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Table of Content - Volume 9 Issue 2 - February 2018
Study of patients with acute fever and thrombocytopenia
Nirav Patel1, Krunal Talsaniya2*
1,2Assistant Professor, Department of General Medicine, B J Medical college Ahmedabad, Gujrat, INDIA. Email: krunal.talsaniya@gmail.com
Abstract Background: Fever is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in hypothalamic set point. This study comprised of all hospitalized patients with fever of less then seven days in duration and thrombocytopenia which is divided into Mild (<150,000 to>100,000/mcl), moderate (<100,000 to>50,000/mcl) and severe (<50,000/mcl) categories. Aims and Objectives: To study the common causes of acute fever and thrombocytopenia like Dengue fever, Chikungunya fever, Malaria, and Leptospirosis in relevance to Indian subcontinent by relevant laboratory and immunological tests. Materials and Methods: A single centric, prospective study of 50 indoor patients with fever < 7 days was carried out at B J Medical college and civil hospital and relevant biochemical and laboratory tests were done. Conclusion: Fever with thrombocytopenia occurs more commonly in younger age group (12-30 years) with dengue as most common cause and males preponderance. The cases showed seasonal variability with most cases occurring between June to September. Key Word: acute fever, thrombocytopenia.
INTRODUCTION Thehealthcarefraternityworkingintropicalconditionisfacedwithchallenge of managing wide spectrum of infectious diseases, which are unique in their country. Acute febrile illness with thrombocytopenia is one such condition. The vector borne viral infections, parasitic infections and bacterial infections often present with non specific symptoms making job of clinician very difficult. The clinical manifestations include permutations and combinations of various symptoms such as rash, arthralgia, backache, retro orbital pain, fever, headache etc. The clinical diagnosis, indicating most probable cause of this condition is must be fore patient is subjected to various lab investigations which will help clinician to confirm the diagnosis and manage the case. In some clinical conditions these investigations also have prognostic significance and indicators of complications. A study of these diseases will help an insight view in the understanding and clinching of diagnosis of some of the important treatable infectious diseases. This study comprised of all consecutive hospitalized patients with fever of less then seven days in duration and thrombocytopenia which is divided into three categories.
A vast majority of diseases present with fever of acute onset with thrombocytopenia as a haematological finding in the hemogram. The list includes: 1) Viral fevers like: Dengue fever, Chikungunya, West Nile fever, Sindbis fever, Ebola fever, Hantavirus infection, Mumps, Hepatitis B infection, Parvovirus B19, Lassa fever, Kayasanur forest disease. 2) Parasitic infections: Falciparummalaria. 3)Bacterial infections: Leptospirosis. Disease entities included in our study included following diseases
Being a tropical country, the prevalence of tropical disease poses a great threat to the country's Social and Economical progress. Hence forth, a study of the prevalent tropical diseases would provide a better prospective for the benefit of the individual and the country as a whole and would further help to improve the management guidelines used in treating these diseases1. AIMS AND OBJECTIVES
MATERIALS AND METHODSIt was an analytical study of prospective type. Sample Size: The no. of patients included in the study were 50. Statistics: Diagnostic accuracy is measured by computing sensitivity, specificity, predictive values and likelihood ratios. The precision of these estimates is evaluated using 95% confidence intervals. Methods: Biochemically:
Inclusion Criteria:
Exclusion Criteria:
Exclusion Criteria:
OBSERVATION AND RESULTS Table 1: Case distribution and study
*Acute viral fever, acute viral hepatitis
Table 2: Sex Distribution
Table 3: Admissions in months
Table 4: Bleeding wise distribution
Table 5: Patient having ascites
Table 6: Patient having splenomegaly on USG
Table 7: Platelet wise distribution
Table 8: Hematocrit wise distribution of patients
Table 9: Signs of plasma leak associated with dengue IgM
Table 10: Association of increase in platelet count with days of illness in dengue IgM positive patients.
Table 11: Association of platelet distribution width (PDW) in Dengue IgM and Malaria positive patients
DISCUSSION A total of 50 patients were studied and found to have acute fever and thrombocytopenia. Table 1 shows that 58% cases were dengue, 32% were malaria, 8% were other fever associated with thrombocytopenia and 2% were chikungunya. Study from Uttar pradesh by Praveen Kumar and Kalpna Chandra (172) shows 32.33% cases of malaria, 15. 78% cases of dengue, unlike ours. And 6.31% cases of other fever with thrombocytopenia which is closely correlating with this study2,3. Table 2 shows that most of the patients were younger.74% of patients were of age group of 12 to 30 years. Least affected population was the geriatric, only 2% of patients were in geriatric population. Median age of the patients was 25 years, which is similar to the study from AIIMS by Sharma et al4 i.e.26.3years. This study was carried out in a period from September 2017 to September 2018. Most of the patients were admitted in the months of June to September. In the month of august there were 28% of admission while in the month of September 30% admissions of patients. It also indicates that dengue fever has seasonal pattern and it’s frequency increases during rainy seasons. (Table 3) The study from Indonesia5 also indicated that dengue infection has seasonal variation and frequency increases during the month of June to September. The study from manglore by V.S. Padabidri6 also indicated the same. Table 4 shows that total of 4 patients had bleeding among them 50% of patients had complain of malena 25% of patients had subconjunctival haemorrhage and 25% of patients had hemoptysis. As study done at AIIMS by Sharma et al.4, 70% of patients had complain of bleeding, as opposed to this study where only 8% had complain of bleeding. The AIIMS study showed that 36.5% patients had skin rashes which is closely correlating with this study of 28%. In the manglore study by V.S.Padabidri,6 retoorbital pain was in 46%of patients, closely correlating with this study of 48%. Table 5 shows that 42% of patients had USG finding of ascites and 58% of patients had no finding of ascites. As shownin table 6 only 16% of patients had USG finding of splenomegaly and 84% of patients had no finding of splenomegaly. Splenomegaly was found in 16% cases in this study which closely correlates with other Indian studies. AIIMS study by S. Sharma showed splenomegaly in 8.2% patients and other one in Delhi by B.K.Tripathi7 showed it in 6% patients while the Chennai study by Manjit Narayan8 showed it in 11% of cases. Thrombocytopenia was present in 100% of patients as it was an inclusion criteria. 30% of cases were having severe, 40% of cases having moderate and 30% of cases having mild thrombocytopenia. (Table7) As shown in Table8 <30 haematocrit was in 24% of cases and >40 was in 48% of cases. 48% of patients had no signs of plasma leak. 52% of patients hadsigns of plasma leak. 30% of cases of dengue IgM positive were showing signs of plasma leak and only 12% of cases were dengue IgG positive with signs of plasma leak. Signs of plasma leak is suggestive of third space loss9,10. (Table9). As shown in table 10 only 15% of dengue IgM positive patient had mild thrombocytopenia on 9th day and their platelet count were normal on 10th day. 45% of dengue IgM positive patient had normal platelet count on 8th day and rest 40% of patient had normal platelet count on 9th day. (normal platelet count 150000 to450000/mcl). SUMMARY AND CONCLUSIONSA total number of 50 randomly selected patients were studied, whopresented with fever and thrombocytopenia. Dengue, malaria and chikungunya are the major diseases presenting as fever with thrombocytopenia. CBC, clinical and Biochemical parameters, USG findings and CXR findings were studied for all 50patients. Fevers with thrombocytopenia have a seasonal variability and cases increases during rainy season. Most of the cases presented between June to September out of which maximum number of cases occurred in them onth of august and September, which indicates the association of these illness with rainy season due to breeding habits of vector for the arbo virus, parasites etc. Fever with thrombocytopenia occurs more commonly in younger age group and males are more commonly affected than females. 74% of patients were age group of 12-30 years, as they are the active group who are not confined in the single controlled environment. so, measures to curb the disease rate should be on large public scale. Bleeding is not due to thrombocytopenia alone but it is multifactorial. Leucopenia and moderate to severe thrombocytopenia with PDW>12fl is suggestive of dengue fever while normal or raised WBC count and mild thrombocytopenia with PDW <12fl is suggestive of malaria. Warning signs in dengue patients: Thrombocytopenia with a platelet count of<50,000/mcl Hemoconcentration with a hematocrit of>45 Raised PDW levels These signs are associated with bleeding in all 4 patients in this study, among which Malena was the commonest manifestation. Low platelet counts and high hematocrit is suggestive of warning sign and must be treated aggressively. Spontaneous bleeding occurs below 20,000/mcl platelet count. So, all patients with <20,000/mcl platelet count in background of fever should be treated aggressively with blood component therapy. PDW is Increased in cases of Dengue fever with thrombocytopenia. Signs of plasma leak in the form of third space loss like ascites, and pleural effusion is associated more with dengue fever Dengue is the most common disease presenting with fever and thrombocytopenia. Ascites was the commonest USG finding followed by GB wall thickening. Other findings like splenomegaly and hepatomegaly are lesscommon. 30% had mild, 40% had moderate and 30% had severe Thrombocytopenia. In this study no case of leptospira is found. Leptospira is the least common cause of fever with thrombocytopenia in my study populations, which suggests that it has an endemic preponderence requiring specific environment. PDW (Platelet Distribution Width) was raised in patients with bleeding suggestive of hyperdestructive Thrombocytopenia, which denotes disturbance in platelet activity. Thrombocytopenia in dengue IgM positive patient, recovers by 8thto 10th days of illness, which go hand -in- hand with clinical improvement. So, all patients with dengue IgM positive should be monitored for atleast 7days.
REFERENCES
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