Clinico-haematological parameters in dengue in adults: a retrospective study from a tertiary care hospital

Abstract

Background: Dengue is an arboviral infection, endemic in India. The clinical presentation can vary for fever with rashes to severe bleeding tendencies as in dengue hemorrhagic fever (DHF), and dengue shock syndrome, leading to death. Various laboratory parameters get deranged in Dengue, like total platelet counts, haematocrit and total leucocyte counts. Monitoring these symptoms and lab parameters can help to prevent the cases from complications. Aims and Objectives: This study was undertaken to study clinical presentations, the haematological and biochemical parameters and the outcome of the patients suffering from dengue.
Materials and methods: This was a retrospective study conducted in the department of Microbiology, Father Muller Medical College Hospital, Mangalore. All patients above the age of 18 years who were diagnosed as dengue, with positive result for NS1Ag or IgM or IgG antibodies were included in the study. The data from individual patients were noted down from individual files and entered in to the Microsoft excel. Data collected will be analysed by frequency and percentage
Results: The study included 130 patients, two third of which were males. Majority of the patients were of the age group of 18-30 years 48(36.92%) and only 12 patients’ (9.23%) were with serious presentation so that be to managed in Intensive care unit. Most of the patients presented with typical symptoms of Dengue i.e., fever 128 (98.46%), 104 (80%) patients had thrombocytopenia. The ultrasonography of abdomen (USG) showed splenomegaly in 24.62% of the patients. The pleural effusion was seen in 10 patients, and ascites seen in 15 patients. Two patients succumbed to death, with best of the efforts.
Conclusion: In Dengue infection, some of the signs and symptoms of low platelet counts and plasma leakage, like bleeding gums, malena, haematuria, and pedal edema, ascites, pleural effusion, respectively, needs to monitored carefully so that the required supportive therapy to be initiated at the earliest so as to reduce the mortality.

Full text

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ISSN Print: 2394-7500
ISSN Online: 2394-5869
Impact Factor: 5.2
IJAR 2018; 4(6): 88-91
www.allresearchjournal.com
Received: 04-04-2018
Accepted: 06-05-2018
Thomas George
MBBS Student, Father Muller
Medical College, Kankanady,
Mangalore, Karnataka, India
Ramakrishna Pai Jakribettu
Department of Microbiology,
Father Muller Medical College,
Kankanady, Mangalore,
Karnataka, India
Sharanya Yesudas
MBBS Student, Father Muller
Medical College, Kankanady,
Mangalore, Karnataka, India
Andrew Thaliath
MBBS Student, Father Muller
Medical College, Kankanady,
Mangalore, Karnataka, India
Michael LJ Pais
MBBS Student, Father Muller
Medical College, Kankanady,
Mangalore, Karnataka, India
Soniya Abraham
MBBS Student, Father Muller
Medical College, Kankanady,
Mangalore, Karnataka, India
Manjeshwar Shrinath Baliga
Father Muller Research Centre,
Kankanady, Mangalore,
Karnataka, India
Correspondence
Ramakrishna Pai Jakribettu
Department of Microbiology,
Father Muller Medical College,
Kankanady, Mangalore,
Karnataka, India
Clinico-haematological parameters in dengue in
adults: a retrospective study from a tertiary care
hospital
Thomas George, Ramakrishna Pai Jakribettu, Sharanya Yesudas,
Andrew Thaliath, Michael LJ Pais, Soniya Abraham and Manjeshwar
Shrinath Baliga
Abstract
Background: Dengue is an arboviral infection, endemic in India. The clinical presentation can vary for
fever with rashes to severe bleeding tendencies as in dengue hemorrhagic fever (DHF), and dengue
shock syndrome, leading to death. Various laboratory parameters get deranged in Dengue, like total
platelet counts, haematocrit and total leucocyte counts. Monitoring these symptoms and lab parameters
can help to prevent the cases from complications. Aims and Objectives: This study was undertaken to
study clinical presentations, the haematological and biochemical parameters and the outcome of the
patients suffering from dengue.
Materials and methods: This was a retrospective study conducted in the department of Microbiology,
Father Muller Medical College Hospital, Mangalore. All patients above the age of 18 years who were
diagnosed as dengue, with positive result for NS1Ag or IgM or IgG antibodies were included in the
study. The data from individual patients were noted down from individual files and entered in to the
Microsoft excel. Data collected will be analysed by frequency and percentage
Results: The study included 130 patients, two third of which were males. Majority of the patients were
of the age group of 18-30 years 48(36.92%) and only 12 patients’ (9.23%) were with serious
presentation so that be to managed in Intensive care unit. Most of the patients presented with typical
symptoms of Dengue i.e., fever 128 (98.46%), 104 (80%) patients had thrombocytopenia. The
ultrasonography of abdomen (USG) showed splenomegaly in 24.62% of the patients. The pleural
effusion was seen in 10 patients, and ascites seen in 15 patients. Two patients succumbed to death, with
best of the efforts.
Conclusion: In Dengue infection, some of the signs and symptoms of low platelet counts and plasma
leakage, like bleeding gums, malena, haematuria, and pedal edema, ascites, pleural effusion,
respectively, needs to monitored carefully so that the required supportive therapy to be initiated at the
earliest so as to reduce the mortality.
Keywords: Dengue, adults, bleeding tendencies, plasma leak
Introduction
Dengue is an arboviral infection transmitted by Aedes aegypti and Aedes albopictus
mosquitoes and is emerging as one of the most important mosquito-borne viral disease. It is a
serious global public health problem, with 2.5 billion people at risk and an annual range of
50 to 390 million infections, which include dengue fever, dengue hemorrhagic fever (DHF),
and dengue shock syndrome (DSS) [1-5]. From a historical perspective, the word dengue came
from “denga or dyengo” which in Africa means haemorrhage. The first definite clinical
report of Dengue is attributed to Benjamin Rush in 1789 [6]. He coined the term “break- bone
fever” because of the symptoms of myalgia and arthralgia [5].
The Dengue virus (DEN) was isolated in Japan in 1943 by inoculation of serum of patients in
suckling mice [7] and at Kolkata in 1944 from serum samples of US soldiers [8]. It is a small
single-stranded RNA virus comprising four distinct serotypes DENV-1, DENV-2, DENV-3
and DENV-4. These closely related serotypes of the dengue virus belong to the genus
Flavivirus, family Flaviviridae [1-4]. Distinct genotypes or lineages (viruses highly related in
nucleotide sequence) have been identified within each serotype, highlighting the extensive
genetic variability of the dengue serotypes [5].
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International Journal of Applied Research
Dengue infection is a systemic and dynamic disease and
causes illness including undifferentiated fever, dengue fever
(DF), dengue hemorrhagic fever (DHF), and dengue shock
syndrome (DSS). It has a wide clinical spectrum that
includes both severe and non-severe clinical manifestations
[9]. After the incubation period, the illness begins abruptly
and is followed by the three phases febrile, critical and
recovery [5]. The mechanisms by which pathophysiologic
changes occur in dengue fever are still not fully understood
[5]. The interaction of several factors seems to be responsible
for the development of the severe disease [1-6]. These factors
include the following: the virulence of the circulating strain,
the presence of efficient or high density vector, the wide
circulation of the virus, and characteristics of the host as
genetic factors, ethnicity, presence of chronic diseases, and
subsequent DENV infections [10, 11].
In general, dengue is a self-limiting acute febrile illness
followed by a phase of critical defervescence, in which
patients may improve or progress to a severe form. Severe
illness is characterized by hemodynamic disturbances,
increased vascular permeability, hypovolemia, hypotension,
and shock. Thrombocytopenia and platelet dysfunction are
common in both cases and are related to the clinical
outcome12. For a disease that is complex in its
manifestations, management is relatively simple,
inexpensive and very effective in saving lives so long as
correct and timely interventions are instituted [5].
India’s notable 2.1% share of global international travel in
2012 [13], its increasing role in the global economy [14] and its
growing public health problem with dengue [15, 16] calls for a
closer look at the dengue challenge. Although dengue has
been notifiable in India since 1996, the disease’s impact has
been underestimated because of insufficient information on
incidence and cost of dengue illness [17]. This study was
undertaken with the principal objectives to study the various
clinical presentations of dengue fever, study the
haematological and biochemical parameters in patients with
dengue fever and to study the outcome of the patients
suffering from dengue.
Materials and methods
This was a retrospective study conducted in the department
of Microbiology, Father Muller Medical College Hospital,
Mangalore in May 2015. All patients above the age of 18
years, who got admitted with the history of fever and
suspicion of dengue from July to August 2014, were
included in the study. The serological assays for Dengue
were performed using standard kit (J Mitra& Co. Pvt Ltd,
New Delhi). Adults with positive result for NS1Ag or IgM
or IgG antibodies against dengue virus were considered
dengue positive group. The exclusion criteria included
patients with pre-existing substantial chronic liver, kidney or
heart disease; patients with history of haematological
disorders and patients diagnosed with malaria, leptospirosis,
scrub typhus, hepatitis and enteric fever. All the clinical and
laboratory details during the study time period were
considered. The data from individual patients were noted
down from individual files and entered in to the Microsoft
excel. Data collected will be analysed by frequency and
percentage.
Results
The study included 130 patients, two third of which were
males (82, 63.08%) and 48 (36.92%) were females (Table
1). Majority of the patients who were diagnosed with
dengue were of the age group of 18-30 years 48 (36.92%),
followed by 31-40 years, 34 (26.15%) (Table 1). The least
were seen in the older age group 51-60years (Table 1). Most
of the patients (118) were managed in the wards and only 12
patients’ (9.23%) were serious presentation so that be to
managed in Intensive care unit (Table 1). Most of the
patients were managed and but two patients (1.54%)
succumbed to death even after best of the efforts (Table 1).
Most of the patients presented with typical symptoms of
dengue i.e., fever 128 (98.46%), followed by body ache
(79.23%), joint pain (54, 41.54%), rashes over body (16,
12.31%), retro orbital pain (6, 4.62%). atypical symptoms
included vomiting (55, 42.31%), loose stools (11, 8.46%)
(Table 1). It was observed that 104 (80%) patients had
thrombocytopenia as per WHO criteria (< 1 lakh/mm3)
(Table 1). Most of the patients (74, 56.9%) had a total count
of 4000-11000 cells/mm3 in contrast to leucocytosis and
leukopenia was seen in 34 and 22 patients, respectively
(Table 1). The hematocrit below 40 was observed in
majority (78) and 22 patients had a hematocrit value >45
(Table 1). The results also indicated that 41 patients had an
abnormal LFT and 27 patients abnormal RFT, with a
mortality of 2 patients (Table 1). The ultrasonography of
abdomen (USG) showed hepatomegaly in 20.77%,
splenomegaly in 24.62% and hepatosplenomegaly in 6.15%
of the patients (Table 2). The study also showed that plasma
leakage in terms of pleural effusion was seen in 10 patients,
and ascites seen in 15 patients (Table 2).
Table 1: Clinical details of the patients admitted for dengue in a
tertiary care hospital
Frequency
(Percentage)
Gender
Male
82 (63.08)
Female
48 (36.92)
Age
18-30
48 (36.92)
31-40y
34 (26.15)
41-50
18 (13.85)
51-60y
11 (8.46)
> 60
19 (14.62)
Platelet
< 1 Lakh
104 (80)
>1 Lakh
26 (20)
Total Leucocyte Count
<4000
22 (16.92)
4000-11000
74 (56.92)
>11000
34 (26.15)
Hematocrit
<40
78 (60)
40-45
30 (23.08)
>45
22 (16.92)
Abnormal Biochemical
parameters
LFT
41 (31.54)
RFT
27 (20.77)
Admissions
MICU
12 (9.23)
Ward
118 (90.77)
Outcome
Mortality
2 (1.54)
Alive
128 (98.46)
Discussion
Dengue fever is a serious global public health problem [1-3].
The number of cases seen in India is on the rise. In most
cases, classical dengue fever presents as an acute febrile
illness and requires only support therapy which includes
mainly anti-pyretics and fluid therapy [1-8]. A small number
of cases progress to Dengue Haemorrhagic Fever (DHF),
which is a more severe form of the disease [5]. It is
important, therefore, to be able to predict which cases of

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International Journal of Applied Research
dengue fever are likely to progress to the severe form of the
disease based on the symptomatology and routine blood
investigations.
In our study, the male: female ratio was 1.7: 1 for male is to
female and was different when compared to previous studies
[18-21]. The reason was not clearly known, as this was a
retrospective study. But it can be attributed to the fact that
more males get exposed to this day-time biting mosquito at
the work place, especially at construction site, etc. With
regard to symptoms, fever was the most common symptom
seen in the patients included in the study and is comparable
with other studies conducted in India [18-26]. Body ache was
seen in about 80% of the patients. Other common symptoms
included myalgia (46.9%) and headache (29.2%) (Table 2).
Other symptoms that patients presented with were edema,
breathlessness, bleeding gums, retro orbital pain, sore throat,
melena, abdominal distension, altered sensorium and
hematuria. These symptoms, though rarely seen are
indicators of the severity of the disease.
Among the haematological parameters, total platelet count
plays a major role. Thrombocytopenia has always been one
of the criteria used by WHO guidelines as a potential
indicator of clinical severity [5, 21-24]. The mechanisms
involved in thrombocytopenia and bleeding during DENV
infection are not fully understood. Several hypotheses have
been suggested to elucidate the mechanism involved. In this
context, DENV could directly or indirectly affect bone
marrow progenitor cells by inhibiting their function [27] to
reduce the proliferative capacity of hematopoietic cells [28].
Indeed, there is evidence that DENV can induce bone
marrow hypoplasia during the acute phase of the disease [29].
We observed thrombocytopenia in 80% of our cases, and
these results are in agreement to various Indian studies [18-26,
30-32].
Out of 130 patients in the study, the evidence of fluid
leakage into interstitial space was evident as Ascites, Pleural
effusion and pedal oedema in 11.54%, 7.69% and 6.15%,
respectively. The frequency of features of fluid leakage was
marginally less when compared to previous studies [19, 20].
As per WHO guidelines pedal oedema, ascites and pleural
effusion are the supporting evidence of plasma leakage, the
distinguishing feature of DHF. Even after the best of the
efforts to manage these dengue cases, we had a two cases
succumbed to death, with the fatality rate of 1.5%. This is
lower to other Indian studies which showed fatality rate
from 3.8% to 7% [21, 22]. The two cases succumbed to death
due to delayed presentation to hospital and had DHF.
Conclusion
India is endemic to Dengue virus as the vector for the
transmission is present all over. The patients can present
with atypical symptoms, so the suspicion of the dengue in
these patients is very important especially during the peak
season of transmission. Some of the signs and symptoms
low platelet counts and plasma leakage, like bleeding gums,
malena, haematuria, and pedal edema, ascites, pleural
effusion, respectively, needs to monitored carefully so that
the required supportive therapy to be initiated at the earliest.
The effective management of Dengue patients mainly
include appropriate fluid management and prevention of
bleeding tendency plays a major role in outcome of the
disease.
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