papua
New
34
Guinea
is
mostly
caused
by
TSS)1
7
as
well
as
some
folic
acid
deficiency].
6
.
It
has
been
shown
that
weekly
chloroquin
for
a
prolonged
period
of
time
will
result
in
increased
haemoglobin
level
of
patients
with
tropical
splenomegalyl
8
.
The
clinical
manifestations
of
G6-PD
deficiency
in
Papua
New
Guinea
have
not
been
defined
though
the
variants
found
result
in
severe
haemolysis.
1
This
study
suggest
that
G6-PD
deficiency
is
not
a
major
contributing
factor
in
the
pathogenesis
of
haemolysis
in
severe
anaemia.
Leukaemia,
chronic
renal
failure,
chronic
infections,
and
aplastic
anaemia
were
not
found
to
be
common
causes
of
severe
anaemia
in
this
study.
This
is
in
sharp
contrast
with
the
findings
in
the
economically
developed
world.
Red
cell
morphology
in
peripheral
blood
provided
a
reliable
guide
to
the
diagnosis
of
iron
deficiency
and
megaloblastic
anaemia.
Although
the
numbers
are
small,
the
mortality
of
transfused
and
non-
transfused
group
suggests
that
blood
transfusion
did
not
influence
the
out-
come
of
the
patients
favourably.
Based
on
this
study,
the
following
conclusions
can
be
made:-
1.
severe
anaemia
in
Port
Moresby
is
commonly
secondary
to
multiple
causes;
2.
administration
of
iron
and
folic
acid
as
well
as
treatment
for
hook-
worm
and
malaria
is
a
logical
approach
when
these
patients
cannot
be
investigated;
3.
blood
transfusion
does
not
appear
to
be
necessary
in
the
majority
of
patients
with
severe
anaemia
despite
a
very
low
haemoglobin.
ACKNOWLEDGEMENTS
Authors
are
indebted
to
Dr.
J.
White
for
his
advice
and
to
Mrs.
C.
Williams
for
her
consider-
able
technical
assistance.
35
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36