Clinical and Hematological Profile of Patients with Dengue Fever at a Tertiary Care Hospital – An Observational Study
1 Assistant Professor, Department of Anesthesiology and Critical Care1, Base Hospital, New Delhi.
2 Associate Professor, Department of Pediatrics2, Army Hospital (Referral & Research), New Delhi.
3 Assistant Professor, Department of Pathology3, Base Hospital, New Delhi.
Received: January 10, 2018
Accepted: February 5, 2018
Mediterr J Hematol Infect Dis 2018, 10(1): e2018021 DOI 10.4084/MJHID.2018.021
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Dengue is a major health issue with seasonal rise in dengue fever cases
imposing an additional burden on hospitals, necessitating bolstering of
services in the emergency department, laboratory with creation of
additional dengue fever wards.
Material and Methods
|Figure 1. Age distribution of Pediatric case.|
patients (337/500; 67.4%) while in 37 patients (37/500; 7.4%) the IgM antibody was negative but they showed positivity for IgG antibody. In 11 patients (11/500; 2.2%) initial sample was negative for NS1 antigen test but IgM antibody test done two to five days later was positive. The commonest presenting complaint was fever (99.8%) with severe arthralgia and myalgia (97.4%). Other symptoms were loose motions (12.6%), rashes (45.8%), vomiting (10.2%), breathlessness (1.6%), headache (47%), retro-orbital pain (65%) and abdominal pain (11.8%). Breathlessness was seen in 8 patients (1.6%) all of whom had serositis. DF was diagnosed in 429 cases (429/500; 85.8 %), DFWS in 55 cases (55/500; 11%), SD with severe bleeding in 10 (10/500; 2%) and SD with severe plasma leakage in 6 cases (6/500; 1.2%) (Table 1). Four hundred and twelve cases (412/500; 82%) were treated as outpatients while 88 patients (88/500; 18%) required admission. All 55 cases of DFWS, 10 patients of SD with severe bleeding, 6 patients of SD with severe plasma leak, all 4 pregnant patients and 13 children were hospitalized. Mild dehydration was noted in 179 patients of DF (179/484; 36.9%) who were treated with oral rehydration therapy, while 45 cases of DFWS (45/484; 9.3%) required intravenous fluid therapy. Sixteen patients (16/490; 3.2%) had severe dehydration requiring IV fluid resuscitation of which 10 cases were of DFWS and 6 were of SD with severe plasma leak (Table 2). Thrombocytopenia was seen in 335 (335/500; 67%) patients while increased hematocrit was seen in 66 (66/500; 13.2%) patients at the time of presentation (Table 1). Bleeding manifestations were seen in 36 patients of DFWS (36/55; 65.4%). Out of these 27 patients had petechiae, 4 patients had epistaxis, 3 had hematemesis and 2 had melena. Amongst these, 10 patients had platelet count < 10,000/cu.mm, 23 patients had platelet count was between 11-20,000/cu.mm while in 3 patients the platelet count was between 21-30,000/cu.mm (Table 3). Platelet transfusions were given in all 36 cases. PRBC transfusion was required in 3 patients with DFWS with hemoglobin < 8.5 gm/dl and 10 patients with SD with severe bleeding. All 10 patients with SD with severe bleeding required platelet transfusions. Three patients of SD with severe plasma leak and 2 patients of SD with severe bleeding died. There was no mortality in the pediatric cases or the pregnant women.
|Table 1. Demographic and clinical characteristics of patients enrolled in the study.|
|Table 2. Treatment and outcome details of the admitted patients.|
|Table 3. Correlation of thrombocytopenia with bleeding manifestation and number of cases in Dengue fever patients.|
|Table 4. Duration of hospitalization with different indications.|
Appropriate timing of NS1 antigen test is important. We performed NS1 antigen testing in patients presenting within 5 days of onset of symptoms in order to reliably identify cases of primary dengue infection as well as secondary dengue infection also in which the NS1 antigen test remains positive for a shorter time frame. There were 11 (2.2%) patients in whom the NS1 antigen test turned out to be negative but were later confirmed to be dengue IgM antibody test positive. We used the one-step immunochromatographic assay for IgM and IgG antibody testing which identifies acute as well as past dengue infections with excellent sensitivity and specificity. There were 37 (7.4%) patients in whom the IgM antibody was negative but IgG antibody was positive. These patients were cases of secondary dengue infection which were confirmed by a ≥ 4 fold elevation in the IgG antibody titres by enzyme-linked immunosorbent assay (IgG-ELISA) in the convalescent serum sample at follow-up done at a reference laboratory. Out of these 37 patients, 4 had DFWS requiring hospitalization but none had SD. The 11 (2.2%) patients in whom the NS1 antigen test was negative were cases of acute infection confirmed by IgM antibody testing who presented more than five days since onset of fever which explains the initial negative NS1 antigen test.
The use of NS1 antigen test, IgM and IgG antibody testing for diagnosis of dengue infection can show false positivity due to cross reaction with other flaviviral infections. We did not use real-time polymerase chain reaction (RT-PCR) for viral RNA detection for diagnosis due to feasibility issues and these are the limitations of our study. The strength of this study is the inclusion of serologically confirmed cases, inclusion of patients of all age groups and threadbare clinical and hematological profile of the enrolled cases, which can help guide local health authorities on resource allocation for capacity expansion. This is a single center experience and since our hospital serves a specific clientele (armed forces personnel, in active service or retired and their dependents), this is a limitation of this study. However this should not affect its external validity and the generalizability of its findings.
Several outbreaks of DF have been reported over the past 2 decades[17-23] and a seasonal trend during the monsoon period has been noted due to the warm environment and high relative humidity favoring vector growth. The reported case fatality rate shows a declining trend from 6-9%[17,18,27] to 0% attributable to increased awareness and better case diagnosis and management. There has been increasing atypical and rare presentations of DF resulting in the expanded dengue definition.[28,29] Some studies similar to ours from other parts of the country have reported significant differences in the incidence of atypical presentation like neurological signs or the incidence of serositis[11,12] while others have reported similar findings. These differences may be due to co-infection with other pathogens or secondary heterotypic dengue virus infections. Dengue is grossly underreported in our country. The WHO estimates that nearly 5 lac people are admitted with dengue in our country annually and that India accounts for nearly 20% of all cases in the south-east Asian region (SEAR).
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