Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 193915

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : SC20 - SC23 Full Version

Clinico-aetiological and Demographic Profile of Pancytopenia among Children in a Tertiary Care Hospital of Northern Part of West Bengal- A Cross-sectional Study


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51595.16135
Mousumi Das, Aniruddha Saha, Amita Giri

1. Resident Medical Officer Cum Clinical Tutor, Department of Paediatrics, Chittaranjan Seva Sadan and Sishu Sadan College of Obstetrics and Gynaecology, Kolkata, West Bengal, India. 2. Medical Officer, CGHS, Kolkata, West Bengal, India. 3. Professor, Department of Pathology, Dr. Bidhan Chandra Roy Hospital Haldia Medical College, Haldia, West Bengal, India.

Correspondence Address :
Mousumi Das,
Skyline Lakeview Complex, H Block, Flat-1B, Purbapara, Laskarpur,
Kolkata-700153, West Bengal, India.
E-mail: mousumids99@gmail.com

Abstract

Introduction: Pancytopenia is a trio of results caused by numerous medical conditions in which all blood cell lineages, such as leukocytes, erythrocytes, and platelets, are diminished in blood. Causes of pancytopenia seem to vary widely in different country and also in different regions within a country. Knowing common cause and common presentation of pancytopenia is of immense importance to determine the diagnosis, especially in resourceconstraint areas.

Aim: To assess the aetiology, clinical profile of pancytopenia in a tertiary hospital in northern part of West Bengal.

Materials and Methods: This hospital-based, cross-sectional, study was conducted in North Bengal Medical College and Hospital, Sushrutanagar, West Bengal, India, from July 2012 to June 2013. Patients having pancytopenia, on primary haematological investigation, admitted in the Paediatric Department of the hospital were included in the study. Patients already on definitive treatment for disease causing pancytopenia like kala-azar, leukaemia were excluded from the study. A physical examination was performed after obtaining a relevant clinical history, followed by a full blood count, including Peripheral Blood Smear (PBS) examination, and appropriate biochemical assays. An aspiration and evaluation of the bone marrow was performed. Statistical Package for Social Sciences (SPSS) Version 16.0 for windows (SPSS 16) was used.

Results: There were 50 children, and the mean age of presentation was 7.3 years. Females constituted 52% and males were 48%. Aplastic anaemia was noted in 44% cases, 30% cases were diagnosed as megaloblastic anaemia, kala-azar in 18%, Acute Lymphoblastic Leukaemia (ALL) in 6% and Idiopathic Thrombocytopenic Purpura (ITP) in 2%, respectively. Mean age of presentation in aplastic anaemia was 7.6 years, while that in megaloblastic anaemia was 6.9 years. Female predominance was seen in both aplastic anaemia (59%) and megaloblastic anaemia (60%), while male preponderance was seen in ALL (66%). Generalised weakness was the most prevalent presenting symptom (100%) followed by fever (80%). Pallor (100%) was the most prevalent presenting sign, followed by glossitis (30%), which is commonly ignored.

Conclusion: Though aplastic anaemia is an important cause of pancytopenia, treatable causes like megaloblastic anaemia, kalaazar should always be looked for as other possible aetiologies for pancytopenia.

Keywords

Aplastic anaemia, Megaloblastic anaemia, Pallor

Pancytopenia is a common clinico-haematological condition seen in day-to-day clinical practice. It’s described as a drop in the number of all three produced blood constituents (red blood cells, white blood cells, and platelets) below the normal reference range (1). It is characterised by the presence of anaemia, leucopenia, and thrombocytopenia all at the same time. Patients with pancytopenia have a variety of clinical signs and symptoms. Pallor, malaise, and other symptoms such as palpitation and dyspnea are common in anaemic patients. A patient with thrombocytopenia has bruises, gum bleeding, and petechiae, whereas a patient with leucopenia has a history of recurrent infections. As a result, people with pancytopenia may exhibit any of the symptoms listed above. Anaemia and thrombocytopenia are the most common causes of clinical symptoms in pancytopenia, but leucopenia (while uncommon) can be life-threatening. Pancytopenia is often discovered by chance in a patient who is suffering from a condition that causes all cellular components in the blood to be depleted. A case of pancytopenia can have a wide range of clinical patterns, therapeutic options, and outcomes (2).

Pancytopenia has diverse aetiology- bone marrow depression due to any cause,or peripheral destruction as well as sequestration of formed elements of blood. Bicytopenia is a term used when only two parameters of a full blood count are low. The method of diagnosis is the same as for pancytopenia (3). Pancytopenia can also occur due to the replacement of marrow by tumour or fibrosis. Management and prognosis of a patient of pancytopenia depends upon the underlying cause (4). Mild marrow dysfunction is initially undetectable, and pancytopenia may manifest only at times of stress or high demand (bleeding, infection etc.,). The incidence of various disorders, causing pancytopenia, varies based on geographical distribution and genetic predispositions (5),(6). A study done at New Delhi found megaloblastic anaemia as the most common aetiology (28.4%) in children. Acute leukaemia and aplastic anaemia accounted for 21% and 20% cases, respectively (7). Aplastic anaemia was shown to be the most common cause of pancytopenia in a study on pancytopenia among children in eastern India (8). The identification of pancytopenia aetiologies in diverse regions can aid in the development of diagnostic and therapeutic techniques, which should lead to improved patient management. A disturbance of each of the principal blood elements is reflected much earlier and the changes are more conspicuous in the marrow than the peripheral blood (9). Though Bone Marrow Aspiration (BMA) is most commonly done test, a dry or blood tap is also done, and even repeated attempts of BMA may fail to obtain sufficient marrow particles for adequate examination. Hence, a Bone Marrow Trephine Biopsy (BMTB) plays an important and ultimate role in this case (2). BMTB along with imprint smear examination gives scope to the histopathological examination along with cytological details.

The aim of this study was to determine the aetiology of pancytopenia, as well as its prevalence and clinicopathologic characteristics within the study population.

Material and Methods

This hospital-based, cross-sectional, study was conducted in North Bengal Medical College and Hospital, Sushrutanagar, West Bengal, India, from July 2012 to June 2013. The study was conducted after getting clearance from the Institutional Ethical Committee.

Inclusion criteria: All children upto 12 years of age having pancytopenia (after examination of their complete haemogram), admitted in the Paediatric Department of the study hospital during the study period were included in the study. Pancytopenia was described as a haemoglobin concentration of <10 g%, a total white cell count of <4×109/L, an Absolute Neutrophil Count (ANC) of <1,500/L, and a platelet concentration of <100,000/L.

Exclusion criteria: Patients already on definitive treatment for diseases causing pancytopenia, and those whose parents refused to take part in the study were excluded from the study.

Sample size calculation: From various previous studies it is seen that incidence of pancytopenia among children range from 2.9-3.1% (10),(11). Taking the maximum value of these findings, which is 3.1%, allowing for 5% margin of error (d) with 95% CI (zα/2=1.96) using single population proportion (p) formula, sample size calculated was

n=(Zα/2)2×p(1-p)/d2=(1.96)2×0.031(0.969)/(0.05)2=46.

Procedure

A thorough history and clinical examination was done and the data was recorded in a self-designed proforma (identification of subject, present history, socio-economic status as per the BG Prasad classification, general survey findings, systemic examination findings) (12). Specific characteristics of pancytopenia symptoms (fatigue, palpitation, shortness of breath, fever, and easy bruising) were also investigated.

Complete Blood Count (CBC) and Peripheral Blood Smears (PBS) tests were performed on blood samples. For PBS examination, the smear was stained with Leishman stain, and fresh methylene examination was used to identify the reticulocyte count. The CBC was calculated using the Sysmex KX21 automated cell counter and blood taken in the ethylenediaminetetraacetic acid vial. The Beckman Coulter Access 2 immunoassay system was used to check the levels of vitamin B12 and folate in the blood to diagnose the cases of megaloblastic anaemia. Salah’s aspiration needle and Jamshidi trephine biopsy needle were used to aspirate and biopsy bone marrow under aseptic conditions. Simultaneous imprint preparation was done from the biopsy material. Leishman staining of the imprint smear was done for cytological details. Cytological and clinico-haematological diagnosis was done in all cases. Decalcification of the biopsy done for a fixed period. Haematoxylin and Eosin (H&E) staining of all the biopsy material was done. Reticulin staining (Gordon’s and Sweet method) of the biopsy material, especially in case of hypoplastic/Aplastic anaemia was done. Periodic Acid Schiff’s (PAS) staining of the biopsy was done in selected cases e.g., Acute Lymphoblastic Leukaemia (ALL).

Statistical Analysis

Statistical Package for Social Sciences (SPSS) Version 16.0 for windows (SPSS 16) was used. Arithmetic mean was calculated.

Results

Total 6205 blood samples from Paediatric Department were examined, within one year of the study period. Out of that, 50 cases were diagnosed to have pancytopenia. The patients’ peripheral blood films were examined for red, white, and platelet morphology, as well as the presence or absence of immature cells and blast cells. The morphology of all cell lineages, cellularity, parasites, and aberrant cells were all examined during the bone marrow examination. Mean age of the population was 7.3 years. There were total 24 males and 26 females (Table/Fig 1).

Most commonly affected age group was 5-8 years. Most common cause of pancytopenia in this age group was megaloblastic anaemia (Table/Fig 2). Aplastic anaemia was seen to be the most common cause of pancytopenia as a whole. Females were seen to be more commonly affected in aplastic anaemia and megaloblastic anaemia (Table/Fig 3). Kala-azar, ALL, ITP were seen more in males. Generalised weakness was seen in all cases of pancytopenia followed by fever as most common presenting symptom. Pallor was most common presenting sign (Table/Fig 4). (Table/Fig 5) shows the presenting symptoms and signs in individual causes of pancytopenia. Socio-economic status and residential details are mentioned in (Table/Fig 6), (Table/Fig 7).

Discussion

Total 6205 blood samples from pediatric indoor were examined within one year of study period; out of which 50 cases were diagnosed to have pancytopenia, after examination of the complete haemogram. So, the incidence rate of pancytopenia among children was (50/6205×100)=0.80%. This is comparable to the studies of Dubey SRK et al., conducted at Kanpur UP and that by Chand R and Singh N., conducted at Kumaon region, noted the incidence of pancytopenia as 2.9%, and 3.04%, respectively (10),(11). Similarly, the study by Memon S et al., conducted at Pakistan, noted the incidence of pancytopenia as 3.57%, and that by Jha A et al., conducted at Nepal mentioned it as 15.74% (13),(14). This variance in pancytopenia incidence can be explained by the fact that pancytopenia is caused by a variety of disease processes that vary by population, age, nutritional condition, and exposure to the environment. In the present study, out of 50 cases, 26 (52%) were females and 24 (48%) were males with the male to female ratio 1:1.08. A study done by Osama I et al., at Rawalpindi, Pakistan, found the male to female ratio to be 1.1:1 (15). Males had a higher incidence than females, according to Jalbani A et al., from Pakistan (16). Some other studies from India also found higher incidence in males (17),(18),(19),(20). Only in very few study like that by Raphael V et al., in India higher incidence in female could be seen (21). Male preponderance in prior research could be related to social/cultural taboos in society that make healthcare facilities more accessible to males than females, resulting in increased male presentation at hospitals, particularly in rural regions (10). Mean age of pancytopenia in the present study was 7.3 years. Gupta V et al., found mean age to be 8.6 years (22). In a study conducted in Kanpur by Dubey SRK et al., the average age of presentation was 10.63±4.60 years (10). Out of 22 cases of aplastic anaemia, 10 were older than 8 years. In the index study, most common cause was found to be aplastic anaemia (44%) and megaloblastic anaemia (30%). Megaloblastic anaemia (47 percent), aplastic anaemia (25.8%), and leukaemia (17.6%) were the most common causes of pancytopenia, according to a study from Uttar Pradesh (10). Another study from New Delhi reported that out of 109 children with pancytopenia, 31 (28.4%) had megaloblastic anaemia, followed by acute leukaemia (including ALL, AML, and myelodysplastic syndrome) and aplastic anaemia, which accounted for 21% and 20% of cases, respectively (7). Study done in Pakistan found aplastic anaemia as the commonest cause followed by hypersplenism. Megaloblastic anaemia was the third most common cause (16).

The most prevalent presenting symptom in this study was generalised weakness (which accounted for 100% of the cases), followed by fever (80%). Pallor (100%) was the most prevalent presenting sign, followed by glossitis (30%). Pallor was also the common presenting sign (81%), in a study done at Uttar Pradesh, which was followed by fever (68%) and petechial haemorrhages (51%) (10).

Fever (51.8%) and pallor (59%) were the most common symptoms in children with pancytopenia, according to another study conducted in Chandigarh, Punjab. Petechial rash and bleeding were also typical symptoms. Hepatomegaly was detected in 51.8% of cases while splenomegaly was seen in 37.4% (23).

In this study, pancytopenia was found more in low socio-economic status. This may be correlated with the fact that megaloblastic anaemia is associated with malnutrition which is more common in low socio-economic status. It is also seen in other studies that aplastic anaemia is linked with lower socio-economic status (24),(25). Lower socio-economic status, which is widespread in this population, is an indirect sign of higher exposure to environmental variables linked to aplastic anaemia pathogenesis (24). Low socio-economic status could be a proxy for one or more environmental conditions that can lead to aplastic anaemia, such as pathogenic infections or chemical exposures (25). In this study, pancytopenia was common among rural population than urban. Similarly, other studies also reported a rural predominance of aplastic anaemia (10),(26). But no proper explanation has been found for this finding. In this study predominance of patients from rural area may be a reflection of distribution of local population attending the hospital.

Pancytopenia is a haematological disorder that affects a large number of people. There is, however, a scarcity of information about the underlying causes of pancytopenia. Variations in the frequency of various aetiologies causing pancytopenia have been attributed to a variety of factors, including differences in diagnostic criteria, study period, laboratory investigations used, geographic area, genetic differences in the study population, and varying exposure to cytotoxic agents (17).

As a result, comparable studies including large sample sizes from different parts of the country should be promoted. This will go a long way toward establishing adequate clinical faculties for managing important diseases including aplastic anaemia and haematological malignancies. Such research will not only aid in a better understanding of the underlying illness processes that contribute to pancytopenia, but it will also aid in the better management for patients with pancytopenia.

Limitation(s)

However, because this is a cross-sectional observational study conducted in a referral tertiary care hospital, there is a risk of selection bias, and the exact causes of pancytopenia prevalent in the region may not have been reflected. As a result, the authors recommend that larger studies be conducted to determine the most common cause of pancytopenia in this area.

Conclusion

Pancytopenia is a common haematological disease in clinical practices, and it should be considered when a patient appears with unexplained anaemia, weight loss, splenomegaly, and a persistent fever. BMA is a useful diagnostic technique for determining the cause and severity of pancytopenia. Aplastic anaemia was the most common cause of pancytopenia in this study (44%), followed by megaloblastic anaemia (30%). Kala-azar (18%) was the primary cause of non haematological reasons. The current study shows that primary haematological examinations, as well as bone marrow examination, are beneficial in understanding the illness process and diagnosing the causes of pancytopenia in pancytopenia patients. This study also shows that kala-azar and megaloblastic anaemia should be considered in the differential diagnosis of pancytopenia. Clinicians, particularly primary care physicians and pathologists, should be aware of the many aetiology and morphological aspects of pancytopenia that can be found in this part of India. This knowledge can help to avoid not just delays in diagnosis, but also unneeded laboratory tests that could impair the patient’s health and wallet.

References

1.
Richard Lee G, Foster J, Lukens J, Paraskevas F, Greer LP, Rodgers GM. Wintrobe’s Clinical Hematology. 10th ed. Baltimore, Williams & Wilkins, 1993; Pp. 1449-84.
2.
Frank Firkin, Colin Chesterman, David Penington, Bryan Rush. De Gruchy’s clinical haematology in medical practice. 5th ed. Blackwell Science Ltd; 1997. pp. 119-121.
3.
Iqbal W, Hassan K, Ikram N, Nur S. Aetiological breakup of 208 cases pancytopenia. J Rawal med Coll. 2001;5(1):07-09.
4.
Niazi M, Raziq FI. The incidence of underlying pathology in pancytopenia- An experience of 89 cases. J Postgrad Med Inst. 2004;18(1):76-79.
5.
International Agranulocytosis and Aplastic Anaemia study group. Incidence of Aplastic Anaemia, the relevance of diagnostic criteria. Blood. 1987;79:1718-21.
6.
Keisu M, Ost A. Diagnosis in patients with severe pancytopenia suspected of having Aplastic Anaemia. Eur J Haematol. 1990;45:11-14. [crossref] [PubMed]
7.
Bhatnagar SK, Chandra J, Narayan S, Sharma S, Singh V, Dutta AK. Pancytopenia in children: Etiological profile. J Trop Pediatr. 2005;51(4):236-39. Doi: 10.1093/tropej/fmi010. Epub 2005 Jul 13. PMID: 160147664. [crossref] [PubMed]
8.
Vikram S, Mridu S, Shankar SP. Pancytopenia: Etiologies and manifestation in eastern India. IJRMS. 2017;5(12):5212-17. [crossref]
9.
Patil LY, Patil YV, D’Costa G, Valand A. Diagnostic utility of bone marrow aspiration and biopsy in paediatric age group. International Journal of Contemporary Medical Research. 2016;3(8):2310-13.
10.
Dubey SRK, Patel SK, Arya AK, Singh RP. Clinico-etiological spectrum of pancytopenia in hospitalized children. Int J Contemp Pediatr. 2016;3:16972. Doi: http://dx.doi.org/10.18203/2349-3291.ijcp20160153. [crossref]
11.
Chand R, Singh N. Clinic-etiological profile of pancytopenia in children: A tertiary care center based study of Kumaun region. Int J Contemp Pediatr. 2018;5:2173-77. [crossref]
12.
Shankar R, Arlappa N. An Updated Prasad’s Socio Economic Status Classification for 2013. International Journal of Research & Development of Health. 2013;1:26-28.
13.
Memon S, Shaikh S, Nizamani MA. Etiological spectrum of pancytopenia based on bone marrow examination in children. J Coll Physicians Surg Pak. 2008;18(3):163-67.
14.
Jha A, Sayami G, Adhikari RC, Patna AD, Jha R. Bone marrow examination in cases of pancytopenia, J Nepal Med Assoc. 2008;47(169):12. [crossref]
15.
Osama I, Baqai HZ, Faiz A, Nisar H. Patterns of pancytopenia patients in a general medical ward and a proposed diagnostic approach. J Ayub Med Coll Abbottabad. 2004;16:03-07.
16.
Jalbani A, Ansari IA, Chutto M, Gurbakhshani KM, Shah AH. Proportion of megaloblastic anaemia in 40 patients with pancytopenia at CMC hospital Larkana. Medical Channel. 2009;15:34-37.
17.
Tilak V, Jain R. Pancytopenia a clinico-hematologic analysis of 77 cases. Indian J Pathol Microbiol. 1999;42(4):399-404.
18.
Khunger JM, Arunselvi S, Sharma U, Ranga S, Talib VH. Pancytopenia a clinicohematological study of 200 cases. Indian J Pathol Microbiol. 2002,45:375-79.
19.
Jain A, Naniwadekar M. An etiological reappraisal of pancytopenia-largest series reported to date from a single tertiary care teaching hospital. BMC Hematol. 2013;13(1):10. [crossref] [PubMed]
20.
Kumar R, Kalra SP, Kumar H, Anand AC, Madan H. Pancytopenia-a six year study. J Assoc Physicians India. 2001;49:1078-81.
21.
Raphael V, Khonglah Y, Dey B, Gogoi P, Bhuyan A. Pancytopenia: An etiological profile. Turk J Hematol. 2012;29:80-81. 10.5505/tjh.2012.21704. [crossref] [PubMed]
22.
Gupta V, Tripathi S, Tilak V, Bhatia BD. A clinicohaematological profile of pancytopenia in children. Trop Doct. 2008;38:241-43. [crossref] [PubMed]
23.
Naseem S, Varma N, Das R, Ahluwalia J, Sachdeva MU, Marwaha RK. Pediatric patients with bicytopenia/pancytopenia: Review of etiologies and clinico- hematological profile at a tertiary center. Indian J Pathol Microbiol. 2011;54:75-80. [crossref] [PubMed]
24.
Malhotra P, Gella V, Guru Murthy GS, Varma N, Varma S. High incidence of aplastic anaemia is linked with lower socioeconomic status of Indian population. J Public Health (Oxf). 2016;38(2):223-28. Doi: 10.1093/pubmed/fdv027. Epub 2015 Mar 8. PMID: 25755247. [crossref] [PubMed]
25.
Issaragrisil S, Kaufman DW, Anderson TE, Chansung K, Thamprasit T, Sirijirachai J, et al. An association of aplastic anaemia in Thailand with low socioeconomic status. Aplastic Anaemia Study Group. Br J Haematol. 1995;91(1):80-84. Doi: 10.1111/j.1365-2141.1995.tb05248.x. PMID: 7577657. [crossref] [PubMed]
26.
Ahmed P, Chaudhry QUN, Satti TM, Mahmood SK, Ghafoor T, Shahbaz N, et al. Epidemiology of aplastic anaemia: A study of 1324 cases. Hematology. 2020;25(1):48-54. Doi: 10.1080/16078454.2019.1711344. PMID: 31906834. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/51595.16135

Date of Submission: Aug 07, 2021
Date of Peer Review: No 23, 2021
Date of Acceptance: Feb 04, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 11, 2021
• Manual Googling: Jan 27, 2022
• iThenticate Software: Feb 03, 2022 (11%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com