Suresh PDF

A STUDY OF CLINICAL PROFILE, CAUSES AND
COMPLICATIONS OF FEVER WITH

THROMBOCYTOPENIA
D R . V. SURESH
REG. NO: 1201091008
A DISSERTATION SUBMITTED TO
SRI BALAJI VIDYAPEETH UNIVERSITY
IN PARTIAL FULFILLMENT FOR THE AWARD OF
DEGREE OF M.D. GENERAL MEDICINE (BRANCH I)
MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE
PONDICHERRY – 607402, INDIA
APRIL 2015
MAHATMA GANDHI MEDICAL COLLEGEAND RESEARCH
INSTITUTE, PONDICHERRY -607402
CERTIFICATE
This is to certify that the dissertation entitled “A STUDY OF CLINICAL
PROFILE, CAUSES AND COMPLICATIONS OF FEVER WITH
THROMBOCYTOPENIA” is a bonafide record of work carried out by
DR. V. SURESH, REG NO: 1201091008 in the Department of General Medicine,
under our guidance and supervision during the period of his post graduate study for
M.D. General Medicine from April 2012 to March 2015.
Dr. M.Narayan
Professor
Department of General Medicine
Guide
Dr. Lokesh.S
Associate Professor
Co-guide
Dr. K.JAYA SINGH,

Professor and HOD
The DEAN
Mahatma Gandhi Medical College
& Research Institute, Pondicherry.
i
MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE,
PONDICHERRY - 607402
DECLARATION OF THE CANDIDATE
I hereby declare that this dissertation/thesis entitled “A STUDY OF
CLINICAL PROFILE, CAUSES AND COMPLICATIONS OF FEVER WITH
THROMBOCYTOPENIA” is a bonafide and genuine research work carried by me
Dr. V. SURESH, under the guidance of Prof. Dr. M.NARAYAN Department of
General Medicine, Mahatma Gandhi Medical College & Research Institute
Pondicherry.
ii
ACKNOWLEDGEMENTS
I take this opportunity with a deep sense of gratitude to express my respect to
my beloved teacher and guide Dr.M.Narayan, Professor and Unit Chief, Department
of General Medicine, Mahatma Gandhi Medical College and Research Institute for his
unparalleled guidance, unwavering support, constant inspiration and expertise
throughout my post graduate study and also towards completion of my dissertation.
I offer my sincere thanks to Dr.Ragupathy, Professor, and Dr.lokesh.s
Associate Professor Department of Cardiology for giving helpful suggestions and
guiding me in this study.
I sincerely thank, Dr. Ananthakrishnan. N, Professor of General Surgery,
Dean of Post graduate studies and Research, Mahatma Gandhi Medical College and
research Institute for lending his expertise towards writing of this dissertation.
I sincerely express my thanks to, Dr. K.Jayasingh, Professor and Head,
Department of General Medicine, for helping me throughout the study and boosting
my morals in time of need.
I express my heartfelt and sincere gratitude to Professors and associate
professors and assistant professors, Department of General Medicine, for the help in
compiling this dissertation.
I would like to thank the entire faculty of department of General Medicine for
their guidance and support all along.
I would like to thank all the patients who volunteered to be a part of my study,
without them this study would not have been possible.
iii
I want to thank Dr. EZHUMALAI, for guiding me in data compilation and
statistical analysis.
I thank the Chairman, Vice Chancellor and Dean of our Medical College and
Hospital for their every help in making this dissertation possible.
I want to acknowledge all my fellow postgraduates from the department of
General medicine and Cardiology, who helped me compile this study.
I would like to thank my parents who have been pillars of strength and support during
my post graduate studies.
Lastly I bow my head before the almighty for bestowing upon his blessings
and his unconditional favours at all times and under all circumstances.
iv
TABLE OF CONTENTS
CERTIFICATE ............................................................................................................. i
ACKNOWLEDGEMENTS ........................................................................................ iii
TABLE OF CONTENTS............................................................................................. v
LIST OF TABLES ..................................................................................................... vii
LIST OF FIGURES .................................................................................................. viii
ABBREVATIONS AND ACRONYMS .................................................................. viii
1 INTRODUCTION............................................................................................... 1
2 AIMS AND OBJECTIVES................................................................................. 2
1. TO EVALUATE CLINICAL PROFILE OF FEVER WITH

THROMBOCYTOPENIA ........................................................................................... 2
3 REVIEW OF LITERATURE ............................................................................. 3
4 PATIENTS AND METHODS .......................................................................... 11
5 RESULTS ......................................................................................................... 15
6 DISCUSSION ................................................................................................... 24
7 CONCLUSION ................................................................................................. 29
8 ABSTRACT ...................................................................................................... 30
9 REFERENCES .................................................................................................. 31
10 APPENDIES APPENDICES ............................................................................ 35
10.1 ETHICS COMMITTEE CERTIFICATE OF APPROVAL...................... 35
10.2 DATA COLLECTION PROFORMA ....................................................... 36
10.3 INFORMED CONSENT ........................................................................... 41
10.4 PATIENT INFORMATION SHEET ........................................................ 42
10.5 MASTER CHART .................................... Error! Bookmark not defined.
10.6 PLAGIARISM CHECK CERTIFICATE.................................................... 2
v
vi
LIST OF TABLES
Table 1: Age distribution of patients studied ............................................................... 15
Table 2: Gender distribution of patients studied .......................................................... 16
Table 3: Distribution of platelets at the time of admission: ......................................... 17
Table 4: Incidence of Blood CS ................................................................................... 18
Table 5: Diagnosis of patients studied ......................................................................... 20
Table 6: Complications ................................................................................................ 21
Table 7: Complications, according to the age distribution of patients studied ............ 23
vii
LIST OF FIGURES
Figure 1: Age distribution of patients studied ............................................................. 15
Figure 2: Gender distribution of patients studied ........................................................ 16
Figure 3: Distribution of platelets at the time of admission ........................................ 17
Figure 4: Incidence of Blood CS ................................................................................. 19
Figure 5: Diagnosis of patients studied........................................................................ 20
Figure 6: Complications............................................................................................... 22
viii
ABBREVATIONS AND ACRONYMS
AIDS Acquired immunodeficiency syndrome
ARDS Acute respiratory distress syndrome
AKI Acute kidney injury
DHF Dengue hemorrhagic fever
DSS Dengue shock syndrome
E.COLI Escherichia coli
FUO Fever of unknown origin
HIV Human immunodeficiency
ITP Idiopathic thrombocytopenic purpura
IL Inter leukins
PUO Pyrexia of unknown oriugin
PV Plasmodium vivax
PF Plasmodium falciparum
Staph.A Staphylococcus aureus
ix
1 INTRODUCTION
Fever is a common presenting feature of disease since ancient times. Fever is
often associated with various sickness patterns, in metabolic and physiological
characteristics of body systems and alterations in immune responses. Therefore fever
remains significant contributor to the clinical presentation, pathogenesis and the result
of many illnesses.
Fever with thrombocytopenia is a usual clinical presentation in the medical
wards and associated with significant complications and mortality. Infective causes
like dengue and malaria are well known for fever with thrombocytopenia. Only a few
studies are available for enteric fever and malaria. There are not many studies
involving other infections for thrombocytopenia.
This study has been undertaken to know the modes of clinical presentation and
possible causes of fever with thrombocytopenia in tropical country like India, where
the other causes of infection could be established like dengue, enteric fever, malaria,
leptospirosis, hepatitis B, HIV infection, scrub typhus etc. There may be other
infections where the aetiology cannot be pointed out because of lack of facilities or
awareness.
1
A STUDY OF CLINICAL PROFILE, CAUSES AND COMPLICATIONS OF FEVER WITH THROMBOCYTOPENIA
2 AIMS AND OBJECTIVES
1. To evaluate clinical profile of fever with thrombocytopenia
2. To identify the cause of fever with thrombocytopenia
3. To assess the clinical complications associated with fever and
thrombocytopenia
2
3 REVIEW OF LITERATURE
3.1 HISTORY
The writings of Hippocrates form the cornerstone of our science of medicine. He
has given many marvellous precise descriptions of febrile diseases, so accurate,
indeed, that it is easy to recognize such entities as malaria and bacterial pneumonias
as well as enteric fevers. The characteristic fluctuations in body temperature occurring
in these diseases-the sustained fevers of pneumonia, the intermittent (tertian or quart -
an) fevers of malaria, and, in particular, the stepwise rise in temperature with the
onset of typhoid fever-are all unequivocally described, although we remain uncertain
how such observations were made long before the advent of the clinical thermometer
in the eighteenth century.(1)
Modern theory of the pathogenesis of fever studied in rabbit’s showed the
leukocytes in inflammatory lesions and exudates substance which produce fever –
pyrogens.(2)
3.1.1 PYREXIA OF UNKNOWN ORIGIN:
In the year 1961 Petersdorf and Beeson defined the following criteria for
pyrexia of unknown origin. (3)
a) Fever higher than 38.3°C (101°F) on several occasions
b) Persisting without a diagnosis for at least 3 weeks
c) At least 1 week's investigation in hospital
3
In 1991 Durack and Street revised the criteria for fever of unknown origin
(FUO) into. (4)
a) Classic FUO
b) Noscomial FUO
c) Neutropenic FUO
d) FUO associated with HIV infections
3.1.2 THROMBOCYTOPENIA:
Thrombocytopenia is defined as a platelet count less than 1.5*10/cumm under
the 2.5th lower percentile of the normal platelet count distribution. The results of the
third US National Health and Nutrition Examination Survey (NHANES III) support
the traditional value of 150 × 109/L as the lower limit of normal. (5)
The observations of SCOTT et al suggested that while patients with malaria
may be predisposed to the development of thrombocytopenia, a reduced platelet count
in some patients may be due to aggregation of platelets which is known as pseudo-
thrombocytopenia. (6)
3.1.3 ETIOLOGY
A study done by Shankar et al in 2013, in 100 patients with fever with
thrombocytopenia concluded that the prevalence is more in younger age groups,
common in males than females . In66% of patients fever was the commonest
presentation and the most common etiology was dengue 52%, followed by malaria
(Vivax 22% & Falciparum 21%). The complications in the form of minor bleeding
tendencies and no deaths were documented and the incidence of disease is high during
the rainy and winter seasons. (7)
4
A study done by P. S. Nair in 109 admitted patients with fever and thrombocytopenia.
Most of the patients had a transient fall in platelet count associated with bleeding
manifestations and the most common etiology was septicemia (26 %) followed
typhoid (14.7%) and dengue (13.8%). (8)
An observational Study done in 309 patients in a tertiary care hospital in
Tamil Nadu, who presented with fever. The commonest aetiology was Scrub typhus
in 147 patients, followed by malaria (53), enteric fever (24), dengue (22),
leptospirosis (9), spotted rickettsiosis (3) and Hantavirus (0.3%). complications like
acute respiratory distress syndrome, aseptic meningitis, mild serum transaminase
elevation and hypoalbuminaemia were reported In Scrub typhus. In malaria
complications in the form of moderate to severe thrombocytopenia, renal failure,
splenomegaly and hyperbilirubinaemia with mildly elevated serum transaminases
were noted. In Dengue associated complications reported was rash, overt bleeding,
moderate to severe thrombocytopenia and significantly elevated hepatic
transaminases. Enteric fever manifested with loose stools, normal to low leukocyte
counts and normal platelet counts. (9)
3.1.4 MALARIA
A study done in Bikaner in the year 2010 among 1064 diagnosed cases of
malaria with thrombocytopenia. 525(49.34%) patients were positive for Plasmodium
falciparum, 460 (43.23 %) were positive for Plasmodium vivax, 79 patients (8.43%)
had mixed infections that are both Plasmodium falciparum and vivax.
Thrombocytopenia was present in 85 (16.19%) patients with P. falciparum,
143(13.4%) patients with P. Vivax and 34 (3.1%) patients with mixed infections.
Complications of thrombocytopenia were more in mixed infections than in
5
monoinfection, which manifested with bleeding tendencies and were treated with
platelet transfusion. (10)
3.1.5 PATHOGENESIS IN MALARIA:
Pathogenesis of thrombocytopenia in malaria is mainly due to: (11)
a. Coagulation disturbances
b. Splenomegaly
c. Bone marrow alterations
d. Platelet aggregation
a) Coagulation disturbances: A study conducted by Dennis et al in Vietnam
among 31 soldiers. They were diagnosed with Plasmodium falciparum, had
characteristic coagulation profile abnormalities in the form of the raised prothrombin
time, reduced platelet count, and factor V, VII and VIII levels . This study indicates
that some haematological abnormalities are due to coagulation abnormalities. (12)
b) Splenomegaly:
In malaria, the spleen has an essential role in immune response in controlling
parasitemia in the form of phagocytosis of infected RBC’s. That there is destruction
of platelets in the spleen during active infections was confirmed by Watier et al in the
year 1992. In experimental models with Plasmodium Chabudi thrombocytopenia was
absent in splenectomised mice. Also a study by Lee et al in 1997 suggested that
increase in macrophage-colony stimulating factor caused increased destruction of
platelets. (13)(14)
6
c) Bone marrow alterations:-
Presence of malarial trophozoites in platelets ensues in the destruction of
platelets and causing thrombocytopenia similar to that of the destruction of RBC’s
and these trophozoites invade the platelets in peripheral circulation. Similarly, studies
in the past in relation to the megakaryocytic lineage in bone marrow found that
megakaryoctes were not affected (Kreilet al. 2000). Megakaryocytes are able to
release mega platelets, which compensates for low platelets in peripheral circulation
and prevents bleeding. (15)
3.1.6 DENGUE:
A study done by Md. Ayule in 80 hospitalized patients with a suspected
diagnosis of dengue, 39 (48.75%) patients were confirmed by dengue serology. The
incidence of was more among Male than female with ratio of 3.3:1. The common
presentation in dengue was fever 100%, followed by myalgia 66%, headache 48%,
and vomiting 25.64%.(16)
Dengue pathogenesis:
In recent times the incidence and complications of dengue are more alarming.
Complications like dengue hemorrhagic fever (DHF) are due to platelet-associated
immunoglobulins involving anti-dengue virus activity, which plays a pivotal role in
the development of bleeding.
DENGUE is further classified into four serotypes based on nucleotide
variations. Each serotype exhibits different levels of virulence but only a few patients
develop severe disease. This indicates that host factors have a significant role to play
in the pathogenesis.
7
Manifestations of dengue may be due to immune response and increased
vascular permeability due to interaction of high levels of cytokines interleukin 6 (IL-
6) and interleukin 2 (IL-2) and tumour necrosis factor alpha and interferon gamma. (17)
Dengue infection in humans causes a spectrum of illness ranging from mild
infection to severe dengue hemorrhagic disease complications are more in adult
female’s secondary dengue infections with co-morbidities like obesity, alcoholism
and diabetes. (18)
In a retrospective survey on dengue conducted in South India from 2002 to
2008, based on medical records regarding manifestations and complications in 466
diagnosed cases, the majority were male, highest number 89 (19.1%) of cases were
diagnosed in the month of September with the commonest symptom being fever 462
(99.1%) followed by myalgia 301 (64.6%) vomiting 222 (47.6%), headache 222
(47.6%) and abdominal pain 175 (37.6%)and hemorrhagic complication in the form
of petechiae in 67.2% of patients and critical complications like ARDS in 22 (33.3%)
and deaths was reported in 11 (2.4%) patients.(19)
HIV
A retrospective study done in 55 HIV- positive patients commonest
haematological abnormality was thrombocytopenia with 62 % of patients are male.
Cause of thrombocytopenia in 63.6% was Immune mediated and 25.5 % patients was
non immune mediated. 23.7% patients were transfused with platelets and one patient
died due to bleeding manifestations.(20)
8
Hepatitis E
A case report on July 2008, Severe thrombocytopenia was reported in acute
hepatitis E viral infection which was believed to be immune mediated, and due to
platelet-associated antibodies.(21)
Septicaemia
A retrospective study done in the year 2013 by mulat etal in 390 blood
cultures out of which 71 were positive. Most common organisms isolated from culture
was coagulase negative in 42.3%, followed by staph aureus in 23.9% and Klebsiella
in 12.9 % of patients, E.coli in 7% and salmonella in 4.2% patients.
Septicaemia is resulting from gram negative 69%and gram positive organisms
in 31% of patients (22)
Scrub typhus:
A study done in the year 2010 in diagnosing cases of scrub typhus in
Pondicherry, commonest presentation is fever followed by other causes like vomiting,
rashes, headache, and breathlessness. Diagnosis was confirmed by the presence of
eschar in 23 patients. The common sites of eschar are axilla, groin and breast. 39
patients were positive for Weil-Felix testing. Complications like multiorgan
dysfunction were seen in 17 patients, ARDS in 4 patients and thrombocytopenia in 5
patients and renal failure in 6 patients were noted and were treated with doxycycline.
According to this study indicates that scrub typhus is not uncommon in this part.(23)
A study done in 44 patients who presented with acute febrile illness in scrub
typhus in which 15 patients were positive for IGM antibodies. The high number of
patients was diagnosed in the month of July to November. Commonest presentation
was fever and then myalgia, followed by gastrointestinal complaints, rash,
9
breathlessness and jaundice. Eschar and lympadenopathy was seen in two patients.
Complications reported are hepatitis (80%), acute respiratory distress syndrome
(ARDS) (60%), thrombocytopenia (40%) and acute renal failure (33%).(24)
Brucellosis:
Infectious causes like brucellosis presented with pyrexia of unknown origin
with thrombocytopenia. It was reported in a 29 year old female who was initially
diagnosed as ITP and managed with steroids, later blood culture and bone marrow
aspirate cultures were positive for Brucella abortus and responded to rifampcin and
doxycycline.(25)
Enteric fever:
A retrospective study done, in diagnosed cases of enteric fever in Jakarta in
2004 in 119 patients, 70 were male and 49 were female. They reported with
predominant clinical manifestations fever, headache, nausea, anorexia and associated
laboratory abnormalities of decreased leukocyte and platelet counts and increased
liver enzymes. Most frequent complications in this study noted were hepatitis,
pneumonia, encephalopathy and intestinal haemorrhage.(26)
10
4 PATIENTS AND METHODS
All patients included in the study were patients who presented with a history
of fever for more than three days and admitted and evaluated during the period from
February 2013 to June 2014 in the Department of General Medicine, Mahatma
Gandhi Medical College and Research Institute Pillyarkuppam, Pondicherry. This
study was carried out after getting clearance from Institutional Human Ethics
Committee of Mahatma Gandhi Medical College and Research Institute,
Pillyarkuppam, Pondicherry.
4.1 CHARACTERISTICS OF THE STUDY
A Prospective observational Study done in the 100 patients who were admitted
in the Department of Medicine of the institution to evaluate the cause, complications
and out come.
4.2 CHARACTERISTICS OF THE PATIENTS
Inclusion Criteria:
Patients of both sexes aged above 18 years were included.
Patients with fever and found to have thrombocytopenia were included.
Only inpatients
Exclusion criteria:
Patients less than 18 years were excluded.
Patients with fever and no thrombocytopenia were not included.
Patients with non infective etiology like ITP, drug induced,
11
4.3 BRIEF EXPLANATION OF THE PROCEDURE
My study is a clinical prospective observational.
Patients presenting with fever(Minimum of 3 days)
History, examination(general physical & systemic )
Complete hemogram, peripheral smear study

renal function test , electrolytes, RBS,urine routine, Chest X ray
R/o causes by specific investigations
Smear for mp/mfBlood c/s,Pf / pv antigen testWidal,NS1 Ag

,dengue IgG/IgM & other specific test’s
Symptomatic &Specific treatment done
complications
Table.1. methodology
All the patients who come under inclusion criteria were evaluated as per above
flow chart and were treated symptomatically and specifically.
From time to time complete data was collected in a special designed case
recording proforma, and transferred into master chart and subjected to statistical
analysis
12
4.4 STUDY PARAMETERS
Study parameters included are given in proforma [10.2 Appendix-2]
4.5 DATA COLLECTION AND STATISTICAL ANALYSIS:
Statistical Methods: Descriptive and inferential statistical analysis has been
carried out in the present study. Results of continuous measurements are presented on
Mean ± SD (Min-Max) and results of categorical measurements are presented in
Number (%). Significance is assessed at 5 % level of significance. (27)
The following assumptions on data is made,
4.6 ASSUMPTIONS
1. Dependent variables should be normally distributed,
2. Samples drawn from the population should be random; Cases of the samples should
be independent
Chi-square/ Fisher Exact test has been used to find the significance of study
parameters on a categorical scale between two or more groups. 95% Confidence
Interval has been computed to find the significant features. Confidence Interval with
lower limit more than 50% is associated with statistical significance.(28)(29)
a. Significant figures
+ Suggestive significance (P value: 0.05<P<0.10)
* Moderately significant ( P value:0.01<P £ 0.05)
** Strongly significant (P value : P£0.01)
13
Statistical software: The Statistical software, namely SAS 9.2, SPSS 15.0, Stata
10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used for the
analysis of the data and Microsoft word and Excel have been used to generate graphs,
tables etc.
14
5 RESULTS
Demographic Data
Study design:: An observational clinical study in 100 patients.
Table 1:: Age distribution of patients studied
No. of
Age in years %
patients
18-20 12 12.0
21-30 28 28.0
31-40 15 15.0
41-50 18 18.0
51-60 18 18.0
>60 9 9.0
Total 100 100.0

Mean ± SD: 39.02±16.25
30
25
20
Percentage
15
Series1
10
0
18-20 21--30 31-40 41-50 51-60 >60
Age in years
Figure 1:: Age distribution of patients studied
15
Out of the total population studied, prevalence of fever with thrombocytopenia
was more among younger age groups between 18 to 30 years.
Table 2:: Gender distribution of patients studied
No. of
Gender %
patients
Female 37 37.0
Male 63 63.0
Total 100 100.0
37%
63%
Female
Gender Male
Figure 2:: Gender distribution of patients studied
Among 100 patient gender wise distribution, prevalence of disease is more
common in males 63% than comparing to females 37%.
16
Table 3:: Distribution of platelets at the time of admission:
No. of
Platelet count % Mean ± SD
patients
· <50000 24 24.0
· 50000-100000 68 68.0 73541.00±50083.82
· >100000 8 8.0
70
60
50
Percantage
40
30
20
10
0
<50000 50000-100000 >100000
Platelet count
Figure 3:: Distribution of pla

platelets
telets at the time of admission
In our study distribution of platelets in the range of 50000 to 100000 was seen
in 67 % of patients followed by less than 50000 in 24 % of cases.
17
Table 4: Incidence of Blood CS
No. of
Blood CS patients %
(n=100)
No Growth 80 80.0
Growth 20 20.0
· E.coli 6 6.0
· Klebsiella 2 2.0
· Pseudomonas 1 1.0
· S.typhi 10 10.0
· Staph.aureus 1 1.0
20%
80%
No Growth
Blood CS Growth
18
10
9
8
7
Percantage
6
5
4
3
2
1
0
E.coli Klebsiela Pseudomonas S.typhi Staph.a
Blood CS
Figure 4: Incidence of Blood CS
19
Table 5
5: Diagnosis of patients studied
No. of
patients Estimated
Diagnosis % 95%CI
odds
(n=100)
A .Dengue 43 43.0 33.73-52.78 0.75
B.Scrub typhus 20 20.0 13.34-28.88 0.25
C. Malaria 18 18.0 11.70-26.67 0.22
D. Sepsis 9 9.0 4.81-16.23 0.09
E.Enteric fever 8 8.0 4.11-15.00 0.08
F. Infective
1 1.0 0.1-5.5 0.01
endocarditis
G .Leptospirosis 1 1.0 0.1-5.5 0.01
45
40
35
30
Percantage
25
20
15
10
5
0
A B C D E F G
Diagnosis
Figure 5: Diagnosis of patients studied
In out of 100 patients on evaluation the most common etiology of fever with
thrombocytopenia was dengue 43 % of cases followed by scrub typhus20 % and
malaria 18%.
20
Table 6: Complications
No. of
Complications patients %
(n=100)
Nil 80 80.0
Yes 20 20.0
A. ARDS 7 7.0
B .AKI 5 5.0
C. ICETERUS/MELENA 4 4.0
D. PETECHIE 4 4.0
E. BledingGUMS 3 3.0
F. DEATH 3 3.0
G. POLYSEROSITIS 1 1.0
20%
80%
Nil
Yes
21
5
Percantage
0
A B C D E F G
Complications
Figure 6: Complications
Out of 100 cases twenty percent patients had complications in the form of
AKI, ARDS, minor bleeding (bleeding gums, purpura..And three patients exp
22
Table 7: Complications, according to the age distribution of patients

studied
No complications Complications
Age in years (n=80) (n=20)
No % No %
18-20 12 15.0 0 0.0
21-30 24 30.0 4 20.0
31-40 11 13.8 4 20.0
41-50 12 15.0 6 30.0
51-60 13 16.3 5 25.0
>60 8 10.0 1 5.0
Higher age was positively associated with presence of complications with
P=0.193
23
6 DISCUSSION
This study was done in 100patients in MGMCRI who presented with a history
of fever and who had thrombocytopenia and admitted.
Aim to know the clinical profile, causes, complications and outcome.
Present study2014(100 Shankar study(2013) Chris Pal(2009)

Aetiology
patients) (100 patients) (398 patients)
No. of No. Of No. of

percentage Percentage Percentage
cases cases cases
Dengue 43 43% 52 52% 28 7%
Scrub 189 47.5%
typhus
20 20% 0 0%
Malaria 18 18% 45 45% 68 17.1%
septicaemia 9 9% 0 0% 0 0%
Enteric 3 3%
fever
8 8% 32 8%
24
Others 2 2% 0 0% 81 20.4%
25
In our study, the Incidence of fever with thrombocytopenia was more common
in younger age group and Incidence was more in male comparing to females, which
was similar to the study done by Shankar et al (7)
In the present study out of 100 patients the main cause was dengue in 43
patients followed by scrub typhus in 20 patients and malaria in 18 patients,
septicaemia in 9 and enteric fever in 8 (8%) and infective endocarditis and leptospira
one each.
When the present study was compared with other studies mentioned above
(7)
dengue was the most common cause similar to Shankar’s study where as scrub
typhus was commonest cause in Chris Pal (9). Second common cause was scrub typhus
in our study where as malaria was the second common cause in Shankar’s study as
well as Chris Pal (9) study
In malaria plasmodium vivax was most common which was seen in 15
patients when compared to plasmodium falciparum was seen in 3 patients
Out of 100 patients the distribution of platelets in 68 patients was in the range
of 50,000 – 1, 00,000/mm3 followed by 24 patients who showed platelet count below
50,000/mm3.
Complications were seen in 20 patients in the form of ARDS, AKI and minor
bleeding manifestations like bleeding gums, petechae. ARDS was reported in seven
and acute kidney injury in five patients.
Prevalence of complications was more in females above forty years . (18)
26
Death was reported in 3 patients, 2 patients had dengue shock syndrome and
one patient had scrub typhus with ARDS. All other patients were treated according to
the cause. Gradually the platelet count improved and all recovered.
The profile of the three deceased patients:
Patient one:
A 55 year old female who presented with fever and associated comorbidity of
diabetes in poor control, she showed no bleeding on admission. Investigations showed
platelet count of 55000/mm3 and deranged liver functions and X-ray chest showed
increased bronchovascularity bilaterally and renal functions were normal and dengue
NS1 antigen was positive and smear for malaria parasite was negative. Repeat platelet
count 30000/mm3 and platelet transfusion was given. Three days after admission the
patient showed fall of blood pressure which did not respond to inotropes and expired
due to DSS. (14)
Patient 2:
A 50 year female who presented with fever of ten days duration no rigors and
bleeding manifestations are dysuria she showed platelet count 40000/mm3 on
admission, liver function was deranged, minimal renal impairment was noted and
dengue IG-M antibody was positive and malaria parasite was negative X-ray chest
was normal. Platelet transfusion was given. Three days after admission patient
showed sharp fall of blood pressure and could not be revived with inotropes. Cause of
death was DSS.
Patient 3:
A 67 year old male who presented with fever and breathlessness for two days.
On examination there were bilateral extensive crepitations in lung fields and an eschar
27
was found in the left inguinal region. No bleeding manifestations were noted. Platelets
36000/mm3 and renal and liver functions were deranged, X-ray showed bilateral
pneumonia. Smear for malaria parasite and dengue tests were negative. Weil-Felix
test was positive. The patient was treated with appropriate antibiotics but sturdily
deteriorated and died on the second day of admission due to ARDS and multiorgan
failure following scrub typhus.
LIMITATIONS OF STUDY
Study was done in a small population. When it is done in a large population
more light will be thrown on the prevalence of various diseases responsible for fever
with thrombocytopenia
28
7 CONCLUSION
In our study of fever with thrombocytopenia, infections were found to be the
commonest cause. Among infections dengue was more prevalent followed by scrub
typhus. Scrub typhus occurred more frequently in this belt (Pondicherry &
Cuddalore).
In our study, in a majority of patients thrombocytopenia was a transient
phenomenon and asymptomatic. Only a few patients developed complications as
described, but most of them recovered.
29
8 ABSTRACT
Background
Fever is known to mankind since ancient times. It is the most common
presentation among all diseases.
Methods: This study was done in 100 patients who are admitted in
Department of General Medicine at my institution. They were evaluated with detailed
history, physical examination, routine and specific investigations being done to know
the cause and the complications and were treated accordingly.
Results: Out of 100 patients, infections were the most common causes.
Among these, dengue (43%) was the leading cause, followed by scrub typhus (20%),
malaria(18%) and enteric fever(8%) and others(leptospirosis & infective endocarditis)
2%. Incidence is more in males than females; more among the younger age group.
Complications were more in elderly females and death was reported in three patients.
Conclusion:
In our study of fever with thrombocytopenia common cause is infections and
more in younger age group and in males. Though complications are few, significant
number of patients had complications.
30
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2. Tissues R, Snell BYES, Atkins E. T H E P R E S E N C E OF ENDOGENOUS P
Y R O G E N IN NORMAL ( From the Department of the Regius Professor of
Medidne, Radcliffe Infirmary,. 1965;
3. Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases.
Medicine (Baltimore).. 1956;1955–7.
4. Durack Dt, Street.AC: Fever of unknown origin--reexamined and redefined. curr
clin top infect dis. 1991;411:35–51.
5. Cheng CK, Chan J, Cembrowski GS, Assendeift OW Van. Complete Blood Count
Reference Interval Diagrams Derived from NHANES III : Stratification by Age,
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6. Scott CS, Van Zyl D, Ho E, Ruivo L, Mendelow B CT. Thrombocytopenia in
patients with malaria: automated analysis of optical platelet counts and platelet
clumps with the Cell Dyn CD4000 analyser. Clin Lab Haematol. 24(5):295–302.
7. Raikar SR, Kamdar PK, Dabhi AS. Clinical and Laboratory Evaluation of
Patients with Fever with Thrombocytopenia. Indian J Clin Pract. 2013;24(4):360–3.
8. Nair PS, Jain A, Khanduri U K V. A Study of Fever-associated
Thrombocytopenias. JAPI. 2003;51:1173.
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9. Chrispal A, Boorugu H, Gopinath KG, Chandy S, Prakash JAJ, Thomas EM, et al.
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spectrum and diagnostic predictors – an experience from a tertiary care hospital in
South India. Trop Doct. 2010 Oct 1;40(4):230–4.
10. Kochar DK, Das A, Kochar A, Middha S, Acharya J, Tanwar GS, et al.
Thrombocytopenia in Plasmodium falciparum, Plasmodium vivax and mixed
infection malaria : A study from Bikaner ( Northwestern India ).
2010;21(December):623–7.
11. Vinícius M, Lacerda G, Paula M, Mourão G, Cristina H, Coelho C, et al.
Thrombocytopenia in malaria : who cares ? 2011;106(Batista 1946):52–63.
12. Dennis LH, Eichelberger JW, Inman MM CM 1967. Depletion of coagulation
factors in drug-resistant Plasmodium falciparummalaria. Blood 29: 713-721. Blood.
1967;29:713–21.
13. Watier H, Verwaerde C, Landau I, Werner E, Fontaine J, Capron A AC. T-cell-
dependent immunity and thrombocytopenia in rats infected with Plasmodium
chabaudi. : Infect Immun. 1992;60:136–42.
14. Lee SH, Looareesuwan S, Chan J, Wilairatana P, Vanijanonta S, Chong SM
CB. Plasma macrophage colony-stimulating factor and P-selectin levels in malaria-
associated thrombocytopenia. Thromb Haemost. 1997;(77):: 289–293.
15. Kreil A, Wenisch C, Brittenham G, Looareesuwan S P-RM 2000. Thrombopoietin
in Plasmodium falciparum malaria. Br J Haematol. 2000;109:534–536.
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16. Ayyub M, Khazindar AM, Lubbad EH, Barlas S, Alfi AY, Al-ukayli S.
Characteristics of dengue fever in a large public hospital, Jeddah, Saudi Arabia.
2006;18(2):9–13.
17. Lei, H.-Y., T.-M. Yeh, H.-S. Liu, Y.-S. Lin, S.-H. Chen, and C.-C. Liu..
Immunopathogenesis of dengue virus infection. 2001 J. Biomed. Sci. 8:377-388
18. Sam S-S, Omar SFS, Teoh B-T, Abd-Jamil J, AbuBakar S. Review of Dengue
Hemorrhagic Fever Fatal Cases Seen Among Adults: A Retrospective Study. Farrar J,
editor. PLoS Neglected Tropical Diseases. 2013 May 2;7(5):e2194
19. Kumar A, Rao CR, Pandit V, Shetty S, Bammigatti C, Samarasinghe CM. Clinical
manifestations and trend of dengue cases admitted in a tertiary care hospital, udupi
district, karnataka. Indian J Community Med. 2010 Jul;35(3):386–90.
20. Nascimento FG, Tanaka PY. Thrombocytopenia in HIV-Infected Patients. Indian
J Hematol Blood Transfus. 2012 Jun;28(2):109–11
21. Colson P, Payraudeau E, Leonnet C, De Montigny S, Villeneuve L, Motte a, et al.
Severe thrombocytopenia associated with acute hepatitis E virus infection. J Clin
Microbiol. 2008 Jul;46(7):2450–2.
22. Dagnew M, Yismaw G, Gizachew M, Gadisa A, Abebe T, Tadesse T, et al.
Bacterial profile and antimicrobial susceptibility pattern in septicemia suspected
patients attending Gondar University Hospital, Northwest Ethiopia. BMC Res Notes.;
2013 Jan;6(1):283.
23. Vivekanandan M, Mani A, Priya YS, Singh AP. Outbreak of Scrub Typhus in
Pondicherry. JAPI. 2010;58(January):24–8.
33
24. Narvencar KPS, Rodrigues S, Nevrekar RP, Dias L, Dias A, Vaz M, et al. Scrub
typhus in patients reporting with acute febrile illness at a tertiary health care
institution in Goa. 2012;(December):1020–4.
25. Sevinc A, Buyukberber N, Camci C, Buyukberber S, Karsligil T.
Thrombocytopenia in brucellosis: case report and literature review. J Natl Med Assoc.
2005 Mar;97(2):290–3.
26. Pohan HT. Clinical and laboratory manifestations of typhoid fever at Persahabatan
Hospital, Jakarta. Acta Med Indones. 1999;36(2):78–83.
27. Bernard Rosner (2000), Fundamentals of Biostatistics, 5th Edition, Duxbury, page
80-240
28.Robert H Riffenburg (2005) , Statistics in Medicine , second edition, Academic
press. 85-125.
29. Sunder Rao P S S , Richard J(2006) : An Introduction to Biostatistics, A manual
for students in health sciences , New Delhi: Prentice hall of India. 4th edition, 86-160
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analysis for Clinical research studies. Journal Human Reproduction Science,5(1), 7-
13.
34
10 APPENDIES APPENDICES
10.1 ETHICS COMMITTEE CERTIFICATE OF APPROVAL
35
10.2 DATA COLLECTION PROFORMA
"A STUDY OF CLINICAL PROFILE, CAUSES AND COMPLICATIONS OF

FEVER WITH THROMBOCYTOPENIA”
Name : I.P.NO.: Age : D.O.A.:
Sex : D.O.D.:
Occupation : Hospital:
Address :
1. Chief COMPLAINTS:
II. HISTORY OF PRESENTING SYMPTOMS
III. PAST HISTORY
Hypertension
Diabetes
IV. DRUG HISTORY
Detailed history of drugs ingested in the past
. PERSONAL HISTORY
1. Appetite :
2. Diet: Veg/Non-Veg
3. Sleep : Disturbed/Normal
4. Bladder :
5. Bowel :
6. Habits
Smoking : Duration :
Frequency :
Amount/Day :
Alcohol consumption : Duration :
36
Frequency :
Amount/day :
IX. OBSTETRIC AND MENESTRUAL HISTORY :
X. GENERAL PHYSICAL EXAMINATION:
1. Built : Skin :
Weight : Conjunctiva:
Height Sclera :
Nourishment : Oral cavity:
Scalp hair : Upper respiratory tract :
2. Neck
Lymph node enlargement Yes/No
Thyroid enlargement Yes/No
Parotid enlargement Yes/No
3. Pallor : Yes/No
- Grade : Mild/Moderate/Severe
4. Icterus :
5. Cyanosis :
6. Clubbing :
- Grade :
7 Lympadenopathy
8. Edema :
9. Vital signs
Temperature
Pulse/Minute
37
Peripheral pulses
JVP
B.P (mmofHg)
Respiratory rate
XI. SYSTEMIC EXAMINATION
1. RESPIRATORY SYSTEM EXAMINATION
INSPECTION:
PALPATION
PERCUSSION
AUSCULTATION
2. CARDIO-VASCULAR EXAMINATION
INSPECTION:
PALPATION
AUSCULTATION:
3. GASTROINTESTINAL SYSTEM EXAMINATION
INSPECTION
PALPATION
PERCUSSION:
AUSCULTATION
CENTRAL NERVOSU SYSTEM EXAMINATION :
a. Higher mental function :
b. Cranial nerves :
c. Motor system :
d. Sensory system :
e. Co-ordination :
38
f. Signs of meningeal irritation : NECK STIFFNESS/KERNIGS SIGN
g. Skull and spine :
h.. Gait :
XII. INVESTIGATIONS
A. Routine Investigations
1. Routine Haematological examination
Hb gm % :
PCV (Hematocrit) (%) :
RBC count (/cumm) :
Total count (/cumm) :
Differential count :
Platelet count :
Erythrocyte Sedimentation Rate :
Peripheral blood smear :
2. Urine analysis
Albumin :
Sugar :
Microscopy :
3. FBS/ RBS :
4. Blood chemistry
Blood urea :
Serum creatinine:
5. Liver function test
Serum total bilirubin :
Serum total proteins :
39
Serum albumin :
Serum globulin :
Albumin/Globulin ratio :
S.G.O.T. :
S.G.P.T. :
Serum alkaline phosphatase :
6. Chest x-ray :
7. Ultrasound abdomen
B specific investigations :
a) Widal test
b) peripheral smear for malarial parasites
c) Rapid spot test for malaria
d) dengue antibodies IgM/IgG
e) NS1 antigen for dengue
f) IgM ELISA for leptospira
g) Blood c/s
h) urine c/s
XIII. TREATMENT:
XIV. FOLLOW UP :
XV. complications and outcome
40
10.3 INFORMED CONSENT
CONSENT FORM
“A STUDY OF CLINICAL PROFILE, CAUSES AND COMPLICATIONS OF

FEVER WITH THROMBOCYTOPENIA”
I, _____________________ have been informed about the details of the study in my

own language.
I have completely understood the details of the study.
I am aware of the possible risks and benefits, while taking part in the study.
I understand that I can withdraw from the study at any point of time and even then, I
will continue to receive the medical treatment as usual.
I understand that I will not get any payment for taking part in this study.
I will not object if the results of this study are getting published in any medical
journal, provided my personal identity is not revealed.
I know what I am supposed to do by taking part in this study and I assure that I would
extend my full co-operation for this study.
Signature/Thumb impression of the Volunteer

Date:
Name and Address of the Volunteer:
Witnesses:
(Signature, Name & Address) Date:
Name & Signature of

the Principal Investigator:
Date:
41
10.4 PATIENT INFORMATION SHEET
INFORMATION SHEET FOR THOSE WHO CONSENT TO PARTICIPATE
IN THE RESEARCH PROJECT
NAME OF THE RESEARCH PROJECT:A STUDY OF CLINICAL PROFILE,

CAUSES AND COMPLICATIONS OF FEVER WITH
THROMBOCYTOPENIA
We welcome you and thank you for having accepted our request to consider
whether you can participate in our study. This sheet contains the details of the study.
The possible risks discomfort and benefits to the participants are also given.
You can read and understand by yourself; if you wish, we are ready to read
and explain the same to you.
If you do not understand anything or if you want any more details we are
ready to provide the same.
Information for the participants:
1. What is the purpose of the study?
To study the cause and complications
2. Who / where this study is being conducted?
This study is being conducted by DR.V.SURESH a Post
Graduate medical student belonging to GENERAL MEDICINE department under the
guidance of DR,M.NARAYANAN.
3. Why am I being considered as one of the participant?
Because you fit the requirement for the study as per iclusion criteria
42
4. Should I have to definitely take part in this study?
No; the choice is yours. If you do not wish to participate, you will not be
included in this study; even then, you would continue to receive the medical treatment
without any prejudice.
5. If I am participating in this study, what would be my responsibilities?
You have certain simple responsibilities such as, coopration ,few ml blood for
investigation and stay in ward.
6. Are there any benefits for me / public?
Yes. Cause can be identified and complications can be prevented.
7. Will there be any discomfort / risks to me?
No risks. But certain discomforts such as giving a few ml of blood for
investigation, undergoing clinical examination, undergoing (Ultrasound scan if
required)
8. Will I be paid for the study?
No. You will not be paid.
9. Will my participation in this study and my personal details kept
confidentially?
Yes, confidentiality will be maintained.
10. Will I be informed of this study’s results and findings?
Yes, if you want you can get the details from us.
11. Can I withdraw from this study at any time during the study period?
Yes. You can withdraw at any time during the study period.
43
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44
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45
8. þó¾ ¬Ã¡öîº¢Â¢ø ¿¡ý ÀíÌ ¦ÀÚÅ¨¾Ôõ, ±ý¨É ÌÈ¢ò¾
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Å¢Ä¸¢ì ¦¸¡ûÇ ÓÊÔÁ¡?
¬õ. ¯í¸ÙìÌ Å¢ÕôÀÁ¢ø¨Ä¦ÂÉ¢ø ±ó§¿ÃÓõ Å¢Ä¸¢ì
¦¸¡ûÇÄ¡õ.
46
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Àø¸¨Äì¸Æ¸õ
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______________________ ±ý¸¢È ±ÉìÌ þó¾ ¬Ã¡öîº¢¨Âô ÀüÈ¢Â
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¦¸¡ñ§¼ý. «¾ýÀÊ ÓØ ´òÐ¨ÆôÒ ¦¸¡Îì¸ ¾Â¡Ã¡¸ ¯û§Çý.
ÀíÌ ¦ÀÚÀÅ¡¢ý ¨¸¦Â¡ôÀõ _________________ §¾¾¢ ___________
Ó¸Å¡¢ : _________________________________________
º¡ðº¢Â¡Ç¡¢ý ¨¸¦Â¡ôÀõ ___________ §¾¾¢ ________________
Ó¸Å¡¢ :
_________________________________________________
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47
10.5 MASTER CHART
COMPLICATI
ANTIBODIES
ANTILEPTO
WEIL FELIX
DIAGNOSIS
BLOOD C/S
PLt count
ANTIGEN
WIDAL
Sl no
AB'S
QBC
ONS
CNS
CVS
NS1
age
sex
HB
DC
RS
PA
TC
PS
1 49 M NS NS NS NS 11.00 3500 90000 56/40/3% - - - pos - - - NIL SCRUB TYPHUS
2 22 M NS NS NS NS 12.70 4200 80000 56/43/1% - - NS1 + - - - - NIL DENGUE
3 21 M NS NS NS NS 13.20 5,900 40000 60/32/4 % PV + - - - - - - - - MALARIA
4 45 M NS NS NS NS 12.90 10200 96000 54/46% - - - - pos - - - NIL SCRUB TYPHUS
5 35 M NS NS NS NS 9.00 16000 55000 30/55/10 - - - - - STAPH.A - - SEPSIS
6 18 M NS NS NS NS 14.70 2900 22000 55/44/1 - - - - - pos S.TYPHI - NIL ENTERIC FEVER
7 32 M NS NS NS NS 14.30 3200 70000 64/35/1 - - NS1 + - - - - - DENGUE
8 55 F NS NS HM + NS 12.00 3300 90000 84/16/0 - - - - - pos S.TYPHI - - ENTERIC FEVER
9 47 F NS NS NS NS 11.50 2300 88000 64/35/1 - - NS1 + - - - - - B.GUMS DENGUE
10 51 F NS NS NS NS 9.30 3500 89000 60/38/2 - - NS1 + - - - - - - DENGUE
11 59 M NS NS SPLEEN + NS 11.00 3330 75000 65/20/5 PV + - - - - - - - - MALARIA
12 31 M NS NS NS NS 10.00 2200 54000 30/55/5 - - NS1 + - - - - - - DENGUE
13 68 M NS NS NS NS 12.00 4500 88000 75/22/3 - - NS1 + - - - - - - DENGUE
14 55 M NS NS NS NS 10.00 2200 60000 70/26/4 - - - - pos - - - - SCRUB TYPHUS
15 52 F NS NS NS NS 9.00 3400 500000 40/54/6 - - - - pos - - - SCRUB TYPHUS
16 72 F NS NS NS NS 12.00 7200 100000 78/22/0 - - NS1 + - - - - - - DENGUE
17 55 F NS NS NS NS 11.00 6200 77000 64/30/6 - NS1 + - - - - - - DENGUE

HEPTO
18 20 M NS NS +SPLEEN+ NS 8.00 5500 45000 62/34/4 PV + - - - - -- -- - MALARIA
19 25 M NS NS HEPTO NS 13.00 4500 82000 72/38 - - - - - pos S.TYPHI - - ENTERIC FEVER
1
20 31 M NS NS SPLEEN + N 12.00 3200 62000 66/23/11 PV + - - -- - - - - - MALARIA
21 34 M NS NS NS NS 13.00 9200 1.04 56/44 - -- - - pos - - - - SCRUB TYPHUS
22 35 F NS NS NS NS 9.00 6400 1.2 74/32/4 - - NS1 + IG-M - - - - - DENGUE
23 49 F B/LCREPTS NS NS NS 8.00 17000 46000 25/65/10 - - - - - - Ecoli - PETECHIE SEPSIS
24 30 M NS NS NS NS 14.00 8000 1.2 79/20 - - NS1 + -- - - - - - DENGUE
25 36 M NS NS NS NS 12.00 6100 31000 50/41/1/2 - - IG-M - - - - GUM BLEEDING DENGUE
26 41 M B/LCREPTS NS NS NS 12.60 17000 44000 45/50/2/3 - - - - pos - - - ARDS SCRUB TYPHUS
27 55 M B/LCREPTS NS NS NS 9.30 6700 96000 91/7/2 PV + - - - - - - - AKI MALARIA
28 65 M NS NS TENDERNESS NS 13.20 4900 55000 35/60/5 - - NS1 + - - - - - B.GUMS DENGUE
29 30 M NS NS NS NS 12.00 9100 1.19 65/35 - - - - pos - - - - SCRUB TYPHUS
30 60 M NS NS NS NS 11.00 10,400 70,000 75/22/1/2 - - - - pos - - - - SCRUB TYPHUS
31 80 M NS NS NS NS 13.00 8200 90000 83/17 - - - - pos - - - - SCRUB TYPHUS
32 73 M B/LCREPTS NS NS NS 10.00 18,400 72000 27/72/1 - - - - - - ECOLI/K.P - - SEPSIS
33 60 F NS NS NS NS 10.00 15200 1.2 80/20 - - - - - - - - DENGUE
34 58 F B/LCREPTS NS NS NS 11.20 12,500 70000 80/17/3 - - NS1+ IG-M - - - - PETECHIE DENGUE
35 29 M NS NS SPLEEN + NS 14.00 7000 60000 72/28 PV + - - - - - - - ICTERUS MALARIA
36 45 F NS NS SPLEEN + NS 8.00 6,000 83000 49/49/2 PV + - - - - - - - ICTERUS MALARIA
37 58 F NS NS TENDERNESS NS 10.00 18000 55000 28/70/2 - - - - - - ECOLI - PETECHIE SEPSIS
38 60 F NS NS HM+ NS 12.00 5,300 1.2 83/17 - - - - - - S.TYPHI - ICTERUS ENTERIC FEVER
39 28 M NS NS SPLEEN + NS 10.00 3000 28000 78/22 PV + - - - - - - - MELENA/ICTERUS MALARIA
40 55 M NS NS HM+ NS 11.00 4,500 1.05 70/30 - - - - - - S.TYPHI - - ENTERIC FEVER
41 42 F BS-RED NS ASCITIES NS 9.00 4800 22,000 80/20 - - NS1 + - - - - - POLYSEROSITIS DHF
42 19 M NS NS TENDERNESS NS 12.20 2,600 77000 63/35/2 - - NS1 IGM - - - - - DENGUE
44 43 F NS NS NS NS 10.00 4,500 90000 69/30/1 - - - - pos - - - - SCRUB TYPHUS
2
45 37 F NS NS NS NS 12.10 3000 74000 50/48/2 - - NS1+ - - - - - PETECHIE DENGUE
46 29 M NS NS HS + NS 6.80 8,400 17000 62/38 PV + - - - - - - - ARDS/AKI MALARIA
47 50 F NS NS TENDERNESS NS 9.00 4600 16000 41/53 - - - Ig-M - - - - ARDS/expired DENGUE
48 45 M NS NS NS NS 11.00 5,200 52000 60/38 - - NS1+ - - - - - DENGUE
49 15 M NS NS NS NS 13.10 2100 2100 75/20 - - NS1+ - - - - - - DENGUE
50 22 M NS NS NS ND 15.00 3,100 22000 75/23 - - NS1+ - - - - - - DENGUE
51 27 F NS NS SPLEEN + NS 10.00 3200 94000 64/35 PV + - - - - - - - - MALARIA
52 33 F B/LCREPTS NS NS NS 9.00 5,800 40000 68/34 - - - - - - pos ARDS/AkI LEPTOSPIROSIS
54 23 M NS NS NS NS 12.00 6,200 77000 84/12 - - NS1+ - - - - - - DENGUE
55 45 M NS NS HEP/SPLEEN NS 8.00 5400 60000 72/28 - - - - - pos S.TYPHI - - ENTERIC FEVER
56 65 M NS NS NS NS 8.70 17,000 55000 80/19 - - - - - - Ecoli - - SEPSIS
57 18 M NS NS SPLEEN + NS 10.00 6000 85000 62/34 PF+ pos - - - - - MALARIA
58 50 F NS NS NS NS 10.00 1,900 46000 64/35 - - NS1+ - - - - DENGUE
59 75 M NS NS NS NS 10.00 5600 68000 60/35 - - - - - - klebsiela - - SEPSIS
60 23 F NS NS HEP/SPLEEN NS 8.00 6,400 45000 72/34 - - - - pos - - - - SCRUB TYPHUS
61 65 M B/LCREPTS NS NS NS 14.00 5600 90000 65/30 - - NS1+ IG-M - - - - - DENGUE
62 17 M NS NS NS NS 15.00 4,000 50000 60/30 - - - - pos - - - - SCRUB TYPHUS
63 47 M NS NS NS NS 9.10 4400 84000 60/30 - - - - pos - - - - SCRUB TYPHUS
64 33 F NS NS HEPT0 + NS 9.80 6,400 80000 60/38 - - - - pos - - - - SCRUB TYPHUS
65 19 M NS NS SPLEEN + NS 12.00 4000 50000 66/34 PV + - - - - - - - - MALARIA
66 25 M NS NS NS NS 13.00 4,600 44000 50/37 - - - - - - DENGUE
67 29 F NS NS NS NS 11.00 3600 80000 58/40 - - NS1+ IG-M - - - - - DENGUE
68 60 F NS NS NS NS 12.00 5,300 90000 83/17 - - NS1+ - - - - - - DENGUE
69 14 M NS NS HEPTO/SPLEEN NS 11.00 4400 64000 64/30 PV + - - - - - - - - MALARIA
3
70 55 F B/LCREPTS NS NS NS 8.00 2,200 40000 62/34 - - NS1+ - - - - - ARDS/EXPIRED DENGUE
71 17 F NS NS SPLEEN + NS 8.00 6200 90000 50/47 PV + - - IG M - - - - - MALARIA
72 45 F NS NS NS NS 11.50 2,800 47000 75/20 - - NS1+ - - - - - - DENGUE
73 35 F B/LCREPTS NS NS NS 8.90 9900 88000 66/34 - - - - pos - - - ARDS SCRUB TYPHUS
74 52 F NS NS NS NS 13.90 4,000 44000 55/45 - - NS1+ IG-M - - - - - DENGUE
75 22 M NS NS SPLEEN + NS 10.40 5200 54000 65/30/1/4 PF+ - - - - - - - - MALARIA
76 21 F NS NS NS NS 9.00 4,400 80000 74/24/2 - - NS1+ - - - - - - DENGUE
77 40 M NS NS NS NS 11.20 3600 55000 65/28/4 - - NS1+ - - - - - - DENGUE
79 23 M NS NS NS NS 13.00 8200 98,000 65/30 - - NS1+ IG M - - - - DENGUE
80 22 F NS NS TENDERNESS NS 11.50 6,800 78000 85/12/3 - - - IG G - - Ecoli - - SEPTICEMIA
82 30 M NS NS NS NS 12.50 7,600 74000 64/16/14 - - NS1+ IGM - - - - - DENGUE
83 28 M NS NS NS NS 12.00 5600 98000 72/24/4 - - - - - pos S.TYPHI - - ENTERIC FEVER
84 44 F NS NS NS NS 8.00 16,600 56000 40/54/4 - - - - - - klebsiela - - SEPTICEMIA
85 29 M NS NS NS NS 9.80 7600 77000 74/28/ - - NS1+ - - - - - - DENGUE
86 26 M NS NS NS NS 13.00 6,400 96000 78/18/4 - - NS1+ - - - - - - DENGUE
87 34 M NS NS NS NS 12.00 2800 39000 54/35/1 - - NS1+ - - - - - - DENGUE
88 44 M NS NS HEPT0 + NS 13.00 9,200 66000 65/35 - - - - - pos S.TYPHI - - ENTERIC FEVER
89 24 F NS NS NS NS 12.00 10800 32000 85/18/2 - - - - - - Ecoli - - SEPTICEMIA
90 42 M B/LCREPTS PSM+ HEPTO/SPLEEN NS 11.00 16,000 44000 88/12 - - - - - - pseudomonas INFECTIVE ENDOCARDITIS
91 67 M B/LCREPTS NS HEPTO NS 13.00 22000 39000 65/32/2 - - - pos - - - ARDS/AKI/expired SCRUB TYPHUS
92 29 F NS NS NS NS 11.00 5,200 72000 62/32/4 - - - - pos - - - - SCRUB TYPHUS
93 24 F NS NS NS NS 12.00 7800 98000 74/22/2 PV + - - - - - - - - MALARIA
4
95 28 F NS NS NS NS 12.00 5400 82000 48/54 - - - - pos - - - - SCRUB TYPHUS
96 64 M NS NS NS NS 11.00 6,200 98000 65/32 - - NS1+ Ig-G - - - - - DENGUE
98 24 M NS NS SPLEEN + NS 12.00 6,700 75000 65/28/7 PF+ - - - - - - - AKI MALARIA
99 54 F NS NS NS NS 11.00 4500 84000 72/24 - - NS1+ - - - - - - DENGUE
100 18 M NS NS SPLEEN + NS 12.00 6,500 64000 65/30 PV + pos - - - - - - - MALARIA
5
KEY TO MASTER CHART
AKI : acute kidney injury
ARDS : acute respiratory distress syndrome
B. GUMS : BLEEDING GUMS
BLOOD C/S : BLOOD CULTURE & SENSITIVTY
Dc : DIFFERENTIAL COUNT
HB : HEMOGLOBIN
HEPATO : HEPATOMEGALY
NEG : NEGATIVE
NS : NOTHING SIGNIFICANT
PF + : PLASMODIUM FALCIPARUM
POS : POSITIVE
PS : PERIPHERAL SMEAR
PV+ : PLASMODIUM VIVAX
S,TYPHI : SALMONELLA TYPHI
SPLEEN + : SPLENOMEGALY
STAPH.A : STAHYLOCOCCUS AUREUS
TC : TOTAL COUNT
+ : POSITIVE
- : NEGATIVE
1
10.5 PLAGIARISM CHECK CERTIFICATE
BONAFIDE CERTIFICATE
This is to certify that the dissertation titled A STUDY OF CLINICAL

PROFILE, CAUSES AND COMPLICATIONS OF FEVER WITH
THROMBOCYTOPENIA is a bonafide original research work, done by
Dr. V. SURESH, Post Graduate, Department of General Medicine Session 2012-
2015.
This study has been authenticated under my supervision and has been
subjected to the mandatory plagiarism check using ‘PLAGIARISM DETECTOR –
anti-plagiarism Scanner’ software. The total plagiarism match has been evaluated to
be 5%.
I hereby certify that this original work has been authenticated and endorsed by
the faculty members in the Department of General Medicine.
Dr. K.JAYA SINGH,

Professor and HOD
2

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A STUDY OF CLINICAL PROFILE, CAUSES AND

COMPLICATIONS OF FEVER WITH

MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE

PONDICHERRY – 607402, INDIA

INSTITUTE, PONDICHERRY -607402

This is to certify that the dissertation entitled “A STUDY OF CLINICAL

PROFILE, CAUSES AND COMPLICATIONS OF FEVER WITH

THROMBOCYTOPENIA” is a bonafide record of work carried out by

DR. V. SURESH, REG NO: 1201091008 in the Department of General Medicine,

M.D. General Medicine from April 2012 to March 2015.

Dr. K.JAYA SINGH,

DECLARATION OF THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “A STUDY OF

CLINICAL PROFILE, CAUSES AND COMPLICATIONS OF FEVER WITH

THROMBOCYTOPENIA” is a bonafide and genuine research work carried by me

Dr. V. SURESH, under the guidance of Prof. Dr. M.NARAYAN Department of

General Medicine, Mahatma Gandhi Medical College & Research Institute

I take this opportunity with a deep sense of gratitude to express my respect to

unparalleled guidance, unwavering support, constant inspiration and expertise

throughout my post graduate study and also towards completion of my dissertation.

I offer my sincere thanks to Dr.Ragupathy, Professor, and Dr.lokesh.s

Associate Professor Department of Cardiology for giving helpful suggestions and

guiding me in this study.

I sincerely thank, Dr. Ananthakrishnan. N, Professor of General Surgery,

I sincerely express my thanks to, Dr. K.Jayasingh, Professor and Head,

my morals in time of need.

I express my heartfelt and sincere gratitude to Professors and associate

compiling this dissertation.

their guidance and support all along.

without them this study would not have been possible.

Hospital for their every help in making this dissertation possible.

I want to acknowledge all my fellow postgraduates from the department of

General medicine and Cardiology, who helped me compile this study.

my post graduate studies.

ACKNOWLEDGEMENTS ........................................................................................ iii

LIST OF TABLES ..................................................................................................... vii

LIST OF FIGURES .................................................................................................. viii

ABBREVATIONS AND ACRONYMS .................................................................. viii

2 AIMS AND OBJECTIVES................................................................................. 2

1. TO EVALUATE CLINICAL PROFILE OF FEVER WITH

3 REVIEW OF LITERATURE ............................................................................. 3

4 PATIENTS AND METHODS .......................................................................... 11

10 APPENDIES APPENDICES ............................................................................ 35

10.1 ETHICS COMMITTEE CERTIFICATE OF APPROVAL...................... 35

10.2 DATA COLLECTION PROFORMA ....................................................... 36

10.3 INFORMED CONSENT ........................................................................... 41

10.4 PATIENT INFORMATION SHEET ........................................................ 42

10.5 MASTER CHART .................................... Error! Bookmark not defined.

10.6 PLAGIARISM CHECK CERTIFICATE.................................................... 2

Table 1: Age distribution of patients studied ............................................................... 15

Table 2: Gender distribution of patients studied .......................................................... 16

Table 3: Distribution of platelets at the time of admission: ......................................... 17

Table 4: Incidence of Blood CS ................................................................................... 18

Table 5: Diagnosis of patients studied ......................................................................... 20

Table 6: Complications ................................................................................................ 21

Table 7: Complications, according to the age distribution of patients studied ............ 23

Figure 1: Age distribution of patients studied ............................................................. 15

Figure 2: Gender distribution of patients studied ........................................................ 16

Figure 3: Distribution of platelets at the time of admission ........................................ 17

Figure 4: Incidence of Blood CS ................................................................................. 19

Figure 5: Diagnosis of patients studied........................................................................ 20

AIDS Acquired immunodeficiency syndrome

ARDS Acute respiratory distress syndrome