JOURNAL OF EVIDENCE BASED MEDICINE AND HEALTHCARE

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Year : 2021 Month : February Volume : 8 Issue : 8 Page : 445-449.

A Cross-Sectional Study of Clinical Profiles and Complications Associated with Fever with Thrombocytopenia

Melvin Dominic1, Hari Hara C. Sudhan2, Karthik Narayan3, Ram Kirubakar Thangaraj4, Abdussamad M.5, Chandrasekaran V.P.6, Syed Abthahir S.7, Chanjal K.S.8

1, 2, 3, 4, 5, 6, 7, 8 Department of Emergency Medicine, Vinayaka Mission's Kirupananda Variyar Medical College & Hospital, Salem, Tamil Nadu, India.

CORRESPONDING AUTHOR

Dr. Ram Kirubakar Thangaraj, Post Graduate, Department of Emergency Medicine, Vinayaka Mission's Kirupananda Variyar Medical College & Hospital, China Seeragapadi, Salem – 636308, Tamil Nadu, India.
Email : ramrkt1992@gmail.com

ABSTRACT

Background

Fever is the commonest cause of thrombocytopenia that narrows the differential diagnosis and management of fever. The complexity of thrombocytopenia and its control can also be determined through fever. Lack of proper surveillance system and limited laboratory services pose a definite challenge for a perfect diagnosis leading to case management primarily based on clinical manifestations

 

Methods

A cross-sectional study was conducted on 90 patients attending outpatient department of Vinayaka Missions Kirupananda Variyar Medical College & Hospitals, during the period of April 2017 to September 2017 (6 months). In patients with fever with thrombocytopenia, a careful history was recorded, general physical examination, laboratory and technical investigation reports were noted down from regular investigations. Culture sensitivity and serology were considered as primary outcome variables. The continuous data was expressed as mean ± standard deviation (SD) and for independent sample “t” test was used to compare the data. A probability value (“P” value) of ≤ 0.05 at 95 % confidence interval was considered as statistically significant using Statistical Package for the Social Sciences (SPSS).

 

Results

The mean age was 44.73 ± 21.18 years in the study population. 39 (43.33 %) were males and 51 (56.67 %) were females. The average period of stay in the hospital was 8.84 ± 5.73 days; the most common chief complaint was chills & rigors seen in 65 (72.22 %) patients. The most commonly observed comorbidity in the patients was diabetes mellitus. The mean and SD of platelet count was 91522.22 ± 32265.13 per µL. 21 (23.33 %) people had dengue. The mean platelet count at discharge was 192215.19 ± 49481.85 per µL.

 

Conclusions

The commonest cause is infection, for fever with decreased platelet count. A significant number of cases of febrile thrombocytopenia were diagnosed as sepsis in the present study.

 

Keywords

Infection, Dengue, Septicaemia, Petechiae / Purpura, Spontaneous Bleeding, Fever

BACKGROUND

Fever is defined as an elevation of the body temperature above the normal circadian range as the result of a change in the thermoregulatory centre located in the anterior hypothalamus.1 An a.m. temperature of > 37.2° C (> 98.9° F) or a p.m. temperature of > 37.7° C (> 99.9° F) would define a fever. The normal daily temperature variation is typically 0.5° C (0.9° F).2

Characteristics of probable severe fever with thrombocytopenia syndrome patients: a perspective study from Pakistan febrile patient with thrombocytopenia is commonly encountered by physicians especially during monsoon and peri monsoon period.3 Thrombocytopenia is defined as platelet count < 1,50,000 / µL. This is due to decreased production, increased destruction (immunogenic and non-immunogenic), and increased sequestration in spleen. Of these infections being the commonest cause of thrombocytopenia.4 Infections like dengue, leptospirosis, malaria, typhoid, military TB, HIV, septicaemia is some of the common causes of fever with thrombocytopenia.5

In 2005, an outbreak of patients with acute febrile illness having in common gastrointestinal (GI) symptoms, thrombocytopenia, and leukopenia were identified in China.6 Due to the lack of laboratory confirmation, these patients were diagnosed as “Probable Human Granulocytic Anaplasia” on the basis of clinical constellation of symptoms.7 In Pakistan, febrile illness with thrombocytopenia is generally seen after monsoon season.8 dengue, malaria, typhoid, chikungunya and Crimean-Congo haemorrhagic fever (CCHF), and so on are the common etiological agents in the country. During 2017, a number of patients with fever and thrombocytopenia were reported at Rawalpindi Medical University (RMU).9

Lack of proper surveillance system and limited laboratory services pose a definite challenge for a perfect diagnosis leading to case management primarily based on clinical manifestations. Hence, a precise systematic approach is to be conducted with focus on aetiology of fever with decreased platelet count which eventually helps in highlighting the diagnosis. Prompt recognition of the underlying condition and treating it with blood transfusion to increase platelet count is required to prevent deadLy consequences.

With this background the present study was undertaken to determine the clinical profile and complications of fever with thrombocytopenia by evaluating clinical and laboratory profile of fever with thrombocytopenia, identify its cause and complications associated with it. The study was conducted to determine the clinical profile and complications associated with fever with thrombocytopenia.

METHODS

A cross-sectional study was conducted on 90 patients selected through convenience sampling, who were presented to emergency room of Vinayaka Missions Kirupananda Variyar Medical College & Hospitals, during the period of April 2017 to September 2017 (6 months). We prospectively collected the data on a series of 90 patients with fever with thrombocytopenia. After obtaining permission from ethical committee of the institution and informed consent from patients with fever with thrombocytopenia; all IP patients of both sexes above 18 years with history of fever with low platelet count were included in the study.

 

Exclusion Criteria

  1. Patients with thrombocytopenic purpura.
  2. Patients diagnosed to have haematological disorder, malignancy, on chemotherapy and immune suppressants.
  3. Patients with platelet disorders and dysfunction.
  4. Patients on antiplatelet drugs and other drugs which will cause thrombocytopenia.
  5. Patients with chronic liver disease including cirrhosis of liver.

 

A detailed case history, general physical examination of various systems was recorded, and a routine investigation and specific & special investigations were done when required. The patients diagnosed with fever were given treatment accordingly and lab investigation for platelet count was done during discharge and they were not followed thereafter. A detailed history, general physical examination and lab investigations were recorded continuously and once the diagnosis was finalised, treatment was given for specific and symptomatic causes (mechanical ventilations, haemodialysis etc.); for bleeding conditions platelet transfusions was made.

 

Statistical Analysis

Investigation, culture sensitivity and serology were considered as primary outcome variables. Age, gender, total number of hospital stays, symptoms, comorbidities, vitals, and general examination were primary explanatory variables. The data obtained was coded and entered into Microsoft Excel worksheet and later fed into SPSS software. Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. The categorical data was expressed as rates, ratios and proportions and comparison and was done using chi-square test. The continuous data was expressed as mean ± standard deviation (SD) and for independent sample “t” test was used to compare the data. A probability value (“P” value) of ≤ 0.05 at 95 % confidence interval was considered as statistically significant.

RESULTS

A total of 90 subjects was included in the final analysis. The mean age was 44.73 ± 21.18 in the study population. Among the study population, 39 (43.33 %) participants were male and remaining 51 (56.67 %) participants were female. The average period of stay in the hospital was 8.84 ± 5.73 days in the study population. During the study, most common chief complaint was chills & rigours seen in 65 (72.22 %) people. The most commonly observed comorbidity in the patients was diabetes mellitus.

 

 

 

The mean systolic blood pressure recorded during the study period was 126.44 ± 24 in the study population. The mean diastolic blood pressure was 79.11 ± 13.95 the mean pulse rate was 105.44 ± 16.35. The mean respiratory rate was 23.38 ± 6.62, the mean temperature was 102.49 ± 0.9 F. The mean oxygen saturation in % was 95.52 ± 5.34 majority (48.89 %) of the subjects had general sign of pallor. 40 % patients had pedal oedema, (24.2 %) patients had lymphadenopathy, (16.7 %) patients had icterus, (14.4 %) patients had clubbing and (2.2 %) patients had cyanosis.

The mean and SD of haemoglobin was 10.03 ± 2.75, WBC count was 14813.33 ± 8035.11 and platelet count was 91522.22 ± 32265.13. The mean values of serum creatinine, urea, serum bilirubin, serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), activated partial thromboplastin time (APT) are shown in the table 3. Among the study population, all of them 90 (100 %) had normal bleeding time, normal clotting time & normal prothrombin time. Majority (62.22 %) of the subjects had normal blood culture, urine culture and pus culture. 21 (23.3 %) patients had NS1 antigen of dengue, 16 (17.8 %) had IgG and 16 (17.8 %) had IgM. Majority (13.3 %) of the subjects had Widal of leptospirosis. The proportion of participants who had HIV, IgG and IgM was 2.2 % each.

 

 

 

Among the study population, 21 (23.33 %) patients had dengue. The number of leptospirosis, malaria, pyrexia of unknown origin (PUO), sepsis and typhoid were 2 (2.2 %), 6 (6.67 %), 11 (12.22 %), 38 (42.22 %) and 12 (13.33 %) respectively, 31 were treated with fluids, antibiotics, inotropes, and supportive care (FAIS), 25  were treated with fluids, antibiotics and supportive care (FAS), 15 were treated with fluids, fresh frozen plasma, platelet transfusion and supportive care (FFPS), 7 were treated with fluids and supportive care (FS), 6 were treated with fluids, antibiotics, antimalarial (artesunate / artemether / chloroquine) and supportive care (FAAS), 6 were treated with fluids, antibiotics, inotropes, platelet transfusion and supportive care (FAIPS) 11 (12.22 %) had expired and 79 (87.78 %) had good outcome. The mean platelet count at discharge in seconds was 192215.19 ± 49481.85 in the study population, minimum level was 126000 and maximum level was 340000.

DISCUSSION

In our study we found that only 23 % of the population suffered from dengue. However, the number of sepsis cases were around 42 %. These results are in contrast with most of the previous studies. Studies by Saini et al, Gandhi et al and Modi et al found that Dengue fever was the most common aetiology for febrile thrombocytopenia.10-12 A similar study done in Coimbatore by P Vishnuram stated that Out of 100 patients only 34 were dengue positive, 66 were dengue negative.13

A study was conducted by Nair PS et al14 (2003) at St. Stephen’s Hospital, New Delhi, for period of one and half years. A total of 109 cases (76 male, 33 female patients) were studied with the same criteria as in our study. In present study 39 were males and 51 were female. In Nair study septicaemia with 29 cases was the leading cause of fever associated with thrombocytopenia contrast to present study with 38 cases of sepsis.

In Srinivas study15 malaria with 41 cases was the leading cause of fever associated with thrombocytopenia which is in contrast to present study where only 6 cases of malaria were seen. In the present study Dengue with 21 cases and sepsis 38 cases as leading cause of fever associated with thrombocytopenia.

Infections (100 %) was the established diagnosis in the present study when compared to Nair study in which infection (68 %) was accompanied by haematological conditions (15 %). In Srinivas study infections (100 %) were the established diagnosis. there were 6 cases of malaria but a study done by M.P Gondhali et al16 showed 17 cases compared to Nair study there were 41 cases of malaria where species were identified. In the present study species was not identified like Nair and Gondhali et al.16

Platelet counts in the range of 27000 - 144000 was seen in 15 (15 %) cases in our study as compared to 28 (25.7 %) in the studies by Nair et al respectively. In the present study, > 50000 / μL was the range for the distribution of cases. In Nair study, during the course of follow up there was increase in platelet count in 63.3 %  cases and decrease in counts was seen in 7.3 % cases, which was in contrast to present study which showed increase in platelet count in all cases who recovered at the time of discharge. As the present study considered only infectious diseases, decrease in platelet count was not observed. In present study out of 100 patients 15 % had thrombocytopenic sign accounting for 15 % which is in contrast to Nair study and Srinivas study where 41.3 % and 49 % of patients showed signs of thrombocytopenia.

In our study the diagnosis of sepsis was made based upon the criteria given by surviving sepsis. According to the Surviving Sepsis Guidelines, a sepsis diagnosis requires the presence of infection, which can be proven or suspected, and 2 or more of the following criteria: However, the cause of such discrepancy is unknown. We could attribute the low incidence of dengue in our centre to the low mosquito levels.

The cause of thrombocytopenia in these patients could be attributed to sepsis. However, thrombocytopenia triggers a knee jerk reaction which leads to screening for dengue, malaria, typhoid etc. The results of this study signify the need for screening of sepsis in these patients. Although the platelet count in our patients was more than 10000 in most cases the presence of bleeding could be due to administration of NSAIDs.

CONCLUSIONS

The study concluded that fever with low platelet count was very difficult to diagnose as it is a hidden presentation of common diseases rather than rare diseases and infection being one of the most common causes of fever with thrombocytopenia. A significant number of cases of febrile thrombocytopenia were diagnosed as sepsis in the present study, also unjustified use of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids must be avoided.

 

Limitations

Sample size was small and hence the results cannot be generalised. This was a hospital-based study, so can affect the generalisability on healthy population. We did not identify the species for malaria. Bone marrow evaluation was not done which would have given more detailed diagnosis of haematological disorders. Further research with large sample and population-based studies has to be carried.

 

Data sharing statement provided by the authors is available with the full text of this article at jebmh.com.

Financial or other competing interests: None.

Disclosure forms provided by the authors are available with the full text of this article at jebmh.com.

We acknowledge the technical support in data entry, analysis and manuscript editing by “Evidencian Research Associates.”

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DATA SHARING STATEMENT

A data sharing statement provided by the authors is available with the full text of this article at jebmh.com

How to cite this article

Dominic M, Sudhan HHC, Narayan K, et al. A cross-sectional study of clinical profiles and complications associated with fever with thrombocytopenia. J Evid Based Med Healthc 2021;8(08):445-449. DOI: 10.18410/jebmh/2021/87