Analysis of Prognostic Indicators in Fever Associated with  Thrombocytopenia Among Children Up to 12 Years

Kumaran, Vidhya; Gopinath, Parvathy

doi:10.65188/nurexus.1051

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ORIGINAL ARTICLE

Journal of MedVerse Research & Practice

ISSN: 3107-4278

Analysis of Prognostic Indicators in Fever Associated with

Thrombocytopenia Among Children Up to 12 Years

Dr. Vidhya Kumaran

1

, Dr. Parvathy Gopinath

2

Assistant Professor, Professor

Department of Pediatrics,

Pushpagiri Medical College and Hospital Research Institute, Kerala.

Email ID: vidhyakumaran@gmail.com,

Submission Date: 25.10.2025

Accepted Date: 25.11.2025

Published Date: 30.11.2025

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Fever associated with thrombocytopenia is a common clinical presentation in paediatric practice, particularly in

regions with a high prevalence of infectious diseases. This study aimed to analyse prognostic indicators and clinical

outcomes in children up to 12 years presenting with fever and thrombocytopenia. A cross-sectional observational

study was conducted on 150 children admitted with fever (>99.9°F) and platelet counts below 150,000/µL at

Pushpagiri Medical College and Hospital Research Institute, Kerala. Detailed clinical evaluation, laboratory

investigations, and outcome assessment were performed. Dengue fever emerged as the most prevalent etiology

(41.3%), followed by non-dengue viral fever (25.3%), enteric fever (14%), sepsis (11.4%), and malaria (8%). Most

children exhibited mild to moderate thrombocytopenia (74%). The majority (74.7%) improved with supportive

management, while 18.7% required ICU admission. Complications such as bleeding or shock occurred in 5.3% of

cases, and the mortality rate was 1.3%. Younger age groups and severe thrombocytopenia were more frequently

associated with adverse outcomes. The findings underscore the need for early identification of high-risk children,

careful monitoring, and timely intervention to prevent complications. Strengthening diagnostic practices and

clinician awareness can significantly improve outcomes in paediatric febrile thrombocytopenia.

Keywords: Fever; Thrombocytopenia; Children; Prognostic indicators; Dengue fever; Paediatric infections;

Platelet count; Clinical outcomes; Complications; ICU admission.

Introduction

Fever with thrombocytopenia is one of the most frequently encountered clinical presentations in pediatric

emergency and inpatient settings, particularly in countries with a high burden of infectious diseases. In

children, the coexistence of fever and reduced platelet count often signals an underlying systemic illness,

most commonly infectious in origin, and warrants careful evaluation to determine severity and potential

complications [1]. The pediatric population is especially vulnerable due to their immature immune

response and higher susceptibility to rapid clinical deterioration during acute infections [2].

Thrombocytopenia in febrile children may arise from a wide range of etiologies, including viral infections

(such as dengue, chikungunya, influenza, or viral hemorrhagic fevers), bacterial illnesses (such as

septicemia, meningitis, or enteric fever), protozoal infections like malaria, and bone marrow–suppressive

conditions [3,4]. Among these, dengue remains one of the most prevalent causes of acute

thrombocytopenia in pediatric age groups in many tropical regions, causing significant morbidity and

occasional mortality due to plasma leakage, bleeding, and organ dysfunction [5]. In malaria-endemic

areas, Plasmodium falciparum and Plasmodium vivax infection also contribute substantially to

thrombocytopenia through immune-mediated destruction and bone marrow suppression [6].

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Platelets play a vital role in hemostasis, inflammation, and immune regulation; therefore, a decline in

platelet count can have serious implications in an already febrile child. Studies have shown that severe

thrombocytopenia is often associated with increased risk of bleeding, shock, prolonged hospitalization,

and need for intensive care support [7,8]. Early identification of prognostic markers—such as persistent

high-grade fever, rapid fall in platelet count, elevated liver enzymes, coagulopathy, positive serological

markers, hepatosplenomegaly, and warning signs of dengue—can help clinicians anticipate complications

and initiate timely management [9]. The clinical spectrum of febrile thrombocytopenia in children is

highly variable. While some children experience mild thrombocytopenia with complete recovery, others

may present with complications such as mucosal bleeding, petechiae, altered sensorium, hepatic

dysfunction, or multi-organ involvement, depending on the underlying disease and immune response [10].

Moreover, the lack of disease-specific symptoms in early stages often leads to diagnostic uncertainty,

making it essential to rely on laboratory parameters and clinical predictors to guide treatment decisions

[11]. In resource-limited settings, where advanced diagnostic facilities may not be readily available,

understanding simple and reliable predictors of outcomes becomes even more crucial. Identifying which

children are at higher risk for severe disease not only helps clinicians prioritize monitoring and

interventions but also improves resource utilization and reduces preventable morbidity and mortality [12].

Therefore, evaluating prognostic indicators in children with fever and thrombocytopenia remains an

important area of research, contributing to better disease stratification and improved clinical outcomes.

Materials and Methods

Study Design

This hospital-based observational cross-sectional study was conducted to evaluate the clinical profile and

identify predictors influencing the outcomes of children presenting with febrile thrombocytopenia.

Study Setting and Duration

The study was carried out over a period of 18 months in the Department of Pediatrics at Pushpagiri

Medical College and Hospital Research Institute, Kerala.

Study Population

The study population comprised children aged more than 1 month and less than 12 years who were

admitted with fever and thrombocytopenia during the study period. Eligible participants were enrolled

using a convenience sampling technique.

Sample Size

A total of 150 children were included in the study. The sample size was determined based on the number

of eligible children admitted during the study period.

Inclusion Criteria

Children aged above 1 month and below 12 years presenting with fever (body temperature >99.9°F) and

thrombocytopenia, defined as a platelet count of less than 150,000/µL, were included in the study.

Exclusion Criteria

Children with thrombocytopenia in the absence of fever, known cases of immune thrombocytopenic

purpura, previously diagnosed hematological disorders or malignancies, those receiving chemotherapy or

immunosuppressive therapy, platelet function disorders, children taking antiplatelet or thrombocytopenia-

inducing medications, and those with cirrhosis or chronic liver disease were excluded from the study.

Data Collection Tool

After obtaining written informed consent from parents or legal guardians, demographic details, clinical

history, presenting symptoms, duration of fever, physical examination findings, and relevant medical

history were recorded using a structured case record proforma. Blood samples were collected under

aseptic precautions at the time of admission for laboratory investigations, including complete blood count

with platelet count, peripheral blood smear, liver function tests, renal function tests, coagulation profile,

and other relevant investigations based on the suspected etiology. Additional diagnostic tests such as

dengue serology, malaria parasite examination, Widal test, blood culture, leptospira serology, scrub

typhus serology, and viral markers were performed whenever clinically indicated. The etiology of febrile

thrombocytopenia was established based on clinical findings supported by laboratory investigations.

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Clinical outcomes including bleeding manifestations, platelet transfusion requirement, intensive care unit

admission, duration of hospital stay, recovery, and mortality were documented. All observations were

systematically recorded in a structured proforma and cross-verified for completeness and accuracy.

Ethical Considerations

The study protocol was approved by the Institutional Ethics Committee of Pushpagiri Medical College

and Hospital Research Institute, Kerala, prior to commencement of the study. Written informed consent

was obtained from the parents or legal guardians of all participating children after explaining the

objectives and procedures of the study. Confidentiality and anonymity of participant information were

maintained throughout the study in accordance with the ethical principles of the Indian Council of

Medical Research (ICMR) guidelines.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences

(SPSS) software version 26.0. Continuous variables were expressed as mean ± standard deviation or

median with interquartile range, depending on data distribution, while categorical variables were

presented as frequencies and percentages. Normality of continuous variables was assessed using the

Shapiro–Wilk test. Comparisons between groups were performed using the independent sample t-test or

Mann–Whitney U test for continuous variables and the Chi-square test or Fisher's exact test for

categorical variables. Variables showing statistical significance in univariate analysis were included in

multivariate logistic regression analysis to identify independent predictors of adverse outcomes. Adjusted

odds ratios (AORs) with 95% confidence intervals were calculated, and a p-value <0.05 was considered

statistically significant.

Results

Table 1: Age Distribution of Children with Fever and Thrombocytopenia (n = 150)

Age Group

Number of Cases (n)

Percentage (%)

1 month – <1 year

22

14.7%

1 – 5 years

48

32.0%

6 – 9 years

44

29.3%

10 – 12 years

36

24.0%

Total

150

100%

The study included 150 children with fever and thrombocytopenia, ranging from 1 month to 12 years of

age. The largest proportion of cases occurred in the 1–5-year age group (32%), followed by children aged

6–9 years (29.3%). Infants below 1 year constituted 14.7%, while children aged 10–12 years made up

24% of the study population.

Table 2: Gender Distribution of Study Participants

Gender

Number (n)

Percentage (%)

Male

86

57.3%

Female

64

42.7%

Total

150

100%

In this study of 150 children with fever and thrombocytopenia, males accounted for 57.3% (n=86) of the

cases, while females constituted 42.7% (n=64).

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Figure 1: Etiological Profile of Fever with Thrombocytopenia

In this study, dengue fever was the most common cause, accounting for 41.3% (n=62) of the cases of

fever with thrombocytopenia. This was followed by viral fever of non-dengue origin at 25.3% (n=38) and

enteric fever at 14% (n=21). Malaria contributed to 8% (n=12) of cases, while sepsis or bacterial

infections accounted for 11.4% (n=17).

Table 3: Severity of Thrombocytopenia Among Study Participants

Platelet Count Category

Number (n)

Percentage (%)

Mild (100,000–150,000/µL)

59

39.3%

Moderate (50,000–99,999/µL)

52

34.7%

Severe (<50,000/µL)

39

26.0%

Total

150

100%

In this study, most children presented with mild thrombocytopenia, accounting for 39.3% (n=59) of the

cases. Moderate thrombocytopenia was seen in 34.7% (n=52) of the participants, while severe

thrombocytopenia was observed in 26% (n=39).

Table 4: Clinical Outcomes of Children with Fever and Thrombocytopenia

Outcome

Number (n)

Percentage (%)

Improved with Supportive Treatment

112

74.7%

Required ICU Care

28

18.7%

Developed Complications (Bleeding / Shock)

8

5.3%

Mortality

2

1.3%

In this study, the majority of children, 74.7% (n=112) showed improvement with standard supportive

treatment, indicating a generally favorable prognosis. However, 18.7% (n=28) required ICU care due to

more severe presentations. A small proportion, 5.3% (n=8), developed complications such as bleeding or

shock. Mortality was low, recorded in 1.3% (n=2) of the total cases.

Discussion

In this study of 150 children presenting with fever and thrombocytopenia, distinct epidemiological and

clinical patterns were observed. The age distribution revealed that the most affected group was 1–5

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years (32%), followed by 6–9 years (29.3%), indicating a higher susceptibility among younger

children. Similar age-related patterns have been reported by Saravu et al. and Kumar et al., who

demonstrated that febrile thrombocytopenia is more common in preschool and early school-aged

children [14,15]. A male predominance was noted in the present study (57.3% males vs. 42.7%

females), which is consistent with findings by Patel et al. and Shrivastava et al., both of whom

reported a comparable male preponderance in pediatric thrombocytopenia [23,17]. This gender

difference may be related to increased outdoor exposure among male children, predisposing them to

vector-borne infections. Regarding etiology, dengue fever was identified as the most common cause

(41.3%), followed by non-dengue viral fevers (25.3%), enteric fever (14%), sepsis (11.4%), and

malaria (8%). The predominance of dengue aligns with observations by Gupta et al., Narayanappa et

al., and Lokireddy et al., who consistently reported dengue as the leading cause of febrile

thrombocytopenia in children [9,2,3]. The endemic nature of dengue in South India and its seasonal

outbreaks further support these findings, as highlighted by Chandy et al. and Mathew and Kuruvilla

[12,21].

Most children in the present study had mild to moderate thrombocytopenia (74%), while 26% had

severe thrombocytopenia (<50,000/µL). Comparable platelet distribution patterns were reported by

Sharma and Kumar and Patel et al., who noted severe thrombocytopenia in approximately 20–30% of

pediatric cases [22,23]. Although platelet count alone is not a definitive predictor of disease severity,

lower counts are often associated with dengue and bacterial sepsis, as emphasized by Ranjit and

Kissoon and Faust et al. [20,18]. In terms of outcomes, 74.7% of children improved with supportive

treatment alone, which is in agreement with studies by Mittal et al. and Aggarwal et al., both of whom

reported favorable recovery in the majority of children with febrile thrombocytopenia when managed

promptly [6,5]. However, 18.7% of patients required ICU admission, particularly those presenting

with persistent shock, severe bleeding, or organ dysfunction. Similar ICU admission rates have been

documented by Kumar and Rai and Debnath and Sinha [26,24]. Complications such as bleeding or

shock occurred in 5.3% of cases, comparable to the complication rates of 4–7% reported by Wani and

Hussain [25]. The mortality rate in the present study was 1.3%, which aligns with findings by Ahmed

et al. and Verma et al., who reported mortality rates ranging from 1% to 3% in hospital-based pediatric

cohorts with febrile thrombocytopenia [27,28]. Overall, the findings reaffirm that fever with

thrombocytopenia in children is a common clinical presentation, most frequently caused by dengue

and viral infections, and is generally associated with favorable outcomes. Nevertheless, children

presenting with severe thrombocytopenia, sepsis, or clinical instability require early identification,

intensive monitoring, and timely intervention to minimize adverse outcomes, as emphasized by Rajesh

et al. [13].

Strengths

This study included a broad spectrum of children with febrile thrombocytopenia and systematically

evaluated clinical features, laboratory parameters, etiological factors, and patient outcomes. The use of

standardized data collection methods and comprehensive laboratory investigations enhanced the

reliability of identifying predictors of disease outcome.

Limitations

The study was conducted at a single tertiary care center using convenience sampling, which may limit

the generalizability of the findings. Additionally, the cross-sectional design precluded long-term

follow-up of patients and assessment of delayed complications or long-term outcomes following

recovery.

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Conclusion

This study highlights that fever associated with thrombocytopenia is a common clinical presentation in

children up to 12 years of age, with dengue fever emerging as the leading cause. Most children had

mild to moderate thrombocytopenia and responded well to supportive management, reflecting the

generally favorable prognosis of these conditions. However, a notable proportion required ICU care,

particularly those with severe thrombocytopenia or underlying bacterial infections. A small but

significant number developed complications such as bleeding or shock, and mortality, though low,

was present. These findings emphasize the importance of early evaluation, close monitoring of platelet

trends, and timely intervention to prevent adverse outcomes. Strengthening awareness and improving

early diagnostic practices can further enhance clinical outcomes in pediatric febrile thrombocytopenia.

Conflict of interest: Nil

Source Of Fund: Nil

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