INTRODUCTION

Malaria is a systemic disease caused by infection with parasitic protozoa of the genus plasmodium. Plasmodium falciparum is one of the parasite that causes the most virulent form of human malaria and kills at least one million children annually1, mostly in African children under the age of five. Death results mostly from the complications of infection: cerebral disease leading to intractable coma and a severe anemia producing hypoxemia and cardiac decompensation .1 Malaria is a serious problem espescially in Africa, where one in every five (20%) childhood deaths is due to the disease. An African child has on average between 1.6 and 5.4 episodes of malaria fever each year. And every 30 seconds a child dies from malaria.2 In Indonesia, malaria is intense on the outer islands of Papua, Maluku, Nusa Tenggara, Sulawesi, Kalimantan, and Sumatra. It occurs with low frequency or is absent on the islands of Java and Bali where approximately 70% of the population live. All species of human malaria were found in Indonesia.3 The prevalence of malaria has increase from 268,000 in 2001 to 411,797 in 2008. The Plasmodium falciparum proportion was static around 45-50%. The raise in confirmed malaria cases are most likely due to an increased focus on diagnosis and treatment of cases in Eastern Indonesia as a result of new investments in malaria control.3 Malaria manifests in a variety form of disease. Acute infections can lead to cerebral malaria (CM), anemia, respiratory distress, or hypoglycemia. Severe malarial anemia is a major public health problem because of the very large numbers of children affected, and these numbers increase as drug resistance spreads. About half of the world's population - are at risk of malaria. Every year, this leads to about 250 million malaria cases and nearly one million deaths. People living in the poorest countries are the most vulnerable.2 Severe Malarial Anemia is seen most frequently in areas of very high malaria transmission and most commonly in young children and pregnant women. The

prevalence of anemia, defined as a hematocrit (Hct) level higher than 0.33, in malaria-endemic areas of Africa, varies between 31% and 91% in children, and between 60% and 80% in pregnant women. Severe malarial anemia is associated with the high degree of malaria morbidity in children, therefore this term usually refers to severe anemia in children with malaria.4 Many studies have supported the theory of the pathogenesis of severe malarial anemia as a multifactorial and highly complex phenomenon. Knowledge about the pathogenesis of severe malarial anemia would be very important in the treatment of malaria, especially for anemic symptoms. And of course, further understanding will be useful for reducing mortality and morbidity of this disease, especially in children and pregnant women.

CONTENT
Pathogenesis of severe malarial anemia Anemia can be resulted from the disturbance of the equilibrium between production and clearance of red blood cells, also the decrease of erythropoiesis as an additive factor. Based on many research that has been carried out, the pathogenesis of malarial anemia is multifactorial.5,6,7,8 Thus, severe malarial anemia in humans may include one or more of the following mechanisms: (1) the clearance and/or destruction of infected red blood cells, (2) the clearance of uninfected red blood cells, (3) inefficient erythropoiesis and erythropoietic suppression. 1. The clearance and/or destruction of infected erythrocytes Malaria is the most common cause of acquired hemolytic anemia in the world. The destruction of red blood cells occurs in a cycle. During infection there is obvious loss of infected erythrocytes through parasite maturation as well as through recognition by macrophages.7 P falciparum infections have high multiplication rates while also expressing clonally variant antigens at the surface of infected erythrocytes (Pf-EMP-1). Pf-EMP-1 binds to ligands on the surface of endothelial cells and mediates sequestration of infected erythrocytes in postcapillary venules. Both of these characteristics allow the P falciparum parasite to evade the host immune system, which results in the occurrence of high parasitemias with repeated infections that contribute to the chronic nature of this disease. In P vivax and P ovale malaria, high parasitemias are rare as invasion of erythrocytes is limited to reticulocytes. However, P vivax can, on occasion, cause severe disease including anemia with severe hemolysis.5 Once infected by malarial parasites, red blood cell undergo lysis as a result of the process of schizogony, wherein the cell rupture to release newly formed merozoites1. Old or infected red blood cells are removed by phagocytosis (extravascular hemolysis) or lysis (intravascular hemolysis), or both simultaneously. Destruction of
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parasitized red blood cells appears to occurs largely in by phagocytosis, thus spleenomegaly is tipically present in chronic malarial infection. The pitting of parasites from infected erythrocytes may also occurs in spleen. Falciparum malaria is occasionally associated with particularly severe hemolysis and may result in the passage of dark, almost black urine.6,7 2. Clearance of uninfected erythrocytes The apparent degree of anemia is caused by destruction of both parasitized and unparasitized red blood cell.7 During human malaria infection, many unparasitized red cells are destroyed, in the spleen and possibly the liver, and their destruction has been identified as the major contributor to malarial anemia. Both mathematical modeling and clinical observations suggest that 10 times as many uninfected RBCs are removed from the circulation for each infected erythrocyte.7 The activity and the number of macrophages are also increased during human malarial infection, and may therefore contribute to the increased removal of uninfected cells. The increased clearance of uninfected erythrocytes is due not only to the activation of splenic macrophages but also to extrinsic and intrinsic changes to the red blood cells that enhance their recognition and phagocytosis.7 There is still a big question about how and which parasite ligands might influence uninfected erythrocyte clearance and their contribution to anemia. Some research have revealed many consideration about this complex phenomenon.6,7,8 Firstly, considering that invasion is an inefficient process and may be completed in only a small fraction of erythrocytes targeted for infection, parasite antigens are shed during entry, and thus many of these parasite-encoded erythrocyte-adhesive proteins are also present at high levels in plasma. It is possible that they may adhere to uninfected erythrocytes and this could result in IgG or complement binding to erythrocytes, leading to their clearance from circulation. The enhanced destruction of uninfected erythrocytes is a prominent and perplexing feature of malarial anemia. In contrast, HT/PEXEL containing proteins are most likely to be released into plasma at the end

of the intraerythrocytic cycle. These released proteins may aberrantly adhere to uninfected erythrocytes and thus trigger a signal for their removal from circulation.8 One of the several mechanism that been proposed to contribute to red blood cells destruction during malaria is the increase release of oxygen radicals. Exposure of oxygen radicals to the membrane will leads to stifftening of red cell membrane and results in lysis of membrane as the consequence. Oxygen radicals may also induce exhaustion of complement receptor 1 (CD35) and decay accelerating factor (CD55) on red blood cell membranes, which leads to sensitization for phagocytosis. All these concepts emerging the idea of accelerated aging phenotype of red blood cells during malaria that leads to clearance of red blood cells by unspecific mechanism.9 In the report by Fendel et al., the patient with severe malarial anemia have increased level of erythrophagocytosis and intravascular hemolysis. The patients are also characterized by significantly low level of reticulocytes (will be explained later)9. Other study reveals the role of complement and complementary regulatory proteins in the removal of erythrocytes. The study shows that complement and complement regulatory proteins are dysregulated in patients with severe malarial anemia. This condition leads to the enhanced removal of erythrocytes because complement binding receptors (CD35 and CD55) on erythrocyte have been consumed by excessive amounts of activated complement in serum and leave red blood cell prone to lysis. This statement may explain the high occurrence of severe malaria anemia in children between age of 1-3 years old. These children constitutively express reduced levels of complement regulators on their red blood cell surface and therefore they have higher possibility to develop severe malarial anemia.9 A study by Fendel et al. emerge a new point of view, that they found the association of high hemolysis with low reticulocyte production index infers an important effect. Reticulocyte production index estimates the quantity of reticulocytes in the pheripheral blood, corrected for the degree of anemia and therefore is a good measure for whether the compensatory erythropoiesis is adequate for the degree of anemia.

They found that removal of reticulocytes and young red blood cells by phagocytosis will inhibit compensatory mechanism of erythropoiesis.9 3. Inefficient erythropoiesis and erythropoietic suppression Erythropoiesis is the process by which erythroid progenitors proliferate and differentiate into non-nucleated reticulocytes in the bone marrow. It is important to note that all of erythropoiesis occurs in the context of the specialized niches termed erythroblastic islands, composed of erythroblasts surrounding a central macrophage in which cells proliferate, differentiate and enucleate. The intimate interaction between erythroblasts and macrophages during production of erythrocytes accounts for the critical role played by various cytokines in regulating erythropoiesis.8 Recovery from anemia is dependent on appropriate increases in erythropoiesis. One essential factor for enhanced erythropoiesis is erythropoietin (EPO), a 30-kDa hormone produced in the kidney, which promotes growth and differentiation of early erythropoietic cells in the bone marrow. Although systemic EPO levels are elevated in children with malarial anemia, other reports have suggested that these increases are insufficient for the degree of anemia. Reduced erythropoietic responses in children with malaria therefore do not appear to result from insufficient production of these known erythropoietic factors.8 The evidence suggests that involvement of cytokines and other mediators of inflammation is involved. IL6 induces hepcidin expression, which is a master regulator of iron trafficking, resulting to reduced iron availability for erythropoiesis; TGF inhibits erythroblast proliferation; TNF induces cleavage of major erythroid transcription factor, GATA-1; interferon (IFN)- induces macrophage production of TRAIL (TNF-related apoptosis-inducing ligand). TRAIL inhibits erythroblast differentiation. Also, decreased levels of IL12 are associated with severe malarial anemia. Suppression of IL12 decreases production of IFN- and IFN-; suppression of IL12 appears to be a consequence of the induction of IL10, which in turn is stimulated by infection. Children with SMA also show increased circulating levels of
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TNF, IL6, IL1b, IL1RA, MIP1a, MIP1b. Further, recent studies suggest that Th2 cytokines such as IL4 play an important role in erythropoietic suppression.8 From other source, the common feature of falciparum malaria, which is the deposition of substantial concentrations of P. falciparum-derived hemozoin (PfHz; malarial pigment) in bone marrow macrophages, may contribute to inefficient and/or inappropriate erythropoiesis.1 Recent studies illustrated that PfHz and PfHzconditioned media suppress the maturation of erythroid precursors. In addition, high levels of PfHz deposition in monocytes are associated with an increased risk of developing severe malarial anemia. The study demonstrating that PfHz elicits dysregulation of cytokines, chemokines, and effector molecules, suggest that acquisition of PfHz by monocytes/macrophages may promote malarial anemia by altering the production of soluble mediators. Both PfHz and sHz suppressed SCGF gene expression over 48 h in culture, confirming the findings of the gene expression profiling experiments. These results are consistent with the previous studies demonstrating that ingestion of PfHz by monocytes results in dysregulation of hostderived cytokines, chemokines, and effector molecules.9

SUMMARY
Severe anemia is one of the manifestation of acute or repeated malarial infection. Its pathogenesis is considered multifactorial as the destruction of parasitized red blood cells alone will not develops the severe degree of anemia. The factors including clearance of unparasitized red blood cells, inefficient erythropoiesis and erythropoietic suppression. Destruction of parasitized red blood cells occurs in two ways, by maturation of parasite that infecting red blood cells and through recognition of parasitized red blood cells by macrophage. In the other side, the pathogenesis of clearance of unparasitized red blood cells is more complicated, involving many mechanism while some of them remains unclear. These mechanism including activation of spleenic macrophage, the enhanced recognition and phagocytosis by extrinsic and intrinsic changes to the red blood cells , dysregulation of complement and complement regulatory protein, and also removal of reticulocytes and young red blood cells which may inhibit compensatory mechanism of erythropoiesis. The mechanism of inefficient erythropoiesis and erythropoietic suppression are more an activity of cytokines and other inflammatory mediator rather than inadequate erythropoietin production. The already known cytokines that involved in this mechanism includes IL-6, IL-10, IL-12, TNF-, IFN-, IFN-, and TRAIL. Other also mention about role of PfHz and PfHz-conditioned media in the suppression of erythroid precursors maturation. In endemic area, one of every five children die due to this disease. This problem occur largely by a poor understanding about what causing severe anemia in children affected malaria and also the parasite multidrug-resistancy. Adequate knowledge about pathogenesis of severe malarial anemia will lead us to a further understanding about how to prevent and solve this threatening condition.