Restrictive Transfusion in Severe Plasmodium vivax Thrombocytopenia: Observations from a Case Series

Severe thrombocytopenia is common in Plasmodium vivax malaria, but its clinical importance and transfusion needs are unclear. Despite limited evidence, platelet transfusions are often given as a precaution. This study examines clinical outcomes using a restrictive, bleeding-guided transfusion approach in adults with severe P. vivax -related thrombocytopenia. A retrospective case series was conducted in a defence hospital ICU over 9 months (Jan-Sep 2025). Adults with confirmed P. vivax malaria and severe thrombocytopenia (platelet count <50 × 10⁹/L) were included. All received artesunate-based therapy and followed a restrictive transfusion policy, only giving platelets if there was active bleeding or a procedural need. The main outcome was platelet recovery (platelet count ≥100 × 10⁹/L). Other outcomes included bleeding, transfusion use, and survival without major bleeding or platelet transfusion, with platelet recovery. Six adults were studied, with a median age of 60 and 67% female. The median lowest platelet count was 20 × 10⁹/L, ranging from 17 to 23, and increased to 136 × 10⁹/L at discharge, a six- to seven-fold increase. No major bleeding was seen; two patients (33%) had minor mucocutaneous bleeding. One patient (17%) received a platelet transfusion, and two (33%) received red-cell transfusions. Five of six patients (83%) had a favourable outcome. Outcomes were similar for patients with shock or acute kidney injury and those without organ dysfunction. Platelet count thresholds within the severe range didn’t predict bleeding risk. Profound thrombocytopenia in P. vivax malaria was reversible with antimalarial therapy and rarely linked to major bleeding. This small case series supports against prophylactic platelet transfusion and suggests a restrictive, bleeding-guided approach is safe in practice.