Title: To assess predictors for platelet transfusion in Tropical Viral fever with

thrombocytopenia

Background:

The relationship of India with dengue has been long and intense. The first recorded epidemic

of clinically dengue- like illness occurred at Madras in 1780 and the dengue virus was isolated

for the first time almost simultaneously in Japan and Kolkata in 1943–1944. After the first

virologically proved epidemic of dengue fever along the East Coast of India in 1963–1964, it

spread to allover the country. The first full-blown epidemic of the severe form of the illness,

the dengue hemorrhagic fever/ dengue shock syndrome occurred in North India, Ludhiana in

1996 and since then Dengue has been endemic in India. June to Sept is usually rainy season in

India and Dengue / Tropical fever cases goes up in this period as well as post-monsoon and

hospitals face tough time to manage these illnesses. These illnesses has spectrum from mild

fever to severe hemorrhagic and encephalitic manifestations leading to mortality. There is no

specific treatment available as far as Dengue fever is concerned.

Medical fraternity globally recognizes the role of platelet transfusion in the management of

hospitalized dengue patients, the exact indications and situations in which these are to be

transfused may vary. Since there is inherent risk associated with the transfusion of blood/blood-

component, it is imperative for each institution (or country) to lay their own criteria for

transfusion of these blood components. But, ensuring availability of components on time is

also a challenge, hence present study was conducted to assess whether there is any association

between presence of comorbidities and requirement of Single Donor Platelet transfusion. This

will help in early recognition of patients at need of transfusion and reduce the incidence adverse

clinical outcomes
Aim and objectives:

AIM: Association of comorbidities with need of platelet transfusion.

Objectives:

1. To separate viral tropical fever from Dengue Fever

2. Demographic distribution of cases

3. Correlation of comorbidities with need of platelet transfusion

4. Pattern of platelet count decrease in various groups of patients

5. Antibiotic use in diagnosed viral fever

6. Assess final outcome of patients

Method:

From 1 Apr 2019 to 30 Sept 2019, medical records of all the patients having diagnosis

mentioned as Febrile Thrombocytopenia / Dengue / Viral Tropical Fever were analyzed.

Daywise platelet count was noted for all patients from laboratory results, blood/blood

component transfusion was noted from patient’s file. Final diagnosis and outcome was

recorded from discharge summary. All the data was eneterd in Microsoft excel and analyzed.

Statistical Analysis

1. Odds Ratio

2. Fisher’s Exact Test

All the conclusions were made based on “p” value

Results:

Total of 4475 patients were discharged during Apr to Sept 2019. Out of which 49 patients were

identified to have dengue fever / viral tropical fever mentioned as a final diagnosis. Out of that

39 were meeting definition for Probable Dengue Fever case as per guideline, 9 were Tropical

Fever, 1 was PUO under evaluation.

Demographic -

 32 Male, 17 Female,

 Male: Female = 1.88

 Age Range = 14 to 82,

 Mean age = 51 yrs

 No Pediatric patient

 Total ALOS = 6.2 Days,

 Dengue ALOS = 5.7 Days

Clinical Diagnosis & Other relevant findings :

PUO Under
Evaluation, 1, 2%
Tropical Fever, 9,
18%

Dengue Shock
Syndrome, 1, 2%

Dengue , 38, 78%

Total 79 % (n=39) patients were found to have Dengue, out of that 28 were Dengue without

any complication, 10 were Dengue with any of the complications which include - Serositis,

MODS, ARF on CKD, ALF etc. and 1 patient was found to have Dengue Shock Syndrome

(DSS). Dengue serology by card test was performed on all the patients, 12 were NS1 Antigen

Positive, 23 IgM Antibody Positive, 2 IGG & IGM Both Positive (possibly secondary dengue

infection) and 2 were negative by serology. 2 Patients were found to have Dengue and Typhoid

co-infection, both were positive for dengue IgM & TyphiDot IgM as well blood culture positive

for Salmonella typhi.

Prescription of antibiotics: Total of 13 patients received antibiotics, out of that 7 patients

received antibiotics for more than 3 days and also at the time of discharge without any obvious

indication for continuing antibiotics. This gives an indication for us about stopping use of

antibiotics when diagnosis of viral fever or dengue fever is made to prevent development of

resistance.

Further these patients were analyzed for presence of any comorbidities. And statistical

association of Comorbidity and Need of platelet transfusion was studied. Out of 49 , 32 (65%)

patients were found to have co-morbidities, 15 were without any comorbidities and it was not

documented in 2 patients hence taken as unknown. 25 patients has more than 1 comorbidities

and 12 had only 1 comorbidity.

There were 2 deaths in in these 49 patients, both were probable dengue cases, cause of death

being MODS with polyserositis , out of these 2 patients 1 patient also had CML and was on

chemotherapy.
 Comorbidities
8
7
7

5
4 4
4
3
3
2 2
2

0
CKD IHD DM DM + IHD Malignancy IHD + CKD

No Of Cases

Platelet Counts :

Platelet counts at Admission in patients

Without comorbidities With Comorbidities

Sr No PLT Sr No PLT

1 1.05 1 0.12

2 0.06 2 0.24

3 0.24 3 0.31

4 0.42 4 0.33

5 0.67 5 0.42

6 1.1 6 0.45

7 1.05 7 0.46

8 1.25 8 0.4

9 1.25 9 0.57

10 1.6 10 0.74

11 1.87 11 0.76
 12 2.03 12 0.82

13 2.1 13 0.8

14 2.19 14 0.6

Mean 1.20571429 15 0.84

SD 0.6938157 16 0.78

17 1.19

18 0.78

19 0.82

20 0.7

21 0.72

22 1.51

23 1.55

24 1.75

25 2.02

Mean 0.7872

SD 0.47883122

There was statistically significant difference between these 2 groups with p value being 0.0323.

Mean platelet count was found to be lower (78,000) in patients with comorbidities that those

without. Earlier group patient having lowest count of 12,000. But, at discharge, there was no

significant difference in platelet counts of these 2 groups, which indicate adequate treatment.

Statistical Analysis :

A 2 by 2 contigency table was prepared as follows

 Need of Platelet Transfusion Total

Yes No

Patient has 1 or more Yes 15 10 25

comorbidities No 3 11 14

Total 18 21 39

Fisher's exact test was applied, and “p” value was calculated to find any significant

association in these 2 groups.

The two-tailed P value was calculated as “p=0.0428”

And hence,

The association between rows (Presence of comorbidities) and columns (Need of Platelet

Transfusion) is considered to be statistically significant. This analysis gave us insight regarding

keeping availability of SDP for patients of dengue who has 1 or more comorbidities.

Discussion :

While medical fraternity globally recognizes the role of platelet transfusion in the management

of hospitalized dengue patients the exact indications and situations in which these are to be

transfused may vary. Since there is inherent risk associated with the transfusion of blood/blood-

component, it is imperative for each institution (or country) to lay their own criteria for

transfusion of these blood components. As per the guideline, we have to classify patients in

high risk groups which are more prone to develop complications. Present audit gives a

substantial evidence that, if we have a patient with comorbidity with dengue, from the day of

admission itself there should be a preparedness for making SDP available at any time to prevent

any adverse clinical outcome.

Conclusion:

Present audit gives a several insights -

1. If we have a patient with systemic comorbidity having Dengue fever, from the day of

admission itself there should be a preparedness for making SDP available at any time

to prevent any adverse clinical outcome.

2. Refrain from prescribing antibiotics when diagnosis of isolated Dengue fever is made

References:

1. Dengue and dengue haemorrhagic fever: Indian perspective, J. Biosci. 33(4),

November 2008, 429–441

2. Dengue in India, Nivedita Gupta, Sakshi Srivastava, Amita Jain, and Umesh C.

Chaturvedi, Indian J Med Res. 2012 Sep; 136(3): 373–390.

3. National Guideline for Clinical Management of Dengue Fever, 2015, Govt Of India

4. Role of platelet transfusion in the management of dengue patients in a tertiary care

hospital, Asian J Transfus Sci. 2007 Jan-Jun; 1(1): 4–7.doi: 10.4103/0973-6247.28065,

R. N. Makroo, V. Raina, P. Kumar, and R. K. Kanth