Study of the Aetiology and Clinical Manifestations of Thrombocytopenia in a Tertiary Care Centre

Introduction Thrombocytopenia is a commonly observed condition in clinical practice, and its diagnosis is often challenging due to numerous aetiologies and variations in clinical presentation. Early identification of thrombocytopenia and its causes can help prevent life-threatening haemorrhagic manifestations. Methodology A prospective observational study was conducted at a tertiary care hospital from February 2019 to January 2020. This evaluation aimed to determine the causes and prevalence of thrombocytopenia in a tertiary care setting. Patients aged 15 or older with a platelet count of fewer than 150,000/ µL were eligible for inclusion in this evaluation. Investigations for aetiology detection were recommended. Results During the one-year study period, a total of 100 patients, including 58 males and 42 females, with thrombocytopenia were selected for the study. The most common age group affected by thrombocytopenia in this study was between 46 and 55 years old. The most common clinical manifestations observed were generalised weakness (70%), haemorrhagic manifestations (60%), fever (50%), joint pain (37%), splenomegaly (35%), headache (30%), breathlessness (23%), lymphadenopathy (22%), hepatomegaly (24%), and abdominal pain (12%). The most prevalent causes of thrombocytopenia were megaloblastic anaemia (19 cases), dengue fever (15 cases), malaria (11 cases), enteric fever (nine cases), immune thrombocytopenia (ITP) (eight cases), and leukaemia (seven cases). Bleeding was reported as a symptom of thrombocytopenia in 60% of individuals in this study. Conclusion In the study, thrombocytopenia was more common in people aged 46-55 years, and males were more commonly affected than females. Megaloblastic anaemia and infectious disease were the most common causes of thrombocytopenia. Bleeding manifestations were found in 60% of patients with thrombocytopenia.


Introduction
Thrombocytopenia is defined as a decrease in peripheral blood platelet counts below the lower normal limit of 150,000/µL [1]. Thrombocytopenia can be caused by one or more of the following mechanisms: hypoplastic bone marrow activity, sequestration in an enlarged spleen, or increased platelet destruction. Platelet production disorders can be inherited or acquired. Thrombocytopenia causes an abnormality in the formation of platelet plugs, resulting in impairments in primary haemostasis. This condition is marked by prolonged bleeding time, and its characteristic physical examination findings include the presence of petechiae, purpura, and bleeding from various sites [2]. A bone marrow examination can determine if the number of megakaryocytes is reduced, normal, or elevated, providing crucial morphological information. The underlying cause can often be indicated by a patient's medical history and physical examination.
The clinical presentations of thrombocytopenia can range from mild to life-threatening, depending on the cause [3]. Specific laboratory tests may be necessary to confirm the presence of conditions such as paroxysmal nocturnal hemoglobinuria or systemic lupus erythematosus. In tropical regions like India, infectious causes are more common, and thrombocytopenia is typically accompanied by fever . Infection,   1  1  1  2  1   1  3 drug-induced thrombocytopenia, autoimmunity, hypersplenism, and disseminated intravascular coagulation are common causes of thrombocytopenia. Fever and thrombocytopenia are commonly seen in conditions such as malaria, leptospirosis, rickettsia infection, septicemia, typhoid fever, brucellosis, arboviruses, Kala-azar (visceral leishmaniasis), and thrombotic thrombocytopenic purpura/hemolytic uremic syndrome.
Thrombocytopenia is often diagnosed through a routine complete blood count in asymptomatic patients. In some cases, discolouration, purpura, petechial bleeding, nasal bleeding, and gingival bleeding may be observed. Rarely, a platelet count as low as 5,000/µL may put the patient at risk for bleeding in the central nervous system, gastrointestinal tract, or genitourinary tract [4]. A platelet count higher than 100,000/µL is typically considered normal, and the bleeding time remains normal [5].

Aims and objectives
The aim of this study was to evaluate the various causes of thrombocytopenia and assess the clinical profile of patients with thrombocytopenia.

Materials And Methods
One hundred patients with thrombocytopenia who were hospitalised at the Indira Gandhi Institute of Medical Sciences (IGIMS) in Patna, Bihar, India, between February 2019 and January 2020 were the subjects of a prospective hospital-based study. All patients who participated in this research underwent a thorough clinical evaluation and investigation.

Inclusion criteria
Patients with a platelet count below 150,000/ µL, aged 15 years or older, and those who provided consent for the study were included in the study.

Exclusion criteria
Patients aged below 15 years and those who did not provide consent for the study were excluded.

Investigations
The following investigations were conducted as per the patient's specific needs: complete blood count, peripheral blood smear, coagulation profile, kidney function test, liver function test, and other special investigations such as chest X-ray (posteroanterior (PA) view), abdominal ultrasound (USG of the whole abdomen), bone marrow examination, Widal test, malarial parasite antigen, dengue serology, and Coombs test were performed on patients only when indicated. Table 1 shows 100 cases of thrombocytopenia chosen for the study, and of them, 58 (58% of the total) were male and 42 (42% of the total) were female.   Figure 1 shows that the most common age group for thrombocytopenia in the present study was between 46 and 55 years, followed by 26-35 years and 15-25 years, accounting for 29 (29%), 24 (24%), and 16 (16%) cases, respectively. Figure 2 shows various aetiologies associated with thrombocytopenia; megaloblastic anaemia accounted for 19% of cases of thrombocytopenia in our study, while rheumatoid arthritis accounted for just 1%.

Conclusions
Thrombocytopenia, a condition commonly encountered in clinical practice, requires a comprehensive evaluation to determine its underlying secondary causes. In certain cases, thrombocytopenia can pose a lifethreatening risk, necessitating a platelet transfusion. Improving our understanding of the etiological factors contributing to thrombocytopenia can lead to better management of the disease, resulting in reduced morbidity and mortality.
The study identified megaloblastic anaemia as the most prevalent cause of thrombocytopenia. Early diagnosis of megaloblastic anaemia is crucial for achieving better treatment outcomes. Dengue fever was found to be the second most common cause of thrombocytopenia in the study, followed by malaria and enteric fever. Therefore, the presence of thrombocytopenia raises suspicion of these diseases and emphasises the need for prompt treatment of the patients.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics Committee, Indira Gandhi Institute of Medical Sciences, Patna issued approval 655/IEC/IGIMS/2018 dated 19/12/2018. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.