Indian J Hematol Blood Transfus (Oct-Dec 2021) 37(4):632–639
https://doi.org/10.1007/s12288-020-01390-w
ORIGINAL ARTICLE
Effect of Asymptomatic Plasmodium falciparum Parasitaemia
on Platelets Thrombogenicity in Blood Donors
Enoch Aninagyei1 • Patrick Adu2 • Tanko Rufai3 • Paulina Ampomah4 •
Godwin Kwakye-Nuako4 • Alexander Egyir-Yawson4 • Desmond Omane Acheampong4
Received: 10 August 2019 / Accepted: 27 November 2020 / Published online: 2 January 2021
 Indian Society of Hematology and Blood Transfusion 2021
Abstract Currently, blood donors in Ghana are not parasite density in malaria infected donors was 1784 par-
screened for malaria parasites. Therefore, this study asites/lL (505-2478 parasites/lL). This led to significant
assessed platelet thrombogenicity in blood donors infected increase in the mean levels of 8-iso-PG2a, hs-CRP, TNF-a
asymptomatically with Plasmodium falciparum and the and D-dimer. However, PF4, P-selectin were significantly
relationship between tumour necrosis factor alpha (TNF- lower in infected donors while vWF levels did not differ
a), 8-iso-prostaglandin F2a oxidative stress biomarker (8- significantly among the groups even though lower levels
iso-PG2a), C-reactive protein (hs-CRP) and D-dimer, and were observed in the infected donors. Significant direct
platelet thrombogenes levels. Haematology analyser was relationship existed between both P-selectin and PF4 and
used to enumerate platelet count and platelet indices in 80 platelet count, and plateletcrit and platelet large cell ratio
P. falciparum infected blood donors and 160 matched non- whereas these thrombogenic factors varied inversely to
infected controls. Replicate serum levels of von Willebrand 8-iso-PG2a, TNF-a and hs-CRP. Relative thrombocy-
Factor (vWF), platelet factor 4 (PF4), P-selectin thrombo- topaenia was associated with significant reduction in
genic factors as well as TNF-a and 8-iso-PG2a were P-selectin and platelet factor 4 levels together with
determined using enzyme immuno-assay while high sen- increased 8-iso-PG2a, hs-CRP, TNF-a and D-dimer levels.
sitive hs-CRP and D-dimer concentrations were determined Taken together, it is recommended that all P. falciparum
by fluorescent immunoassay. The geometric mean of infected blood donors should be deferred.
Electronic supplementary material The online version of this Keywords Platelet thrombogenicity  Platelet factor 4  P-
article (https://doi.org/10.1007/s12288-020-01390-w) contains sup- selectin  8-iso-prostaglandin F2a  Thrombocytopaenia 
plementary material, which is available to authorized users. Blood donors
& Enoch Aninagyei
eaninagyei@uhas.edu.gh
& BackgroundDesmond Omane Acheampong
dacheampong@ucc.edu.gh
In Ghana, the prevalence of Plasmodium falciparum in
1 School of Basic and Biomedical Sciences, Department of blood donors determined by microscopy and rapid diag-
Biomedical Sciences, University of Health and Allied
nostic test was 7.4% and 11.8% respectively [1]. Other
Sciences, PMB 31, Ho, Ghana
study in Ghana reported 10.0% prevalence of P. falciparum
2 Department of Medical Laboratory Science, School of Allied
in blood donors [2]. In other parts of Africa, P. falciparum
Health Sciences, University of Cape Coast, Cape Coast,
Ghana infections among blood donors was reported in the range
3 27.54–65.3% [3–6].Ghana Field Epidemiology and Laboratory Programme,
School of Public Health, University of Ghana, Legon, Accra, Plasmodium falciparum is known to cause relative
Ghana thrombocytopenia in both asymptomatic [7] and symp-
4 Department of Biomedical Sciences, School of Allied Health tomatic infections [8]. The parasite induces thrombocy-
Sciences, University of Cape Coast, Cape Coast, Ghana topenia as a result of excessive removal of platelets by
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Indian J Hematol Blood Transfus (Oct-Dec 2021) 37(4):632–639 633
spleen pooling, an immunologically mediated shortened sample pouch, whole blood was collected into plain glass
platelet life span and destruction of circulating platelets tubes and K2-EDTA tubes.
[9, 10].
Plasmodium falciparum-parasitized red blood cells have Voluntary Donor Selection and Specimen Collection
been shown to induce clumping of platelets in vitro,
mediated by CD36 and P-selectin [11]. Again, anopheline Consented prospective donors were selected according to
anti-platelet protein (AAPP) in the mosquito saliva inhibits Medical History Guide for Donor Selection protocol [18].
adhesion of platelets to collagen. AAPP directly bind to According to 2018 National Blood Service Ghana perfor-
collagen which subsequently blocks platelet adhesion to mance records, male to female ratios of voluntary and
collagen and its subsequent activation [12]. replacement donors were almost the same (4:1) while ratio
Platelets function effectively using three major types of of voluntary to replacement donors was 1:3. In the same
granules; a-granules, dense granules and lysosomes. Over year, a total of about 75,000 units of wholesome blood
85% of granules found on platelets are a-granules [13] units were collected. Per existing criteria for donor selec-
whose major contents are von Willebrand factor (vWF), tion in Ghana, the donors were at least 19 years and at most
P-selectin, fibrinogen and platelet chemokine factor 4 [14]. 60 years, 50 kg with haemoglobin levels above 12.5 g/dL
VWF functions by binding to clotting factor VIII (FVIII). for the purpose of this study, height and body temperature
VWF-FVIII complex subsequently then binds to platelets were also recorded. Body mass index (BMI) was calculated
surface glycoproteins and then to constituents of connec- by dividing weight in kilogram by the square of height in
tive tissues. VWF acts as a stabilizer of FVIII by protecting meters.
it from biodegradation by activated protein C [15]. P-se-
lectin is expressed on the platelet surface where it is rapidly Samples and Control Size Determination
shed into plasma enhancing its bioavailability following
thrombotic events [16] to perform its coagulatory function. The minimum number of infected blood donors were
Finally, platelet factor-4 (PF4), functions by inhibiting determined by using the Cochrane’s formula: n = z2-
local antithrombin III activity by binding to heparin-like p(1 - p)/d2, where n = sample size, p = proportion of
molecules such as polysulfated glycosaminoglycans thus Ghanaian blood donors resident in Greater Accra Region
promoting coagulation [17]. Very little is known about the reported to be infected with P. falciparum by microscopy
effect of malaria parasitaemia on platelet granular contents; (p = 7.4% [1]), 1-p = proportion of blood donors in
von Willebrand Factor, platelet factor 4 and P-selectin Greater Accra Region not infected with P. falciparum,
levels in asymptomatic infections. Therefore, the aim of z = confidence level at 95% (standard value of 1.96),
this study was to evaluate the impact of P. falciparum d = margin of error at 5% (standard value of 0.05). Based
infections on platelet quality in infected Ghanaian blood on these values, the sample size was calculated to be 105.
donors and the relationship between tumour necrosis factor However, only samples from donors of blood group O Rh
alpha (TNF-a), 8-iso-prostaglandin F2a oxidative stress D positive were analysed in this study. Approximately,
biomarker (8-iso-PG2a), C-reactive protein (hs-CRP) and 53.8% [19] Ghanaians are of blood type O Rh D. There-
D-Dimer to platelet thrombogenicity. fore, the minimum number of infected donors of blood type
O Rh D positive recruited in this study was 57. For every 2
infected donor samples analysed, 3 non-infected compar-
Materials and Methods ative controls were analysed.
Study Design Donor Phlebotomy
This study was done in blood donors recruited from the With the aid of a tourniquet, veins, located at the antecu-
Greater Accra Region, Ghana from December 2017 to July bital fossa, were made more prominent and disinfected
2018. A total of 200 donor samples were collected; 80 with 70% isopropyl alcohol and allowed to dry completely.
samples were confirmed microscopically to be infected Venepuncture was perfumed using 16-gauge needle
with P. falciparum while 120 samples were non-infected attached to the blood collection bag. As soon as blood flow
controls (determined by both rapid test and microscopy). was established, the tourniquet was removed. About 40 mL
Donor samples collection have been summarized in Fig. 1. of whole blood was allowed into the sample pouch attached
Malaria infected blood donors and healthy donor controls to the main blood bag. After that, blood was redirected into
were matched. Matched indictors were age, sex, body the main blood containing Citrate Phosphate Dextrose
temperature, height, weight and body mass index. From the Adenine (CPDA-1) anticoagulant. During donation, the
collected blood was gently mixed with the anticoagulant
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634 Indian J Hematol Blood Transfus (Oct-Dec 2021) 37(4):632–639
Fig. 1 Schematic description of donor samples collection algorithm
using mechanical or manual mixer. After adequate blood count and platelet indices determination were done the
has been collected, the needle was removed, injection sites same day of blood collection.
dressed, the needle was severed from the collected tube,
blood labelled and kept on ice packs. Inclusion and Exclusion Criteria
Donor Blood Specimen Collection and Storage Blood donors included in the study were males (blood
group O Rhesus D positive), aged 18–35 years with BMI
Five (5.0) mL of whole blood was collected from the within 16–30 kg/m2 with microscopy detectable malaria
sample pouch attached to the main blood bag (Blue Arrow, parasites. Donors excluded in the study were donors on
China) into plain glass tubes (All-Pro, Dusseldorf, Ger- anti-platelet agents or anti-coagulants. Also donor samples
many) and another 5 mL collected from the sample pouch found to be positive for any of the transfusion-transmitted
into K2-EDTA tubes. About 1.8 mL of serum was stored in infections (TTIs) such as HIV1&II, Treponema pallidum,
cryovial tube at - 80 C (TSX series, Thermo ScientificTM hepatitis B and C viruses were excluded from further
Freezer, USA) till ready for immunoassay while platelet analysis. Finally, infected donors without microscopy
detectable parasitaemia were excluded from the study.
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Indian J Hematol Blood Transfus (Oct-Dec 2021) 37(4):632–639 635
Screening for Malaria and Transfusion-transmitted test cartridge were inserted into the meter in turn. Results
Infections were obtainable after 3 min.
Malaria screening was done with PfHRP2/pLDH SD Bio- Platelet Count and Platelet Indices Determination
line rapid diagnostic test kit (Gyeonggi-do, Republic of
Korea) and parasitaemia determined by 3% Giemsa stain- Absolute platelet counts and platelet indices (mean platelet
ing in positive samples according to WHO protocol [20]. volume, platelet distribution width, plateletcrit and platelet
All infected donor units were discarded. In all blood cen- large cell ratio) were done with a 24-parameter 5-part white
tres in Ghana, only four microbiological markers are blood cell differentiation automated analyser (URIT 5160,
screened for. They are hepatitis B virus, hepatitis C virus, China). Platelets were enumerated on the principle of laser
T. pallidum and human immunodeficiency viruses. Donor beam multi-dimensional cell classification flow cytometry.
units used for this study were negative for all TTIs. In this
studies, specific antibodies against these TTIs were Data Processing and Statistical Analysis
screened for using fourth generation sandwich enzyme
immuno-assays (Abnova, Taiwan). The immuno-assays Laboratory data were entered into Microsoft Excel 2010.
targeted hepatitis B surface monoclonal antibodies, anti- Statistical analysis was done by GraphPad Prism 8.0.1
gp36/gp41 HIV antibodies, antibodies against hepatitis C (GraphPad software, San Diego California USA). Differ-
antigens (core, NS3 and NS5) and Treponema pallidum ences between continuous variables obtained for malaria
antibodies. Manufacturer’s protocols were strictly infected and non-infected blood donors were determined
followed. by unpaired t test with Welch’s correction whilst the
relationship between variables was done by Pearson cor-
Immunoassay for TNF-a, Platelet Factor 4 relation test. p value\ 0.05 was considered statistically
(CXCL4), P-selectin (CD62P), von Willebrand significant.
Factor (vWF) and 8-epi-prostaglandin F2alpha
Oxidative Stress Biomarker
Results
ELISA kits used for quantitative measurement of TNF- a,
Platelet factor 4 (CXCL4), P-selectin (CD62P) and von Characteristics of Infected and Non-infected Blood
Willebrand Factor (vWF) were obtained from Abcam Donors
Trading Shanghai Company Ltd (Pudong, Shanghai,
China; catalogue numbers: ab181421, ab100628, ab100631 Samples from 80 malaria infected blood donors and 120
and ab108918 respectively) while 8-iso-prostaglandin F2 non-infected donors were analysed in this study. The
alpha ELISA kit was also obtained from SunLong Biotech donors were within 18–35 age range; infected donors
(Hangzhou, China, Catalogue Number: SL0035Hu). Man- [mean age: 28 (20–33) years] and non-infected donors
ufacturer’s instruction was strictly followed. The detection [mean age: 27 (19–32) year]s respectively (t = 0.89,
limits for human TNF-a, Platelet factor 4 (CXCL4), p = 0.373). Mean temperature recordings between the two
P-selectin (CD62P), von Willebrand Factor (vWF) and groups were not significant. Similarly, the statistical dif-
8-epi-prostaglandin F2alpha were less than 1.4 pg/mL, ferences between their weights, heights and were also not
20 pg/mL, 20 pg/mL, 9.8 lg/mL and 1.8 pg/ml significant (Table 1).
respectively.
Serum Levels of 8-iso-prostaglandins F2a, hs-C
Fluorescence Immunoassay for hs C-reactive Reactive Protein, Tumour Necrosis Factor, Platelet
Protein and D-dimer Function Tests and D-dimer Levels
Concentrations of high sensitive C-reactive protein (hs- The geometric mean of the parasite density found in the
CRP) and D-dimer were determined using FinecareTM FIA malaria infected blood donors was 1784 parasites/lL (95%
Meter (Wondfo Biotech, Guangzhou, China) based on CI: 1537–2072). The mean 8-iso-prostaglandins F2a
fluorescence immunoassay technology. In brief, the (8-iso-PG2a) oxidative stress biomarker was significantly
respective calibration chip was inserted into the meter, higher in the infected group than in the non-infected
5 lL of serum was mixed with the respective accompa- group (134.2 ± 25.5 pg/mL vs. 94.6 ± 16.3 pg/mL,
nying buffer. Exactly 75 lL of serum-buffer mixture was p\ 0.0001). Again, both inflammatory biomarkers were
dispensed onto the sample well of the hs-CRP and D-dimer significantly elevated in infected donors than non-infected
test cartridge respectively. The hs-CRP and the D-dimer donors (hs-C reactive protein: 1.74 ± 0.19 mg/L vs.
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636 Indian J Hematol Blood Transfus (Oct-Dec 2021) 37(4):632–639
Table 1 Body temperature, age and anthropometric characteristics of the blood donors
Parameters Malaria non-infected blood donors (n = 120) Malaria infected blood donors (n = 80) t-test* p value
Age (mean, nearest year) 27 28 0.89 0.373
Temperature (mean ± SD) 36.8 ± 0.60 37.0 ± 0.53 1.18 0.239
Anthropometric characteristics
Weight (kg) 69.8 ± 11.8 66.9 ± 9.3 1.16 0.250
Height (m) 1.64 ± 0.08 1.62 ± 0.10 1.59 0.117
BMI (kg/m2) 26.1 ± 4.5 25.7 ± 4.3 0.06 0.950
*Unpaired t-test with Welch’s correction
BMI body mass index
0.75 ± 0.23 mg/L), t = 23.2, p\ 0.0001; TNF-a: CRP (r = - 0.195, p = 0.229). However, platelet count
34.3 ± 9.57 pg/mL vs. 23.04 ± 7.78 pg/mL, t = 5.78, significantly varied directly to P-selectin (r = 0.411,
p\ 0.0001). Von Willebrand Factor was lower in the p =\005) and platelet factor 4 (PF4) (r = 0.425,
infected group than the non-infected group but the differ- p = 0.023). While plateletcrit, platelet large cell ratio
ence was not statistically significant (1.48 ± 0.39 lg/mL (P_LCR) and platelet distribution width (PDW) related to
vs. 1.64 ± 0.44 lg/mL, t = 1.82, p = 0.073). However, 8-iso-PG2a, TNF-a, hs-CRP, P-selectin and PF4 in an
both mean platelet factor 4 and mean P-selectin values inverse manner, PDW and P-selectin (p = 0.019) also
were significantly lower in the infected donors than non- inversely related to each other. Also, P-selectin and PF4
infected donors (Platelet factor 4 levels: 32.7 ± 8.57 ng/ significantly varied inversely to 8-iso-PG2a, TNF-a and
mL vs. 51.45 ± 4.33 ng/mL, t = 11.75, p\ 0.0001; P-se- hs-CRP. However, significant direct relationship was
lectin levels: 104.4 ± 21.9 ng/mL vs. 131.9 ± 22.6 ng/ observed between P-selectin and PF4 (r = 0.703,
mL, t = 5.53, p\ 0.0001). Again, mean D-dimer level was p = 0.011). In the non-infected blood donor group, reverse
highly significantly elevated in the infected donors com- of these relationship was observed. (Additional file 1).
pared to non-infected donors (447.3 ± 64.6 ng/mL vs.
157.3 ± 33.3 ng/mL, t = 25.04, p\ 0.0001) (Table 2).
Moreover, absolute platelet counts and platelet indices Discussion
values observed in malaria infected donors significantly
differed from values recorded in non-infected donor. The mean 8-iso-prostaglandins F2a (8-iso-PG2a) levels in
Absolute platelet count (137.9 9 109/L ± 33.4 vs. infected donors were significantly higher than levels in
281.5 9 109/L ± 51.0, t = 14.9, p\ 0.0001), mean pla- non-infected donors. Empirical evidences suggest that high
telet volume (MPV) (7.5 ± 1.11 fL vs. 8.6 ± 1.19 fL, 8-iso-PGF2a levels provoke lipid peroxidation [25–27].
t = 4.13, p\ 0.0001), platelet distribution width (PDW) Concurrently, reductions in absolute platelet count, plate-
(10.6 ± 1.9 fL vs. 12.8 ± 2.6 fL, t = 3.77, p = 0.0003) letcrit and P_LCR in malaria infected donors were
and plateletcrit (0.15 ± 0.06% vs. 0.18 ± 0.06, t = 2.03, observed, a trend that was not observed in the non-infected
p = 0.0454) significantly reduced in malaria infected donors. Here, we speculate that the reduced platelet counts
donors compared to non-infected donors. On the other and platelet indices may be a function of the elevated 8-iso-
hand, platelet large cell ratio (P_LCR) values were sig- PGF2a considering the significant inverse relationship
nificantly higher in non-infected group than infected group between 8-iso-PGF2a and both platelet factor 4 and P-se-
(17.6 ± 5.2% vs. 14.2 ± 4.4%, t = 2.96, p = 0.0041) lectin. These analyses are suggestive of a negative effect of
(Table 2). 8-iso-PGF2a on platelet indices, platelet factor 4 (PF4) and
P-selectin. However, effective thrombogenic activities of
Comparative Correlations Between Variables platelet depends on high absolute count, high P_LCR
together with adequate P-selectin and PF4. Reduction in
Table 3 represents the relationship between significant these parameters will obviously reduce the thrombogenic-
thrombogenic factors and, platelet count, platelet indices, ity of platelets. Given that oxidative stress contributes to
8-iso-PG oxidative stress biomarker, TNF-a pro-inflam- storage lesion of banked blood [28, 29], the additional
matory cytokine and hs-CRP. Platelet count significantly impact of P. falciparum-induced oxidant production cannot
related inversely to 8-iso-PG2a (r = -0.616, p\ 0.05), be neglected.
TNF-a (r = -0.398, p = 0.011) and insignificantly to hs-
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Indian J Hematol Blood Transfus (Oct-Dec 2021) 37(4):632–639 637
Table 2 Analysis of oxidative stress, inflammation, platelets indices and D-dimer in donor blood
Parameters Malaria non-infected blood donors Malaria infected blood donors t-test* p value
Parasite count (geomean) NA 1784
Count range (parasites/lL) NA 505–2478
Oxidative stress biomarker
8-iso-prostaglandins F2a (pg/mL) 94.6 ± 16.3 134.2 ± 25.5 8.26 \ 0.0001
Inflammatory biomarkers
hs-C reactive protein (mg/L) 0.75 ± 0.23 1.74 ± 0.19 23.2 \ 0.0001
Tumour necrosis factor (pg/mL) 23.04 ± 7.78 34.30 ± 9.57 5.78 \ 0.0001
Platelet count and platelet indices
Platelet count (9 109/L) 281.5 ± 51.0 137.9 ± 33.4 14.9 \ 0.0001
MPV (fL) 8.6 ± 1.19 7.5 ± 1.11 4.13 \ 0.0001
PDW (fL) 12.8 ± 2.6 10.6 ± 1.9 3.77 0.0003
Plateletcrit (%) 0.18 ± 0.06 0.15 ± 0.06 2.03 0.0454
P_LCR (%) 17.6 ± 5.2 14.2 ± 4.4 2.96 0.0041
Platelet function tests
Von Willebrand Factor (mg/mL) 1.64 ± 0.44 1.48 ± 0.39 1.82 0.0733
P-selectin (ng/mL) 131.9 ± 22.6 104.4 ± 21.9 5.53 \ 0.0001
Platelet factor 4 (ng/mL) 51.45 ± 6.33 32.7 ± 8.57 11.75 \ 0.0001
Coagulation study
D-dimer (ng/mL) 157.3 ± 33.3 447.3 ± 64.6 25.04 \ 0.0001
*Unpaired t-test with Welch’s correction
NA not applicable, hs-C reactive protein highly sensitive C reactive protein,MPV mean platelet volume, PDW platelet distribution width, P_LCR
platelet large cell ratio. In adult Ghanaians (aged: 18 and 59 years), the normal levels of the study parameters were platelet (145–355x109/L),
PDW (12.6–23.0) [21], 8-iso-PGF2a (67.8-100.4 pg/mL) [22], plateletcrit (0.19-0.29), MPV (6.89-18.69 fL) [23]. TNF-a (42-203pg/mL), hsCRP
(0.175 to 48.7 mg/L) [24]
Table 3 Factors affecting platelet thrombogenicity in P. falciparum infected blood donors
Parameters Platelet count MPV PDW Plateletcrit P_LCR 8-iso-PG2a TNF-a (pg/ hs-CRP P-selectin
(9 109/L) (fL) (fL) (%) (%) (pg/mL) mL) (mg/L) (ng/mL)
8-iso-PG2a - 0. 616 0.061 - 0.215 - 0.542 - 0.714 –
(pg/mL) (\ 0.05) (0.451) (0.318) (0.0047) (\ 0.05)
TNF-a (pg/ - 0.398 - 0.168 - 0.133 - 0.386 - 0.133 0.605 –
mL) (0.011) (0.299) (0.412) (0.014) (0.094) (0.012)
hs-CRP (mg/ - 0.195 - 0.323 - 0.055 - 0.266 - 0.0281 0.711 0.512 –
L) (0.229) (0.451) (0.735) (0.096) (0.863) (0.04) (0.067)
P-selectin (ng/ 0.411 0.144 - 0.318 0.324 0.153 - 0.397 - 0.215 - 0.213 –
mL) (\ 0.05) (0.214) (0.019) (0.004) (0.108) (0.02) (0.09) (0.114)
PF4 (ng/mL) 0.425 0.314 0.478 0.319 0.367 - 0.433 - 0.398 - 0.413 0.703
(0.023) (0.038) (0.011) (0.031) (0.029) (0.013) (0.018) (0.001) (0.011)
Data presented as Pearson correlation r (p value)
Again, high sensitive C-reactive protein (hs-CRP) levels between hs-CRP and platelet count and all the platelet
were also significantly elevated by 56.9% in the infected indices as well as P-selectin and PF4 was observed. These
donors. Meanwhile, hs-CRP is a known biomarker of findings confirm the undesirable effects of increasing hs-
inflammation and systemic infections and also plays a role CRP on platelet population and quality. Storing platelets
in pro-inflammation [30]. Therefore, simultaneous eleva- from malaria infected blood could cause further reduce
tion of both hs-CRP and tumour necrosis factor- (TNF-) in P-selectin and PF4 levels as well as further reduction in
the infected donors was expected. Also, inverse relation platelet count and platelet induced which will ultimately
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reduce the haemostatic functions of platelets. High levels Conclusion
of hs-CRP and acute inflammatory response in malaria is
common [31]; this observation gives credibility to our Asymptomatic P. falciparum infections reduced platelet
observations. Additionally, elevation of TNF- and 8-iso- thrombogenes due to significant increase in oxidative stress
PGF2a seen in this study confirms previous hypothesis that and inflammation, evidenced by elevation of TNF-a and
inflammation and oxidative stress are strongly related and D-Dimer levels, which impacted negatively on platelet
each can be induced by the other [32]. indices. In view of these, it is recommended that blood
In this study, significant lower levels of PF4 were donors in malaria endemic areas should be screened for
observed in the infected donors. PF4 levels in plasma malaria parasites as part of routine selection criteria to
degrades faster, (half-life: 7–11 h) [33] so they may not defer infected donors. It is also recommended that strict
available to in high levels to function. Reduction in PF4 protocols must be instituted to trace all donors with any of
levels could be as a result biodegradation of the protein by the screened transfusion-transmitted infections (HIVI&II,
TNF-a, hs-CRP and 8-iso-PGF2a because of the observed syphilis, hepatitis B, hepatitis C and malaria) and manage
inverse relationship these parameters and PF4. them according to national protocols, to limit spread of the
The study also observed significantly low P_LCR these infections. In this study, only males blood donors
associated with malaria infected blood donors. However, with blood group O positive were studied, it is important
larger platelets are usually relatively younger and contain that the impact of P. falciparum on platelet thrombo-
more intracellular granules therefore with greater throm- genicity in females and other blood groups be assessed for
bogenic potential [34]. Low P_LCR could be due to sup- better understanding of this subject area.
pression of thrombopoetin by TNF-a which will inhibit
thrombopoiesis and of course reduce the number of juve- Acknowledgements The authors are grateful to staff of National
nile thrombocytes. Elevation of TNF-a in malaria infec- Blood Service, Ghana for collaborating with us to implement this
study. We are also grateful to National Malaria Control Programme,
tions is known to down regulate IL-10 which inhibit Ghana for donating the malaria diagnostic kits used for the study.
erythropoietin and possibly thrombopoietin biosynthesis
and its activity [35]. Author’s Contributions EA, AE-Y, DOA conceptualized, super-
In the infected group, there was indication of increased vised the study and analysed study data. PA, TR, PA, GK-N collected
donor specimens and performed laboratory analysis. Manuscript was
fibrinolytic activity as evidenced by elevated serum
drafted by EA, DOA, GK-Nand was reviewed and approved by all
D-dimer. Serum D-dimer is a sensitive and specific marker authors.
of intravascular thrombosis and fibrinolysis [36]. There
was strong suspicion that plasma P-selectin was degraded Funding This work was funded from authors’ own resources.
by circulating TNF-a, 8-iso-PG2a and hs-CRP. This
assumption was supported by the inverse relationship that Data Availability The data used to support the findings of this study
have been deposited in the Harvard Dataverse repository (https://doi.
existed between them and plasma P-selectin in peripheral org/10.7910/DVN/UGYOQF).
blood. As such, the inverse relationship between P-selectin
and D-dimer suggests that P-selectin have been used to Compliance with Ethical Standards
form thrombi, which were subsequently broken down by
Conflict of interest The authors declare that they have no conflict of
plasmin to form D-dimers in donors infected with Plas-
interest.
modium parasites.
In Ghana over 10% of blood donors are infected Ethics Approval This study was approved by Ghana Health Service
asymptomatically with P. falciparum. Not only has P. Ethical Review Committee (GHS-REC002/03/18). The procedures
used in this study adhere to the tenets of the Declaration of Helsinki.
falciparum been found to reduce platelet thrombogenicity
as observed in this study but also it has been found to
severely induce red cells storage lesions during storage [7].
These observations call for deferrals of all P. falciparum References
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Publisher’s Note Springer Nature remains neutral with regard to
Region of Ghana, towards effective blood bank inventory. Sch J
jurisdictional claims in published maps and institutional affiliations.
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