CLINICOETIOLOGICAL PROFILE AND OUTCOME OF ACUTE FEBRILE...

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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

ii

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

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CERTIFICATE

This is to certify that the dissertation titled



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.

iv

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation titled



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

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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.

vi 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.

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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

xi

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

xii

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

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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

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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

1

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

2 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.

3

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

4

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

5 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

6 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

7 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

8 < 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

9 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

10 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

11 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.

12 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

13 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

14 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%).

15 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

16 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

17 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.

18

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,

19 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

20 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

21 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

22 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.

23

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

24 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

25

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

26 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.

27

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

28 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.

29

Figure 4 : Geographic distribution

13%

15%

18%

10%

22%

9%

6%

2%5%

MADURAM

KPM

VANDVASI

UTMRUR

CPT

CHYR

TKM

CHEYUR

TRPORUR

30 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

31

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

32 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.

33

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

911

6

3

8

11

6

Present

34

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.

35 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.

36

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

37

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

38

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.

39 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.

40

Figure 8: Vital signs at admission

22%

24%

14%

19%

11%

19%

0%

5%

10%

15%

20%

25%

30%

Compensatedshock

Hypotensiveshock

ALOC Positive TT Wide PP Narrow PP

Present

41

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.

42 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

43 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%),

44

Figure.9 Grades of thrombocytopenia

10

43

47

mild moderate severe

45

Table 15. comparision of physiological status with severity of

thrombocytopenia

Parameters Mild thrombocytopenia

(n-10)

Moderate thrombocytopenia

(n-43)

Severe thrombocytopenia

(n-47)

Compensated 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.

46

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)


(n=43)


(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

47 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%

36%56%

mild

moderate

severe

48

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

49

Figure.13 comparison of severity of thrombocytopenia in common

etiologies

0%

10%

20%

30%

40%

50%

60%

Mild Moderate Severe

8%

36%

56%Undiagnosed fever

Dengue fever

Scrub typhus

50

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.

51

Figure .14 : bleeding manifestations

35%

19%

46%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

GI bleeds Other bleeds Petechiae

Series1

52

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.

53

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.

54

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

55

Table no.20.Grades of thrombocytopenia in different etiologies

Diagnosis

Bleeding manifestat

ion

No of children with mild

thrombocytopenia

No of children with moderate thrombocytop

enia

No of children with severe

thrombocytopenia

Dengue (n=30)

7 (23%) 0 1(14%) 6(86%)

Scrub (n=16) 4(25%) 1(25%) 1(25%) 2(50%)

Undiagnosed 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.

56

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

57

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

58

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

59 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).

60 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.

61

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.

62

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

63 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

improvedreferred

expired

95

41

Series1

64

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.

65 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

66 12et al study. Ahmed Yaramis et al 15, Aisha Sajid et al10, Chitu CH et

al16 studies also showed GI symptoms was the commonest in more than

two third cases. These studies results were comparable with the

present study.

In contrast Shah GS et al12 and Nikalje anand et al 8 studies

showed headache was the commonest than GI symptoms.

6. Clinical signs

In the present study 88% children were febrile at admission . Two

third children had hepatomegaly, one third children had pallor , one

fourth had splenomegaly and one sixth had petechiae at admission .

Shah G.S12 et al study revealed hepatomegaly in three fourth children,

splenomegaly in one fourth of children and petechiae in half the study

group. Ahmed Yaramis et al 15 study shows hepatomegaly in two fifth

of children, splenomegaly in one fifth and altered sensorium in 6%

children . These study results were comparable with present study. In

contrast Saba Ahmed et al 11study showed pallor was the commonest

presentation with 67 % followed by hepatomegaly in 37 % and

splenomegaly in 6 % children and Aisha Sajid et al10 study showed

that splenomegaly was the commonest presentation in 94% children

followed by pallor in 65 % of children and hepatomegaly in 64%.

67 7. Vital signs

In the present study mean heart rate was 121.33 ± 25.4

beats/minute, mean respiratory rate was 29.29 ± 8.1 breaths / minute.

Mean systolic blood pressure was 98.214 ± 14.9 mm Hg and mean

diastolic blood pressure was 44. 568 ± 9.021 mmHg. 22% children

had compensated shock and 4% children had hypotensive shock of

which one child had respiratory failure and required ventilatory

support. Shock was commonly associated with severe thrombocytopenia.

Pankaj B Palange et al 18study results showed shock in 35% cases of

which 17 % had compensated shock and 18% had hypotensive

shock which is nearly comparable to the present study. Occurrence of

hypotensive shock indicates late presentation. This could be due to

various factors like parental ignorance, lack of access to health care

facility and inappropriate treatment.

8. Thrombocytopenia

In the present study among 100 children 47% had severe

thrombocytopenia , 43% had moderate thrombocytopenia and 10%

had mild thrombocytopenia . Muhammad Ayub et al19 study revealed

severe thrombocytopenia in 60% children , moderate

thrombocytopenia in 20% and mild thrombocytopenia in 20%.

68 Shruthi k Bhalara et al 17 study showed severe thrombocytopenia in

50%, moderate thrombocytopenia in 29 % and mild

thrombocytopenia in 21% children . Pankaj B Palange et al19 study

revealed severe thrombocytopenia in 60%, moderate

thrombocytopenia in 27 % and mild thrombocytopenia in 13%.

These studies are comparable to the present study. In contrast Kriti

Mohan et al13 study showed that mild thrombocytopenia 48% ,

moderate thrombocytopenia in 35% and severe thrombocytopenia

17% of children, Shah G.S et al revealed mild thrombocytopenia in

54 %, moderate thrombocytopenia in 40% and severe

thrombocytopenia in 16% of children and Aisha Sajid et al 10 study

result showed moderate thrombocytopenia in 68%, mild

thrombocytopenia in 21% and severe thrombocytopenia in 11% .

Puttasuresh et al3 study showed that thrombocytopenia in Malaria due

to sequestration and immune mediated destruction with elevated platelet

activated immunoglobulins and thrombocytopenia in Dengue fever due

to immune mediated mechanism. Muhammed Ayub et al 19 study

revealed marrow depression in acute stage of Dengue infection causes

thrombocytopenia.

69 Table. 25: Severity of thrombocytopenia in different studies

Study Mild thrombocytopenia



Muhammed Ayub et al

20% 20% 60%

Pankaj B Palange et al

13% 27% 60%

Shruti K Bhalara et al

21% 29% 50%

Kriti Mohan et al

48% 35% 17%

Shah G.S et al 54% 40% 16%

Aisha Sajid et al

21% 68% 11%

This study 10% 43% 47%

9. Bleeding manifestations

In the present study petechiae was the commonest one which

accounts for 46 % followed by GI bleeds 35% and other bleeds

like epistaxis, subconjunctival hemorrhage , gum bleeds collectively

accounts for 19%. Among bleeding manifestations GI bleeds were

common in infants in contrast to school going children where

petechiae was the common one . Saba Ahmed et al11 study result

showed petechiae in 40 % of the study group . Prithviraj et al20

and Amitha G Gandhi et al 7 studies also showed that petechiae

70 was the commonest bleeding manifestation followed by gum bleeds ,

epistaxis, hematuria and GI bleeds. The above study results were

comparable with the present study. In contrast Shah G.S et al 12 and

Kriti Mohan et al 13 study results revealed GI bleeds were more

common than petechiae and other bleeds and Shruthi K Bhalara et

al 17 study showed gum bleeds was the commonest one.

In the present study bleeding manifestations were more

common in children with severe thrombocytopenia with platelet

count of less than 50, 000 cells / cumm. Shruthi K Bhalara et al17

and Prithvi Raj et al20 studies also shows that bleeding

manifestations were more common with platelet count less than

50,000 cells/cumm. In contrast pankaj K Palange et al18, Kriti

Mohan et al 13, Shah G.S et al12 , Nikalje Anandh et al8 , Shankar

Raikar et al 4 study results revealed that there was no relation

between platelet count and bleeding manifestations.

In the present study mean platelet rising time 2.7 days which

is comparable with Shankar Raikar et al 4 study which shows mean

platelet rising time is 3 days .

Mean duration of thrombocytopenia in this study is 4.07 ±

2.056 days which is comparable with Aisha Sajid et al10 study

where mean duration of thrombocytopenia was 5 days.

71 10. Etiology

In the present study undiagnosed fever was the commonest

etiology for fever with thrombocytopenia followed by Dengue

fever, Scrub typhus, leukemia, Malaria , Enteric fever and Septicemia.

Prithvi Raj et al ,20 Rekha M.C et al5 and Nikhalje Anand et al8

study results shows undiagnosed fever was the commonest etiology

followed by dengue fever and enteric fever. These studies were

comparable with present studies. Shankar Raikar et al4 and Shruti K

Bhalara et al17 studies revealed that Dengue fever was the

commonest etiology followed by malaria and sepsis, these studies

were also comparable with present study in reference to diagnosable

etiology. In contrast Putta Suresh et al3, Praveen Kumar et al6 and

Amita G Gandhi et al 7studies showed malaria as commonest

etiology followed dengue and undiagnosed fever.

11. Outcome

In this study 95 % improved and discharged,4 children referred for

hemato oncological consultation and one child expired due to associated

septicemia and MODS.

72

SUMMARY

Fever with thrombocytopenia is common clinical problem in

pediatric wards. Literature shows very minimal data on febrile

thrombocytopenia in children , even though there are some studies on

profile of individual diseases like dengue fever, typhoid fever, malaria

in children. Hence this study was conducted to analyze clinic etiological

profile in preference to infective etiology and outcome of children with

febrile thrombocytopenia. This was a prospective observational study

conducted in Pediatric Dept, Chengalpattu Medical College from August

2015 to September 2016.100 children between 1 month to 12 years of

age who fulfilled the criteria of fever for 5 days or more with

thrombocytopenia were included in the study and newborn, children

with afebrile thrombocytopenia ,known ITP and hematological

malignancy, pseudothrombocytopenia were excluded. After informed

written consent detailed history, clinical examination and necessary

laboratory investigation were undertaken. Study parameters were

documented in Excel spread sheet and analyzed using SPSS version 16

software. This study demonstrated no gender difference in the study

population .Analysis of different age group revealed two third study

73 group comprised of children more than 5 years. Comparision of different

age group and gender was done which showed in infant and school going

children males are more affected. Geographic and Seasonal analysis

revealed more than 50 % children from Chengalpattu, Vandhavasi,

Kanchipuram and 90 % of study group presented between months of

August and November. Clinical features and Physiological status at

admission were analysed for frequency and occurence in different age

groups which revealed altered sensorium, GI bleeds, seizures and

oliguria were common in infants. Hepatomegaly was seen in two third

children, facial puffiness in 50 % ,pallor in 30 % and shock in 25 %

children.Shock was frequent in infants along with narrow pulse pressue

and ALOC. Tourniquet test was positive in 19 % children mostly in

>5years .Thrombocytopenia were graded as per WHO criteria of which

47 % had severe and 43 % had moderate thrombocytopenia. Severe

thrombocytopenia was commonly associated with bleeding

manifestations. Among bleeding manifestations petechiae was the

commonest followed by melena and other bleeds, bleeding

manifestations were common among infants, school going children.

Bleeding manifestations were common in undiagnosed fever followed by

dengue fever. Univariate analysis of clinical signs and lab parameters

among the bleeding and non bleeding group was undertaken. The

74 analysis revealed significant association between bleeding manifestation

and positive tourniquet test and low platelet count, severe

thrombocytopenia .Early rise in platelet count ( < 3 days) was seen in

non bleeding group compared to bleeding group. In this study

undiagnosed febrile illness was the commonest etiology followed by

dengue fever and scrub typhus. Mortality in febrile thrombocytopenia is

1% . This was due to sepsis ,MODS. No blood product transfusion was

given for children in this study group.

75

CONCLUSION

Ø Febrile Thrombocytopenia is a benign illness in children

Ø GI symptoms are the commonest presenting feature.

Ø 65 % of them presents with hepatomegaly and 50% with facial

puffiness

Ø Shock and ALOC are common in infants with thrombocytopenia

Ø Severe thrombocytopenia is associated with bleeding

manifestations

Ø Petechiae is the commonest bleeding manifestation in children

with thrombocytopenia.

Ø No blood product transfusion was required in children with febrile

thrombocytopenia

Ø Treatment of primary condition improves the platelet count and

this much more earlier in children without bleeding

Ø Even though study group came across platelet count as low as

5000 cells/cumm, shock and bleeding manifestations mortality

was only 1 % , and that too due to associated septicemia.

This shows the benign nature of the condition.

76

BIBLIOGRAPHY

1. Linda S. Field, Deepak Kamet. Fever. In: Kingman RM , Stanton

BF, St Game III JW , Schurz . Nelson Textbook of Pediatrics.

20th Edition. Elsevier ; Philadelphia;2016.176.127.

2. Handbook IMCI-Integrated Management of Childhood

Illness.World Health Organization.2005;32.

3. J.Paul Scott. Platelet and Blood Vessel Disorders .In: Kingman

RM , Stanton BF, St Game III JW, Schurz . Nelson Textbook of

Pediatrics.20th edition. Elsevier; Philadelphia;2016.484.2400.

4. Putta Suresh, Yamani Devi, Crams Kumar, Y. Jalapa. “Evaluation

of the cause in Fever with Thrombocytopenia cases”. Journal of

evidence based Medicine and Healthcare.2015; 2 (15): 2134-2137

5. Shankar R Raikar, Panna K kamdar, Ajay S Dhabi. Clinical and

laboratory evaluation of patients with fever with

thrombocytopenia. Indian journal of Clinical Practice.

2013;24(4):360-363.

6. Rekha M.C, Sumangala B, Ishwarya B. Clinical study of fever

with thrombocytopenia. J of Evolution of Med and Dent Sci.Oct

2014;3(51):11983-11990.

7. Praveen Kumar Kalpana Chandhra. A clinical study of febrile

thrombocytopenia: A Hospital-based Retrospective Study.Indian

Journal of clinical practice.March 2014;24(10):952-957.

77 8. Amita A Gandhi Pankaj J AkhaolKar. Clinical and laboratory

evaluation of patients with febrile thrombocytopenia. National

journal of Medical Research.Jan-Mar 2015;5(1):43-46.

9. Nikalje Anand, Talib S.H, Pagar Bhushan, Patil Piyush , Kurhade

Aniket. Clinical outcomes of patients presenting as fever with

thrombocytopenia in Marathwada Region. Index Copernicus

values.2016;5 (2):611-615.

10. Aisha Sajid, Asim Ikram, Mubashir Ahmed.dengue fever outbreak

2011: clinical profile of children presenting at madina teaching

hospital faisalabad. jumdc.Jan-Jun 2012;3(1):42-47.

11. Saba Ahmed, Fehmina Arif , Yousuf Yahya , Arshaloos Rehman ,

Kashif Abbas , Sohail Ashraf, Dure Samin Akram. Dengue fever

outbreak in Karachi .A study of profile and outcome of children

under 15 years of age.Jan 2008;58(1):4-7.

12. Shah GS, Islam S, Das BK. Clinical and laboratory profile of

dengue infection in children.Clinical and laboratory profile of

dengue infection in children. Kathmandu University Medical

Journal. 2006;4(13):40-43.

13. Kriti Mohan, B J Omar, Rupa D Singh, Aaradhana , Ravi Sachan.

Thrombocytopenia with bleeding manifestations in childhood

malaria. Indian J Child Health.2016;3(3):196-200.

14. Alphonsa J. Rodriguez – morales, Elia sanchez, Miguel Vargas,

Carmelina Piccolo, Rosa Colina and Melissa Arria. Anemia and

Thrombocytopenia in Children with Plasmodium Vivax Malaria.

Journal of Tropical Pediatrics .2006;52(1):49-51.

78 15. Ahmet Yaramis .MD; Idris Yildrim MD; selahatin katar,MD;

M.Nuri Ozbek, MD; Isik Yalcin MD, M. Ali Yalcin, MD. M.Ali

Tas , MD; Salih Hosoglu,MD. Clinical and Laboratory

presentation of Typhoid Fever. International Pediatrics.

2001;16(4).227-231.

16. Chitu CH, Kalpana Chandhra. A clinical study of febrile

thrombocytopenia: A Hospital-based Retrospective Study.Indian

Journal of clinical practice.March 2014;24(12):45-49.

17. Shruthi k Bhalara,Smitha Shah,Hansa Goswami.Clinical and

etiological profile of thrombocytopenia in adults.International

journal of medical science and public health.2015;4(1):7-10

18. Pankaj B Palange, R B Kulkarni,R K Shrawasti.A study of

Clinical profile of patients with dengue fever with

thrombocytopenia. International journal of recent trends in science

and technology.jan 2015;13(3):671-675.

19. Muhammed Ayub, Adel M Khazinder, Eman H Lubbad.

Characteristics of dengue fever in a large public hospital, Jeddah,

Saudi Arabia.J Ayub Med Coll Abottabad.2006;18(2):9-13.

20. Prithivraj Patil, Pranita Solanke, Gayathri Harshe. Clinical

Evaluation and Outcome of Patients with Febrile

Thrombocytopenia. International Journal of Scientific and

Research Publications. October 2014;4(10):1-3.

21. Ernst Beutler,Uri Seligton. Thrombocytopenia. In: Kenneth

kaushansky, Marshall A Lichtman, Thomas J Klipps, Williams

Hematology 8th edition.2010;119:790.

79 22. Comprehensive Guildlines for Prevention and Control of Dengue

and Dengue Hemorrhagic Fever. World Health Oraganisation.

2011;24.

23. Comprehensive Guildlines for Prevention and Control of Dengue

and Dengue Hemorrhagic Fever. World Health Oraganisation.

2011;19.

24. Rigau-Perez JG et al. Dengue and dengue haemorrhagic fever.

Lancet 1998, 352:971–977.

25. Phuong CXT et al. Evaluation of the World Health Organization

standard tourniquet test in the diagnosis of dengue infection in

Vietnam. Tropical Medicine and International Health, 2002,

7:125–132.

26. Kalayanarooj S et al. Early clinical and laboratory indicators of

acut dengue illness. Journal of Infectious Diseases, 1997,

176:313–321.

27. Bethell DB, Gamble J, Loc PP, Dung NM, Chau TTH, Loan HT,

et al. Non-invasive measurement of microvascular leakage in

patients with dengue hemorrhagic fever. Clin Infect Dis 2001; 32:

243-253.

28. Aggarwal A, Chandra J, Aneja S, Patwari AK, Dutta AK. An

epidemic of dengue hemorrhagic fever and dengue shock

syndrome in children in Delhi. Indian Pediatr 1998; 35: 727-732.

80 29. Hayes CG, Manaloto CR, Gonzales A, Ronoa CP. Dengue

infections in the Philippines: clinical and virological findings in 517 hospitalized patients. Am J Trop Med Hyg 1988; 39: 110-116

30. Tripathi BK, Gupta B, Sinha RS, Prasad S, Sharma DK. Exprience in adult population in dengue outbreak in Delhi. J Assoc Physicians India 1998; 46: 273-276.

31. Pushpa V, Venkatadesikalu M, Mohan S, Cherian T, John TJ, Ponnuraj EM. An epidemic of dengue haemorrhagic fever/dengue shock syndrome in tropical India. Ann Trop Pediatr 1998; 18: 289-293.

32. Wali JP, Biswas A, Aggarwal P, Wig N, Handa R. Validity of tourniquet test in dengue hemorrhagic fever. J Assoc Physicians India. 1999; 47: 203-204

33. Vaughn DW, Nisalak A, Solomon T, Kalyanarooj S, Nguyen MD, Kneen R, et al. Rapid serologic diagnosis of dengue virus infection using a commercial capture ELISA that distinguishes primary and secondary infections. Am J Trop Med Hyg 1999; 60: 639-698.

34. Kalayanarooj S, Vaughn DW, Nimmannitya S, Green S, Suntayakorn S, Kunentrasai N, et al. Early clinical and laboratory indicators of acute dengue illness. J Infect Dis 1997; 176: 313-321.

35. Srivastava VK, Suri S, Bhasin A, Srivastava L, Bharadwaj M. An epidemic of dengue hemorrhagic fever and dengue shock syndrome in Delhi: a clinical study. Ann Trop Pediatr 1990; 10: 329-334.

81 36. Vaughn DW, Nisalak A, Solomon T, Kalyanarooj S, Nguyen MD,

Kneen R, et al. Rapid serologic diagnosis of dengue virus

infection using a commercial capture ELISA that distinguishes

primary and secondary infections. Am J Trop Med Hyg 1999; 60:

639-698.

37. Kalayanarooj S, Vaughn DW, Nimmannitya S, Green S,

Suntayakorn S, Kunentrasai N, et al. Early clinical and laboratory

indicators of acute dengue illness. J Infect Dis 1997; 176: 313-

321.

38. Srivastava VK, Suri S, Bhasin A, Srivastava L, Bharadwaj M. An

epidemic of dengue hemorrhagic fever and dengue shock

syndrome in Delhi: a clinical study. Ann Trop Pediatr 1990; 10:

329-334.

39. Lee-Chiong, TL Jr, Stitt, JT. Disorders of temperature regulation.

Comprther 1995; 21:697

40. Woodward TE: The fever pattern as a diagnostic aid from fever –

basic mechanisms and management, 2nd ed.; Phillip A,

Mackwick; Jan. 1, 1997, p216-234.

41. Kelton JG, Keystone J, Moore J, Denomme G, Tozman E, Glynn

M et al: Immune mediated thrombocytopenia of malaria. J Clin

Invest., 1983 April; 71 (4): 832 -6.

42. Nayanalakum, HardikMakwane, Dr. Rekha Shah: “A study of

laboratory profile of fever with thrombocytopenia in adult patients

at C.U. Shah Medical College, Surendranagar” 2014, SEAJCRR

Jan: Feb 3(1): 2319 – 1090: p556.

82 43. Dash HS, Ravikiran P, Swarnalatha G: A study of clinical and

laboratory profile of fever with thrombocytopenia and its

outcoming during hospital stay, IJSR - 445.

44. Nair PS, Jain T, Kanduri U, Kumar V: A study of fever associated

thrombocytopenia, JAPI 2006; 51: 1173.

45. Shirley Parker Levine Wintrobe’s Clinical Haematology. 10th

edition, Volume 2 1993:p.1579-632.

46. Colman W, Hirsch J, Marder VJ, Salzman EW. Hemostansis and

Thrombosis - Basic Principles and Clinical Practice.1982:p.146-7.

47. William-J-William. Eaenst Beutler, Allan J Erslev, Marshal and

Litchman Hematology. 3rd edition p.1290-342.

48. Firkin F. de Gruchy’s Clinical Haematology in Medical Practice.

5th edition 1990:p.375.

49. Robbin and Cotran Pathologic Basis of Disease. 7th edition

2000:p.650.

50. Shirley Parker Levine Wintrobe’s Clinical Haematology. 10th

edition, Volume 2 1993:p.1581.

83 CHENGALPATTU GOVERNMENT MEDICAL COLLEGE AND

HOSPITAL

DEPARTMENT OF PEDIATRICS

SI No:

IP NO:

Name: <1 yr 2 – 5 yrs >5 yrs 5-10yrs

Age:

Sex:

Region:

HISTORY:

Yes no duration Fever

Headache,myalgia

GI symptoms

Cutaneous bleeds

GI bleeds

Other bleeds

Brethlessness

Edema

ALOC

Seizures

Neck stiffness

Oliguria

Rash

h/o antibiotic exposure

84 ON EXAMINATION:

yes No Febrile Pallor Petechiae Ecchymosis Lymphadenopathy Hepatomegaly Sleenomegaly Eschar Ascities Jaundice

Cardinal signs yes no Tachypnoea Bradypnoea Tachycardia Bradycardia Wide pulse pressure ALOC Compensated shock Hypotensive shock Tornique test

investigations elevated decreased Normal total count Hb

Hematocrit

MP SMEAR

urine routine

urine c/s

Widal

MSAT

85 weil felix

Dengue

NEC

Chest X RAY

Date

Hb/PCV

Date

Smear platelet

CBC platelet

increased decreased normal

SGOT

SGPT

s.bilirubin

Urea

Creatinine

peripheral smear thrombocytopenia

peripheral smear hemolysis

86 Tranfusion yes no platelets FFP PRBC

· HOSPITAL STAY:

· DURATION OF FEVER:

· DURATION OF THROMBOCYTOPENIA:

· GRADE OF THROMBOCYTOPENIA:

· VENTILATORY SUPPORT:

· INOTROPE SUPPORT:

· FINAL OUTCOME:

FINAL DIAGNOSIS :

87

PATIENT CONSENT FORM STUDY DETAIL: “CLINICOETIOLOGICAL PROFILE AND OUTCOME OF ACUTE FEBRILE ILLNESS WITH THROMBOCYTOPENIA IN CHILDREN-A HOSPITAL BASED PROSPECTIVE STUDY”

STUDY CENTER:

CHENGALPATTU MEDICAL COLLEGE & HOSPITAL, C HENGALPATTU PATIENT NAME: PATIENT AGE: IDENTIFICATION NUMBER: FATHER’S NAME: I confirm that I have understood the purpose of procedure for the above study. I have the opportunity to ask the question and all my questions and doubts have been answered to my satisfaction. I understand that my child participation in the study is voluntary and that I am free to withdraw my child at anytime without giving any reasons, without my legal rights being affected. I understand that investigator, regulatory authorities and the ethics committee will not need my permission to look at my health records both in respect to the current study and any further research that may be conducted in relation to it, even if withdraw from the study, I understand that my child identity will not be revealed in any information released to third parties or published, unless as required under the law. I agree not to restrict the use of any data or results that arise from the study. I agree my child to take part in the above study and to comply with the instructions given during the study and faithfully cooperative with the study team and to immediately inform the study staff if my child suffer from any deterioration in my health or wellbeing or any unexpected or unusual symptoms. I hereby give consent for my child to participate in this study. I hereby give permission to undergo complete clinical examination and diagnostic test on my child . Signature/Thumb impression: Place: Parent name and address: Date: Signature of the investigator: Place: Study investigator’s name: Date:

88

CHILD ASSENT FORM

STUDY DETAIL: CLINICOETIOLOGICAL PROFILE AND OUTCOME OF ACUTE FEBRILE ILLNESS WITH THROMBOCYTOPENIA IN CHILDREN-A HOSPITAL BASED PROSPECTIVE STUDY STUDY CENTER: CHENGALPATTU MEDICAL COLLEGE & HOSPITAL, CHENGALPATTU PATIENT NAME: PATIENT AGE: IDENTIFICATION NUMBER: I confirm that I have understood the purpose of procedure for the above study. I have the opportunity to ask the question and all my questions and doubts have been answered to my satisfaction. I understand that my participation in the study is voluntary and that I am free to withdraw at anytime without giving any reasons, without my legal rights being affected. I understand that investigator, regulatory authorities and the ethics committee will not need my permission to look at my health records both in respect to the current study and any further research that may be conducted in relation to it, even if withdraw from the study, I understand that my identity will not be revealed in any information released to third parties or published, unless as required under the law. I agree not to restrict the use of any data or results that arise from the study. I agree to take part in the above study and to comply with the instructions given during the study and faithfully cooperative with the study team and to immediately inform the study staff if I suffer from any deterioration in my health or wellbeing or any unexpected or unusual symptoms. I hereby give consent to participate in this study. I hereby give permission to undergo complete clinical examination and diagnostic test . Signature/Thumb impression: Place: Patient name and address: Date: Signature of the investigator: Place: Study investigator’s name: Date:

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