Available via license: CC BY-NC
Content may be subject to copyright.
International Journal of Contemporary Pediatrics | January-February 2019 | Vol 6 | Issue 1 Page 131
International Journal of Contemporary Pediatrics
Subramanian V et al. Int J Contemp Pediatr. 2019 Jan;6(1):131-134
http://www.ijpediatrics.com
pISSN 2349-3283 | eISSN 2349-3291
Original Research Article
Thrombocytopenia in children: a clinico-etiological profile in an urban
tertiary care hospital
Subramanian V.1, Santosh Kumar K.2*
INTRODUCTION
Thrombocytopenia is a common presentation of many
febrile and few non-febrile illness in children.1 The
common febrile illness in children like dengue ,viral
fever, malaria and enteric fever are associated with
thrombocytopenia .Thrombocytopenia is defined as
platelet count less than 150000/µl while severe
thrombocytopenia is defined as platelet count less than
50000/µl.2 Pesudo-thrombocytopneia can occur due to
use of excessive EDTA while sampling.3
Platelets or thrombocytes are small (1-4 um in diameter)
cells which are critical in the initiation of primary
haemostasis when the vascular endothelium is disrupted.
Excessive bleeding occurs if primary haemostasis is
abnormal because of any defective number or function
of platelets. The quantitative defect of platelets is more
common when compared to qualitative defect.
Presentation of platelet type of bleeding is characterised
by petechaie and purpura. Platelet count is essential in the
evaluation of any child with a history of bleeding
manifestations because thrombocytopenia is the most
common of the acquired cause of a bleeding diathesis in
children. The causes of thrombocytopenia broadly fall
into three categories namely, increased platelet
destruction, decreased platelet production or excessive
platelet sequestration. When a patient with
1Department of Pediatrics, 2Department of Neonatology, Saveetha Medical College and Hospital, Chennai, Tamil
Nadu, India
Received: 02 October 2018
Accepted: 31 October 2018
*Correspondence:
Dr. Santosh Kumar K.,
E-mail: drsantoshkmc03@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Thrombocytopenia is a common haematological finding that we come across while managing a sick
child. Etiological profile and presentation of thrombocytopenia varies among children. The objective of this study was
to study the clinical and laboratory profile of children with thrombocytopenia, associated clinical complications and
assess the relationship between platelet levels and severity of disease.
Methods: The study was carried out in 644 children between 1 month and 12 years, admitted in Paediatric
Department of Raja Rajeshwari medical college and hospital, Bangalore between August 2012 to August 2014.
Results: The commonest causes of thrombocytopenia in our study were of infectious aetiology (86.6%). Among
Infections Viral infections were the major cause in more than 78% of cases. Other causes included haematological
problems, drug induced thrombocytopenia and connective tissue disorders. Bleeding manifestations were present in
33.07% of patients and the commonest bleeds were skin and mucous membranes. Bleeding manifestations were seen
most commonly in children with a platelet count less than 50000/µl.
Conclusions: Viral Infections were the commonest cause for thrombocytopenia in Children. Platelet count was
neither predictive of bleeding manifestations nor predictive of need for platelet transfusion.
Keywords: Bleeding manifestations, Platelet transfusion, Thrombocytopenia, Viral fever
DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20185195
Subramanian V et al. Int J Contemp Pediatr. 2019 Jan;6(1):131-134
International Journal of Contemporary Pediatrics | January-February 2019 | Vol 6 | Issue 1 Page 132
thrombocytopenia is assessed, the risk of bleeding
episodes should be estimated. If the risk is significant,
treatment is warranted. There is a direct correlation
between platelet count and risk of bleeding. The risk of
haemorrhage is affected by many factors, such as
associated coagulation defects, trauma, and surgery. In
children serious spontaneous bleeding does not occur
until the platelet count is less than 20,000/ul. Hence many
physicians use a platelet count of 10,000 to 20,000/ul as
the threshold for intervention. This study was done to
determine the aetiology and clinical presentation of
thrombocytopenia among Indian children attending a
tertiary care hospital. To study the etiologic profile,
clinical presentation, and the outcome of
thrombocytopenia in children between 1 month-12 years
attending a tertiary care hospital.
METHODS
A prospective descriptive study was conducted in the
Department of Paediatrics, Raja Rajeshwari medical
college and hospital between August 2012 and August
2014.All children who presented with platelet count less
than 150x109 cells/µl were included in the study.
Children who were managed as outpatient were excluded
from the study. Demographic data such as age, gender
and the presenting symptoms including the history of
drug intake were recorded as per the Performa.
The type of bleeding manifestation namely petechiae,
purpura, ecchymosis (as cutaneous bleeds), hemetemesis,
melena, epistaxis (as mucosal bleeds) and any major
bleeds were recorded and analysed.
Laboratory parameters such as platelet count, coagulation
parameters (PT, aPTT, Bleeding and clotting time).
Complete blood counts were determined by using
automated analyser.
For children with thrombocytopenia manual recheck was
performed using thick and thin smears. The morphology
of platelets, presence of atypical lymphocytes, blasts and
malarial parasites were documented.
Bone marrow examination, dengue serology and other
work up were done in necessary cases. The management
and outcome of the children were also documented and
analysed.
RESULTS
A total of 644 children were admitted in with
thrombocytopenia. The demographic data on age, sex
distribution and severity of thrombocytopenia, the
etiological profile and outcomes were studied.
There was a near equal distribution of children with
thrombocytopenia in the age group 1 to 5 years and 5 to
10 years with both being around 30% of the total cases.
There was a male predominance with nearly 54% cases
being males (Table 1).
Table 1: Study population demographics.
Total no. of children with thrombocytopenia
studied
644
No. of male children
344
No. of female children
300
Age group
<1 year
135
1 to 5 years
190
5 to 10 years
192
>10 years
127
Platelet count (cells/µl)
<20000
60
20000 to 50000
242
50000 to 100000
186
>100000
156
Around 33% of those children with thrombocytopenia
had bleeding manifestations. Cutaneous bleeds were the
most common presentation of bleeds with around 49.1 %
of the children having cutaneous bleeds. 27.2 % Children
had mucosal bleeds.
Other bleeding manifestation like melena, hematemsis,
epistaxis were less than 23%. Regarding etiology of
thrombocytopenia most of the cases were due to
infectious etiology (86.6%), Other causes included
connective tissue disorders, Hematological problems,
drug induced thrombocytopenia.
Among the infective causes for thrombocytopenia that
were analysed predominant children were affected by
Viral fevers including dengue (78%) (Table 2).
Table 2: Etiology of thrombocytopenia.
Total cases
644
Infections causes
558
Dengue
330
Malaria (P. Vivax)
15
Malaria (P. falciparum)
4
Enteric fever
22
Chikunguniya
21
Tuberculosis
3
Sepsis
23
Other viral illness
84
Malignancies
39
Connective tissue disease
5
Hematological (ITP/Thalassemia /Heriditary
sperocytosis/Megaloblastic anaemia)
23
Drug induced
7
Others
12
Initial clinical presentation in the hospital in majority of
the patients was fever, headache, body ache and joint
pain followed by gastrointestinal symptoms like
Subramanian V et al. Int J Contemp Pediatr. 2019 Jan;6(1):131-134
International Journal of Contemporary Pediatrics | January-February 2019 | Vol 6 | Issue 1 Page 133
abdominal pain and vomiting (Table 3). We had 5
mortality in the study group and all were due to dengue.
Table 3: Clinical presentation.
Presentation
% of cases
Fever
91.3
Headache
68.13
Myalgia
70.6
Arthalgia/arthritis
61.13
Abdominal pain
50.77
Vomiting
24.7
Loose stools
29.8
GI bleed
13.19
Cough
11.18
Hematuria
9.93
Shock /hypotension
13.19
Abnormal RFT
18.32
Abnormal LFT
34.06
Rash /Petechia /mucosal bleed
76.2
Children with counts between 20000 to 50000/µl was the
majority with bleeding manifestations .In our study 9.3%
children had a count less than 20000/µl. 37.6% had a
count between 20000 to 50000 /µl while 28.9% children
had a count between 50000 and 100000 and 24.2% had a
platelet count more than 100000.Bleeding manifestations
were invariably present in all groups, more in platelet
count below 20000 (Table 4).
Table 4: Bleeds in thrombocytopenia and need for
blood products.
Platelet
count
Cells/µl
No. of
cases
Bleeding
manifestations
No. of episode
Children
who were
transfused
<20000
60
30
18
20000-
50000
242
81
10
50000-
100000
186
70
6
>100000
156
32
Nil
DISCUSSION
Thrombocytopenia is a common finding in a sick child. It
is very common manifestation of viral haemorrhagic
fevers like Dengue and other Non-dengue infections
including enteric fever and malaria. Transient reduction
in the platelet count occurs in other systemic illness like
connective tissues disorders and Immune mediated
thrombocytopenia. Thrombocytopenia is also a common
manifestation of fungal, bacterial infections (gram
negative) and malignancies. We studied the clinico-
ethiological profile of children with thrombocytopenia
admitted in our hospital. Our study included 644 children
found to be having thrombocytopenia. Among the 644
children studied the commonest aetiology in our study
was infectious diseases of which viral infections were the
common cause accounting for nearly 78 % of the cases.
Other infections like enteric fever, malaria were also
noted. A study done at Delhi4 recently demonstrated the
commonest causes of thrombocytopenia was viral fever
(other than dengue and chikungunya) 27.78%, followed
by Dengue 22.2%, enteric fever 12.22%, chikungunya
11.11% and malaria 8.33% Which is similar to our
results. Adult studies like the one done by Nair in New
Delhi, showed septicemia (26.6%) to be the major cause
of thrombocytopenia Similar to present study, Kumaran
also found viral fever to be the commonest cause in
50.3% cases.5,6 In another study done by Gandhi malaria
was found to be the major cause in 41.07%.7 Similarly,
Lakum, also found malaria as the most common cause of
febrile thrombocytopenia in 46.8% of the cases.8 These
differences could be possibly explained by the seasonal
variations. Another study done by Bhalara, showed
dengue (60.8%) as the main aetiology.9 There was a
predominance of male children compared to female
children. The commonest age group affected was 5 to 10
years accounting for nearly 30 % of all cases. Children
between 1 to 5 years and 1 month to 1 year contributed to
59 % of all the cases. This could possibly be explained by
the prolonged outdoor activities by grown up children
compared to infants and increased exposure to mosquito
bites. These were similar to the results from other studies.
The common clinical presentation other than fever in our
study included headache (68.1%), body ache (70.60%)
and joint pains (61.13%). This could possibly be
explained by the fact that most of our cases were of viral
illness, dengue and chikungunya. Similar results were
shown by Khan et al who showed chills and rigors in
80%, myalgia in 70%, vomiting in 60%, headache in 50%
and rash in 25% as the common presentation in his
study.10 213 Children of the 644 children admitted with
thrombocytopenia had bleeding manifestations Among
the Bleeding manifestations ,Cutaneous and mucosal
bleeds were the most common presentations accounting
for nearly 49.1% and 27.1 % respectively. Around 23%
of children either has Haematemesis, melena and
epistaxis, haematuria, subconjunctival haemorrhage or
intracranial haemorrhage. These finding are similar to the
results of Nair et al where he found 57.7% children
presenting with spontaneous bleeds and nearly 42%
having cutaneous bleeds.4 Contrary to our results in a
study done by Patil et al petechiae was the major
manifestation in 73.9% followed by spontaneous
bleeding only in 26.9%.11 Lohitashwa et al, also showed
that purpura (63%) was the commonest bleeding
manifestations followed by spontaneous bleeding (37%)
in his study.12 Severe thrombocytopenia ( <50000/µl)was
noted in 43.9 % of children with thrombocytopenia.
While 28.9 % children had counts between 50000 to
100000 /µl and 24.2 % had counts above 100000/ µ l.
Bleeding manifestations were noted predominantly in
children with counts between 20000 to 50000/ µl and in
children with counts between 50000 to 100000 / µl.
These two groups of children contributed to nearly 70 %
of all the bleeding manifestations. Children with counts
less than 20000/µl and children with counts more than
Subramanian V et al. Int J Contemp Pediatr. 2019 Jan;6(1):131-134
International Journal of Contemporary Pediatrics | January-February 2019 | Vol 6 | Issue 1 Page 134
100000/µl contributed to 14.08 % and 15.02 % of all
children with bleeding manifestations respectively. These
findings are contrary to findings by Nair et al where he
noticed a predominance of bleeding manifestation in
children with platelet count less than 10000/µl.4 Among
children with platelet count less than 20000/µl nearly 50
% of them did not have any bleeding manifestations
while nearly 39% of children with counts more than
50000/µl had some bleeding manifestation. This
demonstrates that platelet count is not a major predictor
of bleeding in children with thrombocytopenia though
children with counts less than 20000/µl need to be
monitored closely. Among children who were transfused
with blood products it was noticed that children with
counts less than 20000/µl received the maximum platelet
transfusion accounting for nearly 53% of transfusions. It
has been demonstrated from our study that platelet counts
are neither predictive of major bleeds nor are they
predictive of mortality in children with thrombocytopenia
which are similar to the current thinking and also similar
to previous published studies by Nair et al.4
CONCLUSION
Thrombocytopenia is a common haematological
observation in the evaluation of a sick child. This entity is
commonly due infections like viral illnesses, dengue,
malaria, enteric fever etc. Common presentation of
Severe thrombocytopenia is usually Muco-cutaneous
bleeds. However, the platelet counts were not predictive
of bleeding manifestations in our study. Further platelet
counts are also not predictive of mortality.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
REFERENCES
1. Gandhi AA, Akholkar PJ. Clinical and laboratory
evaluation of patients with febrile
thrombocytopenia. Natl J Med Res. 2015;5(1):43-6.
2. Suresh P, Devi CY, Ramesh Kumar C, Jalaja Y.
Evaluation of the cause in fever with
thrombocytopenia cases. J Evidence Based Med
Healthcare. 2015;2(15):2134-7.
3. Nagler M, Keller P, Siegrist D, Alberio L. A case of
EDTA dependent pseudo-thrombocytopenia: simple
recognition of under diagnosed and misleading
phenomenon. BMC Clin Pathol. 2014;14(1):19
4. Nair BT, Sharma K, Paimode SD. A study of
clinical and laboratory profile of febrile children
presenting with thrombocytopenia. Int J Contemp
Pediatr 2017;4(6):2114-9.
5. Nair PS, Jain A, Khanduri U, Kumar V. A study of
fever associated with thrombocytopenia. JAPI.
2003;1151-73
6. Kumaran C. Incidence (prevalence) and causes of
thrombocytopenia at a tertiary health care cen-tre,
Oxford Medical College Hospital, Attibele, Anekal,
rural part of Bangalore. J Evid Based Med Healthc.
2016;3(32):1516-21.
7. Patel U, Gandhi G, Friedman S, Niranjan S.
Thrombocytopenia in malaria. J Nat Med Assoc.
2004;96(9):1212.
8. Lakum N, Makwana H, Shah R. A study of
laboratory profile of fever with thrombocytopenia in
adult patients at C.U. Shah Medical College,
Surendranagar. SEAJCRR. 2014;3(1):556- 61.
9. Bhalara SK, Shah S, Goswami H, Gonsai RN.
Clinical and etiological profile of thrombocytopenia
in adults: a tertiary-care hospital-based
crosssectional study: Int J Med Sci Public Health.
2015;4(1):7-10.
10. Khan AH, Hayat AS, Masood N, Solangi NM,
Shaikh TZ. Frequency and clinical presentation of
dengue fever at tertiary care hospital of
Hyderabad/Jamshoro. JLUMHS. 2010;9(2):88-94.
11. Patil P, Solanke P, Harshe G. To study clinical
evaluation and outcome of patients with febrile
thrombocytopenia. Int J Sci Res Publications.
2014;4(10):01-03.
12. Lohitashwa SB, Vishwanath BM, Srinivas G. A
Study of Clinical and Lab Profile of Fever with
Thrombocytopenia. JAPI. 2009:57.
Cite this article as: Subramanian V, Kumar SK.
Thrombocytopenia in children: a clinico-etiological
profile in an urban tertiary care hospital. Int J
Contemp Pediatr 2019;6:131-4.
