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Correspondence

Indian Pediatr 2016;53: 935

Immune Thrombocytopenic Purpura in Typhoid Fever

 

*Aniruddha Ghosh and Arunaloke Bhattacharya

Department of Pediatric Medicine, Institute of Child Health, Kolkata, West Bengal, India.
Email: [email protected]

 


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 8.4×109/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 26×109/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 84×109/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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