ABSTRACT

CORRESPONDING AUTHOR:
Dr. Rekha M.C,
Associate Professor,
Department of General Medicine,
MIMS, Mandya.
Email: rekhamc73@gmail.com

ABSTRACT: BACKGROUND: In recent days fever with Thrombocytopenia is a common clinical presentation in the medical wards. This study has been undertaken to know the modes of clinical presentations and possible causes of fever with Thrombocytopenia. OBJECTIVE: 1. To determine possible infective etiology for fever with Thrombocytopenia. 2. To correlate clinical features, laboratory studies and infective etiology. METHODS: Case record analysis of fever with Thrombocytopenia admitted to medical wards from june-2013 to December- 2013. RESULTS & CONCLUSION: Dengue, enteric fever and viral fever were the common causes for the Thrombocytopenia.

KEYWORDS: Fever, Infection, Thrombocytopenia.

INTRODUCTION: In recent days fever with thrombocytopenia is common clinical presentation in the medical wards. Established infective causes like Dengue is well known for fever with thrombocytopenia¹. There are not many studies elucidating other infections for thrombocytopenia. Only few studies are available for Enteric fever and Malaria. This study has been undertaken to know the modes of clinical presentations and possible causes of fever with thrombocytopenia where in cause of infection could be established like dengue, enteric fever, malaria, leptospria, hepatitis B, and HIV infection. There may be other infective causes wherein the etiology cannot be pointed out because of lack of facilities or unaffordability.

This study might help us to correlate the clinical features and laboratory findings to come to conclusion regarding the possible infective causes for thrombocytopenia and thus diagnosis and management. Nair P S conducted study of fever with thrombocytopenia and concluded that septicemia was the commonest cause.²

this study was done on patients who were admitted to Alluri Sita Rama Raju Academy of Medical Sciences, ELLURU. 100 patients of fever with thrombocytopenia were studied. Malaria formed the largest group of patients (45%). Septicemia (21%), Dengue (20%), Enteric fever (10%), Leptospirosis (2%), AML (1%), Megaloblastic anaemia (1%)

A study conducted by Md Ayule et al showed that the commonest presentation was fever (100%) followed by headache (48%) myalgia (66%) and vomiting.³ Septicemia resulting from gram negative and gram positive organisms is the commonest cause of thrombocytopenia.^1,4 Causes of fever and thrombocytopenia includes viral, bacterial and protozoal.^1,4

Dengue infection in humans causes a spectrum of illness ranging from in apparent to severe and fatal Dengue haemorrhagic disease.⁵ The observations of SCOTT et al suggested that while patients with malaria may be predisposed to the development of thrombocytopenia, a reduced platelet count in some patients may also be due in part to pseudo-thrombocytopenia.⁷

AIMS AND OBJECTIVES:

       1.      To determine possible infective etiology for fever with thrombocytopenia.

       2.      To correlate clinical features, laboratory studies and infective etiology.

MATERIALS AND METHODS: SOURCE OF DATA: Patient admitted to medical wards with history of fever to MIMS hospital, Mandya from June -2013 to December - 2013. A case record analysis was done. Complete haemogram, blood Widal, malarial parasite smear study, dengue serology, was done. Hbs ag, HCV were in selected cases.

METHOD OF COLLECTION OF DATA:

Sample size:          328 cases.

Study design:        Case Record Analysis from June -2013 to December -2013.

Sample design:     Purposive sampling.

Study duration:    June 2013 to December 2013.

Data analyzed using statistical methods. (Chi square test)

INCLUSION CRITERIA: male and female patients > 14 yrs of age admitted to medical wards with history of fever and thrombocytopenia (PC <1,50,000)

EXCLUSION CRITERIA: Patients with fever with thrombocytopenia other than infective etiology like ITP, drug induced thrombocytopenia, HELLP Syndrome, myeloproliferative diseases, DIC of non-infective etiology (Abruptio placenta, Snake bite), children aged below 14 years are excluded from the study.

STATISTICS:

1. Mean & Standard Deviation of AGE & PC Count in the study subjects

1. Distribution according age & sex in the study subjects

Chi square value 4.818 for 3 degrees of freedom P-Value is 0.186(NS)

1. Distribution according age & Chief complaints in the study subjects

                                Chi square value 6.511 for 6 degrees of freedom P-Value is 0.384 (NS)

1. Distribution according age & Diagnosis in the study subjects

Chi square value 31.57 for 12 degrees of freedom P-Value is 0.3002 (NS)

1. Distribution according to age & Referral for higher centre in the study subjects

Chi square value 5.65 for 3 degrees of freedom P-Value is 0.13(NS)

1. Distribution according to age & PC count in the study subjects

Chi square value 14.799 for 12 degrees of freedom P-Value is 0.253(NS)

Frequency Distribution:

1. Age distribution

1. Sex Distribution

1. Place wise distribution of the study subjects

1. Chief Complaints

1. PC Count

1. Diagnosis

1. Referral

Sex * Chief complaints Code

Crosstab

Count

 Chi-Square Tests

a 2 cells (33.3%) have expected count less than 5. The minimum expected count is 1.98.

Sex * Diagnosis Code

Crosstab

Count

Chi-Square Tests

a 0 cells (.0%) have expected count less than 5. The minimum expected count is 8.40.

Sex * Referral

Crosstab Count

 Chi-Square Tests

a Computed only for a 2x2 table

b 0 cells (.0%) have expected count less than 5. The minimum expected count is 16.30.

Sex * Pccount code

Crosstab

Count

                                               Chi-Square Tests

a 2 cells (20.0%) have expected count less than 5. The minimum expected count is 2.96.

DISCUSSION: In the present study, maximum number of patients (176) was in the age group 21-40 yrs and was from nearby places of Mandya. Males and females were affected almost equally.

The diagnosis was viral fever with mild thrombocytopenia in 129 patients, viral fever with moderate thrombocytopenia in 129 patients, (PC-61000-80000) Dengue was confirmed in 18 patients, Enteric fever was present in 35 patients, mixed infection, (enteric fever and malarial parasite positive) was seen in 17 patients.

Thrombocytopenia was present with a platelet count > 81.000< 1.50.000 in 229 patients (69.8%) platelet count was >61000<80000 in 13.1% of patients, >41000 <60000 in 8.2% of patients, >21000 < 40000 in 7% and < 20000 in 1.8% Clinically bleeding manifestations was seen in 4 patients.

SUMMARY AND CONCLUSION:

1. Viral fever is the commonest cause for thrombocytopenia.
2. Bleeding manifestations are seen when thrombocytopenia in <20000.

REFERENCES:

1.    Dash H S, Ravikiran P, Swarnalatha G. A Study of clinical and Laboratory profile of fever with Thrombocytopenia and its outcome during Hospital Stay IJSR- International Journal of Scientific research445.
2.    Md Ayule et al, Characteristics of Dengue fever in a large public hospital, Jeddah, Saudi Arabia, J of Ayub Med Coll Abott, 2006; 18 (2).
3.    Nair P S, Jain P, Khanduri U, Kumar. V, A study of fever associated thrombocytopenia, J of Asso of Physicians of India.2006; 51: 1173.
4.    Harrison’s Principles of Internal Medicine, 18th ed, chapter 196, Infectious caused by Arthropod and Rodent –Borne Viruses, pg 1621.
5.    Davidson’s principles and practice of Medicine, chapter 13 - Infectious Diseases, 21st ed. pg no 318.
6.    Firkin, Chesterman, Penangton Rush, Haemorrhagic disorders. capillary and platelet defects. In: Degruchi’s Clinical Haematology in Medical Practice, 5 Ed: Oxford Blackwell Science, 1989: 360.
7.    Risdall RJ, Bruning RD, Hermandez JL, Gordan DH, Bacterial associated haemophagocytic syndrome.Cancer.1984 Dec 15; 54 (12).
8.    Gubler DJ, Dengue and Dengue Haemorrhagic fever, Clinical Micro Biol Rev.1998; 113; 480-96.
9.    Sullivan, Patrick S.; Hanson, Debra L.; Chu, Susan Y.; Jones, Jeffrey L.; Ciesielski, Carol A, Surveillance for Thrombocytopenia in Persons Infected With HIV: Results From the Multistate Adult and Adolescent Spectrum of Disease Project, J Acqu Immu Def Synd and Human Retrovirology,1997;14 (4): 374-9.
10.    SCOTT et al, Thrombocytopenia in patients with malaria: automated analysis of optical platelet counts and platelet clumps with the Cell Dyn CD4000 analyser, Clinical and Lab Haematology, 2002; 24 (5): 295-302.