Cardiac involvement in adult patients with febrile thrombocytopenia diagnosed by bedside 2-D echocardiography

INTRODUCTION

Thrombocytopenia may be defined as a subnormal number of platelets in the circulating blood. A normal human platelet count ranges from 1,50,000 to 4,50,000 platelets/µL of blood. Often patients with thrombocytopenia are asymptomatic and are diagnosed by routine complete blood count. Occasionally, there may be bruising, purpura, petechiae, nose bleeding and gum bleeding.¹ Fever is defined as an elevation of the body temperature above the normal circadian range as the result of a change in the thermoregulatory center located in the anterior hypothalamus. An am temperature of >37.2°C (98.9°F) or a pm temperature of >37.7°C(99.9°F) would define fever though thrombocytopenia is encountered in various diseases, it is for sure that potentially fatal bleeding due to thrombocytopenia is rare.^2,3 Dengue fever is an acute febrile infectious disease, caused by any serotypes (1,2,3 or 4) of a virus from the genus flavivirus. Dengue is transmitted by mosquitoes of the genus Aedes. The mosquito Aedes aegypti breeds in clean water bodies and bites during day time. The disease has an incubation period of 4-10 days before the symptoms starts appearing. The characteristic symptoms include fever, body ache, headache, multiple joint pain including both small and large joints of body, retro orbital pain, myalgia, itching and rash. Cardiac manifestations in dengue can range from asymptomatic bradycardia to life threatening myocarditis. The incidence of cardiac manifestations has been correlated with severity of the disease.³ Patients with more severe form of the disease like Dengue Hemorrhagic Fever or Dengue Shock Syndrome are more prone for developing cardiac manifestations.⁴ The aim of present study was to evaluate cardiac abnormalities using handheld echo cardiogram.

METHODS

Two hundred adult patients who had febrile thrombocytopenia and had been hospitalized were enrolled in the study.

Inclusion criteria

Two hundred adult patients who were suffering from pyrexia with thrombocytopenia with platelet count less than 50,000/µL were enrolled in present study.

Exclusion criteria

• • Patients having platelet count more than 50000/µL
• • Patients having inherited platelet abnormalities
• • Patients who were on corticosteroid treatment
• • Patients who were known case of cardiomyopathies.

A detailed medical history, clinical examination and relevant laboratory investigations were done as indicated in each patient. It was a non-randomized prospective observational study. The duration of the study was August 2017 to December 2017. The collaborating departments were Department of Cardiology, Government Rajaji Hospital, Madurai and Department of Medicine, Government Rajaji Hospital, Madurai, Tamil Nadu, India.

Statistical analysis

The information collected regarding all the selected cases were recorded in a master chart. Data analysis was done with the help of computer by using SPSS 16 software and Sigma Stat 3.5 version (2012).

Using this software mean, standard deviation and ‘p’ value was calculated through Student ‘t’ test, One way ANOVA, Chi square test and correlation coefficient from Pearson correlation and P value of < 0.05 was taken as significant.

Echocardiogram

Echocardiography was performed immediately after the patient diagnosed and admitted in present hospital as pyrexia with thrombocytopenia. Screening was done using hand held portable ultrasound equipment. Echo machine was 2D model. 2-5 MHZ probe was used.

RESULTS

In present study there were 138 male patients and 62 female patients.

In present study most of the people are below 20 and implies high prevalence of pyrexia with thrombocytopenia in young patients.

In present study there is high prevalence of DHF.

In the study population cardiac symptoms like giddiness, palpitations and syncope were present in 40 patients (20%) implies high prevalence of cardiac symptoms in febrile thrombocytopenia.

A total of 21 patients (10.5%) had tachycardia at the admission time and 6 patients (3%) had bradycardia at the time of admission.

In the study population a total of 53 patients (26.5%) had hypotension during admission.

In present study, most patients had PCV between 30-40.

Authors studied only whose platelets were less than 50000 and only 6 patients (3%) had platelets less than 10000.

In present study 21 patients (10.5%) had sinus tachycardia and 4 patients (2%) had sinus bradycardia.

In the study population 17 patients (8.5%) had pleural effusion and ascites.

In present study cardiac chambers were normal in 196 patients. 2 patients had dilated LV in the form of myocarditis and 2 patients had dilated RA, RV.

In present study 2 patients (1%) had MVP, and one patient (0.5%) had RHD and one patient had sclerosed AV valve (0.5%).

In present study two patients had Regional Wall motion abnormality. They were newly diagnosed as CAD and managed accordingly.

Pericardial effusions were present in 24 patients (12%) patients indicates significant asymptomatic pericardial effusion in patients of pyrexia with thrombocytopenia.

In present study two patients (1%) had myocarditis as evidenced by global hypokinesia of left ventricle.

In present study cardiac manifestations were present commonly in DSS. In present study there were 138 male patients (69%) and 62 females (31%) patients (Table 1). 70 patients (35%) were below 20 age and 45 patients were between 21-30 (Table 2). In present study 140 patients had Dengue Haemorrhagic Fever (70%) (Table 3), 50 patients had Dengue Shock Syndrome. Cardiac symptoms like giddiness, palpitations and syncope were present in 40 patients, (20%) (Table 4) implies high prevalence of cardiac symptoms in febrile thrombocytopenia. A total of 21 patients (10.5%) had tachycardia at the admission time (Table 5) and 6 patients (3%) had bradycardia at the time of admission. 53 patients (26.5%) had hypotension (Table 6) during admission, 116 patients had BP between 90-120 mmhg. 150 patients had PCV (Table 7) between 30%-40%, 15 patients had PCV <30%.6 patients had severe thrombocytopenia <10000/µL, 146 patients (73%) had platelet count (Table 8) more than 20000/µL and 54 patients (27%) had less than 20000 /µL.21 patients (10.5%) had sinus tachycardia (Table 9),4 patients (2%) had sinus bradycardia,2 patients had first degree AV block and one patient had RBBB. 17 patients (8.5%) had (Table 10) right sided pleural effusion and ascites. Cardiac chambers were normal (Table 11) in 196 patients. 2 patients had dilated LV in the form of myocarditis and 2 patients had dilated RA, RV. Cardiac valves were normal (Table 12) in 196 patients.2 patients (1%) had MVP, one patient had RHD and one patient had sclerosed AV valve (0.5%). Two patients (1%) had Regional Wall motion abnormality. Pericardial effusions were present in 24 patients (12%) patients (Table 13) Two patients (1%) had myocarditis (Table 14) as evidenced by global hypokinesia of left ventricle. Here authors use Chi-square test to test the ECHO and BP, authors got the level of significance is .928 which is greater than p value (0.05) so authors conclude that BP was influenced by the abnormal ECHO and Platelet count. In present study cardiac manifestations were present most commonly in Dengue Shock Syndrome (Table 15).

DISCUSSION

In the present study of 200 patients, 138 (69 %) patients were males and 62 (31%) were females. The mean age was 29.43 ± 13.71 years. Most of the patients were less than 30yrs.Most patients had Dengue hemorrhagic fever [140 patients (70%)] followed by Dengue shock syndrome [50 patients (25%)] and dengue fever [10 patients (5%)]. Some review literatures show high prevalence of dengue hemorrhagic fever in their study. In present study, most common cardiac symptom was giddiness and the most common sign was crepitations. Most of the patients [146 Patients (73%)] had normal BP, 43 patients (21.5%) had hypotension and 11 patients (5.5%) had hypertension. In present study, blood pressure influences both platelet count and abnormal ECHO. In present study authors took patients only whose platelet counts were less than 50000/µL. Among them, 6 patients had severe thrombocytopenia <10000/µL, 146 patients (73%) had platelet count more than 20000/µL and 54 patients (27%) had less than 20000 /µL. 150 patients (75%) had PCV between 30 to 40%, 15 patients (7.5%) had PCV less than 30% and 35(17.5) patients had PCV more than 40%.

Gondhali MP et al study also states most patients had platelets count less than 50000/µL.⁵ In present study, most commonly patients had sinus rhythm [172 patients (86%)] followed by sinus tachycardia [21 patients (10.5%)], sinus bradycardia [4 patients (2%)] and first-degree heart block (1%). In contrast to present study, Arora1 M, Patil RS study sinus tachycardia was less common.⁶ Abhinandya study also states sinus bradycardia was more common than sinus tachycardia in their study.⁷ In the study by Gupta et al, sinus bradycardia was found in 14.28%, and sinus tachycardia in 21.4% patients.⁸ In present study 17 patients (8.5%) had pleural effusion and ascites and most of those patients were in Dengue Shock Syndrome. And all of the pleural effusions were right sided; so, dengue can be a differential diagnosis of right sided pleural effusion.

In present study 24 (12%) patients had pericardial effusion. In Abhinandya study there is 4% prevalence of pericardial effusion.⁷ Cardiac chambers were normal in most of the patients.

RA and RV were dilated in two patients (1%) and they were found to have ASD. They were unfit for device closure due to deficient rims and hence referred for surgery. LV was dilated in two patients (1%). Cardiac valves were abnormal in 4 patients. Two patients had MVP, one patient had RHD-MR, one patient had sclerosed aortic valve as an incidental finding. They were followed and managed accordingly.

In present study 2 patients had RWMA. They were diagnosed to have CAD and treated accordingly. In Abhinandya study there was 2% prevalence of RWMA.⁷ Miranda CH study also shows 2% RWMA.⁹ In the study population, 2 patients had myocarditis described with global hypokinesia of the left ventricle.

In Abhinandya study 2% prevalence of myocarditis.⁷ In a study conducted by Wali et al in 1998, 17 patients with DHF/DSS were studied.¹⁰ 12 patients (70.59%) had global hypokinesia in echocardiography. Present study shows high prevalence of cardiac manifestation in DSS. The incidence of cardiac manifestations was stated to be high (53.33%) in patients with dengue shock syndrome compared to the patients with Dengue Hemorrhagic fever in Abhinandya study.⁷ In Arora M, Rekha S study the incidence of cardiac manifestations was present in 53.33% of the patients with dengue shock syndrome compared to 35.29% of the patients with dengue hemorrhagic fever and 30% with dengue fever.⁶

CONCLUSION

Patients with pyrexia with thrombocytopenia were commonly having cardiac manifestations. Mild to moderate pericardial effusions were more common which can be identified early by bed side screening ECHO. Even though Myocarditis is rare, by routine screening clinicians can detect asymptomatic patients and can monitor them. Early diagnosis at bed side may improve the outcome. Management of patients with pre-existing cardiac diseases should be individualized.

ACKNOWLEDGEMENTS

Authors thank the Department of Medicine GRH Madurai, Professor V. T. Premkumar, Professor R. Balajinathan, Profeesor Nadarajan, Professor Bhagyalakshmi, Professor Sankumani, Professor Dharmaraj, Professor Ravichandran and Assistant Professors, PG students. Authors acknowledge the help of GRH laboratory and fever ward nursing staff for their cooperation in the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Konkle BA. Disorders of platelets and vessel wall. In: Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 17^th ed. New York, NY: McGraw-Hill; 2008;1:718-723.
2. 2. Woodward TE. The fever pattern as a diagnostic aid. In: Mackowiack PA, ed. Fever: basic mechanismsand management. New York: Lippincott-Raven Publishers; 1997:215-235.
3. 3. Gulati S, Maheshwari A. A typical manifestation of dengue. Trop Med Int Health. 2007;12:1087-95.
4. 4. Da Fonseca BA, FonsecaSN. Dengue virus infections. Curr Opin Pediatr. 2002;14:67-71.
5. 5. Gondhali MP, Vethekar M, Bhangale D, Choudhary K, Chaudhary M, Patrike G, et al. ISSN No: 2319-5886. Health Sciences. 2016;5(1):258-77.
6. 6. Arora1 M, Patil RS. Cardiac manifestation in dengue fever. J Assoc Physicians India. 2016;64(7):40-4.
7. 7. Mukhopadhyay A, Kumar R, Singh BK. A study on cardiac manifestations of dengue fever. JMSCR. 2017;5(4):20736-45.
8. 8. Gupta VK, Gadpayle A. Subclinical cardiac involvement in dengue haemorrhagic fever. J Indian Acad Clin Med. 2010 Apr;11(2):107-1.
9. 9. Miranda CH, Borges MD, Matsuno AK, Vilar FC, Gali LG, Volpe GJ et al. Evaluation of cardiac involvement during dengue viral infection. Clin Infect Dis. 2013 Jun 19;57(6):812-9.
10. 10. Wali JP, Biswas A, Chandra S. Cardiac involvement in dengue hemorrhagic fever. Intl J Cardiol. 1998;64(1):31-6.