CLINICOETIOLOGICAL PROFILE AND OUTCOME OF ACUTE FEBRILE ILLNESS WITH THROMBOCYTOPENIA IN CHILDREN-A HOSPITAL BASED PROSPECTIVE STUDY
Dissertation submitted in partial fulfillment of M.D. DEGREE EXAMINATION M.D. PEDIATRICS, BRANCH-VII
CHENGALPATTU MEDICAL COLLEGE AND HOSPITAL CHENGALPATTU
THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI, TAMILNADU
APRIL 2017
DECLARATION
I Dr. M. ARULGANESH have proposed study titled
“CLINICOETIOLOGICAL PROFILE AND OUTCOME OF ACUTE FEBRILE ILLNESS WITH THROMBOCYTOPENIA IN CHILDREN-A HOSPITAL BASED PROSPECTIVE STUDY” in Department of Pediatrics at Chengalpattu Medical College and Hospital, I hereby ensure that I will abide by the rules of the institutional ethics committee.
A PROSPECTIVE STUDY
A bonafide work done by me in the Department of Pediatrics, Chengalpattu Medical College, Chengalpattu, under the guidance of Prof. Dr. V. POOVAZHAGI, M.D., D.C.H., Ph.D., Professor, Department of Pediatrics, Chengalpattu Medical College, Chengalpattu.
(Dr. M. ARULGANESH) Signature of the candidate
CERTIFICATE
This is to certify that the dissertation titled
“CLINICOETIOLOGICAL PROFILE AND OUTCOME OF ACUTE FEBRILE ILLNESS WITH THROMBOCYTOPENIA IN CHILDREN-A HOSPITAL BASED PROSPECTIVE STUDY” is the bonafide work of Dr. M. ARULGANESH in partial fulfillment of the requirements for M.D. BRANCH-VII (PEDIATRICS) examinations of THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY to be held in 2017.the period of study was from August 2015- September 2016.
Signature of the H.O.D Dean
Professor and Head Chengalpattu Medical College Department of Pediatrics Chengalpattu.
Chengalpattu Medical College Chengalpattu.
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation titled
“CLINICOETIOLOGICAL PROFILE AND OUTCOME OF ACUTE FEBRILE ILLNESS WITH THROMBOCYTOPENIA IN CHILDREN-A HOSPITAL BASED PROSPECTIVE STUDY”
submitted by Dr. M. ARULGANESH, M.D. in partial fulfillment for the award of the degree of DOCTOR OF MEDICINE IN PEDIATRICS by The Tamilnadu Dr.M.G.R Medical University, Chennai is bonafide work done by him in the Department of Pediatrics, CHENGALPATTU MEDICAL COLLEGE, CHENGALPATTU, during the academic year 2015-2017 under my guidance .
PLACE: Chengalpattu Dr. V. POOVAZHAGI, M.D., D.C.H., Ph.D., DATE : Professor ,
Department of Pediatrics
Chengalpattu Medical College,
Chengalpattu
ACKNOWLEDGEMENT
I take this opportunity to express my respect and heartfelt gratitude to all my Teachers. First and foremost I would like to express my sincere gratitude ,heartfelt thanks and appreciation for my guide Dr.V.Poovazhagi M.D.,D.Ch.,Ph.D., for her unparalleled encouragement and everlasting patience from the start of my study, my thesis protocol preparation till the completion of my dissertation. I would like to express my sincere gratitude and heartfelt thanks to my co-guide Dr.J.Sathya M.D.,D.Ch., for her valuable suggestions, encouragement and co- operation provided to me throughout my study.
I would like to express my sincere gratitude to Dr.N.Gunasekaran M.D.,DTCD., The DEAN of this institution for allowing me to utilize the facilities in the institution.
I would like to express my sincere gratitude to Dr.M.Jeyakumar M.D.,DCH., for giving constant support and suggestions for my study. I would like to express my sincere gratitude to Dr.J.Ganesh M.D.,DCH., for his valuable suggestions and guidance for my study. I also like to express my sincere gratitude to Dr.A.Vijayalakshmi M.D., Professor of Microbiology for the support provided by her.
I express my sincere gratitude and thanks to Dr.S.A.Ravikumar M.D., Dr.K.Arivoli M.D.,DTCD.,Dr.S.Suresh Kumar M.D., Dr.A.Jagadeeswari DCH.,Dr.D.Sree Nandhini, Dr. D.Suresh M.D., Dr.R.Diana Grace M.D., for their valuable support and guidance during the course of Study. I express my gratitude to all my colleagues and Staff nurses in our Department. I am extremely thankful to all the children and their parents who have participated in this study.
LIST OF CONTENTS
SI
NO TITLE PAGE
NO
1 INTRODUCTION 1
2 OBJECTIVE 3
3 LITERATURE REVIEW 4
4 METHODOLOGY 18
5 OBSERVATION AND RESULTS 23
6 DISCUSSION 64
7 SUMMARY 72
8 CONCLUSION 75
9 BIBLIOGRAPHY 76
ANNEXURES a) Proforma b) Consent form c) Master chart
LIST OF TABLES
TABLE
NO TITLE PAGE
NO
1 Diagnostic criteria 21
2 Age distribution 24
3 Age and sex distribution 26
4 Geographic distribution 28
5. Month wise distribution 30
6 Symptom catergorization 32
7. Symptom categorization according to age 34 8 Examination findings at admission 35 9 Examination finding in different age groups 37
10 Vital signs at admission 38
11 Physiological status at admission 39 12 Physiological status at admission in different age
group 41
13 Mean, range, standard deviation of lab
parameters. 42
14 Grades of thrombocytopenia 43
15 Comparision of physiological status with grades
of thrombocytopenia 45
16 Grades of thrombocytopenia in different etiology 46 17 Frequency of bleeding manifestations 50 18 Bleeding manifestations in different age group 52
TABLE
NO TITLE PAGE
NO 19 Types of bleeding manifestations in different
etiology 53
20 Grades of thrombocytopenia in different etiology 55 21 Univariate analysis of risk factors among
bleeding and non bleeding groups 57
22 Morbidity 59
23 Etiological Profile 61
24 Outcome 63
25 Grades of thrombocytopenia in different Studies 69
LIST OF FIGURES
FIGURE
NO. TITLE PAGE
NO
1 Sex distribution 23
2 Age wise distribution 25
3 Age and sex distribution 27
4 Area distribution 29
5 Month wise distribution 31
6 Symptom categorization 33
7 Examination findings at admission 36
8 Vitals at admission 40
9 Grades of thrombocytopenia 44
10 Severity of thrombocytopenia in undiagnosed fever
47 11 Severity of thrombocytopenia in dengue fever 48 12 Severity of thrombocytopenia in Scrub typhus 48 13 Comparison of severity of thrombocytopenia in
common etiology
49
14 Bleeding manifestations 51
15 Bleeding manifestations in different age group 54 16 Bleeding manifestations in different etiologies 56 17 Causes identified among children with
thrombocytopenia
62
18 Outcome 63
ABBREVIATIONS
DHF Dengue hemorrhagic fever ALOC Altered level of consciousness WHO World Health Organization
MODS Multi organ dysfunction syndrome DIC Disseminated intravascular coagulation ELISA Enzyme linked immune sorbent assay APTT Activated partial thromboplastin time ITP Immune thrombocytopenic purpura ALL Acute lymphoblastic leukemia PCV Packed cell volume
CSF Cerebro spinal fluid
INTRODUCTION
Fever is the most ancient hallmark of disease. Fever is known as pyrexia from Greek “pyretus” meaning fire. The word Febrile is from the Latin word Febris, meaning fever. Fever is defined as rectal temperature of >38° C(100.4° F)1 or axillary temperature of > 37.5°C2 It is a frequent medical sign that implies increase in body temperature to above normal level. It is considered as one of the natural immune mechanisms to attain neutralization of perceived threat inside the body.
It is a symptom caused by a variety of illnesses. Fever usually occurs in response to infection or inflammation. However many other causes are possible, including drugs , poisons , cancer , heat exposure, injuries or abnormalities in the brain, or disease of the endocrine (hormonal or glandular) system.
Fever rarely occurs without other symptoms or signs. It is mostly accompanied by specific complaints. Many times it is associated with thrombocytopenia in children. The normal platelet count is 1, 50,000 - 4, 50,000 cells/cumm 3. Thrombocytopenia is defined as platelet count less than 1,50,000 cells/cumm3. It results from either decreased
production, increased sequestration or destruction of platelets .The causes for thrombocytopenia are varied from idiopathic, infections to malignancies. Patients with acute febrile illnesses in a tropical country like India usually have an infectious etiology and may have associated thrombocytopenia. Infections like malaria, dengue, typhoid, and leptospirosis are some common causes of fever with thrombocytopenia.
If we can analyze the low platelet count as one of the diagnostic marker of some common infections, we can narrow down the differential diagnosis.
In recent years fever with thrombocytopenia is common clinical presentation in pediatric wards. Fever and thrombocytopenia causes significant morbidity in the form of bleeding manifestations, hemodynamic instability and sometimes leads to mortality. This causes increased anxiety among parents. Literature shows studies about fever with thrombocytopenia among adults but not much data exists among children. But some studies do exist on profile of individual disease like dengue, typhoid, and malaria with thrombocytopenia in children.
Hence this study was conducted to analyze the clinical and etiological profile in preference to infective etiology and its outcome among children admitted at our hospital.
OBJECTIVE
• To study the clinical presentation of children with acute febrile illness associated with thrombocytopenia
• To identify the etiological profile of the children with acute febrile illness associated with thrombocytopenia
• To study the severity of thrombocytopenia and the disease outcome
LITERATURE REVIEW
Putt Suresh et al,4 conducted a study in April 2015 at S.V.R.R.G.G.H, Tirupatirap , AndraPradesh aimed at etiology of fever with thrombocytopenia. Study was undertaken among 50 patients . Thrombocytopenia without fever were excluded. History, clinical examination, platelet count and MP smear, dengue serology, widal and other investigations were done. Thrombocytopenia was common in malaria followed by undiagnosed fever, dengue, typhoid, scrub typhus.
Bleeding was not common with platelet count >50,000cells/cumm and severe spontaneous bleeding was unusual with platelet count >20,000 cells/cumm. Transient thrombocytopenia occurred with systemic infections. Thrombocytopenia occurred in 50% of patients in gram- negative bacteria sepsis.
Malaria fever was the commonest cause of fever with thrombocytopenia, in which 16% patients had severe thrombocytopenia (<50,000 cells/cumm),10% had moderate thrombocytopenia (50,000- 1,00,000cells/cumm) and 10% had mild thrombocytopenia (1,00,000–
1,50,000cells/cumm) especially in falciparum type and it is due to sequestration, immune mediated destruction with elevated platelet
activated immunoglobulin. In dengue fever 12% of patients had severe thrombocytopenia, 8% had moderate thrombocytopenia and 4% had mild thrombocytopenia mainly due to immune mediated mechanisms. In undiagnosed cases, 12% of patients had severe thrombocytopenia, 6%
had moderate thrombocytopenia and 14% had mild thrombocytopenia.
Among all cases 42% of patients had severe thrombocytopenia. The study concluded that thrombocytopenia was a common lab finding in fever. It is necessary to do platelet count in all fever cases. Treating the causative agent will improve the platelet count.
Shankar R Raikar et al,5 done a study at Sir T. Hospital and Government Medical College, Bhavnagar, Gujarat in 2013 to evaluate clinical profile, etiological profile and complications of fever with thrombocytopenia.
Study was conducted in 100 patients . History and complete examination, basic investigations, specific and special investigation done as indicated. The most common etiology was dengue followed by malaria, enteric fever. Male affected more than females. Platelet count started rising on day 3 and became normal by 4-7 days of admission.
There was no correlation between platelet count and bleeding
manifestations, mortality. Thrombocytopenia due to infections was common in rainy and winter season.
Rekha M.C et al,6 conducted a study in 2013 at MIMS hospital, Mandya to identify the profile and etiology of febrile thrombocytopenia in preference to infections. Study was conducted in 328 patients . History, examination, lab investigations were taken. Data was analyzed using chi-square test. The most common symptom was fever followed by myalgia and headache than vomiting and other symptoms. Males and females were equally affected. More than 70% patients had moderate to severe thrombocytopenia. Study concluded that viral fever with thrombocytopenia to be the commonest infection in fever with thrombocytopenia followed by dengue fever , enteric fever and mixed infections. Bleeding manifestations were seen with platelet count
<20,000 cells/cumm. Risk factors for bleeding were not reported in this study.
Praveen Kumar et al,7 done a study in 2011 at Sri Ram Murti Smarak Institute of Medical Sciences, Bhojpuri, Bareilly, Uttar Pradesh to identify etiology, clinical presentation of febrile thrombocytopenia and relation between platelet count and disease outcome. 190 patients included in this study. History, examination and lab parameters were
analyzed. Males are more affected than females. Majority of patients admitted between July to September. Fever was present in 100%
patients, 30% had GI symptoms, 15% had cough and headache, and 10%
had bleeds.
Common etiology was malaria followed by septicemia, dengue fever, leukemia, enteric fever. Mortality occurred in 9.6% patients of which 83% was due to septicemia, 17 % due to complicated malaria.
Mortality was not associated with degree of thrombocytopenia but related to underlying etiology which causes Multiorgan dysfunction.
Amite A Gandhi et al,8 conducted a study on clinical and laboratory evaluation of patients with febrile thrombocytopenia in 2015 to identify common etiologies associated and different bleeding manifestations in relation with platelet count. 112 patients were included in this study. History, clinical examination, basic and special Investigations were done as needed. Most common etiology was found to be malaria followed by dengue, viral fever other than dengue and septicemia. 57% patients had platelet count of > 50,000 cells/cumm.
30% patients had platelets between 20,000 to 50,000 cells/cumm . 13%
patients had < 20,000 cells/cumm. Petechiae was the most common
bleeding manifestations, majority of them had platelet count of
< 50,000cells/cumm. Gum bleeds and gastro intestinal bleeds are less common than petechiae. Epistaxis and hematuria occurred in very less number of patients.
Nikalje anand et al,9 done a study in 2013-15 at MGM Hospital Aurangabad to evaluate clinical outcome of patients presenting with febrile thrombocytopenia in Marathwada region. This was a prospective observational study conducted in 150 patients . History, examination and laboratory evaluation data were analyzed. Patients in whom definite diagnosis was arrived platelet count was repeated at discharge. Most common symptom was fever followed by headache and GI symptoms . 60% of patients admitted with platelet count <
50,000cell/cumm . 35% patients had bleeding manifestations but it was not related to platelet count . Unknown viral fever was found to be the commonest etiology; dengue and malaria were the subsequent common ones. 5% patients expired due to multi organ failure caused by dengue, mixed malaria and viral fever.
Aisha Sajid et al,10 conducted a case series at pediatric department, Madina Teaching Hospital/ university medical college Faisalabad in 2011, to analyze clinical profile of children with dengue fever. 35 children who fulfilled WHO clinical criteria and who were
serologically positive were included in this study. Detailed history, complete examination and laboratory parameters were analyzed by SPSS version 19 software. On analysis fever and abdomen pain were the most common symptoms followed by vomiting and loose stools . Splenomegaly was present in 94% of patients, pallor in 65%, hepatomegaly in 54%, bleeding manifestation in 5% patients.
Leucopenia in 14% elevated liver enzymes in 43% of patients. 68% of patients had moderate thrombocytopenia, only 11% had platelet count less than 50000 cells/cumm. More than 60% patients improved platelet count in 5 days. No transfusion was required. No mortality was documented in this study. 66% children had malaria parasite positivity in peripheral smear study.
Saba Ahmed et al ,11 conducted cross sectional descriptive study in serologically positive children with dengue infection in civil hospital, Karachi in 2006 to study the profile and outcome of dengue fever. 39 children were analyzed in this study. Symptoms and signs, laboratory parameters were analyzed. Mean age of children affected was 8.3years (2-15yeaars). Males were more affected than females. Most of the children presented with fever followed by pain abdomen, vomiting, rashes, myalgia, gastro intestinal bleeding and epistaxis. Pallor was
present in 67% of children. Hepatomegaly in 37% cases and splenomegaly in 6% of children. Seizures, jaundice, hypotension were reported in 3%. The study revealed that 86% children had thrombocytopenia, 57% had anemia, 43% had leucopenia, and 11% had increased hematocrit. 40% children developed bleeding manifestation, with petechiae being the commonest. 4% children had bleeding with normal prothrombin and platelet count; this factor signifies functional capacities of platelets in dengue can also lead to bleeding manifestation.
Shah G.S et al,12 conducted a prospective descriptive study at Dhaka children hospital, Bangladesh in 2001 to identify clinical and laboratory profile of dengue infection in children. 100 seropositive cases in the age group of 8 months to 12 years were analyzed with clinical manifestations and laboratory parameters. Only 15 % had primary dengue infection but 85% children with secondary dengue infection.
Mean age of children affected was 8.3 years. Headache, retroorbital pain, fatigue, arthralgia, vomiting and pain abdomen occurred in equal frequency in about 98% of children. Serological test was performed by rapid strip test. Children vaccinated with JE and Yellow fever were excluded in this study to rule out cross reactivity. Frequencies of clinical signs were as follows hepatomegaly (77% ) , splenomegaly (23%), skin
bleeds (59%) of which > 50% had malena followed by gum bleed and epistaxis. 57% of the children had platelet count less than 100000 cells/cumm, 88 % had high hematocrit, 16% children had platelet less than 50,000cells/cumm. There was no correlation between bleeding and severity of thrombocytopenia suggesting that bleeding in dengue was due to multifactorial causes. Mortality may be high with prolonged shock.
Kriti Mohan et al,13 conducted a cross-sectional study in pediatric hospitals of north India to analyze the occurrence and severity of thrombocytopenia with bleeding manifestation in childhood malaria. 185 malaria positive cases included with mean age of 4 years.Data were recorded in preformed proforma and assessed for thrombocytopenia and bleeding manifestations. Thrombocytopenia observed in 43 % children of whom 20% had mild thrombocytopenia, 15% had moderate, 8% had severe thrombocytopenia. 5% of children with thrombocytopenia had bleeding manifestations with malena being the commonest. No strong association between bleeding and severity of thrombocytopenia was documented. No significant relation between severity of malaria and thrombocytopenia was shown in this study.
Alphonso J Rodriguez-Morales et al,14 conducted a study on anemia and thrombocytopenia in children with plasmodium vivax malaria in hospital Santos Anibal Dominicci , sucre, Venezuela from 2000-2002 . 78 children were evaluated with clinical features and laboratory investigations. 94% children had fever, 41% had chills and 14% had headache. 95% children presented with anemia of which 10%
had hemoglobin < 5g/dl. Mean hemoglobin level 8.09g/dl , mean platelet 1.27 lakhs/cumm . 25% co existent with malnutrition, 10% with intestinal parasitosis. 59% children developed thrombocytopenia. No relation between age and occurrence of anemia and thrombocytopenia.
Hemoglobin and platelet count improved significantly after anti malarial treatment.
Ahmed Yaramis et al,15 conducted a study in Dicle University Hospital, Diyarbakir, Turkey to analyze the clinical and laboratory presentations of typhoid fever. 314 children of age group 6 months to 16 years were included in this study. History, clinical examinations and laboratory investigations were studied in detail. The study revealed fever as most common symptom followed by pain abdomen, vomiting, anorexia and weakness. 42% children had hepatomegaly, 20% had splenomegaly, 6-8% had abdomen tenderness, lymphadenopathy and
encephalopathy. Laboratory analysis revealed high total counts in 78% , elevated liver enzymes in 32% , hemoglobulin <12 gm/dl in 38
%,thrombocytopenia in 10 %.
Chitu CH et al,16 conducted a study in Department of Pediatrics, Chang Gung Children's Hospital, Taoyuan, Taiwan to identify the profile of Typhoid fever in children . Fever was the most common presenting symptom followed by vomiting,diarroea,and abdominal pain. Hepatosplenomegaly was the commonest sign followed by abdominal tenderness. Thrombocytopenia occurred in 9% ,which was the commonest cause for complication in the study group followed by intestinal perforation, rectal bleeding,meningitis.There was no Mortality in the study. Most children responded well to appropriate antibiotic therapy and laboratory abnormalities are transient in nature.
Shruthi K Bhalara et al,17 conducted a cross sectional study at Civil Hospital, Ahmedabad in 2013 to identify the clinical and etiological profile of thrombocytopenia. 412 patients with fever and thrombocytopenia were included in the study. After obtaining detailed history, examination and necessary lab investigations were done.
Bleeding manifestations and complications were monitored throughout the hospital stay. Platelet counts were repeated daily in moderate
thrombocytopenia until values became normal. In the study 31% of children had mild thrombocytopenia with platelet count of 1,00,000 to 1,50,000 cells/cumm , 29% of children had moderate thrombocytopenia with platelet count of 50,000 to 1,00,000 cells/cumm , 50% of children had severe thrombocytopenia with platelet count of <50,000 cells/cumm.
The study revealed dengue fever as the most common etiology for febrile thrombocytopenia followed by malaria , chronic liver disease, septicemia and DIC. Among the malarial infections plasmodium falciparum was most common followed by P.vivax and mixed infection.
46% of thrombocytopenia patients had bleeding manifestations of which gum bleed was the commonest. Bleeding manifestation was common with platelet count of <10,000 cells/cumm.
Pankaj B Palange et al,18 conducted a study to analyze the clinical profile of patients with dengue fever with thrombocytopenia at Bharati Vidyapeeth Deemed University Medical College and Hospital, Sangli in 2012. 68 patients were studied with clinical manifestations and laboratory investigations. Study revealed that males were affected more than females. Frequency of symptoms were fever (100%), myalgia
& arthralgia (98%), petechiae (92%), rash(87%) and bleeding manifestations (75%).
Shock was seen in 35% patients of whom 17% had compensated shock and 18% had hypotensive shock of which 20% patients died. 15%
patients who experienced major bleeding manifestations were in shock at admission. Presence of shock was an important contributing factor to hemorrhage. In this study 70% patients had platelet count of
<50,000cells/cumm , 27% patients had platelet count of 50,000 to 1,00,000 cells/cumm. Mean platelet count at admission was 46,000 cells/cumm. 16 patients had severe bleeding with platelet count of 20,000 to 49,000cells/cumm but no bleeding in patients with platelet count <20,000cells/cumm and only 4 patients had bleeding with platelet count of >50,000 cells/cumm. This signifies that there is no correlation between platelet count and severity of bleeding manifestations. The study concluded that shock with severe bleeding and organ dysfunction was the major factor contributing to mortality. The study also suggested that preventing the development of shock and rapid correction of shock is the key to prevent organ dysfunction and mortality.
Muhammad Ayyub et al,19 conducted a prospective study at King Abdulla Hospital, Jeddah, Saudi Arabia in 2014 to 2015 to determine clinical and laboratory profile of dengue fever and disease
outcome. 80 serology positive dengue cases were included in the study and clinical features and laboratory parameters were analyzed. Males were more affected than females with the ratio of 3:1. Maximum cases were admitted from the months of June to August. Commonest clinical presentation was fever followed by myalgia , headache and vomiting. Rash , hemorrhagic manifestations and positive Hess test were rare in this study.
Laboratory evaluation revealed thrombocytopenia as the commonest abnormality followed by leucopenia. Thrombocytopenia may be due to depression of bone marrow in acute stage of dengue infection. 60% patients had platelet count of <50,000 cells/cumm and remaining 40% patients had mild and moderate thrombocytopenia. 66%
patients had elevated liver enzymes, 25% patients had elevated APTT and 25% patients had increased hematocrit >20% of baseline . This study confirmed endemic occurrence of dengue fever in Jeddah and suggested to focus on sustainable community based environmental control rather than eradication.
Prithviraj patil, et al20 in 2014 conducted a study to evaluate clinical profile and outcome of patients aged >12 years with febrile thrombocytopenia at D.Y. Patil hospital, Kolhapur . It was a prospective
observational study done in 100 patients. Complete history, clinical examination and basic and special laboratory investigation for etiology were done and hospital course was monitored. Platelet count was done on 0,3,5 days and before discharge if <1,50,000 cells/cumm . Platelet counts were repeated until increasing trend in the count was documented.
The study data revealed malaria (54%) was the most common etiology followed by viral fever(17%) , dengue(15%) , enteric fever(6%), and septicemia(4%). Bleeding manifestations mostly occurs with <50,000 cells/cumm and major bleeds in patients with <20,000 cells/ cumm . Petechiae is most common manifestation followed by hematuria and rectal bleed. 95% improved and 5% mortality was documented and was mainly due to septicemia followed by malaria, viral fever. Treatment of cause and supportive therapy yields good outcome.
METHODOLOGY
This was a prospective observational study conducted at the Department of Pediatrics, Chengalpattu Medical College over a period of 12months from September 2015 to August 2016, among children in the age group 1 month to 12 years. In this study all children admitted with history of fever for 5 days or more with thrombocytopenia were included. Neonates, children with afebrile thrombocytopenia, ,known ITP, children with already with diagnosed hematological malignancies or marrow disorders, children on anti- platelets drugs and pseudothrombocytopenia were excluded. Pseudothrombocytopenia 21 is a relatively uncommon phenomenon caused by ex vivo agglutination of platelets. As a result of platelet clumping, platelet counts reported by automated counters may be much lower than the actual count in the blood because these devices cannot differentiate platelet clumps from individual cells. Children were recruited for the study,after informed written consent from parents or care givers at admission , Assent was obtained from children who were more than 7 years of age. Age, gender and geographical location of these children were noted in the pretested preformed. Detailed history included the duration of fever, headache,
myalgia, gastro intestinal symptoms, cutaneous or gastro intestinal or other bleeds like hematuria and epistaxis , breathing difficulty, seizures, edema, puffy face, oliguria and antibiotic exposure prior to hospitalization . Following this, children were subjected for a detailed clinical examination . Clinical features at admission were recorded. The parameters included fever, heart rate, respiratory rate, blood pressure, capillary refill time, hepatomegaly, eschar, splenomegaly, lymphadenopathy, petechiae and ALOC. Tourniquet test 22 was Performed by inflating a blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes. The test is considered positive when 10 or more petechiae per square inch are observed.
In DHF the test usually gives a definite positive with 20 petechiae or more . The test may be negative during the phase of profound shock. It usually becomes positive, sometimes strongly positive after recovering from shock. Following clinical examination, all children were subjected to the investigations as per the unit protocol.
The investigations included Complete blood count, peripheral smear study, urine albumin, blood urea, serum creatinine, liver enzymes and serum bilirubin, xray chest depending upon detailed examination on suspicion of tropical infections MP smear, dengue IgM , scrub typhus
IgM ELISA , widal test , leptospirosis IgM were performed along with blood culture and urine culture. Children with suspected hematological malignancy underwent bone marrow examination. CSF study was not undertaken in any child with thrombocytopenia. However if viral encephalitis was a suspicion CSF analysis was done after recovery from thrombocytopenia as per our unit policy. Children in the study group were followed up till outcome for complications like shock, bleeding manifestations, hepatic failure, renal failure, respiratory distress, cardiac failure , pulmonary edema and multi organ failure. Platelet count and hematocrit were monitored frequently during complications like shock and bleeds in the pediatric intensive care unit (PICU). Platelet count were repeated on alternate days in hemodynamically stable children until it reached 1,50,000 cells/cumm, for the purpose of this study. Need for any blood product transfusion was documented. Platelet transfusion was not routinely undertaken among children in our unit. Presence of DIC or need for surgical or invasive interventions were considered as the indication for transfusion of platelets in our unit.
Final diagnosis was arrived in these children based on clinical and / or laboratory features for the common pediatric infections and other conditions as shown in table no( 1).Children with acute febrile illness
but could not be placed in any of the common diagnosis either clinically or by investigations were labeled as undiagnosed fever for this study category. Outcome was defined as recovery to hospital discharge or death.
Table 1: Diagnostic Criteria Used In This Study
S.NO. DISEASE DIAGNOSIS
1. Malaria Peripheral smear / Rapid diagnostic test positivity
2. Dengue fever Dengue IgM positivity
3. Scrub typhus Presence of Eschar and/or Scrub typhus IgM positivity
4. Enteric Fever Serial rise in widal titres/ enteric culture positivity
5. Leukemia , ITP Peripheral smear, Bone marrow examination
6. Septicemia Blood culture 7. Viral
encephalitis
CSF , MRI Brain 8. Undiagnosed
fever
Absence of a clinical clue with negative investigations
The study was approved by the institutional ethics committee.
Data were entered in Excel Spreadsheet and analyzed using SPSS software Version 16. Simple calculations like Percentages, Proportions and Mean values were derived.
Appropriate statistical tests like Chi- Square test, T test were used to compare the study parameters among the children with bleed and those without bleed. Data was analyzed for any statistical significance with a P value < 0.05 being considered significant.
OBSERVATION AND RESULTS
This study included 100 children with fever and thrombocytopenia. Since the study subjects n = 100, this will be mentioned as n= percentage in the result section in all statistical analysis involving the entire study group. Demographics that like age , gender and location of the patient were analysed using simple statistics like proportions.
1. Sex distribution
Among the 100 children gender distribution revealed 52 % male and 48 % female with male female ratio of 1.1: 1 as depicted in the pie diagram figure.1
Figure 1: Sex distribution
52%
48% MALE
FEMALE
2. Age distribution:
Study group comprised of children between 1 month to 12 years of age. They were categorized as infants, toddlers, preschool children and school children.
Table No. 2 Age Distribution
Age Frequency / Percent
< 1 year 7%
1 -3 years 10%
3-5 years 16 %
>5 years 67%
Out of 100 children 67% were more than 5 years, 16 % were 3 to 5 years, 10 % were 1 to 3 years, 7 % were infants. Infants and toddlers contributed to less than one fifth of the study group in comparison to the preschool children and school going children .Two thirds of study group was constituted by children beyond 5 years . The same has been shown in figure.2
Figure 2: Age wise distribution
7% 10% 16%
67%
0%
10%
20%
30%
40%
50%
60%
70%
80%
<1year 1-3years 3-5years >5 years
3. Age and Sex distribution
Male and female children in various age group in this study is shown in the table no.3.
Table No.3 Age and Sex Distribution.
Age Males (N- 52)
N(%)
Females (N-48) N(%)
Infants 5(9.6) 2(4.1)
Toddlers 4(7.7) 6(14.3)
Preschool children 5(9.6) 11(22.2)
School children 38(74.1) 29(60.4)
In infants and school children males were more affected than females contrast to Toddlers and Preschool children where females were more affected. The same has been shown in figure no.3.
Figure 3: Age and Sex distribution
9.60%
7.70% 9.60%
73.10%
4.20%
12.50%
22.90%
60.40%
0%
10%
20%
30%
40%
50%
60%
70%
80%
<1year 1-3years 3-5years >5 years
MALE FEMALE
Geographic area distribution:
Since Chengalpattu Medical College is the only available tertiary care institute, this caters to the needs of a number of nearby villages from various health union districts . The study group had children from different localities as shown in table no 4.
Table No.4. Geographic Area Distribution
Place Frequency / Percent
Chengalpattu 22
Vandavasi 18
Kanchipuram 15
Maduranthagam 13
Uthiramerur 10
Cheyar 9
Thirukazhukundram 6
Thiruporur 5
Cheyyur 2
Majority of children came from Chengalpattu (22),18 children from Vandhavasi, 15 from Kanchipuram, 13 from Madhuranthagam, 10 from Uthiramerur, 9 from Cheyyar, 6 from Thirukalukundram, 5 from Thiruporur, 2 from Cheyyur. Majority of these areas are located within 30 kilometers from Chengalpattu. The same as depicted in figure 4.
Figure 4 : Geographic distribution
13%
15%
18%
10%
22%
9%
6%
2%
5%
MADURAM KPM VANDVASI UTMRUR CPT CHYR TKM CHEYUR TRPORUR
Though thrombocytopenia occurs uniformly in any common pediatric illness, seasonal variation of the common infections did reveal predominance of children with thrombocytopenia during certain months of the year. Month wise distribution revealed 90% of the study group presenting between the months of August and November.
Table No.5. Month Wise Distribution
Month of admission Frequency / Percent
September 22
October 31
November 22
December 1
January 0
February 1
March 0
April 0
May 0
June 5
July 2
August 15
The same has been depicted in figure .5
Figure 5: Month wise distribution
22%
31%
22%
1% 0% 1%
0% 0% 0%
5%
2%
15%
0%
5%
10%
15%
20%
25%
30%
35%
Percent
Clinical features of children presenting with thrombocytopenia revealed predominant GI symptoms followed by myalgia. Rash as a presentation was encountered in 6% of the children.
Table No.6 Symptom Catergorization
Symptom Frequency / percent
GI symptoms 42
Headache, myalgia 27
GI bleeds 11
Altered sensorium 11
Cutaneous bleeds 9
Other bleeds Seizures 6
Rash( Erythema) 6
Oliguria 3
Seizures 3
In this study 42% children had GI symptoms, 27% children had headache and myalgia, and 22% children had GI bleed and altered sensorium . The same has been represented in figure 6.
Figure 6: Symptom categorization
The clinical presentation was analyzed with respect to the different age groups and this revealed predominant GI symptoms across all age groups. Analysis of the distribution of symptoms in various age groups was undertaken to look for any variation as shown in table no.7
0 5 10 15 20 25 30 35 40 45
27
42
9
11
6
3
8
11
6 Present
Table.7. Symptom distribution in different age groups
Symptom < 1yr (n =7) N(%)
1 to 3 yrs (n=10)
N(%)
3 to 5yrs (n=16) N (%)
>5 yrs (n=67) N(%) Headache,
myalgia
0 0 5(31%) 22(33%)
GI symptoms 4(57%) 6(60%) 6(37%) 26(39%) Cutaneous bleeds 1(14%) 2(20%) 2(12%) 4(5.9%)
GI bleeds 2(28%) 0 1(6%) 8(11.9%)
Other bleeds like gum bleed, epistaxis.
0 1(10%) 1(6%) 4(5.9%)
Seizure 2(28%) 0 0 1(1.4%)
Breathlessness 3(43%) 1(10%) 1(6%) 3(4.4%)
Oliguria 2(28%) 1(10%) 2(12%) 4(5.9%)
Rash (erythema) 1(14%) 1(10%) 1(6%) 3(4.4%) Altered sensorium 6(85%) 1(10%) 0 4(5.9%)
85 % of infants presented with altered sensorium in comparision to the children more than 5 years . GI bleeds ,breathlessness, oliguria and seizures were also occurred in increased frequency among infants.
Examination findings at admission has been tabulated in table no.8
Table No 8.Examination findings at admission
Signs Frequency/ percentage (n=100)
Fever during hospital stay 88
Hepatomegaly 62
Facial puffiness 48
Pallor 37
Lymphadenopathy 25
Splenomegaly 25
Petechiae 14
Eschar 10
Jaundice 1
Out of 100 children studied, 88 children were febrile at admission with temperature of >100.4 F. 50 % of the children had facial puffiness, one third of them had pallor ,one fourth had lymphadenopathy and two third had hepatomegaly. Petechiae,eschar and splenomegaly were less common.
Figure 7 : Examination findings at admission
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 88%
37%
25%
1%
14%
62%
25%
48%
10%
PRESENT
Table No. 9.Examination findings in different age groups
Signs <1 yr (n-7) N(%)
1 - 3 yrs (n-10) N(%)
3 – 5 yrs (n-16) N(%)
>5 yrs (n-67) N (%)
Fever 7(100%) 10(100%) 13(81%) 58(86%)
Pallor 7(100%) 7(70%) 6(37%) 17(25%)
Lymphadenopathy 1(14%) 4(40%) 5(31%) 15(22%)
Petechiae 1(14%) 0(0%) 1(6%) 12(18%)
Hepatomegaly 4(57%) 8(80%) 12(75%) 38(57%) Splenomegaly 2(28%) 6(60%) 6(37%) 11(16%)
Eschar 0(0%) 2(20%) 5(31%) 9(13%)
More than two third of children < 3 years of age had pallor at admission, 75 % of toddlers and preschool children presented with hepatomegaly,two third of toddlers presented with splenomegaly and about one third of preschool children had eschar than other groups
All children in the study groups were evaluated with their vital signs at admission and the findings are tabulated in table no.10
Table .10. Vital signs at admission
Vitals Minimum Maximum Mean Standard deviation
Heart rate / min 64 200 121.33 25.403
Respiratory rate / min
18 72 29.29 8.093
Systolic BP mmHg 62 136 98.214 14.983
Diastolic BP
mmHg
20 74 44.568 9.021
Among the study group 1 child had respiratory distress and subsequently required ventilator support for respiratory failure and septic shock.
Physiological status at admission revealed the following findings . Table no .11. Physiological status at admission
Parameter Frequency / Percent
Compensated shock 22
Narrow pulse pressure 19
Tourniquet Test positive 19
ALOC 14
Wide pulse pressure 11
Hypotensive shock 4
In this study pulse pressure <20 mmHg was defined as narrow pulse pressure, pulse pressure >40 mmHg was defined as wide pulse pressure. Among 100 children, 26 % developed shock of which 22%
children had compensated shock and 4% children had hypotensive shock. 14% children presented with altered sensorium. Abnormal pulse pressure was noted in 30% children of which 19% children had narrow pulse pressure, 11% children had wide pulse pressure. The same has been shown in the following figure 8.
Figure 8: Vital signs at admission
22%
24%
14%
19%
11%
19%
0%
5%
10%
15%
20%
25%
30%
Compensated
shock Hypotensive
shock ALOC Positive TT Wide PP Narrow PP Present
Table 12 : Physiological status at admission in different age groups
Parameter < 1 year (n-7)
1 to 3 years (n-10)
3 to 5 years (n-16)
>5 years (n-67) Compensated
shock
3(42%) 1(10%) 3(19%) 15(22%) Hypotensive
shock
1(14%) 0(0%) 1(6%) 2(3%)
Wide pulse
pressure
1(14%) 3(30%) 1(6%) 6(9%)
Narrow pulse pressure
3(42%) 0(0%) 4(25%) 10(15%)
ALOC 5(71%) 1(10%) 1(6%) 7(10%)
Tourniquet test positive
1(14%) 1(10%) 3(12%) 14(20%)
ALOC, narrow pulse pressure and compensated shock were more common in infants. Tourniquet test positivity was commonly seen in school going children.
Table No:13. Summarizes the range ,mean and standard deviation of the common lab parameters of the study group
Parameters Minimum Maximum Mean Standard deviation
Total count
(cells/cumm)
1700 74000 8540.00 10725.425 Hemoglobin
(grams/dl)
4.3 16.2 11.237 2.1899
Hematocrit (%) 14 48 34.801 6.3928
Highest PCV 16 48 35.532 5.799
Slowest PCV 14 44 31.221 4.9228
Platelet
count(cells/cumm) at admission
5000 270000 75920 48762.3
Lowest platelet count(cells/cumm)
5000 130000 52580 29720.985
SGOT(IU/L) 12 52 26.40 7.742
SGPT(IU/L) 14 46 27.65 7.004
S.Bilirubin (mg/dl)
0.6 2.0 0.908 0.16
Urea (mg/dl) 15 54 23.97 7.881
Creatinine (mg/dl)
0.4 2.0 0.674 0.1952
Severity of thrombocytopenia was graded based on the platelet counts. Platelet count was graded as mild ,moderate,severe and analysis was done as shown below
Grades of Thrombocytopenia :
Platelet count between 1,00,000 cells/cumm and 1,50,000 cells/cumm is mild thrombocytopenia, platelet count between 50,000 cells/cumm and 1,00,000 cells/cumm is moderate thrombocytopenia and platelet count below 50,000 cells/cumm is severe thrombocytopenia 23 .
The same is shown in table no.14.
Table no 14.Grades of thrombocytopenia
Grade of thrombocytopenia Frequency /Percent
Mild 10
Moderate 43
Severe 47
Most of the children had severe thrombocytopenia(47%),
Figure.9 Grades of thrombocytopenia
10
43 47
mild moderate severe
Table 15. comparision of physiological status with severity of thrombocytopenia
Parameters Mild
thrombocytopenia (n-10)
Moderate thrombocytopenia
(n-43)
Severe thrombocytopenia
(n-47)
Compensate d shock
1(10%) 8(19%) 13(28%)
Hypotensive shock
0(0%) 0(0%) 4(8%)
Wide pulse pressure
2(20%) 6(14%) 3(6%)
Narrow pulse pressure
0(0%) 5(12%) 12(25%)
Tourniquet test positive
0(0%) 7(16%) 12(25%)
In this study, compensated shock, hypotensive shock, narrow pulse pressure and positive tourniquet test were common with severe thrombocytopenia.
Analysis was undertaken to identify the severity of thrombocytopenia in different illness among the study group .This is summarized in table no.16
Table no .16.Grades of thrombocytopenia in specific etiology
Etiology Mild
thrombocytopenia (n=10)
Moderate thrombocytopenia
(n=43)
Severe thrombocytopenia
(n=47%)
Undiagnosed fever
4 (8%) 16 (36%) 26(56%)
Dengue fever
0 13 (43%) 17(57%)
Scrub typhus 4 (25%) 8(50%) 4(25%)
ALL 0 4 (100%) 0
Malaria 1 (100%) 0 0
Enteric fever 0 1 (100%) 0
Viral
encephalitis
0 1 (100%) 0
septicemia 1 (100%) 0 0
Among the children affected by undiagnosed fever 56% had severe Thrombocytopenia, 36 % had moderate thrombocytopenia, 8 % had mild thrombocytopenia . The same has been shown in figure.10.
In Dengue fever, severe thrombocytopenia was more common and scrub typhus had moderate thrombocytopenia.
Figure . 10 Severity of thrombocytopenia in undiagnosed fever
In dengue fever 57 % had severe thrombocytopenia, 43% had moderate Thrombocytopenia.
8%
56% 36%
mild moderate severe
Figure.11 Severity of thrombocytopenia in dengue fever
In scrub typhus positive cases 50 % had moderate thrombocytopenia, 25 % had mild, and 25 % had severe thrombocytopenia
Figure12.Severity of thrombocytopenia in scrub typhus
0%
43%
57%
mild moderate severe
25%
50%
25%
mild moderate severe
Figure.13 comparison of severity of thrombocytopenia in common etiologies
0%
10%
20%
30%
40%
50%
60%
Mild Moderate Severe
8%
36%
Undiagnosed fever 56%
Dengue fever Scrub typhus
Bleeding manifestations among children with thrombocytopenia is summarized in table 17. Among the bleeding manifestations petechiae were the commonest bleeding manifestation.
Table No. 17 . Bleeding Manifestations
Bleeding manifestation Frequency/percent(n-31)
Petechiae 14 (46 %)
GI bleeds 11( 35%)
Other bleeds 6 (19%)
Among children with bleeding manifestation 46% had petechiae, 35% had GI bleeds and remaining 19 % children had other bleeds like episatxis,hematuria, gum bleeds, subconjuntival hemorrhage.The same has been depicted in figure no.14.
Figure .14 : bleeding manifestations
35%
19%
46%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
GI bleeds Other bleeds Petechiae
Series1
Table no.18.Bleeding manifestation in different age groups:
Age group With bleeding Without bleeding
< 1 year(n-7) 3(43%) 4(57%)
1 – 3 years(n-10) 1(10%) 9(90%)
3– 5 years(n-16) 3(19%) 13(81%)
>5 years(n-67) 24(36 %) 43(64%)
Bleeding manifestations were most common in infants followed by school going children and rare in toddlers.
Table no.19. Type of bleeding manifestation in different age group:
Bleeding manifestation
<1 year (n=3)
1 – 3 years (n=1)
3 – 5 years (n=3)
>5 years (n=24)
GI bleeds 2(67%) 0 1(33%) 8(33%)
Other bleeds like epistaxis, gum bleed
0 1(100%) 1(33%) 4(17%)
Petechiae 1(33%) 0 1(33%) 12(50%)
Among different bleeding manifestations GI bleeds were more common in infants in contrast to school going children where petechiae was the commonest. The same has been illustrated in the figure no.15.
Figure 15.Bleeding manifestation in different age groups
Platelet count was analysed in individual subgroup of major infections in this study group and is summarized in table.20.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 yr 1-3 yrs 3-5 yrs >5 yrs
67%
0%
33% 33%
0%
100%
33%
17%
33%
0%
33%
50%
GI bleeds Other bleeds Petechiae
Table no.20.Grades of thrombocytopenia in different etiologies
Diagnosis Bleeding manifestat
ion
No of children with mild thrombocytop
enia
No of children with moderate thrombocytop
enia
No of children with severe thrombocytop
enia Dengue
(n=30) 7 (23%) 0 1(14%) 6(86%)
Scrub
(n=16) 4(25%) 1(25%) 1(25%) 2(50%)
Undiagno sed fever (n=46)
13(28%) 0 2(15%) 11(85%)
Among 30 children with dengue fever 7 had bleeding manifestation (23%),among 16 children with scrub typhus 4 had bleeding manifestations (25 %) and among 46 children with undiagnosed fever 13(28%) had bleeding manifestations. In reference to etiology, bleeding manifestations were more common in undiagnosed fever (28%) followed by scrub typhus (25%) and dengue fever (23%).
Bleeding manifestations were more common in children with severe thrombocytopenia.
Figure.16. Bleeding manifestation in different etiologies
Univariate analysis of risk factors for bleeding in children with acute febrile illness and thrombocytopenia were evaluated. The study parameters are compared between two groups with bleeds and without bleeds .The results were summarized in table no.21.
28%
25%
23%
0%
5%
10%
15%
20%
25%
30%
undiagnosed fever scrub typhus dengue fever
bleeding manifestations
bleeding manifestations
Table.no.21 . Univariate analysis of risk factors for bleeding in children
s.no Parameters With Bleeds
Without Bleeds
Chi- Square
P value 1. Gender M
F
11(21.2%) 18(37.5%)
41(78.8%) 30(62.5%)
3.239 0.080 2. Age <5yr
>5yr
9(27.3%) 20(29.9%)
24(72.7%) 47(70.1%)
0.070 1.000 3. GI symptoms
yes no
14(33.3%) 15(25.9%)
28(66.7%) 43(74.1%)
0.660 0.504 4. Compensated shock
Yes No
10(45.5%) 19(24.4%)
12(54.5%) 59(75.6%)
3.709 0.066 5. Hypotensive shock
Yes no
2(50%) 27(28.1%)
2(50%) 69(71.9%)
0.892 0.577 6. Tourniquet test
Positive Negative
12(63.2%) 17(21%)
7(36.8%) 64(79%)
13.292 0.001 7. Platelet count
<50,000cells/cumm
>50,000cells/cumm
20(40%) 9(18%)
30(60%) 41(82%)
4.857 0.020 8. Platelet rising time
< 3 days
>3 days
19(23.5%) 10(52.6%)
62(76.5%) 9(47.4%)
6.362 0.022 9. Duration of
Thrombocytopenia
< 5days
>5days
23(79.3%) 6(20.7%)
60(84.5%) 11(15.5%)
0.394 0.564
S.
No Parameters
Mean value ± SD
F Sig Bleeding group Non Bleeding group
1. Total count
(cells/cumm) 7113.7 ± 4392 9122 ± 12401.131 0.720 0.398
2.
SGOT (IU/L) 26.38 ± 7.42 26.41 ± 7.92 0.000 0.986 3. SGPT(IU/L) 28.10 ± 6.26 27.46 ± 7.32 0.170 0.681 4. Platelet count
at admission (cells/cumm)
59900 ± 39589 79300 ± 48856 3.605 0.061
5. Lowest Platelet count (cells/cumm)
37900 ± 20613 58600 ± 30888 10.917 0.001
The above analysis revealed statistically significant association between bleeding manifestation and positive tourniquet test, lowest platelet count with p value of 0.001 for both parameters.
The above analysis revealed the children without bleeds had an earlier rise in platelet count (< 3 days of hospitalization) in comparison to those with bleeds, this was statistically significant with p value- 0.0221
The above analysis also shows statistically significant risk for bleeding with platelet count of < 50,000 cells/cumm with p value of 0.020
Other study parameters analyzed in this study were duration of fever, duration of thrombocytopenia, PICU stay and hospital stay. The range, mean and standard deviation is represented in the table no .22.
Table no .22. Morbidity
Duration in days Minimum Maximum Mean Standard deviation
Fever 5 16 7.34 2.442
Thrombocytopenia 1 14 4.07 2.056
PICU stay 1 12 2.28 2.055
Hospital stay 2 19 6.90 2.611
In this study fever duration were ranged 5-16 days(mean -7.34 days), duration of thrombocytopenia ranged between 1-14days ( mean - 4.07days), PICU stay ranged from 1-12 days ( mean -2.28 days ) and hospital stay ranged from 2-19 days (mean- 6.9 days).
Final diagnosis was arrived based on the criteria as mentioned in the methodology section. Infective etiology was the commonly identified cause and nearly 45 % of them could not be classified into any of the common illness. Majority of them may be viral or other causes of fever with thrombocytopenia . A repeat evaluation for common infections might have helped to identify more common causes however the invasive blood sampling tests were not repeated for this reason in children who had recovered. The inclusion of bone marrow analysis would have thrown more light into the etiology of thrombocytopenia especially in the undiagnosed fever group. However this being an invasive procedure was not undertaken for ethical reasons unless clinical examination and diagnosis warrented the same. This is a limitation of the present study.
Table no.23.Etiological profile
Diagnosis Frequency Percentage
Undiagnosed Fever 46 46
Dengue Fever 30 30
Scrub Typhus 16 16
Acute Lymphoblastic Leukemia
4 4
Enteric Fever 1 1
Viral Encephalitis 1 1
Septicemia 1 1
Malaria 1 1
In this study ,the most common etiology was found to be dengue fever which is 30% followed by Scrub typhus in 16% . Acute lymphoblastic leukemia was seen in 4% children. Enteric Fever, viral encephalitis, septicemia and malaria all occurred in 1% .Nearly 46 % of the children had undiagnosed febrile illness. The same has been depicted in figure:17.
Figure.17: causes identified among children with thrombocytopenia.
46%
30%
16%
4%
1% 1% 1% 1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Series1
OUTCOME:
Table No.24.Outcome of the study
Parameters Numbers
Recovered to discharge 95
Expired 1
Referral 4
Among 100 children, 95 children were improved with appropriate treatment, 4 children referred for hematological malignancy evaluation and management, 1 child died of septicemia and multiorgan dysfunction.
Figure.18. outcome
0 20 40 60 80 100
improved
referred
expired 95
4
1
Series1
DISCUSSION
As discussed in literature, fever with thrombocytopenia has varied clinical presentation and diverse etiology. In this study clinical profile , etiological profile of febrile thrombocytopenia and its outcome were studied.
1. Sex
In this study male female ratio was almost equal, with male female ratio of 1.1:1 which is comparable with Rekha .M.C et al 5, Praveen Kumar et al 6 and Saba Ahmed et al11 studies that also had male female ratio of 1.2:1. This is an observation in my study as well as other studies
2. Age
In this study the mean age of children affected was 8.5 ± 2.95 years. Saba Ahmed et al11 and Shah G.S et al 12 studies also had a mean age of 8.3 ± 3.5 years. In the present study infants and toddlers were less in comparison to the preschool children and school going children.
3. Geographic area
In the present study most of the children came from Chengalpattu , Vandhavasi and Kanchipuram.
4. Seasonal variation
In the present study 90% of the children presented between the months of August and November. Praveenkumar et al 6 study revealed a major distribution of cases between July to September and Muhammad
Ayub et al19 study documented increased prevalence of cases between June to August. These study results were nearly comparable to the present study. This could be universal phenomenon where certain infective conditions like dengue and scrub are known to have seasonal presentation.
5. Clinical presentation
In the present study majority of children presented with gastro intestinal symptoms followed by headache, myalgia, GI bleeds and altered sensorium. Praveen Kumar et al6 and Saba Ahmed et al12 studies also revealed GI symptoms were the commonest followed by headache and bleeds in Praveen Kumar et al 6 study and rashes in Saba Ahmed
