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Table of Content Volume 15 Issue 1 - July 2020
Study of clinico-haematological profile in dengue fever - A prospective study
K Naveen1*, R S Shankarappa2, S Vathsala3
{1Associate Professor, 2Assistant Professor, Department of General Medicine} {3Associate Professor, Department of Dermatology}, Shridevi Institute Of Medical Sciences And Research Hospital, Tumakuru, Karnataka, INDIA. Email: drnaveen26@gmail.com
Abstract Background: Dengue fever with its severe clinical manifestations as dengue haemorrhagic fever and dengue shock syndrome has emerged as a major health problem of international concern. We commonly see patients referred in view of dengue serology positive without warning signs and non severe dengue. Hence the present study is planned to study various clinical manifestations of dengue and analyse the haematological parameters of the same. Methodology: This is an observational study and conducted prospectively total of 100 cases with fever and dengue serology positive were studied. Results: In our study, bradycardia documented in 39% of cases, leucopenia seen in 53% of cases, thrombocytopenia of less than 1lakh is found in 74% of patients, Haematocrit of less than 40 found in 44% of patients, dengue fever diagnosed in 69% of cases followed by dengue haemorrhagic fever diagnosed in 23% and dengue shock syndrome in 8% of cases. Conclusion: Majority of cases are still DF, requires only supportive management and not requiring platelet transfusion. So most of the cases should be managed at the local hospital without referring, to reduce cost burden on patients. Early recognition of warning signs and meticulous management reduce the morbidity and mortality of dengue. Key Word: dengue fever.
INTRODUCTION The origin of word dengue is derived from the Swahili phrase “Ka-dingapepo” meaning “cramp like seizure caused by an evil spirit”. The Swahili word “dinga” may possibly have origin in the Spanish word “dengue”. Dengue made its debut as early as 1780, when Benjamin Rush described the condition as “break bone fever”. Dengue fever (DF) with its severe clinical manifestations as dengue haemorrhagic fever(DHF) and dengue shock syndrome (DSS) has emerged as a major health problem of international concern. Dengue is the most extensively spread mosquito borne disease, transmitted by infected mosquitoes of aedes species. Dengue infection in humans results from four serotypes DENV 1 to 4 of Flavivirus genus. With an estimated 50-100 million cases of dengue infection occurs annually in over 100 endemic countries, most cases are reported from Southeast Asia.1 India comes under category B of the classification meant for SEAR. Here DHF is an emerging disease with multiple virus serotypes and cyclical epidemics are frequently exist. Although the first recorded outbreak of dengue fever in India was in 1812, evidences of dengue infection was studied only by 1954, which showed that DEN-1 and DEN-2 were widespread.2 The prevention and control of dengue infection in India is carried by National vector borne disease control programme (NVBDCP). As per NVBDCP guidelines, blood samples were collected, to screen for vector borne disease between April 2016 to march 2017 in state of Karnataka. About 34084 blood samples were suspected for dengue and blood samples were collected from 17130 cases, out of them 3453 cases showed positivity for dengue with slide examination rate of 80.8% and slide positivity rate of 93.3%.Out of population of 28,33,214 of tumakuru,957 cases were suspected of dengue in which 439 tested positive.3 Dengue fever is an acute febrile illness and has a wide spectrum of clinical presentations with unpredictable clinical outcome. Majority of patients have self-limiting clinical course and only a small proportion of patients progress to DHF or DSS. This is when they acquire a second infection by a different dengue viral antigen.4 Hematopoetic system is the earliest and commonly affected system in Dengue infection with thrombocytopenia being most common laboratory finding.5 The mechanism of thrombocytopenia remains unclear in DF. Possible mechanisms may include.6
The study findings confirmed that, by using a set of clinical and/or laboratory parameters, one sees a clear-cut difference between patients with severe dengue and those with non-severe dengue. We commonly see patients being referred in view of dengue serology positive without warning signs and non severe dengue. As this is a tertiary care referral centre with availability of blood products, for few surrounding taluks. Hence the present study is planned to study various clinical manifestations of dengue and to further analyse the haematological parameters of the same. And we found very few studies from this region with detailed description of both clinical and haematological profile in dengue illness. The study of clinic haematological profile in dengue would have a substantial impact on treatment of dengue. By reducing unnecessary burden on patients By reducing referals to higher centres By reducing morbidity and mortality associated with dengue. Aims and objectives 1. To study the clinical presentations of dengue fever. 2. To study the hematological features of dengue fever.
MATERIALS AND METHODS This is an observational study and conducted prospectively for a period of 6 months from August 2019 to January 2019 from Department of Medicine, Shridevi Institute of Medical Sciences and Research Centre, Tumakuru. A total of 100 caseswho gave consent to participate in the study was included through the inclusion and exclusion criteria mentioned below. Inclusion criteria
Exclusion criteria
Written informed consent for the study was obtained from all of the patients aged 18 years or older or from the parents or guardians of the patients younger than 18 years. Detailed clinical history, examination and required investigation were done for all patients. Data was entered in Microsoft Office Excel Sheet 2010. Definition used in the study7,8 Dengue fever Fever is an acute febrile illness of 2-7 days duration (sometimes with two peaks) with two or more of the following manifestations:
DHF: Dengue Haemorrhagic Fever is a probable case of dengue and haemorrhagic tendency evidenced by one or more of the following:
>20% rise in haemotocrit for age and sex >20% drop in haemotocrit following treatment with fluids as compared to baseline Signs of plasma leakage (pleural effusion, ascites or hypoproteinaemia). DSS(Dengue shock syndrome ): Some patients of DHF manifest signs of restlessness, abdominal pain, and shock (rapid andweak pulse, cold clammy extremities, diaphoresis,circumoral cyanosis, irritability or change in mentalstatus). These cases known as DSS, are characterised by narrowing of the pulse pressure to 20 mm Hg or hypotension and in severe cases undetectable BP and pulse. Thus, diagnosis of DSS is based on all the criteria of DHF plus manifestations of shock. Ethical approval taken from Institutional Ethical Committee. Table A : Grading of severity of dengue fever.9
*DHF Grade III and IV are also called as DSS.
RESULTS In our study a total of 100 patients were studied and all patients undergone dengue serology testing. Dengue NS1antigen positive in 37% patients, IgM Dengue positive in 27 %patients, NS1 and IgM Dengue positive in 20% patients, NS1 and IgG positive in 4%, IgM and IgG Dengue positive in 3% patients. All three tests(NS1,IgM and IgG) positive in 9% patients (table no.1). Table 1: Dengue serology report of patients
In our study, age and gender distribution shows majority of the patients age is between 21 to 40years. Its about 49% among them 63% are male and rest 37% were female.28% of patients are in age group between 41 to 60 years among them 68% are female and 32% were male,19% of patients are in less than 20 years of age among them 74%male and rest 26% were female.4% of patients belong to more 61years of age among them both male and female shares 50% each(table no 2). Table 2: Age and Gender distribution of patients
In our study patients fever is present in 100% of cases. Headache present in 68% of patients, like wise myalgia in 72% of patients, joint pain in 43% of cases, vomiting in 31% of patients, pain abdomen in 33% of patients, generalised weakness in 81% of patients, cough in 11% of patients, itching in 14% of patients and viral rash present in 20% of patients. Bleeding manifestation seen in 23% of patients, pedal edema in 9% of patients, ascites in 28% of patients, pleural effusion in 3% of patients, hepatomeghaly seen in 18% of patients and signs of shock in 8% of cases(table no 3). Table 3: Symptoms and Signs of patients
In our study, bradycardia was documented in 39% of cases, tachycardia in 2% of cases and normal pulse rate in 59% of cases (table no 4). Table 4: Pulse rate among patients
In our study, leucopenia was seen in 53% of cases followed by normal total leucocytes in 42% and remaining 9% hadleucocytosis(table no 5). Table 5: Total leucocyte counts among patients
In our study, thrombocytopenia of less than 1lakh was found in 74% of patients and platelet count of more than 1 lakh was found in 26% of cases(table no 6). Table 6: Platelet counts among patients
In our study, haematocrit of less than 40 was found in 44% of patients, haematocrit of 40.1 to 45 was found in 36% and haematocrit of more than 45.1 was found in 20% of cases(table no 7). Table 7: Haematocrit among patients
In our study, DF was diagnosed in 69% of cases followed by DHF diagnosed in 23% of cases and DSS in 8% of cases (table no 8). Table 8: Spectrum of dengue illness among patients
DISCUSSION In this study, a total of 100 patients were admitted with fever and they were evaluated and studied for dengue NS1antigen and IgM dengue antibody positivity. In this study, confirmation of dengue by serology shows, NS1antigen positive in 37% patients, as compared to Patta Apparao et al..10 NS1antigen positive in 50.3% and study done by Vidyadhara Rani P et al..11NS1 antigen positive in 63%. In this study, IgM Dengue was positive in 27 %patients,NS1 and IgM Dengue was positive in 20% patients, as compared to study by Patta Apparao et al..10 IgM positive in 14.4%,NS1 and IgM in 25.2% and study done by Vidyadhara Rani P et al..11 IgM positive in 6%,NS1 and IgM positive in 5%. In this study on dengue, age distribution shows majority of the patients are of age group of 21 to 40 years its about 49%,28% of patients are of age group between 41 to 60 years,19% of patients are in less than 20years. Study done by Shekar EC et al..12is almost comparable with our study,47% cases belong to 21-40 years, 32% belong to >40years and 21% belong to 13-20 years group, as compared to study done by Vidyadhara Rani P et al..11where majority of cases 43.52% cases were in the age group of 15-30 years, 20.5% belonged to 31to 50 years of age and 6.64% cases belonged to above 50 years of age group. In our study, gender distribution shows 56% males and 44% females, as compared to study by Shekar EC et al..12 where 53% were males and 47% were females and study done by Vidyadhara Rani P et al..11 where61.46% were males and 38.53% were females. In our study, all of patients presented with fever(100%) followed by generalised weakness 81%. Myalgia in 72%, headache in 68% and multiple joint pain in 43% of patients, as compared with other studies done by Shekar EC et al..12, Pradnya Mukund Diggikar et al..13 and Vijay Sagar et al.14 where fever present all 100 % of patients. Study done Shekar EC et al..12 documented common symptom as myalgia (71%) followed by joint pain (65%), headache (61%),pain abdomen(56%) and simultaneously documented signs of bleeding manifestation in 21% and shock in 9% of cases. Study done by Pradnya Mukund Diggikar et al. 13 documented myalgia in 80% of patients, joint pain in 46% and bleeding manifestation in 10% of patients. Study done by Vijay Sagar et al.14 documented headache in 70%, joint pain in 66%, myalgia in 37% of cases and bleeding manifestation in 15% of cases.
Table 9
In this study, pulse rate documentation demonstrates bradycardia in 39% of the cases as compared to study done by Yadav RK et al.15 where showed sinus bradycardia in 60% 0f cases and study done by Ramesh S et al.16 showed bradycardia in 27% of cases. In this study, leucopeniais seen in 53% of cases which is almost comparable with study done by Butt N et al..17where shows 52.8%. Where-as the study done by Shekar EC et al.12 showed Leucopeniaonly in 18% cases. In this study, thrombocytopenia of less than 1lakh is found in 74% of patients meeting the WHO criteria i.e< 1 lakh cells / cumm which is almost comparable with the study by Pradnya Mukund Diggikar et al.13 which shows 78% and study done by Vidyadhara Rani P et al.11 which shows 73.02% cases of thrombocytopenia. But study done by Vijay Sagaret al.14 observed only 15% of cases with thrombocytopenia. In the present study, DF is the most common type seen in69% followed by DHF in 23% and DSS in 8% of cases. Study by Pradnya Mukund Diggikar et al. 13 observed 76% of DF, 12% of DSS, 10% had DHF. Study by Shekar EC et al.12 shows DF in 81%, DHF in 10% and DSS in 9% of cases. Study by Vijay Sagar et al. 14 observed DF in 79%, DHF in17% and DSS in 4% of cases.
CONCLUSION Dengue fever is the one of the most common important arboviral infections. It has become a one of the major public health problem. in India where cyclic epidemics are becoming more frequent. Spectrum of dengue illness varies from non severe to more severe form of dengue(DHF and DSS). Majority of cases are still DF, requires only supportive management and do not require platelet transfusion. So most of the cases should be managed at the local hospital without reffering to higher centre, so as to reduce cost burden on patients. Early recognition of warning signs and meticulous management can reduce the morbidity and mortality of dengue.
REFERENCES
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