J Vector Borne Dis 52, December 2015, pp.

304308

Role of platelet transfusion in children with bleeding in dengue fever

Sriram Pothapregada1, Banupriya Kamalakannan1 & Mahalakshmy Thulasingam2

1Department of Paediatrics, Indira Gandhi Medical College and Research Institute, Puducherry; 2Community Medicine, Jawaharlal Institute

of Postgraduate Medical Education and Research, Puducherry, India

ABSTRACT

Background & objectives: The indications for platelet transfusion in dengue fever are clearly defined in World
Health Organization (WHO) guidelines (2011) for dengue fever, but physicians face practical difficulty in its
implementation in an epidemic setting. On one hand there is an intense social pressure created by the panic-struck
parents to transfuse platelets in presence of bleeding and on the other hand there is a need for its judicious use as
the requirement is more than its availability. The study was aimed to assess the clinico-hematological parameters,
and the requirement and need for platelet transfusion in children with dengue fever.
Material & Methods: All children (012 yr of age) diagnosed and confirmed with dengue fever at a tertiary care
hospital in Puducherry between 1 August 2012 and 31 January 2015 were reviewed retrospectively from hospital
case records as per the revised WHO guidelines for dengue fever. The diagnosis was confirmed by NS1 antigen-
based ELISA test or dengue serology for IgM and IgG antibodies and the data were analyzed using SPSS 16.0
statistical software.
Results: Out of 261 cases of dengue fever, hemorrhagic manifestations were observed in 52 children (19.9%),
which mainly included petechiae (38.5%), gum bleeding (34.6%) and melena (26.9%). Thrombocytopenia was
seen in 211 (80.8%) cases. Bleeding manifestations were present in 20(39.2%), 8(15.7%), 13(25.5%) and 11(21.6%)
cases with platelet count <50,000/mm3, 50,000100,000/mm3, 11.50,000/mm3, and >1.50,000/mm3 respectively.
Bleeding manifestations did not always correlate with platelet count in non-severe dengue infection in comparison
to severe dengue infection. The most common mode of presentation of severe dengue infection was shock with
102(39.1%) cases and among them only 22 children (21.6%) had bleeding. About 17 children (6.5%) with severe
dengue infection required platelet transfusion and out of them, 12 children (70.6%) had a platelet count <20,000/
mm3 whereas five children (29.4%) had platelet count in the range of 20,00050,000/mm3.
Interpretation & conclusion: Platelet transfusion was required in children with severe dengue infection
in the form of significant spontaneous bleed, shock and severe thrombocytopenia. Bleeding should not be considered
only indicator to transfuse platelets as it occurred in children even with normal platelet counts. The community
and treating physicians should be educated regarding the judicious transfusion of platelets. Unnecessary and
empirical use of platelets should be completely avoided especially during an epidemic when there is scarcity in its
availability.

Key words Bleeding manifestations; dengue fever; platelet transfusion; thrombocytopenia

INTRODUCTION dengue fever is recognized globally and indications and

Dengue fever has become a major public health con-
cern. The disease is now endemic in more than 100 coun-
tries with very high case fatality rate and children are the
most affected age group worldwide1. An estimated 500,000
people with severe dengue require hospitalization each year
and 90% of them are children < 5 yr of age. Without proper
treatment, the case fatality rates can exceed 20% and with
timely intervention it can be reduced to < 1%1. Bleeding
and shock are the most dreaded complications in children
with dengue fever leading to high mortality2.
The role of platelet transfusion in the management of
situations in which they need to be transfused are clearly
defined in the 2011 guidelines given by the WHO.
However, they are most often not practiced by the physi-
cians, where they find it difficult to avoid giving platelets
in presence of bleeding. There is an added intense social
pressure created by the panic-struck parents on the pe-
diatricians to transfuse platelets even when not indicated.
The requirement for platelets during an epidemic is high
and the availability is low. The objective of the study was
to evaluate the clinico-hematological parameters, require-
ment and the need for platelet transfusion in children with
dengue fever.
 Pothapregada et al: Platelet transfusion in dengue fever 305

MATERIAL & METHODS
The present study was conducted on confirmed cases
of dengue infection admitted in the Department of Pedi-
atrics at a tertiary care hospital at Puducherry from Au-
gust 2012 to January 2015. The case definition, diagno-
sis and management of dengue fever in children were as
per the WHO guidelines1. Clinical data, hematological
parameters and the requirement of platelet transfusion to
the confirmed cases of dengue fever were retrospectively
analyzed from hospital case records. The study protocol
was approved by the Institute Ethics Committee of Indira
Gandhi Medical College and Research Institute at
Puducherry, India. The data were analyzed using SPSS
for window version 16.0 (SPSS, Chicago, IL).
bleed 2 (3.8%) and pulmonary bleed 4 (7.7%). Tourni-
quet test was positive for 33 (12.6%) cases.
The clinico-hematological profile among severe and
non-severe dengue is given in Table 1. Non-severe den-
gue and severe dengue was present in 60.9 and 39.1%
cases respectively. Among the children with severe den-
gue infection, shock was present in 102 (39.1%) cases, in
which 22 (21.6%) children had bleeding. Thrombocytope-
nia was seen in 211 (80.8%) cases and hematocrit >40
were seen in 25.1% of cases. Platelet count <1,00,000/
mm3 was detected in 101 (38.6%) cases and among them

RESULTS

In total, 398 children were provisionally diagnosed

as dengue fever and the diagnosis was confirmed in 261
(65.5%) children. The most common affected age group
was 6-12 yr and the mean age of presentation was 6.9 yr.
The cases were from Puducherry (72%), Tamil Nadu Fig. 1: Graph showing relationship between bleeding, platelet counts
(23%), Karaikal (3%) and Yanam (2%). Male to female and platelet transfusion (X-axis indicates number of dengue
ratio was 1.2 : 1. The mean duration of hospital stay was fever cases in platelet range in mm3).
6.5 days.
The common clinical presentations included fever
(94.3%), conjunctival congestion (89.7%), myalgia
(81.8%), coryza (79.9%), vomiting (77.1%), headache
(70.2%), palmar erythema (64.5%), retro-orbital pain
(52.3%), pain abdomen (31.8%), joint pain (26.6%), rash
(17.7%), peripheral circulatory failure (41.7%), hypoten-
sion (30.3%), seizures (1.3%), jaundice (2.6%), hepatome-
galy (62.9%), splenomegaly (21.2%), ascites (7%) and
pleural effusion (5.1%) .
Hemorrhagic manifestations were present in 52 chil-
dren (19.9%), which mainly included petechiae
Fig. 2: Relationship between bleeding and platelet counts among
20 (38.5%), gum bleeding 18 (34.6%), melena 14 (26.9%), severe and non-severe dengue cases (X-axis indicates number
epistaxis 12 (23.1%), hematemesis 5 (9.6%), intracranial of dengue fever cases in platelet range in mm3).

Table 1. Platelet transfusion in relation to the platelet count and bleeding

Platelet range Non-severe dengue Severe dengue Total Bleeding Platelet transfusion

<10,000/mm3 0 7 (6.9) 7 (2.7) 5 (9.6) 7 (41.2)

10,00020,000/mm3 0 5 (4.9) 5 (1.9) 5 (9.6) 5 (29.4)
20,00050,000/mm3 7 (4.4) 24 (23.6) 31 (11.9) 10 (19.2) 5 (29.4)
50,000100,000/mm3 25 (15.7) 33 (32.3) 58 (22.2) 08 (15.4) 0
100,0001.50,000/mm3 83 (52.2) 31 (30.3) 114 (43.7) 13 (25) 0
>1.50,000/mm3 44 (27.7) 2 (2) 46 (17.6) 11 (21.2) 0

Total 159 (60.9) 102 (39.1) 261 (100) 52 (19.9) 17 (6.5)

Figures in parentheses indicate percentages.

306 J Vector Borne Dis 52, December 2015
69(68.3%) cases had severe dengue infection. Severe
thrombocytopenia (platelet count <50,000/mm3) was seen
in 35.4 and 4.4% cases in severe dengue infection and
non-severe dengue infection respectively. All the chil-
dren who had platelet counts <20,000/mm3 had features
of severe dengue infection (Table 1). 79.9% of cases with
platelet count >1,00,000/mm3 had non-severe dengue in-
fection. 46 children (17.6%) had normal platelet counts
and among them 95.7% had non-severe dengue infec-
tion.78.8% of cases with spontaneous bleeding had throm-
bocytopenia but bleeding manifestations did not always
correlate with platelet counts as it occurred in 21.2% of
cases with normal platelet counts (Fig. 1). However, it
was also observed that the bleeding manifestations
correlated well with platelet counts in severe dengue
infection in comparison to non-severe dengue infection
(Fig. 2).
Platelet transfusion was given in 17 children (6.5%)
with severe dengue infection and out of them 12 children
(70.6%) had a platelet count <20,000/mm3; whereas five
children (29.4%) had platelet count in the range of 20,000
50,000/mm3 (Table 1). All the children with a platelet
count <10,000/mm3 with severe dengue received platelet
transfusion and among them five had melena and two
children had intracranial haemorrhage. 64.2% of children
who received platelet transfusion recovered completely
and the average platelet count at the time of discharge
was 75,000/mm3. The mean platelet recovery time was
4.1 days. Two children developed platelet transfusion
reactions in the form of fever and rash. Apart from plate-
let transfusion, blood transfusion was given in 10(3.9%)
cases, fresh frozen plasma in 6(2.3%) cases, colloids in
3(1.2%) cases, i.v. fluids in 96(37.7%) cases and inotropes
in 5 (1.9%) cases. A total of 250 children were discharged
with complete recovery and there were six deaths (2.3%).
The most common factors associated with poor outcome
(death cases) were refractory shock, disseminated intra-
vascular coagulation (DIC), encephalopathy and
multiorgan failure.
DISCUSSION
In our study children > 6 yr were the most commonly
affected age group which is similar to the previous stud-
ies of Agarwal et al3 and Hema et al4, however, Narayanan
et al5 and Gurdeep et al6 showed < 6 yr of age as the
commonly affected age group. The most common mode
of presentation of severe dengue infection was peripheral
circulatory failure without bleeding, indicating a chang-
ing pattern of presentation and there was difficulty is clas-
sifying them as dengue haemorrhagic fever as per 2007
WHO guidelines. Bleeding manifestations were seen in
19.9% and was lower in comparison to the previous
studies5, 7-8. Melena was the most common form of gas-
trointestinal bleeding in our study, however, earlier
studies3, 5, 7 showed hematemesis to be the most common
form of bleeding. The tourniquet test in our study was
positive in 12.6% cases and was much lower compared
to that reported in the previous studies4-5, 8. It did not
correlate well with bleeding manifestations or with throm-
bocytopenia, similar to the finding reported by Wali
et al10 and Narayanan et al5.
Thrombocytopenia was found in 80.8% of cases in
our study and was lower compared to that in the previous
studies by Hema et al4 and Makroo et al11. Severe throm-
bocytopenia with platelet count <50,000/mm3 were seen
in 16.5% cases which was much lower compared to the
previous studies.4, 11, 12-13 In our study 78.8% of children
with spontaneous bleeding had thrombocytopenia and
75% cases of bleeding manifestations in severe dengue
occurred in patients with platelet count < 20,000/mm3
correlating to the previous studies by Chairulfatah et al14,
Ratageri et al7, Shivbalan et al2 and Makroo et al11.
Bleeding manifestations were highly variable and did
not always correlate with thrombocytopenia as it occurred
even with normal platelet counts. The correlation between
thrombocytopenia and bleeding was more common in
severe dengue infection than non-severe dengue infec-
tion. The mechanism for bleeding manifestations is mul-
tifactorial in dengue fever and the factors such as throm-
bocytopenia, coagulation defects, vasculopathy and
hepatic derangement act synergistically. Therefore, other
causes of bleeding needs to be evaluated before transfus-
ing platelets2, 14-16. In case of deranged coagulation pro-
file, fresh frozen plasma was given instead of platelets.
Children who had features of shock with rising hemat-
ocrit, not responding to crystalloids, received fresh fro-
zen plasma or colloids and with falling hematocrit received
whole blood transfusion.
Platelet transfusion was given in children with se-
vere dengue infection associated with significant bleed-
ing and with severe thrombocytopenia (platelet count
<50,000/mm3). Skin bleeds, single episode of epistaxis
or mucosal bleed were not given empirical platelet trans-
fusion. Platelet transfusion was given in 17 (6.5%) chil-
dren and among them two children developed transfu-
sion reactions. The inappropriate use of platelet
transfusion was completely avoided in the study. The need
for platelet transfusion was much lower compared to the
previous studies11, 17. Makroo et al11 in their study showed
that 42.6% were given platelet transfusion and 13.7% re-
 Pothapregada et al: Platelet transfusion in dengue fever
ceived inappropriate platelet transfusion. Kumar et al17
reported that 56.2% patients received inappropriate plate-
let transfusion, and opined that low risk patients should
not be given platelet transfusion and should be managed
on i.v. fluids and supportive therapy. The mean platelet
recovery time was 4.1 days and similar to the previous
studies.7, 18. There were six deaths (2.3%) in this study
and common factors for poor outcome were refractory
shock, multiorgan dysfunction and disseminated intravas-
cular coagulopathy. Children with severe dengue required
longer recovery period and more supportive management
in the form of blood component therapy, fluids and ino-
tropic support.
As per the WHO guidelines (2011) the indication for
platelet transfusion in children with dengue fever is the
presence of severe dengue with significant bleeding with
severe thrombocytopenia, which was followed in this
study1. The use of prophylactic platelet transfusion for
very severe thrombocytopenia (platelet count <10,000/
mm3) has been recommended by WHO only in adults
and not in children and was not given in this study. Blood
transfusion requirement was much lower compared to the
use of platelets in our study which was a deviation from
the guidelines.
The clinicians find the WHO guidelines for platelet
transfusion not pragmatic enough to be followed, espe-
cially during the present times when there is an intense
social pressure on the treating pediatricians by the par-
ents and their relatives. The need for platelet transfusion
is often overemphasized, but it is a myth and the fact is
that the platelet count alone is not a predictor of bleeding.
So, it is extremely important to be selective in giving plate-
let transfusion in children. The crux in the treatment of
dengue patient is maintenance of good hydration, moni-
toring for any overt bleeding, periodic check on periph-
eral pulses, blood pressure, well supported with estima-
tion of serial hematocrit and platelet counts and no
panicking on seeing lower platelet counts.
CONCLUSION
Children with severe dengue with significant sponta-
neous bleed and severe thrombocytopenia necessitated
platelet transfusion in the study. Bleeding should not be
the only indicator to transfuse platelets as it occurred in
children even with normal platelet counts. The commu-
nity and treating physicians should be educated regard-
ing the judicious transfusion of platelet and the unneces-
sary and empirical use of platelets should be completely
avoided especially during an epidemic when there is scar-
city in availability of platelets.
307
ACKNOWLEDGEMENTS
The authors are thankful to Dr Vijayalakshmi
Sivapurapu, Intensivist, Indira Gandhi Medical College
and Research Institute, Puducherry for the critical inputs
in preparing the manuscript.
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Correspondence to: Dr Sriram Pothapregada, Associate Professor, Paediatrics, Plot No 7 & 8, Ground Floor, Logu Nagar, Periyar Street,
Gorimedu, PO: Dhanvantri Nagar, Puducherry605 006, India.
E-mail: psriram_ped@yahoo.co.in.

Received: 1 March 2015 Accepted in revised form: 13 August 2015