|Year : 2016 | Volume
| Issue : 2 | Page : 121-124
Spectrum of thrombocytopenia: A clinicopathological study with review of the literature
Ekta Paramjit, Rajiv Rao, S Sudhamani, Prakash Roplekar, Zeba Shaffi, Sukriti Roy
Department of Pathology, Dr. DY Patil Medical Hospital, Pune, Maharashtra, India
|Date of Web Publication||30-Jun-2016|
House No. 99, Sector 24 A, Chandigarh - 160 023, Punjab and Haryana
Source of Support: None, Conflict of Interest: None
Background: Thrombocytopenia has been defined as a subnormal number of platelets in the circulating blood and may result from four processes: Artifactual thrombocytopenia, deficient production of platelets, accelerated destruction, and abnormal distribution or pooling of the platelets. Aims: To find out the etiology of thrombocytopenia with clinicopathological correlation, to grade it on the basis of platelet count, and to know the age and sex distribution of the cases. Materials and Methods: The study was conducted from January 2015 to June 2015. A total of 300 cases of thrombocytopenia were selected. All the patients with platelet counts less than 150 Χ 10 3 / micro liter (μL), were included. On the basis of platelet count, the cases were divided into the four grades and clinicopathological correlation was done. Statistical Analysis: Simple random sampling, mean, and percentage. Results: The most common cause for thrombocytopenia was infection. Alcoholic liver disease was the most common noninfective cause. Maximum number of patients were in the age group of 20-39 years. The commonest grade of thrombocytopenia was Grade 1, the least common being Grade 4. Conclusion: Thrombocytopenia is usually associated with infections such as malaria, dengue, sepsis, and viral diseases. It is less common in noninfective conditions, for example alcoholic liver disease. It is seen mainly in adults, significantly more in males, and present as Grade I.
Keywords: Dengue, malaria, thrombocytopenia
|How to cite this article:|
Paramjit E, Rao R, Sudhamani S, Roplekar P, Shaffi Z, Roy S. Spectrum of thrombocytopenia: A clinicopathological study with review of the literature. Muller J Med Sci Res 2016;7:121-4
|How to cite this URL:|
Paramjit E, Rao R, Sudhamani S, Roplekar P, Shaffi Z, Roy S. Spectrum of thrombocytopenia: A clinicopathological study with review of the literature. Muller J Med Sci Res [serial online] 2016 [cited 2020 Apr 10];7:121-4. Available from: http://www.mjmsr.net/text.asp?2016/7/2/121/185012
| Background|| |
Lusitanus in the 16 th century and La Riviere in the early 17 th century first recognized purpura in the absence of fever. In 1735, Werlhof described maculosus hemorrhagicus as a separate entity, and in 1808, William classified purpura under the headings simplex, hemorrhagica, urticans, and contagiosa. 
| Introduction|| |
Platelets are formed by fragmentation of megakaryocytes in the bone marrow and have an average life of 7-10 days, they play a critical role in hemostasis.  Thrombocytopenia is defined as platelet count below the normal range for the population (plus or minus 2 Standard Deviations).  Generally, the normal range of platelet count is taken as 150,000-450,000/ Micro Liter (μL). No concrete definition of mild, moderate, or severe thrombocytopenia exists.  However, we have followed the Common Toxicity Criteria that the National Cancer Institute (NCI) has developed to describe severity of thrombocytopenia (Common Terminology Criteria for Adverse Events (CTCAE) v3.0 August 9, 2006). 
| Materials and Methods|| |
The study was conducted for a period of six months from January 2015 to June 2015, which included the dry period to the monsoon period in the region. Blood samples were sent for Complete Blood Count (CBC) in the Department of Laboratory Medicine, which were run on Mindray BC 5300 and BC 5600 Automated Hematology Analyzer.
All the patients with platelet count less than 150 × 10 3 /μL and confirmed on peripheral blood smear were included in our study. Clinical history of the patients was traced with a focus on finding etiological correlation. Patients whose clinical details were not available were excluded from the study.
On the basis of platelet count, the cases were divided into the four following grades: μL (micro liter)
Grade 1: 75-150 × 10 3 /μL
Grade 2: 50-75 × 10 3 /μL
Grade 3: 25-50 × 10 3 /μL
Grade 4: <25 × 10 3 /μL
Clinicopathological correlation was done and the findings were tabulated.
| Results|| |
Between January 2015 and June 2015, a total of 300 patients were selected by simple random sampling and were categorized according to their age, sex, and etiology of thrombocytopenia and their respective percentages were calculated.
Out of which, maximum number of patients were in the age group 20-39 years (157 cases, i.e., 52.3%), followed by the age group of 0-19 years (63 cases, 21%), and least in the age group of over 80 years (six cases, 2.1%) [Table 1]. In our study, 68% were male and 32% were female [Table 1].
Infectious etiology was the most important cause, with malaria (173, 57.7%) being the principal reason. Other common causes included dengue (83, 27.7%), liver disease (23, 7.7%), and sepsis (14, 4.7%) [Table 2].
Grade 1 (75-150) thrombocytopenia was the largest group (48.4%) and Grade 4 (<25) was the least (8.3%) [Table 3].
| Discussion|| |
Bleeding time is not prolonged until the platelet count is below 100,000/μL; for platelet counts above 20,000/μL, clinical manifestations are mild, often limited to easy bruising.  At less than 10,000/μL, the risk of spontaneous mucocutaneous bleeding (epistaxis, gingival bleed, menorrhagia, petechiae, and ecchymoses) and life-threatening, spontaneous intracranial hemorrhage, or gastrointestinal bleeding increases rapidly. 
Our study had 300 cases with a sex distribution: 67.8% male and 32.2% female; these findings were similar to a study at conducted over 4 months by Lakdum et al.  A total of 500 patients were studied on fever with thrombocytopenia in which 65.2% were male and 34.8% were female respectively. Another study by Bhalara et al., however, had a total of 400 cases, out of which 59% were male and 41% were female. 
Age correlation was not possible with above studies as we additionally included cases less than 18 years of age. Our studies showed that most of the cases of thrombocytopenia belonged to the age group of 20-39 years (52.3%), followed by the age group of 0-19 years (21.0%), the least being in the age group of over 80 years (2.1%).
Prospectively, cases were collected and we found that infectious cause was the most common. Among all causes, malaria (60%) was the commonest cause of thrombocytopenia that correlated with the study by Lakdum et al. (46.8%) but it differed from the study by Bhalara et al. in which malaria was only 22.8% of the total number of cases. , The cause for this variation may be due to seasonal and regional variations. A similar study by Amita et al. from Gujarat Medical Education & Research Society (GMERS) Medical College showed malaria [Plasmodium vivax (P. Vivax), Plasmodium falciparum (P. falciparum), and mixed infections] was the etiology in 41% cases. 
Thrombocytopenia is a common feature of both falciparum and vivax malaria. As seen in our study as well, thrombocytopenia is a diagnostic clue to the presence of malaria.  The frequency of thrombocytopenia (i.e., platelet count below 150,000/mm 3 ) in malaria infection ranges from 24-94% in the literature.  It is postulated that the cause of thrombocytopenia is most probably due to the binding of malarial antigens to the surface of platelets that causes antimalarial antibodies to additionally bind to the platelets, leading to the in situ formation of immune complexes (ICS).  The fall of platelet count is independent of age, duration of illness, spleen size, and parasite count. 
Dengue was found to be the second most common cause with 27.7%, which had similar distribution as Bhalara (28.6%), Lakdum (35.4%), and Amita et al. (26.79%). ,, The two mechanisms are probably involved in dengue-induced thrombocytopenia; these are impaired thrombopoiesis and peripheral platelet destruction. 
Liver disease constituted only 7.7%, whereas in the study by Bhalara et al., it was 15.2% of the total number of cases. Septicemia was 4.7%, which was the most common cause in the study by Nair (26.6%) but had similar values as Bhalara (6.3%), Lakdum (7.8%), and Amita et al. (4.46%) studies. ,,, Other causes included aplastic anemia (0.6%), typhoid fever (0.3%), human immunodeficiency virus (HIV) (0.3%), disseminated intravascular coagulopathy (DIC) (0.3%), drug-induced (0.6%) etc.
In our study, most patients presented with Grade 1 thrombocytopenia (48.7%) followed by Grade 2 (28%), Grade 3 (15.3%), and Grade 4 thrombocytopenia (8.3%) with platelet count as low as 2000/μL noted in a case of aplastic anemia. These findings could not be correlated with other studies in which, the range for mild, moderate, and severe thrombocytopenia were different as there is no uniformly accepted criteria for the grading of thrombocytopenia. However, Gupta et al. conducted a study that included cases of malaria and graded the severity of thrombocytopenia from Grade 1 to Grade 4. Results were incomparable, as no other cause of thrombocytopenia was considered. 
There is scarcity of literature on thrombocytopenia, which is the most common finding in a clinicopathological setup. Especially in developing countries such as India, during monsoons there is a rapid surge of cases of thrombocytopenia, sometimes leading to fatal consequences due to bleeding episodes. The principle cause in such cases was reportedly being infectious in origin. There is an urgent need to study and categorize the etiological factors leading to thrombocytopenia so that control measures could be initiated and hence, the need of the study.
| Conclusion|| |
While dengue is the most common cause of thrombocytopenia throughout the year, it is quickly overtaken by malaria as there is a surge in malaria cases in the monsoon season.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Rodgers GM. Thrombocytopenia: Pathophysiology and classification. In: Greer JP, Foerster J, Rodgers GM, Paraskevas F, Glader B, Arber DA, editors. Wintrobe′s Clinical Hematology. 12 th
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013. p. 2451.
Sekhon SS, Roy V. Thrombocytopenia in adults: A practical approach to evaluation and management. South Med J 2006;99:491-8; quiz 499-500, 533.
Bhalara SK, Shah S, Goswami H, Gonsai RN. Clinical and etiological profile of thrombocytopenia in adults: A tertiary-care hospital-based cross-sectional study. Int J Med Sci Public Health 2015;4:7-10.
Lakum DN, Makwana DH, Shah DR. A study of laboratory profile of fever with thrombocytopenia in adult patients at C.U. Shah Medical College, Surendranagar. SEAJCRR 2014;3:556-61.
Gandhi AA, Akholkar PJ. Clinical and laboratory evaluation of patients with febrile thrombocytopenia. Natl J Med Res 2015;5:43-6.
Skudowitz RB, Katz J, Lurie A, Levin J, Metz J. Mechanisms of thrombocytopenia in malignant tertian malaria. Br Med J 1973;2:515-8.
Gallup JL, Sachs JD. The economic burden of malaria. Am J Trop Med Hyg 2001;64(Suppl):85-96.
Kelton JG, Keystone J, Moore J, Denomme G, Tozman E, Glynn M, et al
. Immune-mediated thrombocytopenia of malaria. J Clin Invest 1983;71:832-6.
Srikanth J, Srinivas S, Krishna CR, Ramulu PR. Prevalence of thrombocytopenia in a diagnosed case of malaria in rural population of South India. J NTR Univ Health Sci 2012;1: 152-5.
Yeolekar ME. Dengue. In: Munjal YP, Sharma SK, Agrawal AK, Gupta P, Kamath SA, Nadkar SA, et al
., editors. API Textbook of Medicine. 9 th
ed. Chapter 42. Jaypee Brothers; 2012. p. 1158.
Nair PS, Jain A, Khanduri U, Kumar V. A study of fever associated with thrombocytopenia. JAPI 2003;1151-73.
Gupta NK, Bansal SB, Jain UC, Sahare K. Study of thrombocytopenia in patients of malaria. Trop Parasitol 2013;3:58-61.
[Table 1], [Table 2], [Table 3]