High mean platelet volume‑to‑platelet count ratio as a diagnostic maker for increased risk of liver function damage in pediatric patients with infectious mononucleosis in China

  • Authors:
    • Xiucui Han
    • Pengfei Xu
    • Xiuzhi Duan
    • Yongxia Liu
    • Junfeng Zhang
    • Hui Xu
  • View Affiliations

  • Published online on: October 15, 2019     https://doi.org/10.3892/etm.2019.8104
  • Pages: 4523-4527
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Abstract

The aim of the present study was to provide novel laboratory indexes for infectious mononucleosis (IM) in pediatric patients. In the present prospective study, a total of 141 pediatric patients with IM and 146 healthy subjects were enrolled. The white blood cell count (WBC), red blood cell count (RBC), hemoglobin (HB), platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ‑glutamyl transferase (GGT), uric acid (UA), urea, creatinine, total cholesterol (TC) and triglycerides (TG) in peripheral blood were evaluated. WBC, ALT, AST, GGT, UA, TG, MPV and the MPV/PLT ratio in the patients were significantly higher compared with those in the controls (P<0.01), while RBC, HB, urea, TC, PLT and PDW were significantly lower in the patients (P<0.05 for PDW and P<0.01 for others). Regression analysis under stepwise adjustment indicated that PLT and MPV/PLT were significantly associated with IM (P<0.01). Furthermore, MPV/PLT was positively correlated with ALT, AST, GGT, UA and TC (P≤0.01). In the receiver operating characteristic analysis, a sensitivity of 83.7% and specificity of 76.0% regarding the prediction of IM in pediatric patients using the MPV/PLT ratio was achieved at the cutoff of MPV/PLT(%)=3.42. In conclusion, the MPV/PLT ratio may be a novel diagnostic indicator for pediatric IM and indirectly predict damage to liver function.

Introduction

Epstein-Barr virus (EBV), which is carried in >95% of the population worldwide, is a human γ-1 herpes virus (1). This virus is the cause of a range of lymphoid and epithelial malignancies and autoimmune diseases (2,3). EBV usually infects B cells in oropharyngeal lymphoid tissues and then establishes a persistent infection in the circulating memory B cells (4,5). EBV infection may lead to downregulation of the expression of most of the viral genes with the ability to evade the host's immune response (6).

Infectious mononucleosis (IM) is a typical form of primary EBV infection. It usually affects pediatric, adolescent and young adult patients. It is characterized by fever, pharyngitis, lymphadenopathy and hepatosplenomegaly. Local or generalized rash usually occurs during the onset or end of the disease and lasts for 1–6 days (7,8). IM frequently manifests as hepatosplenomegaly and the enlargement of the spleen is highly correlated with the platelet count (PLT) in the peripheral blood. The mean platelet volume (MPV), as an indicator of platelets, is a simple biomarker of inflammation and is increased in cardiovascular diseases, peripheral diseases and diabetes mellitus (911). Hepatic dysfunction is common in IM patients. Numerous studies have indicated that elevation of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and γ-glutamyl transferase (GGT) was more common than elevation of bilirubin (12).

Although the MPV/PLT ratio is known to be a useful index for the diagnosis of numerous diseases in adult patients (13,14), its utility in pediatric patients with IM has remained elusive. The aim of the present study was to investigate the ability of MPV/PLT to detect IM in pediatric patients. The correlation between MPV/PLT and liver function indices was also determined. To the best of our knowledge, the present study was the first to perform this assessment.

Materials and methods

Patients

The present prospective study was performed at the Children's Hospital of Zhejiang University School of Medicine (Hangzhou, China). A total of 141 patients (sex, 54 males and 83 females; mean age, 4.9±3.0 years; age range, 0.8–16.6 years) with a confirmed diagnosis of IM and a normal control cohort consisting of 146 healthy participants (sex, 69 males and 77 females; mean age, 5.2±3.0 years; age range, 0.3–16.3 years) were enrolled. In Western developed countries, the diagnostic criteria are as follows (15): i) Clinical triad: Fever, angina, lymphadenopathy; ii) peripheral blood lymphocyte ratio ≥0.50 and atypical lymphocyte ratio ≥0.10; iii) serum heterophilic agglutination antibody-positive. However, the diagnostic criteria for the aforementioned standard adaptation population was composed of IM cases of 10–30 years of age. China is a developing country and the peak age of IM is during childhood (<18 years old) (16). Referring to previous studies (17,18), the following criteria were used to diagnose IM in the present study: i) 3 of the following clinical symptoms: Fever, angina, large cervical lymph nodes, hepatomegaly, splenomegaly; ii) serological evidence of primary EBV infection, meeting any of the following two standards: a) Positivity for anti-EBV-capsid antigen (CA)-IgM and anti-EBV-CA-IgG antibodies; b) negativity for anti-EBV-CA-lgM but positivity for anti-EBV-CA-IgG antibody, which is a low-affinity antibody. Those patients meeting the two criteria described above were diagnosed with IM. The participants selected for the present study met the diagnostic criteria aforementioned. Healthy participants were those who visited the hospital for a general health examination and with excluded inflammatory diseases based on WBC and hypersensitive C-reactive protein measurements. The present study was approved by the medical ethics committee of the Children's Hospital of Zhejiang University School of Medicine (Hangzhou, China). Written informed consent was obtained from the guardians on behalf of the participants of the study.

Blood and liver function examination

Routine complete blood count (CBC) of peripheral blood from all participants was performed using the BC-5380 instrument (Mindray Medical International Ltd) and liver function parameters were detected on an AU5800 (Beckman Coulter). All reagents for testing were the original reagents of the instruments.

Statistical analysis

The Kolmogorov-Smirnov normality test was used to determine if the data is normally distributed. The Mann-Whitney U-test was used to compare differences in non-parametric variables (non-normally distributed data). Categorical variables were presented as a proportion and analyzed with the Chi-squared test. Continuous data were analyzed using Student's t-test. Values were expressed as n (%), the mean ± standard deviation or median (interquartile range). Spearman correlation analysis was used for grading variable data, whereas Pearson correlation analysis was used for continuous variable data. For the prediction of IM based on platelet indices, logistic regression analysis was used to determine odds ratios (OR) with 95% CI. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic accuracy of MPV/PLT for IM. All statistical analyses were performed using SPSS version 22.0 (IBM Corp.). P<0.05 was considered to indicate statistical significance.

Results

Characteristics of IM patients and controls

In the IM group, a total of 91.5% of the 141 pediatric patients had fever, 85.8% had angina, 92.9% had cervical lymphadenopathy, 71.6% had liver enlargement and 65.2% had splenomegaly. Furthermore, 61.7% were positive for EBV-CA-IgM antibody and 97.9% were positive for EBV-CA-IgG antibody.

Apart from age and gender for which no statistical significance were found between the IM and control groups, it was observed that WBC, ALT, AST, GGT, uric acid (UA) and triglycerides (TG) were significantly higher in the IM patients compared with in the healthy controls (P<0.001; Table I). However, RBC, hemoglobin (HB), urea and total cholesterol (TC) were significantly reduced (P<0.001; Table I). The four platelet indices, PLT, platelet distribution width (PDW), MPV and MPV/PLT, exhibited statistically significant differences between the two groups (PLT, P<0.001; PDW, P=0.035; MPV, P<0.001; MPV/PLT, P<0.001; Table I).

Table I.

Baseline characteristics of pediatric patients with IM and controls.

Table I.

Baseline characteristics of pediatric patients with IM and controls.

CharacteristicIM group (n=141)Normal rangeControl group (n=146)P-value
Male gender  54 (38.3)  69 (47.3)0.125
Age (years)4.9±3.0 (0.8–16.6)5.2±3.0 (0.3–16.3)0.334
WBC (109/l)   15.06±6.40   4.0–12.0   7.19±1.470.000
RBC (1012/l)   4.37±0.333.50–5.50   4.52±0.36<0.001
HB (g/l)119.7±9.2110–155125.0±8.4<0.001
ALT (U/l)  79.0 (36.0–178.5)<50  13.0 (11.0–16.0)<0.001
AST (U/l)  69.5 (45.0–116.3)15–60  31.0 (27.0–35.3)<0.001
GGT (U/l)  52.5 (16.0–106.3)  8–57  11.0 (10.0–13.0)<0.001
CREA (µmol/l)46.0 (41.0–51.0)15–77  46.0 (40.0–52.3)0.922
Urea (µmol/l)2.95 (2.47–3.55)1.79–6.43  4.14 (3.64–4.90)<0.001
UA (µmol/l)304 (254–364)155–357257 (228–296)<0.001
TC (mmol/l)   3.19±0.723.00–5.70   4.28±0.95<0.001
TG (mmol/l)   1.87±0.84<1.70   1.07±0.86<0.001
PLT (109/l)208.4±73.0100–400308.4±81.2<0.001
MPV (fl)   9.73±1.25   6.5–11.5   8.39±1.00<0.001
PDW (%)15.37±1.44   0.0–20.015.65±0.640.035
MPV/PLT (%)   5.43±2.66   2.95±1.06<0.001

[i] Values are expressed as n (%), mean ± standard deviation or median (interquartile range). IM, infectious mononucleosis; PLT, platelet count; MPV, mean platelet volume; WBC, white blood cell count; RBC, red blood cell count; HB, hemoglobin; PDW, platelet distribution width; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, γ-glutamyl transferase; UA, uric acid; CREA, creatinine; TC, total cholesterol; TG, triglycerides.

Predictive value of platelet indices in IM patients

Regression analysis was used to analyze the predictive value of the four indices of platelets in the disease group. For regression analysis, three models were built (Table II). Using Model 1 without any correction factors, all four indices were statistically significant predictors of IM within the 95% CI (P<0.05). Following adjustment for age and gender in Model 2, the four indices remained statistically significant in the 95% CI (P<0.05). However, based on Model 2, after WBC, RBC, HB, ALT, AST, GGT, UA, urea, creatinine (CREA), TC and TG were adjusted in Model 3, MPV and PDW were no longer statistically significant (PDW, P=0.350; MPV, P=0.353), while PLT and MPV/PLT remained significant predictors of IM (P=0.005 and 0.006, respectively; Table II).

Table II.

Logistic regression analysis for platelet indices to distinguish pediatric patients with infectious mononucleosis from healthy controls.

Table II.

Logistic regression analysis for platelet indices to distinguish pediatric patients with infectious mononucleosis from healthy controls.

Model 1Model 2Model 3



VariableOR (95%CI)P-valueOR (95%CI)P-valueOR (95%CI)P-value
PLT (109/l)0.982 (0.977–0.986)<0.0010.981 (0.976–0.985)<0.0010.976 (0.959–0.993)0.005
MPV (fl)2.938 (2.212–3.902)<0.0013.225 (2.381–4.368)<0.0011.425 (0.675–3.006)0.353
PDW (%)0.782 (0.617–0.989)0.0400.778 (0.614–0.984)0.0360.693 (0.322–1.493)0.350
MPV/PLT (%)2.997 (2.268–3.961)<0.0013.297 (2.448–4.442)<0.0013.224 (1.396–7.447)0.006

[i] Model 1 was not adjusted. Model 2 was adjusted for age and gender. Model 3 was adjusted as Model 2 + white blood cell count, hemoglobin, red blood cell count, aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, uric acid, urea, creatinine, total cholesterol and triglycerides. OR, odds ratio; PLT, platelet count; MPV, mean platelet volume; PDW, platelet distribution width.

Correlation of MPV/PLT with laboratory parameters in IM and healthy control groups

In the IM group, age, WBC, ALT, AST, GGT, CREA and UA were positively correlated with MPV/PLT, while RBC, HB, urea, TC and TG were negatively correlated with MPV/PLT. The correlation of MPV/PLT with ALT, AST, GGT, CREA, UA and TC was statistically significant (P≤0.01). Regarding the correlation between MPV/PLT (%) and other variables in healthy controls, only age, creatinine and WBC were statistically significant (P<0.05). Of note, the correlation between MPV/PLT and liver function indices in the IM patients was statistically significant (ALT, P=0.005; AST, P=0.010; GGT, P=0.004). The details are provided in Table III.

Table III.

Correlation between mean platelet volume-to-platelets ratio (%) and other variables in pediatric patients with IM and controls.

Table III.

Correlation between mean platelet volume-to-platelets ratio (%) and other variables in pediatric patients with IM and controls.

IM group (n=141)Control group (n=146)


VariablerP-valuerP-value
Age (years)0.1250.1400.2470.003
WBC (109/l)0.0130.877−0.1740.036
RBC (1012/l)−0.1370.106−0.0470.574
HB (g/l)−0.1090.2000.0540.517
ALT (U/l)a0.2350.005−0.0480.574
AST (U/l)a0.2160.010−0.1520.071
GGT (U/l)a0.2440.004−0.1330.114
CREA (µmol/l)a0.292<0.0010.2020.016
Urea (µmol/l)a−0.0390.6530.1130.182
UA (µmol/l)a0.2710.0010.1000.237
TC (mmol/l)−0.300<0.001−0.0950.261
TG (mmol/l)−0.1310.123−0.0480.570

a Spearman correlation analysis was used. Pearson correlation analysis was used for continuous variable data. IM, infectious mononucleosis; WBC, white blood cell count; RBC, red blood cell count; HB, hemoglobin; PDW, platelet distribution width; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, γ-glutamyl transferase; UA, uric acid; CREA, creatinine; TC, total cholesterol; TG, triglycerides.

Diagnostic accuracy of MPV/PLT in IM

As indicated above, it was possible to distinguish pediatric patients with IM from healthy controls based on the MPV/PLT. ROC curve analysis was therefore used to evaluate the diagnostic sensitivity and specificity of MPV/PLT for pediatric IM (Fig. 1). When the cut-off value for MPV/PLT was set at 3.42%, the sensitivity was 83.7%, the specificity was 76% with an area under the curve calculated to be 0.862.

Discussion

EBV has a high prevalence worldwide (19). In industrialized countries, it is estimated that >50% of the population under the age of 5 years have been infected with EBV (20). Most individuals infected with EBV are either asymptomatic or have mild symptoms; however, certain patients develop IM, particularly during childhood.

Numerous studies have investigated the association between certain diseases and readily available parameters from CBC data, including the neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, PLT-to-lymphocyte ratio and MPV/PLT (15,16,21,22). MPV, PDW and PLT are three general indicators of platelets. Studies have suggested that a high MPV may be associated with an increased risk of vascular complications (23,24).

MPV mainly reflects the proliferation, metabolism and platelet production of megakaryocytes in the bone marrow. In addition, it reflects the survival time of platelets in the circulation. When the function of myeloproliferation is normal, the decrease in the number of platelets stimulates the production of large-volume platelets by megakaryocytes, resulting in an increase in MPV (25). Thrombocytopenia in aplastic anemia or acute leukemia is caused by bone marrow damage and as a result, the MPV is reduced. Idiopathic thrombocytopenic purpura (ITP), also known as primary or immune thrombocytopenic purpura, is an autoimmune disease, and most pediatric patients affected have a history of viral infections (e.g., viral upper respiratory tract infection, rubella or chickenpox) (26). Thrombocytopenia occurs 1–3 weeks after viral infection, indicating that it is not a virus that directly destroys platelets. Intravascular platelet destruction may be another mechanism for thrombocytopenia in pediatric patients with ITP (26).

The present study indicated that in pediatric patients with IM, the MPV was higher than that in the control group and the difference was statistically significant (P<0.01). IM patients frequently have splenomegaly, while the spleen has a close association with platelets in peripheral blood. Thus, PDW and PLT were examined in the present study. Of note, the disease group had a higher MPV and a lower PDW (P<0.01). As the MPV was relatively higher and the PLT was lower in IM patients, the MPV/PLT ratio was introduced to observe the difference between the two groups. As expected, the MPV/PLT ratio in IM patients was significantly higher than that in the controls (P<0.01). ITP has a good bone marrow compensatory function and PLT feedback activates megakaryocytes, resulting in an increase in platelet volume. Increased MPV and thrombocytopenia lead to an increase in MPV/PLT; however, this occurs one to three weeks after viral infection.

IM usually unfolds as a benign clinical process but serious complications may occur. Hepatic failure has been reported in patients with IM (27,28). ALT, AST and GGT are the three transferases with the highest clinical relevance and primary indices of liver function. GGT is widely used as a marker of excessive alcohol intake in patients with alcoholic liver disease (29). In addition, serum GGT levels are frequently increased in patients with non-alcoholic fatty liver disease (30). As GGT is a manifestation of liver injury, the present study aimed to predict liver damage in the early stage of IM.

In the clinic, anti-viral therapy is generally applied in pediatric IM complicated with liver function damage. Early prediction and intervention of liver function damage in children is necessary. In order to study the diagnostic value of each indicator, regression analysis was used in the present study to assess various indicators. After adjustment for other variables, only PLT and MPV/PLT were obtained as diagnostic indices independent of other clinical indices (P<0.01). It was indicated that MPV/PLT had a higher predictive value for IM than PLT alone (MPV/PLT, 95% CI=1.396–7.447 and OR=3.224; PLT alone, 95% CI=0.959–0.993 and OR=0.976). Although 0.976 appears to be an insufficient OR, MPV/PLT was significantly superior in predicting disease compared with PLT.

The present study indicated that the liver function indices of pediatric patients with IM were significantly higher than those of the control group. Sampling of liver biopsies from patients with IM may explain the cause of the increased transferase levels (31). Of note, liver biopsy places high emotional and physical burden on children. In the present study, MPV/PLT was indicated to be an independent diagnostic factor for IM, which also had a significant positive correlation with liver function indicators. Although MPV/PLT had a significantly correlated with creatinine (P<0.001) in a positive manner, it is a renal index which can be investigated further in future research. At the same time, the ROC curve analysis for MPV/PLT to predict IM had high sensitivity and specificity (sensitivity, 83.7%; specificity, 76%).

CBC is an examination that is routinely performed for almost all diseases. The present study indicated that the MPV/PLT ratio has a certain diagnostic value for pediatric IM. At the same time, it was revealed that if the MPV/PLT ratio is increased, liver function damage is more likely to occur. MPV/PLT may be a novel indicator for the diagnosis of pediatric IM and indirectly predict damage of liver function.

Acknowledgements

Not applicable.

Funding

No funding was received.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Authors' contributions

XCH and PFX designed the current study and were major contributors in writing the manuscript. XZD, YXL and JFZ were responsible for the collection and analysis of data. HX performed the statistics of the data and gave final approval of the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The present study was approved by the medical ethics committee of the Children's Hospital of Zhejiang University School of Medicine (Hangzhou, China). Written informed consent was obtained from the guardians on behalf of the participants of the present study.

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

References

1 

Young LS and Rickinson AB: Epstein-Barr virus: 40 years on. Nat Rev Cancer. 4:757–768. 2004. View Article : Google Scholar : PubMed/NCBI

2 

Posnett DN: Herpesviruses and autoimmunity. Curr Opin Investig Drugs. 9:505–514. 2008.PubMed/NCBI

3 

Salvetti M, Giovannoni G and Aloisi F: Epstein-Barr virus and multiple sclerosis. Curr Opin Neurol. 22:201–206. 2009. View Article : Google Scholar : PubMed/NCBI

4 

Babcock GJ, Decker LL, Volk M and Thorley-Lawson DA: EBV persistence in memory B cells in vivo. Immunity. 9:395–404. 1998. View Article : Google Scholar : PubMed/NCBI

5 

Rickinson AB, Long HM, Palendira U, Munz C and Hislop AD: Cellular immune controls over Epstein-Barr virus infection: New lessons from the clinic and the laboratory. Trends Immunol. 35:159–169. 2014. View Article : Google Scholar : PubMed/NCBI

6 

Kurth J, Spieker T, Wustrow J, Strickler GJ, Hansmann LM, Rajewsky K and Küppers R: EBV-infected B cells in infectious mononucleosis: Viral strategies for spreading in the B cell compartment and establishing latency. Immunity. 13:485–495. 2000. View Article : Google Scholar : PubMed/NCBI

7 

Hall LD, Eminger LA, Hesterman KS and Heymann WR: Epstein-Barr virus: Dermatologic associations and implications: Part I. Mucocutaneous manifestations of Epstein-Barr virus and nonmalignant disorders. J Am Acad Dermatol. 72:1–19. 2015. View Article : Google Scholar : PubMed/NCBI

8 

Di Lernia V and Mansouri Y: Epstein-Barr virus and skin manifestations in childhood. Int J Dermatol. 52:1177–1184. 2013. View Article : Google Scholar : PubMed/NCBI

9 

Berger JS, Eraso LH, Sha D and Mohler ER III: Mean platelet volume and prevalence of peripheral artery disease, the National Health and Nutrition Examination Survey, 1999–2004. Atherosclerosis. 213:586–591. 2010. View Article : Google Scholar : PubMed/NCBI

10 

Abalı G, Akpınar O and Söylemez N: Correlation of the coronary severity scores and mean platelet volume in diabetes mellitus. Adv Ther. 31:140–148. 2014. View Article : Google Scholar : PubMed/NCBI

11 

Sansanayudh N, Numthavaj P, Muntham D, Yamwong S, McEvoy M, Attia J, Sritara P and Thakkinstian A: Prognostic effect of mean platelet volume in patients with coronary artery disease. A systematic review and meta-analysis. Thromb Haemost. 114:1299–1309. 2015. View Article : Google Scholar : PubMed/NCBI

12 

Yang SI, Geong JH and Kim JY: Clinical characteristics of primary Epstein Barr virus hepatitis with elevation of alkaline phosphatase and γ-glutamyltransferase in children. Yonsei Med J. 55:107–112. 2014. View Article : Google Scholar : PubMed/NCBI

13 

Golwala ZM, Shah H, Gupta N, Sreenivas V and Puliyel JM: Mean platelet volume (MPV), platelet distribution width (PDW), platelet count and plateletcrit (PCT) as predictors of in-hospital paediatric mortality: A case-control Study. Afr Health Sci. 16:356–362. 2016. View Article : Google Scholar : PubMed/NCBI

14 

Loonen AJ, de Jager CP, Tosserams J, Kusters R, Hilbink M, Wever PC and van den Brule AJ: Biomarkers and molecular analysis to improve bloodstream infection diagnostics in an emergency care unit. PLoS One. 9:e873152014. View Article : Google Scholar : PubMed/NCBI

15 

Naess A, Nilssen SS, Mo R, Eide GE and Sjursen H: Role of neutrophil to lymphocyte and monocyte to lymphocyte ratios in the diagnosis of bacterial infection in patients with fever. Infection. 45:299–307. 2017. View Article : Google Scholar : PubMed/NCBI

16 

Zheng CF, Liu WY, Zeng FF, Zheng MH, Shi HY, Zhou Y and Pan JY: Prognostic value of platelet-to-lymphocyte ratios among critically ill patients with acute kidney injury. Critical Care. 21:2382017. View Article : Google Scholar : PubMed/NCBI

17 

Chan CW, Chiang AK, Chan KH and Lau AS: Epstein- Barr-virus-associated infectious mononucleosis in Chinese children. Pediatr Infect Dis J. 22:974–978. 2003. View Article : Google Scholar : PubMed/NCBI

18 

Taai MH, Hsu CY, Yen MH, Yan DC, Chiu CH, Huang YC, Lin SJ and Lin TY: Epstein-Barr-virus-associated infectious mononucleosis and risk factor analysis for complications hospitalized children. J Microbio Immunol Infect. 38:255–261. 2005.

19 

Hislop AD, Taylor GS, Sauce D and Rickinson AB: Cellular responses to viral infection in humans: Lessons from Epstein-Barr virus. Annu Rev Immunol. 25:587–617. 2007. View Article : Google Scholar : PubMed/NCBI

20 

Luzuriaga K and Sullivan JL: Infectious mononucleosis. N Engl J Med. 362:1993–2000. 2010. View Article : Google Scholar : PubMed/NCBI

21 

Liu X, Shen Y, Wang H, Ge Q, Fei A and Pan S: Prognostic significance of neutrophil-to-lymphocyte ratio in patients with sepsis: A prospective observational study. Mediators Inflamm 2016:. 191254:2016.

22 

Oh GH, Chung SP, Park YS, Hong JH, Lee HS, Chung HS, You JS, Park JW and Park I: Mean platelet volume to platelet count ratio as a promising predictor of early mortality in severe sepsis. Shock. 47:323–330. 2017. View Article : Google Scholar : PubMed/NCBI

23 

Ulutas KT, Dokuyucu R, Sefil F, Yengil E, Sumbul AT, Rizaoglu H, Ustun I, Yula E, Sabuncu T and Gokce C: Evaluation of mean platelet volume in patients with type 2 diabetes mellitus and blood glucose regulation: A marker for atherosclerosis? Int J Clin Exp Med. 7:955–961. 2014.PubMed/NCBI

24 

Kodiatte TA, Manikyam UK, Rao SB, Jagadish TM, Reddy M, Lingaiah HK and Lakshmaiah V: Mean platelet volume in type 2 diabetes mellitus. J Lab Physicians. 4:5–9. 2012. View Article : Google Scholar : PubMed/NCBI

25 

O Malley T, Langhome P, Elton RA and Stewart C: Platelet size in stroke patients. Stroke. 26:995–999. 1995. View Article : Google Scholar : PubMed/NCBI

26 

Gao Ju and Luo Chunhua: The pathogenesis and diagnosis of autoimmune thrombocytopenic purpura progress in governance. Chin J Prac Pediatrics. 18:772003.

27 

Harries JT and Ferguson AW: Fatal infectious mononucleosis with liver failure in two sisters. Arch Dis Child. 43:480–485. 1968. View Article : Google Scholar : PubMed/NCBI

28 

McMahon JM, Elliott CW and Green RC: Infectious mononucleosis complicated by hepatic coma. Am J Gastroenterol. 51:200–207. 1969.PubMed/NCBI

29 

Rosalki SB and Rau D: Serum-glutamyl transpeptidase activity in alcoholism. Clin Chim Acta. 39:41–47. 1972. View Article : Google Scholar : PubMed/NCBI

30 

Banderas DZ, Escobedo J, Gonzalez E, Liceaga MG, Ramírez JC and Castro MG: γ-Glutamyl transferase: A marker of nonalcoholic fatty liver disease in patients with the metabolic syndrome. Eur J Gastroenterol Hepatol. 24:805–810. 2012. View Article : Google Scholar : PubMed/NCBI

31 

Wadsworth RC and Keil PG: Biopsy of the liver in infectious mononucleosis. Am J Pathol. 28:1003–1025. 1952.PubMed/NCBI

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December-2019
Volume 18 Issue 6

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Han X, Xu P, Duan X, Liu Y, Zhang J and Xu H: High mean platelet volume‑to‑platelet count ratio as a diagnostic maker for increased risk of liver function damage in pediatric patients with infectious mononucleosis in China. Exp Ther Med 18: 4523-4527, 2019
APA
Han, X., Xu, P., Duan, X., Liu, Y., Zhang, J., & Xu, H. (2019). High mean platelet volume‑to‑platelet count ratio as a diagnostic maker for increased risk of liver function damage in pediatric patients with infectious mononucleosis in China. Experimental and Therapeutic Medicine, 18, 4523-4527. https://doi.org/10.3892/etm.2019.8104
MLA
Han, X., Xu, P., Duan, X., Liu, Y., Zhang, J., Xu, H."High mean platelet volume‑to‑platelet count ratio as a diagnostic maker for increased risk of liver function damage in pediatric patients with infectious mononucleosis in China". Experimental and Therapeutic Medicine 18.6 (2019): 4523-4527.
Chicago
Han, X., Xu, P., Duan, X., Liu, Y., Zhang, J., Xu, H."High mean platelet volume‑to‑platelet count ratio as a diagnostic maker for increased risk of liver function damage in pediatric patients with infectious mononucleosis in China". Experimental and Therapeutic Medicine 18, no. 6 (2019): 4523-4527. https://doi.org/10.3892/etm.2019.8104