|Year : 2016 | Volume
| Issue : 1 | Page : 120-123
Correlation study between platelet count, leukocyte count, nonhemorrhagic complications, and duration of hospital stay in dengue fever with thrombocytopenia
Hari Kishan Jayanthi1, Sai Krishna Tulasi2
1 Consultant Physician, Kamineni Hospitals, Hyderabad, Telangana, India
2 Department of General Medicine, Kamineni Hospitals, Hyderabad, Telangana, India
|Date of Web Publication||24-Jun-2016|
Hari Kishan Jayanthi
Kamineni Hospitals, LB. Nagar, Hyderabad - 500 068, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: Dengue is one of the common diseases presenting as fever with thrombocytopenia, also causing significant morbidity and complications. Objectives: Though the correlation between platelet count, bleeding manifestations and hemorrhagic complications has been extensively studied, less is known about the correlation between platelet count and non hemorrhagic complications. This study was done to see the correlation between platelet count and non hemorrhagic complications, duration of hospital stay and additive effect of leucopenia with thrombocytopenia on complications. Methods: Our study is prospective observational study done on 99 patients who had dengue fever with thrombocytopenia. Correlations were obtained using scatter plot and SPSS software trail version. Results: Transaminitis (12.12%) was the most common complication followed by acute renal injury (2%). In our study we found that, as the platelet count decreased the complication rate increased (P = 0.0006). In our study duration of hospital increased (P is 0.00597) with decreasing platelet count when compared to other study where there was no correlation between the two. There was no correlation between thrombocytopenia with leucopenia and complications (P is 0.292), similar to other study. Conclusion: Platelet count can be used to predict the complication and duration of hospital stay and hence better use of resources.
Keywords: Dengue fever, nonhemorragic complications, platelet count
|How to cite this article:|
Jayanthi HK, Tulasi SK. Correlation study between platelet count, leukocyte count, nonhemorrhagic complications, and duration of hospital stay in dengue fever with thrombocytopenia. J Family Med Prim Care 2016;5:120-3
|How to cite this URL:|
Jayanthi HK, Tulasi SK. Correlation study between platelet count, leukocyte count, nonhemorrhagic complications, and duration of hospital stay in dengue fever with thrombocytopenia. J Family Med Prim Care [serial online] 2016 [cited 2021 Apr 14];5:120-3. Available from: https://www.jfmpc.com/text.asp?2016/5/1/120/184635
| Introduction|| |
Dengue fever is caused by small single-stranded RNA virus belonging to Flaviviridae. Dengue virus is transmitted to humans through the bites of infected Aedes mosquitoes, principally Aedes aegypti. This mosquito is a tropical and subtropical species widely distributed around the world. Dengue is characterized by leucopenia followed by thrombocytopenia. 
Data from different sources suggest that endothelial cell activation could mediate plasma leakage. , Plasma leakage is thought to be associated with functional rather than destructive effects on endothelial cells.
Activation of infected monocytes and T-cells, the complement system and the production of mediators, monokines, cytokines, and soluble receptors may also be involved in endothelial cell dysfunction.
Thrombocytopenia may be associated with alterations in megakaryocytopoieses by the infection of human hematopoietic cells and impaired progenitor cell growth, resulting in platelet dysfunction (platelet activation and aggregation), increased destruction or consumption (peripheral sequestration and consumption). Hemorrhage may be a consequence of the thrombocytopenia and associated platelet dysfunction or disseminated intravascular coagulation.
The disease progresses in three phases - febrile phase, critical phase, recovery phase, complications develop during the critical phase. 
Warning signs include pain abdomen or tenderness, persistent vomiting, mucosal bleeds, lethargy, restlessness, hepatomegaly, increasing hematocrit with decreasing platelet count, and clinical signs of fluid accumulation
During the early stages of the disease, virus isolation, nucleic acid, or antigen detection can be used to diagnose the infection. At the end of the acute phase of infection, serology is the method of choice for diagnosis [Figure 1].  Antibody response to infection differs according to the immune status of the host. 
|Figure 1: Approximate time-line of primary and secondary dengue virus infections and the diagnostic methods that can be used to detect infection|
Click here to view
Patients who are ambulatory and who can accept fluids orally can be sent home, with daily monitoring by the care provider. 
Patients with dengue with warning signs should be managed with normal saline, at the rate 5-7 ml/kg/h for first 1-2 h, 3-5 ml/kg/h for next 2-4 h, 2-3ml/kg/h according to the clinical response.
Treatment of hemorrhagic complications includes whole blood or packed cell transfusions. Platelet or fresh frozen plasma infusions should be given only if bleeding is not being controlled by whole blood transfusions. 
This study was done to see the correlation between platelet count and nonhemorrhagic complications, duration of hospital stay and additive effect of leukopenia with thrombocytopenia on complications.
Aims and objectives
- To study the correlation between platelet count and nonhemorrhagic complication rate
- To study the effect of leukopenia in patients with thrombocytopenia on complications
- To study the correlation between platelet count and duration of hospital stay.
| Materials and Methods|| |
The study was done in Kamineni Hospitals a Tertiary Care Hospital with bed strength of 300. Data were collected from patients attending outpatient and inpatient services in Department of General Medicine. The patients of both sexes aged >18 years. Patients admitted with fever and found to have thrombocytopenia are included in the study. Data were collected from 99 patients after obtaining consent in due format. Data are collected by using interview, physical examination, radiological examination, sputum examination, and laboratory data.
| Observation and Results|| |
Complications associated with dengue fever in our study
Various nonhemorrhagic complications were known to occur in patients having dengue with thrombocytopenia. Of 99 patients in our study, 11 patients had hepatitis (11.11%), 12 patients had transaminitis (12.12%), two patients had acute kidney injury (2%). Other complications found were acute respiratory distress syndrome (ARDS) (2%), meningoencephalitis (1%) [Table 1].
Correlation between platelet count and complications
The mean platelet count was 0.79 lakhs/cumm. The relation between platelet count and number of complications was studies. There was a negative correlation between platelet count and complications rate (P = 0.0006). This indicates that lower the platelet count more are the complications. The same correlation is shown in scatter plot [Figure 2].
Correlation between thrombocytopenia and leukopenia with complications
In our study, 44 patients had leukopenia. The relationship between leucopenia and platelet count was studied. Leukopenia with thrombocytopenia showed a positive correlation but was not statistically significant (P is 0.292). This suggests that platelet count may not have any relation with leukocyte count. The same correlation is shown in scatter plot [Figure 3].
Correlation between platelet count and duration of hospital stay
The average duration of hospital stay was 3.96 days. There was a negative correlation between platelet count and duration of hospital stay and it was statistically significant (P is 0.00597). This suggests that as platelet count decreases the duration of hospital stay increases. The possible explanation could be that as per above correlation number of complications is increasing with lower platelet count, hence increased duration of hospital stay. Further studies to predict the platelet count during the early phase of the disease and hence the complications are required. The same correlation is shown in scatter plot [Figure 4].
|Figure 4: Correlation between platelet count and duration of hospital stay|
Click here to view
| Discussion|| |
In our study, out of 99 patients, 28 patients had nonhemorrhagic complications. Forty-four patients had leukopenia. A study by Ahmed et al., leukopenia was observed in 43%.  A study by Dhooria et al., (2008) in children leukopenia was observed in 26% of cases.  In a study by Cam et al., 2001 encephalopathy occurred in 0.5% of patients with Dengue hemorrhagic fever (DHF).  In a study by Dhooria et al. two patients in his study had ARDS, both of which expired.  Dengue associated ARDS is associated with a high mortality.  In a study Dhooria et al., hepatic dysfunction was seen in 14.8%. 
World Health Organization defined severe dengue as presence of one or more of the following: (i) Plasma leakage that may lead to shock (dengue shock) and/or fluid accumulation, with or without respiratory distress, and/or (ii) severe bleeding, and/or (iii) severe organ impairment.  Relationship between platelet count and bleeding manifestations has been extensively evaluated. Raikar et al. showed in his study that bleeding manifestations are not related to platelet count.  The relationship between platelet count and nonhemorrhagic complications is less studied.
Patient with lower platelet count was found to have higher chances of nonhemorrhagic complications including ARDS and encephalopathy. In our study, there was a statistically significant positive correlation between platelet count and complications. As the platelet counts decreased complications rate increased.
Ibrahim et al. in his study showed that there was no correlation between initial platelet counts and age, use of intravenous fluids, or length of hospital stay.  In our study, there was statistically significant negative correlation between platelet count and duration of hospital stay, as the platelet count decreased duration of hospital stay increased.
Prathyusha et al. in her study at eluru showed that with increasing severity of leukopenia there is increased the incidence of hemorrhagic manifestations including petechiae (P value 0.023). However, she found no significant association of leukopenia with significant bleeding manifestations.  In our study, there was no statistically significant correlation between leukopenia and complications rate in patients with dengue with thrombocytopenia.
| Conclusion|| |
Platelet count can be used to predict complication rate in a patient admitted with dengue fever. Though leukopenia is seen early in the disease there is no significant correlation to complication (nonhemorrhagic) rate. Platelet count can be used to predict the duration of hospital stay hence disease burden and resource requirements.
We would like to thank Dr. E. Jayshankar consultant pathologist for providing us hematological information.
Financial support and sponsorship
We would like to thank Kamineni Hospitals staff for the support and permission to utilize resources in completion of this work.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kalayanarooj S, Vaughn DW, Nimmannitya S, Green S, Suntayakorn S, Kunentrasai N, et al.
Early clinical and laboratory indicators of acute dengue illness. J Infect Dis 1997;176:313-21.
Avirutnan P, Malasit P, Seliger B, Bhakdi S, Husmann M. Dengue virus infection of human endothelial cells leads to chemokine production, complement activation, and apoptosis. J Immunol 1998;161:6338-46.
Cardier JE, Mariño E, Romano E, Taylor P, Liprandi F, Bosch N, et al.
Proinflammatory factors present in sera from patients with acute dengue infection induce activation and apoptosis of human microvascular endothelial cells: Possible role of TNF-alpha in endothelial cell damage in dengue. Cytokine 2005;30:359-65.
Deen J, Lum L, Martinez E, Tan LH. WHO; Dengue: Guidelines for diagnosis, treatment, prevention and control, 2008, Ch 2:25.
World Health Organization (WHO) and the Special Programme for Research and Training in Tropical Diseases (TDR). Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. Ch. 4. France: 2009. p. 91-2. [Figure 1].1].
Rigau-Pérez JG, Clark GG, Gubler DJ, Reiter P, Sanders EJ, Vorndam AV. Dengue and dengue haemorrhagic fever. Lancet 1998;352:971-7.
Deen J, Lum L, Martinez E, Tan LH. WHO. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. Ch. 2:34. France: WHO; 2009. p. 25-54.
Ahmed S, Arif F, Yahya Y, Rehman A, Abbas K, Ashraf S, et al.
Dengue fever outbreak in Karachi 2006 - A study of profile and outcome of children under 15 years of age. J Pak Med Assoc 2008;58:4-8.
Dhooria GS, Bhat D, Bains HS. Clinical profile and outcome in children of dengue hemorrhagic fever in North India. Iran J Pediatr 2008;18:222-8.
Cam BV, Fonsmark L, Hue NB, Phuong NT, Poulsen A, Heegaard ED. Prospective case-control study of encephalopathy in children with dengue hemorrhagic fever. Am J Trop Med Hyg 2001;65:848-51.
Lum LC, Thong MK, Cheah YK, Lam SK. Dengue-associated adult respiratory distress syndrome. Ann Trop Paediatr 1995;15:335-9.
Raikar SR, Kamdar PK, Dabhi AS. Clinical and laboratory evaluation of patients with fever with thrombocytopenia. Indian J Clin Pract 2013;24:360-3.
Prathyusha CV, Srinivasa Rao M, Sudarsini P, Uma Maheswara Rao K. Clinico-haematological profile and outcome of dengue fever in children. Int J Curr Microbiol Appl Sci 2013;2:338-46.
Ibrahim S, Horadagoda C, Maithripala C, Lokunarangoda N, Ranasinghe G, Wickramarathne T, et al.
Characteristics and management patterns of patients admitted with fever and thrombocytopenia to an acute general medical unit in Sri Lanka. J Glob Infect Dis 2011;3:203-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]