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Indian Pediatr 2016;53: 935 |
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Immune Thrombocytopenic Purpura in Typhoid
Fever
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*Aniruddha Ghosh and Arunaloke Bhattacharya
Department of Pediatric Medicine, Institute of Child
Health, Kolkata, West Bengal, India.
Email: [email protected]
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A 10-year-old boy presented with fever for 5 days along with pain
abdomen, headache and anorexia. On exami-nation, there were echhymotic
spots over soft palate and venepuncture sites. Patient had
hepatosplenomegaly; signs of meningeal irritation were absent.
Investigations were as follows: hemoglobin, 11.3 g/dL,
total lececocyte count 8.4×10 9/L
(N83 L15 M2), Platelet: 45×109/L;
C-reactive protein: 123 mg/dL, and ALT 110 U/L. Electrolytes and renal
function tests were normal. Urine and stool examination showed 10-15 red
blood cells/high power field. Coagulation profile was within normal
range.
Patient was started on intravenous Ceftriaxone from
the day of admission. Widal test showed titre of 1:320 against S.
typhi. Blood culture also revealed growth of S. typhi,
sensitive to Ceftriaxone.
From day three of admission, fever spikes started to
decrease in severity as well as frequency. On fourth day, platelet count
further decreased to 26×10 9/L
whereas CRP decreased to 23 mg/dL. On day 5, patient became afebrile but
there were new echhymotic spots around elbow joint with platelet count
further reducing to 12×109/L.
Bone marrow examination revealed increased numbers of megakaryocytes
with other blood cell-precursors in normal ranges; a picture suggestive
of Immune Thrombocytopenic Purpura (ITP).
We started oral prednisolone (2 mg/kg/d) with gradual
tapering over 4 weeks. On day-10 of admission, platelet count increased
to 84×10 9/L, and at 1-month
follow-up, it was 183×109/L.
Hematological changes in typhoid fever constitute of
anemia, leucopenia, thrombocytopenia and subclinical disseminated
intravascular coagulation [1]. Toxin-mediated bone marrow suppression,
chronic granulo-matous changes and hemophagocytic histiocytosis are
among the reported bone marrow changes [2,3]. Isolated thrombocytopenia
in typhoid fever has been reported earlier [4], but documented bone
marrow changes suggestive of ITP in blood culture proven typhoid fever
is rarely documented.
References
1. Khosla SN, Anand A, Singh U. Hematological profile
in typhoid fever. Trop Doctor. 1995;25:156-8.
2. Lee JH, Lee YH, Ahn SH, Choi HS. Granulomatous
bone marrow disease- a review of the hematopathologic analysis of 27
cases. Kor J Clin Pathol. 1985;5:515-21.
3. Miller SI, Pegnes DA. Salmonella species,
including Salmonella typhi. In: Mandell GL, Bennet JE,
Dolin R. Principles and Practice of Infectious Diseases. Philadelphia:
Churchill Livingstone; 2000. p. 2344-63.
4. Serefhanoglu IK, Kaya E, Aydogdu I, Sevinc A, Kuku I, Ersoy Y.
Isolated thrombocytopenia: the presenting finding of typhoid fever. Clin
Lab Haematol. 2003;25:63-5.
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