Retention of erythrocytes in the spleen: a double-edged process in human malaria

Splenomegaly is frequent in acute or chronic forms of Plasmodium falciparum malaria, and splenectomy is associated with more frequent fever and parasitaemia. A novel role for the spleen in malaria is indicated by recent epidemiological and experimental data, bringing about a novel paradigm on severe malaria pathogenesis.

In Sudanese children, severe malarial anaemia was associated with larger spleen, longer fever duration, and lower parasitaemia than cerebral malaria. These findings are consistent with evolution toward severe malarial anaemia being linked to the presence of a spleen-dependent mechanism that is absent or inefficient in cerebral malaria. An isolated-perfused human spleen model revealed unexpected retention of numerous erythrocytes harbouring young parasite stages (rings), probably through an innate mechanical process.

A new paradigm is discussed, whereby the extent of erythrocyte retention in the spleen conditions not only haemoglobin concentration and spleen size but also the rate of parasite load increase. The prediction is that, in nonimmune children, stringent splenic retention of rings and uninfected erythrocytes reduces the risk of cerebral malaria (a complication associated with high parasite loads) but increases the risk of severe malarial anaemia. This hypothesis casts new light on epidemiological, genetic, and experimental studies in malaria pathogenesis.