INTRODUCTION
Pyrexia or fever is a clinical manifestation of a bacterial or viral infection. Viral fever is characterized by a temperature above 38.0°C–38.4°C (100.4 F–101 F) and is often accompanied by symptoms such as sudden onset of pyrexia, myalgia, nausea or vomiting, and thrombocytopenia.[1,2] The etiology of viral infections includes disorders such as herpes, dengue, and influenza.[3] Thrombocytopenia is characterized by decreased platelet counts, resulting from increased destruction, increased consumption, or decreased production of platelets.[1] Normal platelet counts range from 150,000 to 450,000 cells/μL. Platelets play a vital role in inflammation and immunity.[4] Thrombocytopenia may lead to uncontrolled bleeding and may lead to severe postoperative complications even after minor surgery. However, identifying the cause of postoperative thrombocytopenia may be challenging.
Viral pyrexia with thrombocytopenia often has an insidious onset. Numerous interventions can be used for the management of this condition, including fluid administration and transfusion of blood products. The timely diagnosis and prompt treatment of this disorder will ensure minimal morbidity and mortality.
The present study reported a case of postoperative viral pyrexia with thrombocytopenia following a periodontal flap procedure and its management.
CASE REPORT
A 19-year-old male patient presented to our dental clinic with a complaint of bleeding gums while brushing and loosening of teeth in the right mandibular posterior and anterior region for 4 months. No abnormality was detected on extraoral examination. Intraoral examination exhibited mobile teeth with gingival recession and periodontal pockets >7 mm. The condition was diagnosed as localized severe periodontitis.
Preoperative blood investigations such as hemogram, differential leukocyte count, and bleeding and clotting time with rapid antigen COVID-19 test were advised. An orthopantomogram (OPG) was also advised. OPG exhibited severe bone loss in the left and right mandibular posterior region (33–36 and 43–46) and the mandibular anterior region (32–42) [Figure 1]. Considering the severity and extent of bone loss, a regenerative periodontal flap surgery as per Kirkland was planned for these regions.[5]
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Figure 1: Preoperative radiograph
After obtaining the consent from the patient, Complete oral prophylaxis was performed. Then, laser-assisted new attachment procedure was performed in the 32–42 regions. Access flap surgery was performed in the left and right mandibular posterior region (33–36 and 43–46). A G-graft augmented with platelet-rich fibrin growth factor was placed in this region. The periodontal flaps were secured with direct loop sutures. No active bleeding was observed postoperatively, and the patient was discharged 5 h later. Approximately 48 h postoperatively, the patient presented with severe intraoral bleeding and pyrexia. On examination, buccal ecchymosis was observed. Intraoral examination exhibited a sublingual hematoma and active intraoral bleeding [Figure 2]. The sutures on both the buccal and lingual flaps were intact. Intramuscular ethamsylate injection was administered, and hemostasis was achieved. The patient was shifted to the general ward and kept under observation. A platelet count and an international normalized ratio (INR) were advised to identify the etiology of the vascular abnormality.
Figure 2: (a and b) Ecchymosis after flap surgery
The INR was 1.1, whereas the platelet count was 60,000 cells per cubic millimeter. The patient tested negative for dengue antibody. After differential diagnosis, the patient was diagnosed with idiopathic viral pyrexia with thrombocytopenia. Subsequent treatment was administered under the supervision of the general physician. The platelet count on the 4th, 5th, and 6th postoperative days was increased up to 83,000, 120,000, and 180,000. The patient was admitted to the general ward, and no further systemic complications were observed. On the 9th postoperative day, the platelet count was increased to 315,000. At this point, the general condition of the patient was stable, and he was able to take oral feed. Comprehensive general and oral examination performed on the 9th postoperative day exhibited resolution of intraoral ecchymosis and hematoma. Suture removal was performed. The patient was discharged with doxycycline 100 mg and vitamin supplements for 1 week. Two-month postoperative figures depicted completely healed sites where ecchymosis was noticed previously [Figures 3 and 4].
Figure 3: One-month postoperative healed picture after the treatment received for decreased platelets
Figure 4: Two-month postoperative healed picture after the treatment received for decreased platelets
DISCUSSION
The diagnosis and management of pyrexia with thrombocytopenia with or without definite etiology is often challenging for physicians. The etiology of thrombocytopenic pyrexia includes viral or bacterial infections such as dengue, varicella, mumps, and Gram-negative sepsis; malignancies such as leukemia and lymphoma; disseminated intravascular coagulation; and anemia.[6]
Postoperative hemorrhage ranging from a minor ooze to extensive bleeding at the surgical site is a common complication after periodontal flap surgery.[7] Few causes of postoperative hemorrhage include infection, intraoperative trauma to vital structures, dislodgement of clot due to manipulation of the surgical site by the patient, and negative pressure created by the tongue resulting in secondary bleeding.[8] However, in the present case, no immediate postoperative bleeding was observed. The patient presented with severe intraoral hemorrhage accompanied by pyrexia 48 h postoperatively, eliminating an intraoperative etiology and suggesting a systemic one.
Several infectious causes of pyrexic thrombocytopenia have been identified. A recent addition to this group of diseases is severe fever with thrombocytopenia syndrome (SFTS). This is a type of hemorrhagic fever, caused by SFTS virus, a novel Phlebovirus of family Bunyaviridae.[9] It is a tick-borne disease reported in countries such as China, Japan, South Korea, Taiwan, and the US. This disease is characterized by symptoms such as pyrexia, leukopenia, thrombocytopenia, and gastrointestinal abnormalities. Multisystemic organ failure is observed in severe cases. This virus is commonly observed in the elderly population.[9,10] The age and the geography of the present case eliminated this diagnosis.
Dengue is a common infectious cause for pyrexic thrombocytopenia in the tropical and subtropical areas of the world.[11]
However, the antibody test for dengue was negative in this patient. Thrombocytopenia may occur in febrile patients due to decreased platelet production, increased platelet destruction, hemophagocytosis, direct effect on progenitor cells, and antibody-mediated platelet destruction.[12]
Thrombocytopenia associated with viral infection results from both lowered platelet production from megakaryocytes and decrease in platelet half-life.[13] The role of platelets in viral infection has been extensively studied. Apart from their crucial role in hemostasis, platelets facilitate and modulate inflammatory and immune responses through direct interaction with leukocytes and endothelial cells. In addition, they release inflammatory mediators that trigger leukocyte activation and improve their recruitment.[4] Furthermore, platelets express surface receptors such as toll-like receptors, integrins, lectins, and Fc receptors that directly interact with pathogens and recognize immunocomplexes.[4,14] Thus, platelet activation occurs as both a response to injury and in infections. In the present study, intramuscular ethamsylate injection was administered to achieve hemostasis. Ethamsylate enhanced the platelet response to thromboxane A2 and calcium ionophore. This improves platelet functions to achieve hemostasis.[15]
No platelet or blood transfusion was performed in the present case. Platelet transfusion for thrombocytopenia treatment must be considered only when the platelet count is <10,000.[9] In the present study, the patient presented with a platelet count of 60,000. Prophylactic platelet transfusion must be avoided as it may cause alloimmunization and platelet refractoriness.[11]
CONCLUSION
The present case study demonstrates the significance of a rigid follow-up routine even after minor surgery. Clinicians must be aware of the optimal diagnosis and treatment for pyrexia with thrombocytopenia.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The authors extend their appreciation to the Deanship of Postgraduate and Scientific Research at Dar Al Uloom University, Riyadh, KSA, for supporting this work.
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