Study of thrombocytopenia in acute febrile illness and it’s prognostic significance at tertiary care hospital

 

 

Abstract              Background: Febrile thrombocytopenia is a usually condition commonly caused by infections. India is a tropical country and a spurt in the number of cases of febrile thrombocytopenia has been noted, especially during the monsoon season. Objectives: To study the clinical profile and prognostic outcome of thrombocytopenia in acute febrile illness patients admitted in medicine ward. Material and Methods: A prospective study on 300 randomly selected cases presenting with acute febrile illness were selected after fulfilling inclusion and exclusion criteria’s. Detailed history was taken with preformed questionnaire. Appropriate laboratory investigations were done. Data was collected and analyzed using SPSS vs 20. Results: Dengue cases were found in majority with 143 (47.7%). Total of 101 (33.6%) cases had severely low platelets, most cases 169 (56.4%) belonged to moderate thrombocytopenia group. Dengue (71) was main etiology among 50,000 group, while viral fever (72) was major etiology in 50,000-1,00,000 group. Most common clinical presentations were rigors 72%, myalgia 67%, headache 44%. In 73% cases there were no any complications. Among 219 non complicated cases ARDS (12.7%) was most commonly seen. Out of total cases, 50 (6%) cases expired due to multiorgan failure. Severity of thrombocytopenia was significantly associated with death cases. Conclusions: Males forming greater burden, dengue being most common etiology in this study. Severity of thrombocytopenia was significantly associated with complication and death cases.

Key Word: Acute undifferentiated febrile illness, Thrombocytopenia, Dengue

 

INTRODUCTION

Infectious diseases are leading causes of morbidity and mortality in tropical countries. The term acute undifferentiated febrile illness (AUFI) connotes fever of <14 days duration without any evidence of organ or system specific aetiology.¹In the recent period there is an upsurge in the number of patients with fever and thrombocytopenia. This may be due to several emerging and re-emerging infections in the recent period.² Patient with severe thrombocytopenia and bleeding manifestations have high mortality and early detection of etiological factor is important in reducing the mortality. Platelets play a central role in normal haemostasis and also in thrombosis.² Febrile thrombocytopenia is the thrombocytopenia associated with fever. Diseases which commonly present with fever and thrombocytopenia are malaria, leptospirosis, rickettsial infections, septicemia, typhoid, borreliosis, arbovirus such as dengue or yellow fever, rodent-borne viruses such as Hanta and Lassa fever, human immunodeficiency virus (HIV), visceral leishmaniasis and TTP-HUS.^3-7 Occasionally these patients can go on to develop a stormy course with multiorgan dysfunction requiring intensive care unit admission associated with high morbidity and mortality.^8,9 The climatic conditions in tropical countries like India are favorable for the transmission of most of these infections and every year, with onset of monsoons, a rising trend has been observed in the number of cases admitted into wards and intensive care units with febrile thrombocytopenia with a variable clinical course and an unpredictable outcome. ¹⁰ There is seasonal variation in the epidemic of fever. At times non-infective causes and drugs can also cause thrombocytopenia and fever. The mortality is very high when there is severe thrombocytopenia and mortality increases due to hemorrhagic manifestations. So, it is imperative that there should be regional studies to assess the etiology of fever with thrombocytopenia.¹¹ There is less data available on this subjects in this area, so we planned to do a study to find out the clinical profile and prognostic outcome of thrombocytopenia in patients with acute febrile illness.

 

MATERIALS AND METHODS

This was a prospective observational study carried out at Medicine wards of Dr. Shankarrao Chavan Government Medical College, Nanded during a study period of one year. Total of 300 cases presenting with acute febrile illness aged 18-65 years were concluded in this study after taking informed consent. Known cases of platelet disorder were excluded from our study. Detailed history regarding personal and disease history was taken with the help of preformed questionnaire. Appropriate laboratory investigations like CBC, PS, PS for MP, dengue IgM/IgG/ELISA, RFT, LFT, CXR, ECG, S. electrolytes were done. Data was collected and analysed using SPSS vs 20. Thrombocytopenia was grouped into three types based on platelet count: Mild 100000-150000, Moderate 100000-50000 and Severe less than 50000.¹⁰Descriptive statistical method like mean, standard deviation (SD), frequencies, proportions, was used.

 

RESULTS

Figure 1: Distribution of cases as per different etiology

Dengue cases were found in majority with 143 (47.7%), next were with viral fever 91 (30.3%), malaria 24 (8%), viral hepatitis 17 (5.6%), Lower respiratory tract infections 16 (5.4%) and Leptospirosis was seen in 9 (3%).

 

Table 1: Distribution of case as per platelet count

Total of 101 (33.6%) cases had severely reduced platelets, most cases 169 (56.4%) belonged moderate thrombocytopenia group and least cases 30 (10%) belonged to mild thrombocytopenia group.

Figure 2: Distribution of thrombocytopenia in different infections

Dengue (71) was main etiology in severe thrombocytopenia group, while viral fever (72) was major etiology in moderate thrombocytopenia group and again dengue (10) was major etiology in mild thrombocytopenia group.

Figure 3: Clinical presentation of cases of fever with thrombocytopenia

Most common clinical presentations were rigors 72%, myalgia 67%, headache 44%, bleeding in 41% and breathlessness was seen in 15% cases.

Figure 4: Distribution as per systemic complication in thrombocytopenia cases

In 73% cases there were no any complications. Among 219 non complicated cases ARDS (12.7%) was most commonly seen. Next was ARF seen in (7%) cases.

Figure 5: Distribution of fever with thrombocytopenia cases as per outcome

Out of total cases, 18 (6%) cases expired due to complications. 9 deaths were due to dengue, 4 due to malaria, 3 viral fever, 2 due to hepatitis. Thrombocytopenia was significantly associated with death cases, severe thrombocytopenia had 10 deaths, moderate had 5 and mild had 3 cases each.

 

DISCUSSION

Total 300 cases of acute febrile illness with thrombocytopenia were evaluated in this study. There were 192 (64%) males and 108 (36%) females, with male: female ratio of 1.7:1. Similar male dominance was reported by study done Nikalje A et al¹² showed ration of 1.4:1, Krishna SA et al¹³ had 1.8:1 sex ratio. While a bit higher ratio seen in Nair PS et al¹⁴ study, who showed ratio of 2.3:1. Total of 101 (33.6%) cases had severely low platelets, most cases 169 (56.4%) belonged to moderate thrombocytopenia group and least cases 30 (10%) belonged to mild thrombocytopenia group. Krishna SA et al¹³ (38%) had platelet count in the range between 20001-50000 cells/μl, which was also in accordance with this study. Nikalje A et al¹² concluded (38.66%) with mild thrombocytopenia, 69(46%) cases with moderate thrombocytopenia, 23(15.33%) with severe thrombocytopenia, which is more or less in support of our findings. Dengue cases were found in majority with 143 (47.7%), next were with viral fever 91 (30.3%), malaria 24 (8%), viral hepatitis 17 (5.6%), Lower respiratory tract infections 16 (5.4%) and Leptospirosis was seen in 9 (3%). Almost similar finding was seen with Krishna SA et al¹³ with Dengue (55%) as the commonest cause, Raikar S et al¹⁵ also concluded the same with dengue (52%) as the most common cause of thrombocytopenia then malaria in (42%). Nikalje A et al¹² also found dengue fever in majority cases 62 (42%). While in Gandhi A et al¹⁶ (2015) found that malaria(42%) was the most common cause followed by dengue (26%),undifferentiated fever(17%). Most common clinical presentations were rigors 72%, myalgia 67%, headache 44%, bleeding in 41% and breathlessness was seen in 15% cases. Similarly Khan AH et al¹⁷ (2010) showed typical clinical features of chills and rigors in 80%, myalgia in 70%, headache in 50%, this was in accordance with our study. Nikalje A et al¹² also found similar features with rigors in 67%, myalgia in 54% cases, headache in 35% cases. While on the contrary Tong FS et al¹⁸ concluded myalgia (69.7%), headache (66.7%) as most common symptoms. In 73% cases there were no any complications. Among 219 noncomplicated cases ARDS (12.7%) was most commonly seen. Next was ARF seen in (7%) cases. Nikalje A et al¹² also had similar results with ARDS in 10%, ARF in 7% cases while they had no complications in 81% cases. The mortality rate was 6% among thrombocytopenia patients. Similar was reported by Krishna SA et al¹³. while in Nikalje A et al¹² the mortality was 5% of total cases. Both these studies had similar observation as with our study. Muthaiah B et al¹⁹ showed a mortality of 28%, this might be due to late presentation of cases in hospital. In the present study out of total cases, 18 (6%) cases expired due to complications. 9 deaths were due to dengue, 4 due to malaria, 3 viral fever, 2 due to hepatitis. All the deaths were due to multiorgan failure. Nikalje A et al¹² study out of total 8(5.33%) deaths, 3 were of dengue, 2 were of mixed malaria, 2 were of undifferentiated fever, and 1 was of mixed infection of malaria and dengue. Thrombocytopenia was significantly associated with death cases, moderate to severe thrombocytopenia had 15 (83%) deaths, and mild had 3 (16%) cases. In Raddi D et al²⁰ study out of total 61 deaths, moderate to severe thrombocytopenia counted for 86% of cases, which was in accordance with our study. Mortality can be reduced by timely and accurate diagnosis, early and effective treatment and care.

 

CONCLUSION

Febrile illness with thrombocytopenia is an important clinical spectrum commonly caused by infections, particularly dengue and malaria. Deaths in febrile thrombocytopenia is not directly linked with severity of thrombocytopenia but with associated involvement of other organs leading to multiorgan dysfunction. Timely diagnosis and appropriate treatment can improve patient survival.

 

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