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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