The differential diagnosis and management for each disease that come with fever and thrombocytopenia. From infectious disease, connective tissue disease to malignanciec

1. FEVER WITH
THROMBOCYTOPENIA
Case Based Discussion
Dr. Nik Abdul Hadi

2. Objectives
◦Able to identify differential diagnosis and
investigate accordingly
◦Able to identify red flags

3. Case 1
◦ 29 year old Malay lady
◦ NKMI
◦ p/w fever 3/7
◦ Sore throat
◦ Headache
◦ Athralgia/myalgia

4. Further history?

5. Examination
◦ Tongue moist, good pv, crt <2 sec,
◦ Temp 38.2
◦ Bp 124/86, HR 101
◦ Spo2 99% under RA
◦ Throat injected, tonsil not enlarged
◦ Lungs clear
◦ Cvs, abd unremarkable

6. Investigation
◦ Hb 13
◦ Twbc 4.3
◦ Plt 119
◦ Hct 37

7. Differential diagnosis?

8. Further investigations?

9. ◦Dengue combo test negative
◦Rtk covid negative

10. Management?

11. ◦Viruses can trigger a decrease in platelet
production by infection of megakaryocytes, which
can lead to apoptosis of megakaryocytes, decreased
maturation and ploidy of megakaryocytes, or
decreased expression of thrombopoietin receptor c-
Mpl.

12. Case 2
◦ 32 yo, Indian Male
◦ NKMI
◦ Fever 4/7
◦ Myalgia
◦ Retroorbital headache
◦ Vomiting x3 past 2 days
◦ No loose stool
◦ Abdominal discomfort

13. Anything else?

14. On examination
◦ Alert, concious, tongue dry, good pulse volume, crt <2 sec, no jaundice
◦ Bp 115/76
◦ Hr 104
◦ Temp – 38.8
◦ Spo2 98% under RA
◦ Lungs clear
◦ Cvs drnm
◦ Abd – mild epigastric tenderness, soft

15. Investigations
◦ Hb 13
◦ Hct 39
◦ Plt 78
◦ Twbc 9
◦ Urea 12
◦ Creat 115
◦ Ast 88
◦ Alt 97
◦ T. bili 24

16. Differential diagnosis?

17. Any further investigations to support
diagnosis?

18. ◦Leptospira serology
◦Leptospira culture
◦MAT
◦PCR

19. What are your plan of management?

20. Treatment

21. Case 3
◦ 29 year old Chinese male
◦ NKMI
◦ p/w fever for 3/7
◦ Chills and rigors
◦ Profuse sweating
◦ Nausea
◦ Vomiting x4 for 1 day
◦ Myalgia
◦ Headache
◦ Yellowish discoloration of sclera

22. Further history?

23. Examination
◦ Alert, concious, dry tongue, good pv, crt < 2 sec, jaundice sclera
◦ Bp 102/63
◦ Hr 110
◦ Temp 39
◦ Spo2 97% under RA
◦ Lungs clear
◦ Cvs drnm
◦ Abd soft, not tender, dull traube space

24. Initial investigations
◦ Hb 10
◦ Twbc 5
◦ Plt 69
◦ Urea 7
◦ Creat 89
◦ Total bilirubin 65 umol/L indirect predominant
◦ Ast 56, alt 75

25. Differential diagnosis?

26. Any further investigations to support
diagnosis?

27. ◦Bfmp – P. knowlesi , parasite density 23 000/uL

28. How do you classify his severity?

29. ◦What are your plan of management?

30. SYMPTOMS
Main symptoms : Headache ,Nausea, Muscular
pain,High fever
Each malarial attack is of 6-10hours duration and
consists of the 3 stages:
.Cold Stage feeling very cold and shivering
(half – 1H)
Hot stage
high fever, high RR and HR (1-
4H)
Sweating stage
Due to profuse sweating 
normal temperature (1-4H)

31. DIAGNOSIS :
- Fever
- Traveling history to/ from
malaria endemic area
- Laboratory presence of
-Thrombocytopenia
-Relative lymphopenia
-Atypical lymphocytes
-Elevated LDH
CLINICAL FEATURES
• Incubation period average 10-
14 days
• Symptoms occur within :
• 6 weeks in >90% for P
falciparum infections
• 1 year for P Vivax infections
• 9-12 days for P Knowlesi
infections

32. DEFINITION
UNCOMPLICATED
MALARIA
Symptomatic malaria without
signs of severity or evidence
(clinical or laboratory) of
vital organ dysfunction.
The signs and symptoms of
uncomplicated malaria are
non-specific

33. WHO CRITERIA FOR SEVERE F.MALARIA
Clinical
Features
1.Impaired consciousness GCS <11
2.Prostration ( severe weakness- generalized)
3.Failure to feed
4.Multiple convulsions > 2/24H
5.Respiratory distress
6.Shock
7.Jaundice + other organ failure
8.Abnormal spontaneous bleeding
9.Pulmonary oedema
Laboratory Findings :
1. Hypoglycemia (< 2.2)
2. Severe anaemia (<7g/dl)
3. Lactate >5
4. Renal impairment ( Cr > 265), urea
>20mmol/L
5. Metabolic acidosis ( HCO3 < 15)
6. Haemoglobinuria
7. Se bilirubin>50umol/L & parasite count
>100,000/uL
8. Hyperparasitemia : P. falciparum
parasitaemia > 10%

34. SEVERE MALARIA
• defined as for falciparum malaria but with no parasite density
thresholds.
Severe vivax malaria:
• P. knowlesi hyperparasitaemia: parasite density > 100 000/ μL
• Jaundice and parasite density > 20 000/μL.
Severe knowlesi malaria is defined as for
falciparum malaria but with two differences:

35. UNCOMPLICATED MALARIA
P. vivax, P. ovale, P. malariae or P. knowlesi
 REGIME : ORAL
 Artemisinin based combination therapy (ACT)
 (Riamet) - Artemether (20mg) & Lumefantrine
(120mg) – for weight > 35kg
 4 tablets STAT  followed by 4 tablets 8H
later  then 4 tablets BD x 2 days
 TOTAL 6 DOSES (24 tablets)
 Treat pregnant women in their first trimester who
have chloroquine-resistant P. vivax malaria with
quinine.
P.Falciparum
( New infection/ Relapse or treatment
failure)
REGIME :
- Alternative oral Artemisinin based
combination therapy (ACT)
1st time : Riamet, then use ASMQ
(Artesunate / Mefloquine)
- T Quinine 10mg/kg TDS + Doxycyline
100mg BD for 7 days (ALTERNATIVE)
- Treat pregnant women with uncomplicated P.
falciparum malaria during the first trimester with
7 days of quinine + clindamycin.

36. P.VIVAX & P.OVALE -TO PREVENT RELAPSE
ADD PRIMAQUINE TO ERADICATE HEPATIC STAGE OF MALARIA
G6PD normal :
• Primaquine 0.5mg/kg
(max 30mg) PO OD x
14 days
G6PD Deficient :
• Primaquine
0.75mg/kg PO q7d
for 8 weeks
• If significant
hemolysis occurs,
should be stopped.
Severe G6PD
Deficiency :
• Chloroquine
prophylaxis for 6-8
weeks
PREGNANT AND BREASTFEEDING WOMEN
- Chloroquine 300mg prophylaxis weekly until delivery or breastfeeding completed
If failed chloroquine (resistance), mefloquine can be used
Primaquine (full course) to be given post-delivery

37. TREATMENT FOR SEVERE MALARIA-
P.FALCIPARUM/P.MALARIAE/P.KNOWLESI
DAY 1:
 IV Artesunate 2.4mg/kg at 0 hour, 12 hour, 24 hour and daily till day 7*
 T.Doxycycline 100mg BD (given together with IV artesunate)
* IV artesunate should be given MINIMUM 24 hours (3 DOSES) or until patient can tolerate orally
THEN SWITCHED to complete course of oral ACT (Riamet or AS+MQ)
**FOR ALL STAGES OF PREGNANCY : IV artesunate as for normal adults
Adjustment of parenteral dosing in renal failure or hepatic dysfunction
The dosage of artemisinin derivatives does not have to be adjusted for patients with vital organ dysfunction.