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Has history of gingival localized bleeding from 4 days
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Clinical Analysis: Ramesh Chaudhary, 44Y Male - Localized Gingival Bleeding x 4 days
Consolidated Lab Findings (from two separate reports - UCMS 18-Jul-2026 & SIAS 16-Jul-2026)
| Parameter | UCMS Result | SIAS Result | Reference Range | Flag |
|---|---|---|---|---|
| Haemoglobin | 13.0 g/dL | 13.0 g/dL | 13-16 g/dL | Normal |
| WBC Count | 4800 | 5580 cells/cumm | 4000-11000 | Normal |
| Platelet Count | 101,000 | 1.45 lakh (145,000) | 150,000-450,000 | LOW |
| RBC Count | 5.4 million/cumm | 5.51 million/cumm | 3.8-5.8 | Normal |
| PCV/HCT | 42.5% | 41.5% | 36-46% | Normal |
| MCV | 78.3 fL | 75.4 fL | 83-101 fL | LOW |
| MCH | 23.9 pg | 23.6 pg | 27-32 pg | LOW |
| MCHC | 30.6% | 31.3% | 31.5-34.5% | Low-borderline |
| RDW | - | 16.0% | 11.0-16.0% | Upper-borderline |
| Eosinophils | 8% | - | 2-6% | HIGH |
| PT | - | 19.6 sec | - | (INR 1.49 - mildly elevated) |
Serology/Microbiology (SIAS): HCV Non-reactive, HIV I & II Non-reactive, HBsAg Non-reactive
LFT (SIAS): Total Bilirubin 0.7 mg/dL, Direct Bilirubin 0.2 mg/dL, SGOT 71 IU/L (mildly elevated), SGPT 114 IU/L (mildly elevated), ALP 133 IU/L, Albumin 4.2 g/dL, Total Protein 6.8 g/dL
Renal Function (SIAS): RBS 112 mg/dL (borderline), Creatinine 0.7, Sodium 136, Potassium 3.6 - all normal
Key Abnormalities Summary
1. Thrombocytopenia (Moderate)
- UCMS: 101,000/cumm; SIAS (2 days prior): 145,000/cumm
- The platelet count has dropped by ~44,000 in 2 days - this is a dynamic, worsening thrombocytopenia
- This directly explains the gingival bleeding (mucosal/"wet" bleeding is characteristic of platelet disorders)
- Platelet count < 100,000 = thrombocytopenia; the UCMS value is now crossing below 100,000
2. Microcytic Hypochromic Pattern
- MCV 75-78 fL (low), MCH 23-24 pg (low), MCHC 30-31% (borderline-low)
- RDW elevated at 16% (upper limit) - suggests anisocytosis
- Despite normal Hb (13 g/dL), this pattern suggests underlying iron deficiency or thalassemia trait
- Note: Hb is maintained but indices suggest iron-depleted erythropoiesis
3. Mildly Elevated INR (1.49) / Prolonged PT (19.6 sec)
- Suggests some coagulopathy beyond just platelets - could be mild liver dysfunction
- Supported by elevated SGOT (71, ref 0-45) and SGPT (114, ref 0-45)
4. Mild Transaminitis
- SGOT 71, SGPT 114 - mildly elevated (about 2-2.5x upper limit of normal)
- This is an important finding in the context of thrombocytopenia in a patient from Nepal
5. Eosinophilia (8%)
- Mild eosinophilia - raises question of parasitic infection or allergic process
Differential Diagnosis (Most to Least Likely)
Given the geographic context (Nepal/Dang district), fever workup implied, mildly elevated LFTs, and falling platelet count:
1. Dengue Fever (Most likely)
- Thrombocytopenia + elevated transaminases (SGOT/SGPT) + trend of falling platelets = classic dengue
- Dengue causes platelet counts < 100,000 in ~50% of patients; gingival bleeding is a hemorrhagic manifestation (Grade I-II dengue hemorrhagic fever)
- Nepal is endemic for dengue; July is peak monsoon season = peak dengue season
- The fall from 1.45 lakh → 1.01 lakh over 2 days is typical dengue kinetics
- NS1 antigen / Dengue IgM/IgG not yet sent - this is a critical missing test
2. Immune Thrombocytopenic Purpura (ITP)
- Isolated thrombocytopenia with normal WBC, normal Hb
- However, transaminitis and rapidly falling counts argue against pure ITP
- Cannot be excluded - a diagnosis of exclusion
3. Viral Hepatitis-associated Thrombocytopenia
- HBsAg, HCV, HIV are all non-reactive - common hepatotropic viruses excluded
- Consider HEV (Hepatitis E - common in Nepal, especially monsoon season), CMV, EBV
4. Hypersplenism due to undiagnosed liver disease
- Elevated transaminases could represent early cirrhosis/portal hypertension
- Would explain thrombocytopenia + slightly elevated PT
5. Leishmaniasis (Kala-azar)
- Endemic in Terai region of Nepal (Dang is in Terai/mid-hills)
- Causes thrombocytopenia + hepatosplenomegaly + transaminitis
What is Missing / Further Investigations Needed
| Test | Reason |
|---|---|
| Dengue NS1 Ag + IgM/IgG | Most likely diagnosis given epidemiology |
| Peripheral Blood Smear | Rule out malaria, blasts (leukemia), microangiopathy |
| Malaria RDT / Thick smear | Endemic region, monsoon |
| Abdominal Ultrasound | Assess splenomegaly, hepatomegaly, portal hypertension |
| Serum Ferritin, Serum Iron, TIBC | Confirm iron deficiency etiology of microcytic anemia |
| LFT repeat + Coagulation (APTT, Fibrinogen) | Monitor coagulopathy progression |
| Bone marrow aspiration | If thrombocytopenia worsens or etiology unclear |
| HEV IgM | Hepatitis E (common in monsoon Nepal) |
| Kala-azar rK39 rapid test | If splenomegaly found |
Clinical Interpretation
The microcytic hypochromic picture (low MCV, MCH, MCHC) with a normal hemoglobin suggests a pre-existing iron deficiency state or thalassemia trait that was not causing significant anemia. This is a separate issue from the current acute presentation.
The acute problem is the moderate and worsening thrombocytopenia with gingival bleeding, elevated transaminases, and a mildly prolonged PT/INR - this constellation in a 44-year-old male from Dang, Nepal in July (monsoon peak) strongly points to dengue fever as the leading diagnosis until proven otherwise.
The patient is admitted to the Emergency/IPD unit, which is appropriate. The gingival bleeding with a platelet count now at 101,000 represents "wet bleeding" - this warrants close monitoring. Platelet transfusion is generally not indicated until platelets fall below 10,000-20,000 unless active hemorrhage is uncontrolled.
Note: BT/CT values are not filled in the UCMS report - this should be repeated. A dengue serology result is needed urgently to confirm the primary diagnosis. - Tintinalli's Emergency Medicine; Goldman-Cecil Medicine
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