alaria is a public health problem in Sub Saharan Africa, some parts of South East Asia and South America with considerable morbidity and mortality. This disease was almost eradicated in India during 1960's but to reemerge as a public health problem in last few decades 1 . This is mainly due to development of resistance by mosquitoes against the insecticides and to therapeutic agents by the plasmodium organism. The social and environmental changes also plays major role in this situation. Usually the disease malaria results from the parasites belonging to Plasmodium species. Human malaria is a result of four different species of plasmodium including Vivax, Falciparum, Ovale and Malariae.

Nowadays, Plasmodium Knowlesii a fifth parasite which was known cause malaria in monkeys has been implicated in some parts of Karnataka.

Simple techniques including examination of the peripheral smear is used to establish the diagnosis in Malaria. Fluorescent technique can also be employed to detect the malarial parasite. Nowadays, Malaria is often considered as grey area between the parasitology and hematology. Recent text books have considered malaria as a typical example of Hemolytic Anemia as result of acquired extra corpuscular causes. The common hematological abnormalities accompanied with the malarial infection are anemia, thrombocytopenia, spleenomegaly, mild to moderate atypical lymphocytosis and rarely DIC. 2 The available literature had shown that, the main reason for hemolytic anemia especially in malaria is due to occurrence of cold agglutinins. The cold agglutinins are capable of agglutinating RBCs and hence result in hemolysis. But the literature available shows that the cold agglutinins occur transiently in malaria. This is mainly due to activation of polyclonal B lymphocytes which is predominantly of IgM variety. Rarely might they be either IgA or IgG variety which has the specificity for blood group antigen. The literature suggests that the hemolysis appears in 2 -3 weeks after the malarial infection. The hemolysis is usually mild and self limiting and occasionally severe and fatal. 3,4 Increasing emphases is now given for these antibodies in protection against human malaria which is directed at erythrocytic stages of Plasmodium falciparum. But the protection offered by such antibodies is relatively unstable and the precise role of specificities remains unclear regarding the antigenic variability of parasite proteins. Even though parasite specific antibodies formed contribute to protection, it is not evident to what extent antibodies so formed contribute to protection 5 . Many studies have shown that these antibodies result in hemolytic anemia due to complement mediated RBC destruction in the reticuloendothelial system.

Studies regarding role of cold agglutinins are scant in India and World. This made us to take up this study in order study the profile of patients with Cold agglutinins in Malaria.

This cross sectional study was undertaken in the Department of Microbiology, Basaveshwara Medical College and Hospital, Chitradurga. About 150 patients who were diagnosed as having Malaria by peripheral Results: Out of 150 Patients, who are diagnosed as positive for malaria, 83.3% of the patients had negative for cold agglutinin and only (4%) were found to have high titers of cold agglutinins. The mean age group of the patients who were positive for the test was 45.25 ± 19.7 years. The Hemoglobin percentage and platelet count in cold agglutinin positive patients were 8.85 (± 3.72) gms% and 1, 03, 500 (± 1.16) respectively. About 50% of the Malarial patients with positive cold agglutinin test were infected with Plasmodium vivax and 50% had mixed vivax and Falciparum infection. The difference in type of parasite and results of the cold agglutinin test was statistically significant.

The prevalence of cold agglutinins in patients infected with Plasmodium vivax or P falciparum was 2.67%. There was a significant change in hematological parameters like hemoglobin but not platelets.

smear examination (both thick and thin), MPQBC or by malarial antigen assay before starting the antimalarial treatment were included in the study. An informed consent was obtained from each patient before the study was started and clearance from Intuitional ethical committee was obtained. This study was carried out between January, 2012 to March, 2013.

A detailed history was taken followed by detailed clinical examination for all the patients included in the study. These patients were also investigated for Hemoglobin estimation by cyanmethemoglobin method and Total platelet count by modified Dacie Leurs method.

Cold agglutinin test was used to detect cold agglutinins in the malarial patients. The cold agglutinins if present in patient's serum in high titers may be pathologic and result in cold agglutinin disease. Serum or plasma of all the malarial patients was separated at 37 0 C from a Blood sample collected. A pool of 2 or more examples of washed group O1 adult red cells and Phosphate buffered saline (PBS) at pH 7.3 were used as reagents. A serial two fold dilutions of the patient's serum or plasma in PBS were prepared followed by Two drops of each dilution 1 drop of a 3% to 5% suspension of red cells was mixed. The solution was mixed and incubated at 4 0 C for 1 to 2 hours.

The tubes were centrifuged for 15 to 20 seconds at 900 to 1000 X g. Then it was placed in ice water bath. The tubes were examined microscopically for agglutination, starting with the tube at highest dilution. The results were graded and recorded.

All the details were collected in a pre-structured, self administered proforma. The data thus obtained was compiled and analysed in the form of frequency and proportions. Chi square test and Student T test were used as significance test by using Statistical Package for Social Sciences (SPSS vs 18). A p value of less than 0.05 was considered as statistically significant.

50% had less than normal level of hemoglobin. There was statistically significant difference in the hemoglobin levels between the negative and positive cold agglutinin test patients. IV.

This study was mainly undertaken to study the prevalence of cold agglutinins in malaria patients. The results from this study had shown that about 2.67% of the malarial patients were positive for cold agglutinins with titres above 1:64 dilutions. In a study in 1980 the authors have failed to demonstrate any cold agglutinins in 1980. 6 A study of monoclonal gammopathies of cold agglutinin disease in mayo clinic had shown that the prevalence was 1.1%. A study by Torres et al had shown prevalence similar to that observed in this study. 7 The mean age group of the patients who were positive for the test was 45.2 (± 19.7) years. About 50% of the patients who were positive for the test belonged to 41 -50 years and 61 years and above age group. However there was a statistically significant difference between age group and result of the Cold agglutinin test. The finding from our study shows that the prevalence of cold agglutinins was common in the patients above 40 years. In contrary to these findings, Sharon 4 states that the secondary cold agglutinin disease is common in children and young adults. About 75% of the patients who had cold agglutinins were males in this study.

The mean haemoglobin levels in the positive patients for cold agglutinins was 8.85 (± 3.72) gm% in this study. About 50% of the patients had hemoglobin more than normal and 50% had hemoglobin below normal. This study is able to demonstrate haemolysis similar to the study by Gertz et al 18 . There was no drop in platelet count in patients who were positive for cold agglutinins in this study. Reduced levels of Haemo-globin and Platelet count in malaria patients were recorded by other author 8