A STUDY OF CLINICAL AND LABORATORY PROFILE OF FEBRILE CHILDREN PRESENTING WITH THROMBOCYTOPENIA

1. Final Year Junior Resident, Department of Paediatrics, SreeBalaji Medical College and Hospital. 2. Professor, Department of Paediatrics, SreeBalaji Medical College and Hospital. 3. HOD, Department of Paediatrics, SreeBalaji Medical College and Hospital. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 August 2020 Final Accepted: 12 September 2020 Published: October 2020 Copy Right, IJAR, 2020,. All rights reserved.

Baseline platelet counts were done on the day of presentation. Repeat platelet counts were done in subjects with marked thrombocytopenia until normal or near-normal values were reached. Other investigations as necessary were done to achieve diagnosis such as bone marrow trephine biopsy, serological study for HIV infection, TSH, Serum widal, D-Dimer, Serum vitamin B12 level, Anti-Nuclear Antibody (ANA). Once the specific diagnosis was reached, patients were treated for it specifically and symptomatically. For platelet count, two methods were used. Primarily, an automated cell counter was used with features of counting RBC's, WBC's, platelets and haemoglobin estimation along with blood indices all together. If thrombocytopenia was documented, then direct visualization was done in which 0.02 ml EDTA blood was diluted with 2ml of diluting fluid followed by charging the Neubaur's chamber with the fluid and number of platelets was counted.

Statistical analysis:
Statistical analysis was done using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Chi-square test was done for qualitative variables and t-test was used for quantitative variables. P<0.05 was considered as statistically significant.
Haematemesis, melena and epistaxis was seen in 2 patients each, haematuria, subconjunctivalhaemorrhage and intracranial haemorrhage was seen in 1 patient each. The platelet count at which each of these manifestations was seen is shown in Table 3.
Thirty five (19.45%) cases of thrombocytopenia were symptomatic and had bleeding manifestations. Majority of patients with bleeding manifestations (77.14%) were having platelet count <20,000/ mm3. Only seven patients (3.89%) with count between 20,000-50,000/ mm3 and one case suffering from dengue with platelet count more than 50,000, demonstrated bleeding manifestation (Table 3).
Eight patients presented with platelet count <10,000/ μl but had no hemorrhagic manifestations. Ten patients having bleeding manifestations required platelet transfusions irrespective of their platelet count.
Remaining patients were given disease specific treatment only. The diagnosis of 3 cases of haematological malignancy and 2 cases of megaloblasticanaemia were confirmed by bone marrow aspiration study. Initial clinical presentation in the hospital in majority of the patients was fever, headache, body ache and joint pain followed by gastrointestinal symptoms like abdominal pain and vomiting (Table 4). Only 10 patients (5.55%) presented with cough and dyspnoea. We had 2 mortality in the study group and both were due to dengue.

Discussion:-
Fever is the presenting complaint in many illnesses especially the infectious causes. Peripheral smear of many of these illnesses show thrombocytopenia.
Transient thrombocytopenia occurs with many systemic infections. It is also a very common manifestation in tropical infections like malaria especially the falciparum type, dengue, chikungunya, a variety of viral infections and enteric fever. Thrombocytopenia usually occurs in 50-75% with bacterial or with fungal infections. It occurs in 50% cases of gram negative bacterial infections and also in sepsis. It is even seen in other viral infections including HIV. 6 The commonest causes of thrombocytopenia in our study were viral fever (other than dengue and chikungunya) 27.78% (50), followed by Dengue 22.2% (40), enteric fever 12.22% (22), chikungunya 11.11% (20) and malaria 8.33% (15). However in other studies like that done by Nair in New Delhi, septicemia (26.6%) was the major cause of febrile thrombocytopenia. 7 In another study done by Gandhi malaria was found to be the major cause in 41.07%. 8 Similarly, Lakum, also found malaria as the most common cause of febrile thrombocytopenia in 46.8% of the cases. 9 Another study done by Bhalara, showed dengue (60.8%) as the main aetiology. 10 221 In present study, viral infections were the commonest cause due to the higher prevalence of these infections during the rainy season. This difference could have been due to seasonal and regional variation. Similar to present study, Kumaran also found viral fever to be the commonest cause in 50.3% cases. 11 Early diagnosis of viral infections remain a challenge to all clinicians. In a study by Ho, they calculated several parameters to predict early diagnosis of laboratory confirmed dengue and other viral infections. 12 No single laboratory test was good enough in terms of positive predictive value for acute dengue infection. In cases where all the available investigations were negative, we labelled them as probably viral fever (27.78%).
Nair labelled them as unknown aetiology in his study. 7 Serological diagnosis of viral infections is expensive, cumbersome and not easily available. Owing to limited resources and laboratory facilities, the diagnosis of fever could not be made in 71 (47%) cases. Hence labelled as undiagnosed fever.
In present study, spontaneous bleeding was seen in 57.14% while petechiae was seen only in 42.86%. In a study by Nair et al spontaneous bleeding was seen in 77.78% as a major manifestation followed by petechiae/purpura seen in 22.22%. 7 However, in a study done by Patilpetechiae was the major manifestation in 73.9% followed by spontaneous bleeding only in 26.9%. 13 While in another study by Lohitashwa et al, purpura (63%) was the commonest bleeding manifestations followed by spontaneous bleeding (37%). 14 In present study, other than fever most patients had headache (61.11%), body ache (66.67%) and joint pains (51.11%). The reason for these clinical features may have been because majority of our patients were of viral illness, dengue and chikungunya. Similar results were seen in Khan's study, which showed chills and rigors in 80%, myalgia in 70%, vomiting in 60%, headache in 50% and rash in 25%. 15 Unusual clinical feature was pharyngitis in 7% of patients. Murthy's study and Kochar showed deranged renal parameters in 24.68% and 6.25% cases respectively. 16,17 In the present study, renal function tests were deranged in 16.67% cases of fever with thrombocytopenia.
Firstly, present study was applicable only to the pediatric age group and hence, we do not know whether the same results can be extrapolated to the general population as well. Secondly, many acute febrile cases may have been treated in the peripheral clinics and hospitals without any complete blood count being done at all. Hence, our hospital based model might not reflect all the cases of fever with thrombocytopenia in the given locality or population. Lastly, our study did not do an in-depth correlation with other clinical manifestations.

Conclusion:-
Febrile thrombocytopenia is a commonly observed haematological entity commonly caused by infections like viral illnesses, dengue, malaria, enteric fever etc. It commonly manifests with clinical features of underlying disease condition and sometimes with bleeding manifestation also. There is no relation between platelet count and bleeding manifestations. Thrombocytopenia also has no correlation to mortality and morbidity. Mortality in febrile thrombocytopenia is not directly associated with degree of thrombocytopenia.