Dengue Fever and Malaria in Thrombocytopenic Patients

Frequency of co-existence of dengue fever and malaria in thrombocytopenic patients presented with acute febrile illness

Dr. Shazia Yasir*, Dr. Muhammad Owais Rashid, Dr. Faisal Moin, Dr. Komal Owais

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ABSTRACT

Introduction: Hepatitis c virus infection affects more than 170 million people worldwide. [1] About 80% of patients with acute infection will afterward develop chronic disease. [15] Interferon (IFN) alpha in combination with ribavirin (RBV) is the current standard care of treatment of chronic hepatitis C virus infection worldwide. Unfortunately, both drugs have significant hematological toxic effects (anemia, neutropenia and thrombocytopenia)

Objectives: To determine the frequency of hematological side effects (anemia, neutropenia and thrombocytopenia) during combination therapy with interferon and ribavirin in chronic hepatitis C patients.

Study Design: Cross-sectional, observational study.

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Place and Duration of Study: Department of Emergency Medicine, Ziauddin University Hospital, Karachi from Ten months from April 2013 to January 2014.

Methodology: A total of 228 patients of chronic HCV, and meeting inclusion criteria were included from OPD of Ziauddin Hospital North Campus Karachi, Sarwar Zuberi Liver Centre and Hepatogastroenterology Section, SIUT. After taking informed consent, patients were given injection IFN 3 MIU subcutaneously thrice weekly and ribavirin 800 – 1200 mg/day, as per body weight, that was, those less than 50 kg will receive 800 mg/day, 50 – 75 kg was received 1000 mg/kg and more than 75 kg was received 1200 mg/day.

Result: Overall mean age was 39.6 (±9.2) years with Male: Female = 2.2: 1. Hematological abnormalities was seen in 79 (37.3%) cases. Anemia was the most common type of hematological abnormalities developed in 41 (19.3%) cases followed by neutropenia in 33 (15.6%) and thrombocytopenia in 21 (9.9%) cases.

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Conclusion: Amongst the hematological disorders. Anemia and thrombocytopenia was the most common and least common respectively during the combination therapy of chronic hepatitis C. while neutropenia followed as second common and serious hematological disorder.

Key words: HCV, anemia, neutropenia, thrombocytopenia, Interferon, ribavirin. _____________________________________________________________________________________________

INTRODUCTION

Hepatitis C Virus (HCV) infection is a global health problem. The virus infects approximately 3% of the world population; placing approximately 170 million people at risk of developing HCV related chronic liver disease. [1] Currently, chronic hepatitis C infection is the most frequent indication for liver transplantation and accounts for estimated 8000 – 10000 deaths each year in the United States. [2] HCV infection is endemic in Pakistan [3] and is a considerable threat to our population. [4] The prevalence of HCV in Pakistan is reported to be 3.29% [3], 3.3% [4] and 3.69% [5] in different studies. Cure of chronic hepatitis C in the natural course is rare, and the rate of progression to cirrhosis and hepatocellular carcinoma is also significantly high. The eradication of hepatitis C virus during the chronic stage is, therefore, extremely important. [6]

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Department of Emergency Medicine, Ziauddin University Hospital, North Campus, Karachi

* Correspondence Email: [email protected]

Treatment with pegylated interferon plus ribavirin has become the standard of care for patients infected with chronic hepatitis C. [7] However, standard interferon and ribavirin combination is still widely in use in Pakistan for chronic hepatitis C infection, because of its low cost. Unfortunately, both drugs (interferon and ribavirin) have significant hematological toxic effects (anemia, neutropenia and thrombocytopenia). [8,9,10]

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Anemia during combination therapy for chronic hepatitis C begins to develop almost immediately after therapy is initiated and becomes most pronounced after 4 to 6 weeks of treatment.8 Hemoglobin levels do not usually change after week 12 to the completion of treatment. [6] The values for incidence and severity of anemia during combination therapy for chronic hepatitis C are higher in Asian studies than in the non-Asian studies. In a study conducted in Taiwan, the mean decrease of hemoglobin was 3.9 ± 1.3 g/dL and 39% of the patients developed severe anemia (hemoglobin levels below 10 g/dL). [9]

Treatment with interferon and ribavirin combination therapy is also associated with neutropenia that is more frequent with peg interferon as compared to standard interferon. [11] A study from the National Institutes of Health specifically examined neutropenia associated with combination therapy. The mean neutrophil count decreased by 34% during the 24 to 48 week course of therapy and the frequency of neutropenia was noted to be 63%. [12]

Thrombocytopenia is another well known complication of antiviral therapy for chronic hepatitis C but has been infrequently associated with dose reduction or discontinuation. [11] During therapy with at least one dose of standard or pegylated interferon, platelet count decreased by nearly 28%. [13] Few studies have been conducted in Pakistan to assess the side effects of combination therapy in chronic hepatitis C. The frequency of anemia is reported to be 19.6% and of thrombocytopenia to be 13.7% in one study. [14] Another study stated that hematological side effects were noted in 92% of the patients. [10] No local study is available reporting the frequency of neutropenia during treatment for chronic hepatitis C.

Hematological abnormalities are the most common indications for dose reduction in chronic hepatitis C therapy. Hematological abnormalities accounts for at least one dose reduction in approximately 25% of patients during therapy. Dose reductions or premature discontinuations results in significantly lower sustained virological response. [11] Because hematological side effects have implications on virological response, therefore, knowledge regarding frequency of these side effects is of utmost importance. As stated earlier, there are very few trials conducted in Pakistan that examined the hematological side effects of combination therapy and most of the data in this regard have come from western population. Pakistani population is different from western population in many ways, for example, the HCV genotype 1 infection is more common in west while genotype 3 infection in Pakistan. Moreover, host factors like different genetic makeup, difference in immune status and lower body mass index (resulting in lesser dose of ribavirin required during therapy) for Pakistani population may have implications on frequency of the hematological side effects of combination therapy. In addition, there is an enormous difference in the frequencies of side effects reported in different studies conducted at national level. Therefore, there is a need to add-to and strengthen the national literature. This study was designed to determine the frequency of the hematological side effects of combination therapy (interferon and ribavirin) in patients with chronic hepatitis C.

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METHODOLOGY

The study was planned to be conducted on patients attending the out-patient department of Civil Hospital Karachi, Sarwer Zuberi Liver Centre and Hepatogastroenterology Section, Sindh Institute of Urology and Transplantation.

Sample size ( n ) = 182 + 25% of 182 = 228*

Proportion of thrombocytopenia ( P ) = 13.7%14 or 0.137

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Confidence level (1 – α ) = 0.05

Margin of error (d ) = 5%

* A meta-analysis noted that during treatment for chronic hepatitis C approximately 25% of patients required at least one dose reduction for hematological abnormalities (anemia, neutropenia and thrombocytopenia) [11], therefore the sample size is augmented by 25% to cover the drop-outs because of dose reduction and drug discontinuation. Patients who will require dose reduction and drug discontinuation will be excluded from the study. The criteria for dose reduction and drug discontinuation are stated in data collection.

Inclusion Criteria:

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Patients of either gender with chronic hepatitis C:

• Between the age of 18 and 50 years,
• Presence of anti – HCV, HCV – RNA and persistently raised ALT levels for more than 6 months (on at least two occasions).
• HCV Genotype 2 and 3; and
• Compensated liver disease (indicated by presence of all of the following: no history of ascites, bleeding esophageal varices or hepatic encephalopathy, serum albumin > 3 g/dL, serum bilirubin ≤ 2 mg/dl and prothrombin time < 3 seconds prolonged)

Exclusion Criteria:

Patients with:

• Decompensated liver disease
• HCV Genotype 1 (Infection with HCV Genotype 1 requires combination therapy for 48 weeks. The study is planned to be completed in 6 months.)
• Co-infection with HBV
• Pregnancy,
• Significant systemic illnesses other than liver disease (cardiovascular or renal dysfunction, chronic obstructive pulmonary disease, uncontrolled diabetes)
• Other contra-indications or precautions to combination therapy (history of epilepsy, depression or other psychiatric disorders, thyroid dysfunction, autoimmune hepatitis)
• Interferon/ribavirin therapy in the past
• Pre-treatment hemoglobin level less than 13 g/dL in males and less than 12 g/dL in females, pre-treatment neutrophil count less than 1500 cells/μL and platelet count less than 150,000 cells/μL
• Who require dose reduction or drug discontinuation during treatment. Criteria are mentioned in data collection.

The source of the sample was the patients attending the out-patient department of Civil Hospital Karachi, Sarwar Zuberi Liver Centre and Hepatogastroenterology Section, Sindh Institute of Urology and Transplantation. Informed consent was taken from the patients who were meet the inclusion and exclusion criteria and the patients were given injection IFN 3 MIU subcutaneously thrice weekly and ribavirin 800 – 1200 mg/day, as per body weight, that was, those less than 50 kg will receive 800 mg/day, 50 – 75 kg was received 1000 mg/kg and more than 75 kg was received 1200 mg/day. The patients were evaluated at week 4, 12 and 24 and blood was drawn for complete blood counts. Dose of the interferon and/or ribavarin was reduced for any patient in whom hemoglobin level falls below 10 g/dL and/or neutrophil count drops below 750 cells/μL and/or platelet count falls below 50,000 cells/μL during the course of treatment. The therapy was discontinued in the patients in whom hemoglobin level drops below 8.5 g/dL and/or neutrophil count falls below 500 cells/μL and/or platelet count falls below 30,000 cells/μL. These criteria for dose reduction and drug discontinuation were in accordance with the guidelines for treatment of chronic hepatitis C. The patients who were required dose reduction or drug discontinuation during the course of treatment was excluded from the study. The final outcome was measured at week 24, when the values for hemoglobin level, neutrophil count and platelet count was recorded for each patient in the performa given in annex 1. The patient was said to have developed anemia if the hemoglobin level falls below 13 g/dL in males and less than 12 g/dL in females, neutropenia if neutrophil count drops below 1500 cells/μL and thrombocytopenia if platelet count falls below 1,50,000 cells/μL. Confounding variables like age, gender and body weight were controlled by stratification at the time of analysis.

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The collected data was analyzed with the help of SPSS program version 19.0. Frequencies and percentages were computed for presentation of qualitative variables like gender and side effects (anemia, neutropenia and thrombocytopenia). Mean ± Standard Deviation was computed for variables like age and body weight. Confounding variables like age, gender and body weight were controlled by stratification.

RESULT

A total of 228 patients with chronic hepatitis C were included in this study. Sixteen (7.02%) of the patients were excluded due to dose modification or discontinuation during the follow-up period. Due to anemia dose was reduced in 6 and discontinued in 4 cases, due to neutropenia dose was reduced in 3 and discontinued in 1 case and in thrombocytopenia dose was reduced in 2 cases.

Mean (±SD) age of patients was 39.6 (±9.2) years with range = 18 – 50 years. Majority of cases 113 (53.3%) had age between 20 – 40 years. Figure-1

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Gender distribution showed male preponderance (male: female = 2.2: 1), 145 (68.4%) were males and 67 (31.6%) were females. Figure-2

Seventy Nine (37.3%) of the patients developed significant hematological abnormalities during treatment with interferon and ribavirin. Figure-3

Anemia was the most common type of hematological abnormalities developed in 41 (19.3%) cases followed by neutropenia in 33 (15.6%) cases and thrombocytopenia in 21 (9.9%) cases. Figure-4

Proportions of hematological abnormalities were similar in both genders. Fifty five (37.9%) were male and 24 (35.8%) were female. Figure-5

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Types of hematological abnormalities were also similar in both males and females, 29 (52.7%), 23 (41.8%) and 15 (27.3%) of males and 12 (50%), 10 (41.7%) and 6 (25%) of females developed anemia, neutropenia, and thrombocytopenia, respectively in male cases. Table-1

Mean (±SD) age of those patients who developed hematological side effects was 38.4 (±8.6) years with range = 19 – 50 years. Majority of cases 56 (62.2%) had age between 20 – 40 years. Figure-6

FIGURE-1

AGE DISTRIBUTION

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n = 228

Mean ±SD = 39.6 ±9.2 years

Range = 18 – 50 years

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FIGURE-2

GENDER DISTRIBUTION

n = 228

Male: Female = 2.2: 1

FIGURE-3

OVERALL HEMATOLOGICAL SIDE EFFECTS (SE)

n = 212

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Keys: hematological side effects were evaluated in this study as:

Anemia = hemoglobin level 10 – 13 g/dL in males and 10 – 12 g/dL in females.

Neutropenia = Neutrophil count between 750 – 1500 cells/μL.

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Thrombocytopenia = Platelet count of between 50,000 – 1, 50,000 cells/μL.

SE = Side Effects

FIGURE-4

TYPES OF HEMATOLOGICAL SIDE EFFECTS (SE)

n = 212

^{Multiple response exist}

Keys:

Anemia = hemoglobin level 10 – 13 g/dL in males and 10 – 12 g/dL in females.

Neutropenia = Neutrophil count between 1500 – 750 cells/μL.

Thrombocytopenia = Platelet count of between 1,50,000 – 50000 cells/μL.

SE = Side Effects

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FIGURE-5

OVERALL HEMATOLOGICAL SIDE EFFECTS (SE) IN GENDER

n = 212

Table-1

TYPES OF HEMATOLOGICAL SIDE EFFECTS (SE) IN GENDER

n = 212

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Types of Side Effects	Male	Female
Anemia	29 (52.7%)	12 (50%)
Neutropenia	23 (41.8%)	10 (41.7%) How Do You Manage Big Projects? We tackle each chunk with precision, keeping quality consistent and deadlines on track from start to finish. Whether it’s a dissertation or a multi-part essay, we stay in sync with you, delivering top-notch work every step of the way.
Thrombocytopenia	15 (27.3%)	6 (25%)
Multiple Effects	12 (21.8%) Do You Follow Global Academic Rules? Yes—we’ve got it down! Our writers switch seamlessly between UK, US, Australian, or any other standards, matching your school’s exact expectations. Your paper will feel native to your system, polished and ready for wherever you’re studying.	4 (16.7%)

Keys:

Anemia = hemoglobin level 10 – 13 g/dL in males and 10 – 12 g/dL in females.

Neutropenia = Neutrophil count between 750 – 1500 cells/μL.

Thrombocytopenia = Platelet count of between 50,000 – 150000 cells/μL.

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FIGURE-6

OVERALL HEMATOLOGICAL SIDE EFFECTS (SE) IN AGE GROUPS

n = 212

Mean ±SD = 38.4 ±8.6 years

Range = 19 – 50 years

DISCUSSION

The treatment of CHC is now well established with conventional interferon or pegylated interferon in combination with ribavirin. [61] However, one of the main drawbacks of this combination therapy is the development of side effects, which can result in suboptimal dosing or discontinuation of therapy. This can limit the likelihood of SVR, since one of the determinants of SVR is adequate dose and duration of therapy, as previously discussed in this supplement. Among the side effects of combination therapy, hematologic abnormalities such as anemia, neutropenia, and thrombocytopenia have been reported to result in dose reduction and discontinuation of therapy in up to 25% and 3% of patients, respectively. [11]

The withdrawal rate increases with both the duration of treatment and use of combination therapy. [101] For example, therapy was stopped in 13–14% of patients treated with interferon mono therapy for 48 weeks [102] compared with 19–21% of patients receiving combination therapy for the same duration. The withdrawal rate for combination therapy was lower when therapy was administered for only 24 weeks (8%). [103] Mean (±SD) age of patients was 39.6 (±9.2) years with range = 18 – 50 years.

In this study seventy Nine, 37.3% of the patients developed significant hematological abnormalities during treatment with interferon and ribavirin and Sixteen (7.02%) of the patients were excluded due to drug modification or discontinuation during the follow-up period. A study from USA reported 38.2% of the cases developed hematological side effects during the combination therapy, a figure is similar to what is seen in this study.104 Another study conducted in Pakistan reported 92% mild to moderate hematological side effect during the combination therapy. [10]

In this study anemia was the most common type of hematological abnormality seen in 19.3% of cases followed by neutropenia in 15.6% and thrombocytopenia in 9.9% cases. Study from USA reported 20.6%, 22.1%, and 8.1% developed neutropenia, anemia, and thrombocytopenia, respectively. [104] In another study from Pakistan, mild to modest anemia was noted in 70 % of the patients. [10] Anemia is caused both by interferon due to myeloseupression and ribivirin causing hemolysis. [24, 25] In same study mild to moderate neutropenia was reported in 64% of cases and thrombocytopenia in 61% of patients. [10] neutropenia is one of the expected side effects of combination therapy but the risk of the serious infection is very low even with severe neutropenia. [12] Similarly in clinically practice thrombocytopenia does not pose significant problem. [11]

In conclusion hematologic abnormalities are common during combination antiviral therapy for chronic hepatitis C. Although dose reduction or discontinuation is tool of overcome these side effects, they can adversely affect the efficacy of combination antiviral therapy. This is especially true in the cases of ribavirin induced anemia. Recent evidence has led to increasing recognition that optimal dosing of ribavirin is a crucial determinant of viral clearance. Preliminary data suggest that hematopoietic growth factors may be useful for managing the hematologic side effects of combination therapy (especially anemia).

CONCLUSION

The frequency of hematological abnormalities during the treatment of chronic hepatitis C (HCV) in this study was comparable to those seen in certain other studies. Anemia was the most common and thrombocytopenia was the least common hematological side effect noted. The number of patients excluded from the study because of dose modification or drug discontinuation was also greatest due to anemia and least due to thrombocytopenia

ACKNOWLEDGEMENT

We would like to acknowledge faculty of Ziauddin Hospital, North Campus for helping us during the study, staff for helping in data collection and all others who have given their input.

SOURCE OF FUNDINGS

We would like to thank HighQ pharma for financially aiding the research and authors for their contribution.

CONFLICT OF INTEREST

There is no conflict of interest in any term regarding the article from any authors.

REFERENCE

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