Trop Doct 2008;38:241-243
doi:10.1258/td.2008.070422
© 2008 Royal Society of Medicine Press
A study of clinico-haematological profiles of pancytopenia in children
V Gupta MD DNB *
S Tripathi MD *
V Tilak MD 
B D Bhatia MD FAMS *
* Department of Pediatrics;
Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India
Correspondence to: Dr Vineeta Gupta, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India Email: vineetaguptabhu{at}gmail.com
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SUMMARY
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We report on the clinico-haematological profile of pancytopenia
in children from the Departments of Pediatrics and Pathology,
Institute of Medical Sciences, Banaras Hindu University, India,
over a period of 30 months. Pancytopenia was defined as: haemoglobin
<10 g/dL, absolute neutrophil count 1.5
x 10
9/L and platelet
count <100
x 10
9/L. A detailed history, clinical examination
and haematological parameters were recorded. Bone marrow aspiration
and trephine biopsy were carried out in all cases. One hundred
and five cases aged 1.5–18 years, with a mean age of 8.6
years, were included in the study. Aplastic anaemia was the
most common cause of pancytopenia (43%) followed by acute leukaemia
(25%). Infections were the third most common cause of pancytopenia
of which
kala azar was the most common. Megaloblastic anaemia
was seen in 6.7%.
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Introduction
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Pancytopenia is a deficiency of all three cellular elements
of blood (red blood cells, white blood cells and platelets)
resulting in anaemia, leukopenia and thrombocytopenia. Depending
on the degree and duration of the impairment it can lead to
serious illness and death. While bone marrow failure syndromes
and malignancies are important causes, certain non-malignant
conditions such as infection and nutritional anaemia are equally
important causes.
Although there have been several studies of the aetiopathogenesis of pancytopenia in adults,1,2 there is a paucity of data on children. There has been no study from this region. The aim of this study was to document the clinico-haematological profile of children presenting with pancytopenia.
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Material and methods
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This prospective study was carried out in the Departments of
Pediatrics and Pathology, Institute of Medical Sciences, Banaras
Hindu University, India, from November 2004 to April 2007 over
a period of 30 months. All patients up to the age of 18 years
fulfilling the inclusion criteria who had been admitted to the
paediatric ward or were attending the paediatric outpatient
clinic were included in the study.
Pancytopenia was defined as haemoglobin (Hb) <10 g/dL, absolute neutrophil count (ANC) <1.5 x 109/L, platelet count <100 x 109/L. Detailed histories, clinical examinations and haematological parameters at presentation were recorded. Haematological parameters included Hb, total and differential leukocyte count, ANC, red cell indices and examination of peripheral smear. Bone marrow aspiration and trephine biopsies were carried out in all the cases. For the diagnosis of nutritional anaemia, serum iron, serum ferritin, vitamin B12 and folic acid levels were noted. The investigative workup was directed by the suspected underlying pathology. In cases of kala azar K39 antigen tests, splenic aspirates and cultures for Leishmania donovani bodies were carried out. Similarly, in other conditions such as typhoid, sepsis and TB appropriate tests were done to confirm the diagnosis.
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Results
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One hundred and five cases fulfilling the inclusion criteria
and with a definite diagnosis were studied for the aetiology
of pancytopenia. The ages ranged from 1.5 to 18 years with a
mean age of 8.6 years. There were 76 males and 29 females with
an overall male:female ratio of 2.6:1.
Table 1 shows the underlying cause of pancytopenia in the study group. Aplastic anaemia was the most common diagnosis accounting for almost 43% of cases, followed by acute leukaemia (25%). Among the infections, kala azar was the most common cause of pancytopenia. Other infections, such as enteric fever, malaria, sepsis and disseminated tuberculosis (TB), were less common. Interestingly, megaloblastic anaemia was a less common cause of pancytopenia accounting for 6.7% of cases. Myelodysplastic syndrome was the underlying pathology in 3.8%. There was one case each of neuroblastoma, non-Hodgkins lymphoma and tropical splenomegaly syndrome.
Fever and progressive pallor were the most common presenting
complaints being present in 81.4% followed by bleeding manifestations
in 72.9%.
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Discussion
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Pancytopenia is a feature of many serious and life-threatening
diseases. The pattern of diseases leading to pancytopenia may
vary in different population groups with their differences in
age pattern, nutritional status and the prevalence of infections.
In India, the causes of pancytopenia are not well defined. Most
cases reports are limited to adults.
1,2 Few of them have included
children.
3,4 In this study, aplastic anaemia was the most common
aetiology of pancytopenia. This is in contrast to another study
among children where megaloblastic anaemia was the most common
cause.
5
Aplastic anaemia was found to be the most common cause of pancytopenia in adults in reports by Kumar et al.1 (29.5%) and Varma and Dash2 (40.6%). However, some other studies have found megaloblastic anaemia to be the most common cause of pancytopenia in adults.3,4 In a study from Zimbabwe6 comprising 134 patients with pancytopenia, megaloblastic anaemia was the most common cause followed by aplastic anaemia and acute leukaemia. The authors of that report concluded that patients with aplastic anaemia and acute leukaemia were mostly children and those with megaloblastic anaemia were adults. These findings are similar to those reported in our study.
Kala azar was also found to be an important cause of pancytopenia in our study. Our hospital, being a tertiary care referral centre, receives a large number of patients from the neighbouring state of Bihar which is an endemic area for kala azar. This may be the reason for the large number of patients presenting as having pancytopenia (9.5%). The haematological changes were reversed after the institution of appropriate therapy with parenteral sodium antimony gluconate or amphotericin B. In an earlier study,5 kala azar accounted for only 4% of the cases.
Enteric fever and malaria were each responsible for 2.9% of the cases. Varying degrees of cytopenias have been reported in other series of enteric fever.7 There were three cases of malaria in this series, all with Plasmodium falciparum infection, which had pancytopenia at the time of presentation. Pancytopenia due to falciparum infection has been reported also previously8 when it accounted for a large number of cases. Myelodyspastic syndrome caused pancytopenia in four patients (3.8%). All were >6 years of age and two were >12 years of age. Sepsis and disseminated TB were responsible for a small number of cases. Both the patients had Gram-negative sepsis and all the three cell lines were affected. Sepsis leading to pancytopenia has occasionally been reported in the literature.9 Disseminated TB is an uncommon cause of pancytopenia, but has been previously reported.10
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Conclusion
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Aplastic anaemia and acute leukaemia were found to be the most
common causes of pancytopenia in this series.
Kala azar was
also found to be an important cause in this region. Megaloblastic
anaemia was a less common cause.
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References
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- Kumar R, Kabra SP, Kumar H, Anand AC, Madan H. Pancytopenia – a six year study. J Assoc Phys India 2001;49:1078–81
- Varma N, Dash S. A reappraisal of underlying pathology in adult patients presenting with pancytopenia. Trop Geogr Med 1992;44:322–27[Medline]
- Tilak V, Raini J. Pancytopenia – a clinico-hematologic analysis of 77 cases. Indian J Pathol Microbiol 1999;42:399–404[Medline]
- Khunger JM, Arunsehi S, Sharma V, Ranger S, Talib VH. Pancytopenia – a clinico-hematologic study of 200 cases. Indian J Pathol Microbiol 2002;45:375–9[Medline]
- Bhatnagar SK, Chandra J, Narayan S, Sharma S, Singh V, Dutta AK. Pancytopenia in children: etiological profile. J Trop Pediatr 2005;51:236–9
- Savage DG, Allen RH, Gangaidzo IT, et al. Pancytopenia in Zimbabwe. Am J Med Sci 1999;317:22–31[Medline]
- James J, Dutta TK, Jayanthi S. Correlation of clinical and haematologic profiles with bone marrow responses in typhoid fever. Am J Trop Med Hyg 1997;57:313–6[Abstract/Free Full Text]
- Arya TVS, Prasad RN. Fatal pancytopenia in falciparum malaria. J Assoc Phys India 1989;37:469–70
- Garewal G, Marwaha N, Marwaha RK, Das KC. Bone marrow necrosis and pancytopenia associated with gram-negative septicemia. Indian Pediatr 1991;28:79–81[Medline]
- Glasser RM, Walker RI, Hewrion JC. The significance of hematologic abnormalities in patients with tuberculosis. Arch Intern Med 1970;125:691–5[Abstract/Free Full Text]
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SUMMARY
Introduction
