PaJR Case Reports: 21M Fever, Thrombocytopenia Telangana PaJR.

18-08-2025

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[18-08-2025 11:53] PPM 3: 21/M

1. COMPLAINTS AND DURATION

C/o fever since 7 days

Vomiting since 3 days

Cough since 2 days

2. HISTORY OF PRESENT ILLNESS

Patient was apparently normal 7 days back then he developed fever; insidious in onset, high grade, associated with chills & rigors.

H/o diurnal variation (↑ at night). Vomiting – 8–9 episodes/day, non-bilious, non-blood stained, containing food particles.

Cough – non-productive, h/o diurnal variation (↑ at night).

No h/o hemoptysis. No h/o hemetemesis

3. HISTORY OF PAST ILLNESS

No h/o DM, HTN, CVA, CAD, TB, Epilepsy, Thyroid illness

[18-08-2025 11:57] PPM 3: After test dose of injection monocef was given, he developed a swelling right forearm, and a swelling at left arm (after pricking for sample)

On 14/8/25 he developed petechiae over the chest

On 15/8/25

SDP transfusion was done.

[18-08-2025 10:09] PPM 1: @PPM3 please share more about this patient.

Begin with an image of his fever chart, serial hemogram and platelets and history

[18-08-2025 10:10] PPM 3: Ok sir, sharing in sometime.

[18-08-2025 11:31] PPM 1: Thanks. This needs to be updated and deleted because the patient identifiers are visible

[18-08-2025 11:31] PPM 1: Appears to have recovered from his dengue

[18-08-2025 11:32] PPM 3: Sorry about that sir

[18-08-2025 11:32] PPM 3: Yes sir, but he developed another complication meanwhile

Sharing Everything in detail soon

[18-08-2025 11:50] PPM 1: Today is 18th. The chart shows till 15?

[18-08-2025 11:51] PPM 3: He stopped having fever spikes, only 1 episode at presentation

[18-08-2025 11:57] PPM 3: Has reached to this stage

[18-08-2025 12:08] PPM 1: Fever charting needs to show that the fever is absent, and hence charting needs to continue.

The chart also serves as an important patient timeline for other data such as daily platelet count

Check out PPM4's work here when he was a PG: https://durgakrishna09.blogspot.com/2023/08/graphical-patient-timeline-in-soap.html?m=1

[18-08-2025 12:14] PPM 3: Alright sir, I'll complete it

[18-08-2025 12:14] PPM 3: I wrote the platelets here though

[18-08-2025 12:15] PPM 1: Could be classified as minor bleeding and didn't warrant sdp transfusion!

Here's an elegant study from Malaysia which should have put a stop to this practice but clearly the evidence doesn't percolate although we journal clubbed it: https://pubmed.ncbi.nlm.nih.gov/28283286/

[18-08-2025 12:16] PPM 3: This was not the bleeding

[18-08-2025 12:16] PPM 3: He had petechiae on the chest

[18-08-2025 12:16] PPM 1: Helps to see everything at a single glance in one fever chart timeline

[18-08-2025 12:17] PPM 3: Ok sir,will update now👍🏻

[18-08-2025 12:17] PPM 1: All skin bleeds are same.

[18-08-2025 12:23] PPM 3: He didn't have the ecchymosis then

[18-08-2025 12:37] PPM 1: Petechiae is the same skin bleed pinpoint and less than 5 mm and echymosis is more than that

[18-08-2025 12:40] PPM 3: I meant on 14 he just had a swelling not a ecchymosis

[18-08-2025 12:40] PPM 3: He did have petechiae though

[18-08-2025 12:40] PPM 3: On chest

[18-08-2025 12:40] PPM 3: But I understand now

[18-08-2025 12:40] PPM 3: Anything doesn't warrant for sdp transfusion

[18-08-2025 12:41] PPM 3: No unfortunately didn't take that picture

[18-08-2025 12:41] PPM 1: Major or moderate bleed would warrant

[18-08-2025 12:41] PPM 3: By anything I meant the ecchymosis or petechiae

[18-08-2025 12:46] PPM 1: Recruited patients aged at least 21 years who had laboratory-confirmed dengue (confirmed or probable) and thrombocytopenia (≤20 000 platelets per μL), without persistent mild bleeding or any severe bleeding

The primary endpoint was clinical bleeding (excluding petechiae)

https://pubmed.ncbi.nlm.nih.gov/28283286/

[20-08-2025 12:46] PA: Pain undhi

[20-08-2025 12:53] PPM 1: @PPM5 can you ask him to show with a pointer where exactly is the pain?

[20-08-2025 12:54] PA: Ok

[20-08-2025 12:55] PPM 5: pain ekkada undho akkada velu 👆🏽 petti photo pampandi

[21-08-2025 12.24] PPM 3: @PA ela vunnaru

[23-08-2025 12.29] PPM 3:

[23-08-2025 12:36] PPM 1: @PPM6 @PPM5@Meta AI the above are serial images of a patient with dengue thrombocytopenia driven bruising of the forearm. What are the known colour changes in bruising day wise before it recovers fully?

[23-08-2025 12:36] Meta AI: There was a problem generating a response. Please try again later.

[23-08-2025 12:40] PPM 6: Of course. The serial images show a classic presentation of bruising (ecchymosis) in a patient with dengue fever, directly resulting from thrombocytopenia (low platelet count). The color evolution of a bruise is a visual record of the body's complex process of breaking down and reabsorbing escaped blood from damaged capillaries.

Here is a detailed, day-wise breakdown of the known color changes in bruising before it fully recovers, with specific considerations for dengue fever:

The Science Behind the Colors

The changing colors of a bruise are essentially a "biological flowchart" of hemoglobin breakdown occurring in the subcutaneous tissue. Thrombocytopenia in dengue accelerates the initial bleeding and can prolong this process, often making the bruising more pronounced and widespread than a standard bruise from trauma.

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🗓 Day-by-Day Progression of Bruise Coloration

Here is a visual summary of the typical timeline for bruise healing, followed by a detailed explanation of each phase:

mermaid

timeline

title Typical Bruise Healing Timeline

section Initial Phase (Days 0-2)

Red/Red-Purple : Bruise forms due to blood<br>leaking under the skin.

section Early Breakdown (Days 2-5)

Blue/Dark Purple : Deoxygenation of hemoglobin.

Green : Biliverdin formation.

section Late Breakdown (Days 5-7)

Yellow/Golden : Conversion to bilirubin.

section Resolution (Days 7-14+)

Brown/Fading : Reabsorption of byproducts.

Fully Faded : Complete healing.

Phase 1: Initial Bruise Formation (Days 0-2)

· Colors: Red, Red-Purple

· Physiology: Immediately after the capillary leak, oxygen-rich hemoglobin in the blood gives the bruise its initial red hue. In dengue patients, due to significant thrombocytopenia and potential coagulopathy, this initial leakage can be more extensive, leading to a larger and more visibly intense bruise that appears quickly .

· Dengue Context: This phase aligns with the late febrile phase or the transition to the critical phase, precisely when platelet counts are dropping precipitously and hemoconcentration may occur .

Phase 2: Early Hemoglobin Breakdown (Days 2-5)

· Colors: Blue, Dark Purple, then Green

· Physiology: As oxygen is depleted from the pooled blood, hemoglobin becomes deoxygenated, turning the bruise a bluish or dark purple color. Around days 3-5, the enzyme heme oxygenase begins breaking down hemoglobin into biliverdin, a green pigment. The presence of a green hue is a clear sign the healing process has begun.

· Dengue Context: This color evolution typically occurs during the critical phase of dengue. The stability of the patient's overall condition (e.g., avoiding shock) is the primary concern during this time. The bruise's progression is a secondary but visible sign of the underlying pathophysiology.

Phase 3: Late Breakdown and Reabsorption (Days 5-10)

· Colors: Yellow, Golden-Brown

· Physiology: Biliverdin is rapidly converted to bilirubin, which has a yellow pigment. This is why the bruise takes on a yellowish or golden-brown appearance. This stage is often colloquially called "yellowing." The body's macrophages (white blood cells) are now actively clearing these cellular debris.

· Dengue Context: This phase corresponds with the recovery phase of dengue. The patient's overall condition improves, appetite returns, and most importantly, the platelet count begins to rise as plasma leakage subsides . The sight of yellowing, while seemingly dramatic, is a normal and expected step toward resolution.

Phase 4: Resolution (Days 10-14+)

· Colors: Fading Yellow-Brown to Imperceptible

· Physiology: The yellowish-brown color continues to fade as the body completes the reabsorption process. The skin gradually returns to its normal color. The entire process can take up to two weeks or longer, especially if the initial bruise was very large or if the patient has ongoing thrombocytopenia.

· Dengue Context: By this stage, the patient is usually in full recovery. Platelet counts have normalized, and other symptoms have resolved. The fading bruise is a residual marker of the recent illness.

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Dengue-Specific Considerations & Important Notes

1. Variable Timeline: The exact timeline can vary based on several factors:

· Severity of Thrombocytopenia: The lower and longer the platelet drop, the more pronounced the bruising may be and the longer it may take to resolve .

· Individual Physiology: Age, skin tone, and the specific location on the body can influence the appearance and duration of a bruise.

· Size and Depth: Larger and deeper bruises will take longer to resolve completely.

2. Not a Sole Indicator of Severity: While bruising indicates low platelets, it is not the primary marker for severe dengue. The critical complication to monitor for is plasma leakage, which leads to shock. A patient with mild bruising can develop severe dengue, while a patient with dramatic bruising might have an uncomplicated recovery if their plasma leakage is minimal .

3. When to Seek Immediate Medical Attention: For a dengue patient, the bruise itself is less concerning than the systemic warning signs. Immediate medical attention is required if the bruising is accompanied by:

· Any signs of active bleeding (e.g., gum bleeding, nosebleeds, black stools, vomiting blood) .

· Severe abdominal pain and persistent vomiting.

· Cold, clammy skin, restlessness, or lethargy (signs of impeding shock).

· Difficulty breathing (a sign of pleural effusion from plasma leakage) .

In summary, the serial images vividly capture the body's natural healing process unfolding in the context of a dengue infection. The progression from red/purple → green → yellow → resolved is a classic sign of hemoglobin breakdown and is generally a self-limiting process that completes as the patient recovers and platelet counts regenerate.

[23-08-2025 12:47] PPM 5: Look like we are in blue-purple stage sir @PPM1Sir @PPM6