Sham P Toshniwal¹, Sanjay B Jagtap², Mali Arjun Uddhav^3*

^1,2Associate Professor, ³Junior Resident, Department of General Medicine, Government Medical College, Latur, Maharashtra, INDIA.

Email: dr.maliarjun@gmail.com

RESULTS

Table 1: Distribution according to type of serology among patients

It was observed that that most common type of serology test which was positive was NS1 (61%), IgM was positive in 29% patients and 10% patients had mixed positivity (NS1/IgM ± IgG).

Table 2: Age and sex wise distribution of patients

In present study majority of the patients belonged to the age group 20-29 years of age (38%) followed by 13-19 years (28%) and then 30-39 years age group (18%). It was seen that males (62%) were more affected than females (38%).

Table 3: Distribution of the patient according to clinical symptoms and clinical signs

It was observed that dengue fever patients present with varying manifestations. Fever was the most common clinical feature with which patients present to the hospital. Fever is observed in 96% patients followed by headache 82%, myalgia 78%, backache 52%, nausea and vomiting 36%, arthralgia 25%, abdominal pain 21% rash 16%, breathlessness 16%, hemorrhagic manifestations 15%, retro- orbital pain 9%, cough 9%, increased frequency of stool 7%, conjunctival suffusion 5%, seizures 4% and altered sensorium in 3% of patients.                In the present study dengue fever patients had varying signs. Dehydration was the most common clinical sign (41%) followed by ascites 29%, tourniquet test 20%, pleural effusion 15%, splenomegaly 14%, hypotension 12%, pallor 10%, hepatomegaly 9%, jaundice 7%, bradycardia 4%, neck rigidity and altered sensorium in 3% of patients.

TABLE 4: Distribution of patients according to site of bleeding and complication

Hemorrhagic manifestations of varying degree and from different sites were observed in 13% of the patients. Epistaxis was the commonest bleeding manifestation in 4% of the patients, followed by hematuria 3%, skin 3%, melena 2%, gums 1%, menorrhagia 1%, hematemesis in 1% of patients. In present study, hepatic dysfunction was the most common complication in 21% of the patients followed by renal dysfunction 18%, multiorgan failure 13%, hypotension 12%, myocarditis 4%, ARDS 4%, encephalopathy 3%, myopathy in only 1% of the patient.

Table 5: distribution of dengue cases according to WHO case classification

In the present study, 47% patients were classified into dengue without warning signs, 42% patients were classified into dengue with warning signs and 11% were classified into severe dengue. It was observed that, 21% patients had platelets count less than 20000, out of which 3% patients were diagnosed with dengue without warning sign, 13% patients were diagnosed with dengue with warning signs and 5% patients were diagnosed with severe dengue. The difference observed was not statistically significant (Chi-square 47.17; df-6; p<0.001; highly significant).        It was observed that 44% patients had WBC count less than 4000, out of which 16% patients were diagnosed with dengue without warning sign, 21% patients were diagnosed with dengue with warning signs and 7% patients were diagnosed with severe dengue. And the difference observed was not statistically significant (Chi-square 4.22; df-2; p>0.05; not significant) In the present study, 29% patients had HCT less than 35%, out of which 17% patients were diagnosed with dengue without warning sign, 12% patients were diagnosed with dengue with warning signs. 40% patients had HCT count in between 35% to 45%, out of which 25% patients were diagnosed with dengue without warning sign, 13% patients were diagnosed with dengue with warning signs and 2% patients were diagnosed with severe dengue. 31% patients had HCT count more than 45%, out of which 5% patients were diagnosed with dengue without warning sign, 17% patients were diagnosed with dengue with warning signs and 9% patients were diagnosed with severe dengue. And the difference observed was statistically significant (Chi-square 24.90; df-4; p<0.001; highly significant).

Table 6: Dengue case classification to assess its severity and outcome

In the present study, 47 patients were classified into dengue without warning signs of which all cured. 42 patients were classified into dengue with warning signs of which all cured. 11 were classified into severe dengue of which 2 patients died and 9 patients cured. Thus 81.81% patients were cured in severe dengue group.

DISCUSSION

The emergence of dengue in India has gone into epidemic proportions and dengue outbreaks are frequently engulfing different parts of the country in both urban and rural populations. Dengue infections may vary from flu-like self-limiting illness to life-threatening dengue hemorrhagic fever. In recent years some new presentations of dengue have been reported. Many atypical presentations have led to delayed suspicion and diagnosis of dengue. Some presentations have been completely different from any of the features of dengue described until now in literature. The WHO in 2009 improved the dengue case classification based on clinical severity, and this has been included in the WHO 2009 guidelines and therefore it would be better to use this as a reference. We observed in present study that most common type of serology test which was positive was NS1 in 61% while IgM was positive in 29% patients and 10% patients had mixed positivity (NS1/IgM ± IgG). This was corresponding with other studies by Rabbani MU et al⁹, Tejaswi CN et al¹⁰, Chhotala YH et al¹¹. In Krishnamurthy V et al¹² NS1 was positive in 39.7% followed by mixed infection (35.6%) which was higher than that reported in the present study and IgM (24.7%). In the present study, majority of the patients belonged to the age group of 20-29 years age group (38%) followed by 13-19 years (28%) and then 30-39 years age group (18%). This was corresponding with other studies by Sreenivasulu T et al¹³, Shah V et al¹⁴, Laul A et al¹⁵, Chhotala YH et al¹¹. In the present study males were more affected than females. Males were affected in 62% while females are affected in 38% with Male to female ratio was 1.6:1. This was corresponding to the other studies done by Rabbani MU et al⁹, Deepa L et al¹⁶, Sreenivasulu T et al¹³, Morlawar R et al¹⁷, Chhotala YH et al¹¹.        It was observed that Fever (96%) was the most common clinical symptom. In the study conducted by Tewari K et al¹⁸, Tejaswi CN et al¹⁰, Laul A et al¹⁵, Deshwal R et al¹⁹, Ali M et al²⁰, Lima FR et al²¹ fever was most common symptom which was present in 99.8%, 90.3%, 100%, 100%, 100% and 98.3% respectively. In present study, headache (82%) was the second most clinical symptom, which was correlated with the study done by Tejaswi CN et al¹⁰ (71.9%), Laul A et al¹⁵ (87%), Deshwal R et al¹⁹ (94.8%). It was observed that dehydration was the most common clinical sign with which patients presented to the hospital. Dehydration was observed in 41% patients followed by ascites 29%, tourniquet test 20%, pleural effusion 15%, splenomegaly 14%, hypotension 12%, pallor 10%, hepatomegaly 9%, jaundice 7%, bradycardia 4%, neck rigidity and altered sensorium in 3% of patients. In the study conducted by Chhotala YH et al¹¹ and Spoorti et al (2015)²² also observed dehydration was the most common presenting sign in (61%) and (38%) respectively. In contrast to present study Sreenivasulu T et al¹³ observed hepatomegaly (56%) was the most common presenting sign. Hemorrhagic manifestations of varying degree and from different sites were observed in 13% of the patients. Epistaxis was the commonest bleeding manifestation in 4% of the patients, followed by hematuria 3%, skin 3%, melena 2%, gums 1%, menorrhagia 1%, hematemesis in 1% of patients. In contrast with present study, petechiae, purpura and ecchymosis were the most common bleeding manifestation in studies conducted by Tewari et al¹⁸ (4.5%), Jahnavi K et al²³ (31%), Sreenivasulu T et al¹³ (66%), Lima FR et al²¹ (51.61%). Gum bleeding (16%) was the most common bleeding observed in study conducted by Deepa L et al¹⁶. In the present study, hepatic dysfunction was the most common complication in 21% of the patients followed by renal dysfunction 18%, multiorgan failure 13%, hypotension 12%, myocarditis 4%, ARDS 4%, encephalopathy 3%, myopathy in only 1% of the patient. Similarly, hepatic dysfunction was found most common complication in many other studies conducted by Jahnavi K et al²³ (17%), Tejaswi CN et al¹⁰ (4.3%), Mohan Kashinkunti et al²⁴ (34%). In the present study, 47% patients were classified into dengue without warning signs, 42% patients were classified into dengue with warning signs and 11% were classified into severe dengue. It was observed that 21% patients had platelets count less than 20000, out of which 16% patients were diagnosed with dengue with and without warning signs, 5% patients were diagnosed with severe dengue. 28% patients had platelets count in between 20000 and 50000, out of which (25%) patients were diagnosed with dengue with and without warning signs, and (3%) patients were diagnosed with severe dengue. Thus maximum number of severe dengue cases were classified under platelets less than 20000. Similar findings were seen in studies done by Jayaratne SD et al²⁵ and Fernando S et al²⁶. It was seen that 44% patients had WBC count less than 4000, out of which 37% patients were diagnosed with and without warning signs, and 7% patients were diagnosed with severe dengue. Maximum number of severe dengue cases were classified under WBC count less than 4000. Similar findings were seen in studies done by Jayaratne SD et al²⁵. Studies by Shah V et al¹⁴, Krishnamurthy et al¹², Deshwal R et al¹⁹, Spoorti et al²² showed leukopenia in 15.2%, 32,9%, 20.1%, and 34.1% respectively and this was in comparable with the present study. In the present study, 31% patients had >45% HCT and 69% patients had <45% HCT. Similar findings were seen in studies conducted by Shah V et al¹⁴, Krishnamurthy V et al¹², Deshwal Ret al¹⁹, Spoorti et al²².   In the present study, 47% patients were classified into dengue without warning signs of which all cured. 42% patients were classified into dengue with warning signs of which all cured. 11% were classified into severe dengue of which 2% patients died and 9% patients cured. 81.81% patients were cured in severe dengue group. In study done by Tewari K et al¹⁸, 85.8% patients were classified into dengue without warning signs of which all cured. 11% patients were classified in to dengue with warning signs of which all cured. 3.2% patients were classified into severe dengue of which 1% patients died. In study done by Lima FR et al²¹, 24.86% patients were classified into dengue without warning signs of which all cured. 59.11% patients were classified in to dengue with warning signs of which all cured. 16.02% patients were classified into severe dengue of which 1.1% patients died. In study done by Pozo Aguilar et al²⁷, 36.2% patients were classified into dengue without warning signs of which all cured. 43.6% patients were classified in to dengue with warning signs of which all cured. 20.2% patients were classified into severe dengue of which 1.8% patients died. Similar to our study, in studies done by Tewari K et al¹⁸, Lima FR et al ²¹, Pozo Aguilar et al²⁷ all patients were cured in dengue with/without warning signs. All death occurred in severe dengue group. Similar to our study, maximum patients were classified under dengue without warning signs in the study done by Tewari K et al¹⁸. In contrast to our study, maximum patients were classified under dengue with warning signs in the studies done by Lima FR et al²¹, Pozo Aguilar et al²⁷.

CONCLUSION

Thus we conclude that Majority of the patients suffering from dengue were young male. Fever, headache, myalgia, backache, rash along with thrombocytopenia, leukopenia, elevated liver enzymes with signs of plasma cell leakage should prompt a clinician on the possibility of dengue fever. Statistically significant association was observed association was observed platelet count and HCT with sever type of dengue. Mortality of dengue was observed in Severe Dengue cases as compared to Dengue without Warning Signs and Dengue with Warning Signs. Thus WHO classification helps to predict the outcome of Dengue.

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