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Subhaschandra Kadadavar, Lokapur, Nadig, Prabhu M H, and Masur: Hematological parameters in dengue fever: A study in tertiary care hospital


Introduction

Dengue epidemics are known to have occurred regularly over the last three centuries in tropical, subtropical and temperate areas around the world. The first epidemic of dengue was recorded in 16351 in the French West Indies, although a disease outbreak compatible with dengue had been reported in China as early as 992 AD.1 The first dengue fever in India was reported during 1956 from Vellore and the first dengue haemorrhagic fever occurred in Calcutta in 1963.2 In India the annual incidence is estimated to be 7.5 to 32.5 million.3 All the four serotypes i.e. Dengue 1, 2, 3 and 4 have been isolated in India. The Dengue virus infection may be asymptomatic or may cause may cause undifferentiated febrile illness (viral syndrome), dengue fever (DF), or dengue haemorrhagic fever (DHF) including dengue shock syndrome (DSS). Though Dengue infection is self limiting disease, it can prove lethal if not diagnosed and treated at the early stage. Diagnosis of Dengue is by viral isolation, detection of viral genomic sequence by reverse transcription polymerase chain reaction (RT-PCR) and detection of NS1 antigen.4, 5, 6, 7 The haematological parameter of upmost importance for Dengue diagnosis is the platelet count.5, 7, 8 Many studies and literature have proven the importance of decrease in platelet count and rise in hematocrit as a predictive and recovery parameter of DHF/DSS.9 The other hematology parameters like total white cell count and atypical lymphocyte count aid in diagnosis and prognosis in dengue.9, 10, 11

In the present study, we have emphasised the importance of platelet count, rise in hematocrit, total leucocyte count and atypical lymphocytes on peripheral smear and total leucocyte count in diagnosing Dengue infection even in peripheral areas with very little resources where viral isolation and genomic sequencing may not be possible. This will help in alerting the clinicians in preventing complications and mortalities.

Materials and Methods

It was a prospective study done from August 2016 to August 2018. All the patients of both sexes aged >15years admitted at medicine wards with proven case of Dengue fever using IgM/IgG ELISA Test were included in this study. All adult patients who were negative for dengue IgM/IgG ELISA Test were excluded from the study. Demographic data like age, gender, address and occupation was recorded on predesigned and pretested proforma. All baseline investigations like complete blood count, coagulation profile, liver function test, kidney function test, X-ray chest, ultrasound abdomen were done at admission. The level at which the hematocrit and hemodynamic status stabilized during recovery was used as an index of each patient baseline (normal) hematocrit. The ratio was calculated to evaluate the degree of hemoconcentration in patients as follows.12

[(Highest HCT – Recovery HCT) / Recovery HCT] X 100

A value of 20% or more was considered as evidence of significant hemoconcentration. The patients who bleed enough to lower his hematocrit were excluded from these calculations. Blood sample for serological testing were centrifuged for detection of IgM antibodies by MAC ELISA test. All cases were graded according to severity criteria based on the technical guidelines from the WHO.13, 14, 15

Statistical methods

Descriptives, Frequencies, Crosstabs, Chi-Square Test were used.

The Statistical software namely SPSS (version 16.0) and Minitab (version 11.0) were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc.

Results

The male:female ratio was 3:2, majority (32%) of the patients were in the age group of 15 to 25 years and the least patients were more than 55 years of age. Fever was the most common presenting symptom followed by vomiting, backache and myalgia. 54% of the patients with dengue virus infection at the time of admission had dengue fever, 17 (17%) were DHF Grade I, 12(12%) were DHF Grade II, 17(17%) were in DSS that is DHF Grade III + Grade IV. The mean temperature among the dengue patients during the hospital stay had decreasing trend. Out of 100 patients, 15 (15%) had hematocrit levels > 20%, 57 (57%) had < 20% and 28 (28%) had normal hematocrit and the results were statistically significant. Thrombocytopenia in 97% of patients as seen in Table 1. Leucocyte count was normal in majority of the cases as seen in Table 2. Peripheral smears showed atypical lymphocytes in 97% of the cases. LFT in the present study, out of 100 patients, 53(53%) patients had normal liver function test and 47 (47%) had deranged liver function. Activated partial thromboplastin time in 64(64%) patients was normal and in 36 (36%) patients aPTT was raised and the findings were statistically significant (P<0.005). Bleeding manifestations were seen commonly when the platelet dropped below 10,000/cu.mm as depicted in Table 3. Classical Dengue fever showed no positive IgG antibodies while DHF 1, 2, 3 and 4 showed positivity. The mean Platelet count among the dengue patients during the hospital stay had increasing trend (Table 4). In present study there was no mortality in dengue fever and grade-I, II and III dengue hemorrhagic fever. Two (2%) patients with dengue hemorrhagic fever Grade IV succumbed to death.

Majority 18% of the patients received platelet transfusion followed by 10% received vitamin K, 5% received fresh frozen plasma and least being 3% received steroid.

Table 1

Platelet count on day

Platelet count (/mm3) No. of patients Percentage
<10,000 12 12%
10,000-20,000 29 29%
20,000-50,000 42 42%
50,000-1,00,000 14 14%
>1,00,000 3 3%
Total 100 100%

Table 2

Leucocyte count

Leucocyte count (/mm3) No. of patients Percentage
<4000 22 22%
4,000-11,000 62 62%
>11,000 16 16%
X2 = 37.520, DF = 2, P = 0.000

Table 3

Correlation between thrombocytopenia and bleeding

Platelet count Bleeding manifestations Without bleedingmanifestations Total
Number % Number % Number %
<10,000 10 10% 2 2% 12 12%
10,000 –20,000 11 11% 18 18% 29 29%
20,000 –50,000 18 18% 24 24% 42 42%
50,000 –1,00,000 5 5% 9 9% 14 14%
>1,00,000 2 2% 1 1% 3 3%
Total 46 46% 54 54% 100 100%
P = 0.000

Table 4

Platelet trend during the hospital stay

Duration Platelet count (/mm3)
Mean SD
Day 1 36892.7835 28659.01272
Day 2 61333.3333 29993.87693
Day 3 89437.8947 38918.92604
Day 4 105242.4242 44510.34819
Day 5 120447.3684 54025.36810
Day 6 127687.5000 56757.63532
Day 7 179666.6667 65178.72864

Discussion

In the present study, the sex ratio was comparable to the studies done by Agarwal et al16 and Sharma et al17 with males being affected the most. Fever was the most common mode of presentation as was also seen in studies done by Sharma et al,17 Rachel Daniel et al,18 SK Agarwal et al19 and Eva Harris et al.20 Petechial/ecchymosis was the most common sign seen in our study as well as study done by Sharma S et al17 while the studies done by Rachel Daniel et al18 and Krishnamurthy K et al21 showed hepatomegaly as the most common sign of presentation. Dengue viral infection presents most commonly as dengue fever as seen in our study as well as studies done by Eva Harris et al20 and Kalayanarooj S et al.22

Hemoconcentration with an increase in the hematocrit of 20% or more is considered to be definitive evidence of increased vascular permeability and plasma leakage.23 In the present study, Hct> 20% was present in 15 (15%) of cases and <20% in 57 (57%). Sharma S et al17 showed an epidemic of DHF in adults in Delhi during 1996 that raised Hct> 48% were present in 6 (6.12%) cases and Hct> 20% were present in 14 (14.28%) cases. Hematocrit was raised in more than half of the patients in a study done by Nazis et al24 and Joshi AA et al.25 In one of the study, a raised hematocrit of more than 20% was seen in only 1 (2.17%) patient26 while in another, an increase in hematocrit levels was above 45% in DHF AND DSS.27 In the present study a low Hct value is probably due to high prevalence of anemia in this region.

Thrombocytopenia (<1, 00,000/mm3) is one of the defining criteria for dengue haemorrhagic fever and was seen in 97% of the cases in the present study, study done by Sharma S. et al, 17 Joshi AA et al,25 Tahlan A et al26 and Surendra Nath Singh Yadav.28

Dengue infection had no much impact on the total leucocyte count. The leucocyte count was normal in majority of the cases as seen by in the present study,and studies done by Krishnamurthy K. et al21 and Joshi AA et al. 25 While the studies done byNazish Butt et al,24 Shamsunder Khatroth,27 Surendra Nath Singh Yadav28 and Meena KC et al29 observed leucopeniain more than 50% of the cases.94% of the cases showed leucopenia in a study done by Fu-Xi Qiu et al.30 Peripheral smear showed atypical lymphocytes, few showing dark basophilic cytoplasm and large nucleus while few had plasmacytoid morphology. Similar observations were seen in studies done by Singh Yadav28 and Choudhary et al.31

Liver function tests were normal in 53% of cases while was deranged in 47% of the cases. Sharma S et al 17 observed elevation of SGOT in 88.4% of cases and SGPT in 76.7% of the cases. Raised liver transaminases of more than 80% were seen in studies done by Mohan et al,32 Deshwal et al,33 Kularatneet al34 and Mandal et al.35

In our study out of 100 patients, 64(64%) had normal PT/APTT and 36 (36%) patients had raised PT/APTT. Prolonged APTT was seen in 26% cases,20% and 10% of the cases in studies done by Irfan Arshad, Choudhary et al and Ayub et al36, 31, 37 respectively. Bleeding manifestation was seen in majority of the patients whose platelet count dropped below 20,000/mm3. But was also seen in patients whose platelet count was more than 1 lakh/mm3. So bleeding manifestation is independent of the platelet count. Similar observations were made by a study conducted in Indonesia.38 Average time taken for the rise of the platelet count to near normal was six to seven days.

In the present study out of 100 patients 54 (54%) were only IgM positive out of which 2 (2%) had dengue hemorrhagic fever. Remaining 44 (44%) patients had both IgM and IgG positive dengue serology in which all had dengue hemorrhagic fever. A study conducted in Thailand39 in 2000 recorded 32 IgM positive patients out of which 23 had dengue hemorrhagic fever and 133 patients with both IgM and IgG positive out of which 53 had dengue hemorrhagic fever.

There is no specific treatment indicated for dengue fever. Despite majority (41%) of the patients with the platelet count being less than 20,000/mm3 only 18 patients received platelet transfusion in combination with Vitamin K, fresh frozen plasma and fluid therapy. Even though steroids are not indicated in dengue fever some of the patients (3%) responded to steroid therapy in the form of rapid recovery and stabilizing bloodpressure.

In the present study, overall out of 100 patients of DF, DHF/DSS, 2 (2%) patients died.

There was no mortality in DF and DHF Grade I and Grade II.

In DSS, one patient died, due to hypovolemic shock and respiratory failure. Another due to acute kidney injury and disseminated intravascular coagulation (DIC).

Hence, early recognition of the disease and prevention rather than treatment of complications are most important for the favorable outcome of the disease.

Conclusion

Hematological parameters like reduced platelet count, raised hemotocrit, coagulation profile and atypical lymphocytes in peripheral smear supported by liver function tests and serology aid in early detection of Dengue infection and thus help in preventing complication and mortality.

Source of Funding

None.

Conflict of Interest

None.

References

1 

G M Howe A world geography of human diseasesAcademic PressNew York197730217

2 

Special Programme for Research. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control2009World Health OrganizationGeneva, Switzerland

3 

N Gupta S Srivastava A Jain U C Chaturvedi Dengue in IndiaIndian J Med Res2012136337390

4 

V Sindhamni S Banoo N Rajkumar V C Sureshchandra Evaluation of correlation between dengue serological marker and platelet countSch J App Med Sci201642661822

5 

Basavaraj C Metri Parameswarappa Jyothi Correlation of serological markers and platelet count in the diagnosis of Dengue virus infectionAdv Biomed Res20154126

6 

M T Cordeiro Laboratory diagnosis for dengueRev Inst Med trop S Paulo201254181012

7 

K D Mehta B Ghediya S Sheth S Khandhediya H Shingala M Sinha Study of Correlation Between Platelet Count and Serological Markers of Dengue Infection with Importance of NS1 Antigen in Western Region of IndiaNatl J Lab Med201652559

8 

R D Kulkarni G S Ajantha A S Kalabhavi P C Shetty S S Patil A K Upadhya Association of platelet count and serological markers of dengue infection- importance of NS1 antigenIndian J Med Microbiol201129435962

9 

K Jayashree G C Manasa P Pallavi G V Manjunath Evaluation of Platelets as Predictive Parameters in Dengue FeverIndian J Hematol Blood Transfus201127312730

10 

K Khatri A Rajani R Kallaa Plasmacytoid Lymphocytes: A Diagnostic clue to Dengue InfectionInt J Sci Res20165310025

11 

G Dhir T Dhir V Suri D Dhir K Khatri Hematological and Serological Test Profile in Dengue, Dengue Hemorrhagic Fever and Dengue Shock Syndrome in Bathinda Region of PunjabSch J App Med Sci201538C29262956

12 

Sanford N. Cohen Scott B. Halstead Shock associated with dengue infectionJ Pediatr196668344856

13 

S Nimmannitya Clinical manifestations of dengue/yellow haemorrhagic fever. In: WHO Regional Office for South-East Asia. Monograph on dengue/dengue haemorrhagic feverNew Delhi19934861

14 

S Nimmannitya S B Halstead S N Gohen M R Margotta Dengue and chikungunya virus infection in Thailand 1962-64: Observations on hospitalized patients with haemorrhagic feverAm J Trop Med Hyg19691895471

15 

S. Kalayanarooj D. W. Vaughn S. Nimmannitya S. Green S. Suntayakorn N. Kunentrasai Early Clinical and Laboratory Indicators of Acute Dengue IllnessJ Infect Dis1997176231321

16 

R Agarwal S Kapoor R Nagar A Misra R Tandon A Mathur A clinical study of the patients with dengue hemorrhagic fever during the epidemic of 1996 at Lucknow, IndiaSoutheast Asian J Trop Med Public Health199930473540

17 

S Sharma S K Sharma A Mohan J Wadha L Dar Thulkars Clinical Profile of Dengue Hemorrhagic Fever in Adults during 1996- Outbreak in Delhi, IndiaDengue Bull1998222030

18 

R Daniel Rajamohanan A Z Philip A Study of Clinical Profile of Dengue Fever in KollamDengue Bull200529197202

19 

N P Singh Rajat Jhamb S K Agarwal Outbreak of dengue fever in Delhi, India Southeast Asian J Trop Med Public Health200336511748

20 

E Harris E Videa L Perez E Sandoval Y Tellez M L Perez Epidemiological and Virologic Features of Dengue in the 1998 Epidemic in NicaraguaAm J Trop Med Hyg200063511

21 

K Krishnamurthy T E Kasturi G Chittipantulu Clinical and pathological studies of an outbreak of Dengue like illness in VisakhapatanamInd J Med Res196553880012

22 

S. Kalayanarooj D. W. Vaughn S. Nimmannitya S. Green S. Suntayakorn N. Kunentrasai Early Clinical and Laboratory Indicators of Acute Dengue IllnessJ Infect Dis1997176231321

23 

World Health Organization. Dengue hemorrhagic fever: diagnosis, prevention and control. 2nd ed1997WHOGeneva

24 

Nazish Butt S M Abbassi S Munir Masroor Ahmad Qurban Hussain Sheikh Hematological and Biochemical Indicators for the Early Diagnosis of Dengue Viral InfectionJ Coll Physicians Surg Pak20081852825

25 

Anagha A Joshi B N Divyashree B R Gayathri Hematological Parameters in Dengue: The Serological Angle AStudyInt J Hematol Res2018411804

26 

Anita Tahlan Amrita Bhattacharya Haematological profile of dengue feverInt J Res Med Sci2017512536771

27 

Shamsunder Khatroth A Study on Clinical and Hematological Profile of Dengue Fever in a Tertiary Care HospitalIAIM20174896102

28 

Surendra Nath Singh Yadav A study of abnormal hematological parameters in dengue feverIAIM20185511720

29 

K C Meena A study of hematological profile in dengue fever at tertiary care centerInt J Adv Med2016336214

30 

F X Qui D J Gubler J C Liu Q Q Chen Dengue in China. A clinical reviewBull World Health Organ1993713/434959

31 

B Shaista Choudhary Adisesha Rshivkumar Y A Shankar M M Manjunatha Priyadarshini Haematological changes in dengue feverNatl J Basic Med Sci20144428993

32 

B Mohan A K Patwari V K Anand Hepatic Dysfunction on Childhood Dengue InfectionJ Trop Pediatr2000461403

33 

R Deshwal M I Qureshi R Singh Clinical and laboratory profile of dengue feverJ Associ Physicians India201563302

34 

S A Kularatne I B Gawarammanaib P R Kumarasiri Epidemiology, clinical features, laboratory investigations and early diagnosis of dengue fever in adults: a descriptive study in Sri LankaSoutheast Asian J Trop Med Public Health 20053668692

35 

S K Mandal Gangulyj Clinical profiles of dengue fever in a teaching hospital of eastern indiaNat J Med Res201331736

36 

Irfan Arshad Aamir Hussain Fayyaz Ahmed Malik A Shahidaa R Shah Clinico-pathologic correlations and their associations with poor outcomeProfessional Med J20111815763

37 

Muhammad Ayub Adel M Khazinder H Eman Lubbad Shahid Barlas Adnaan Y Alfi Sawsan AI-Ukayli Characteristics of Dengue fever in a large public hospital, Jeddah, Saudi ArabiaJ Ayub Med Coll Abbottabad 2006182913

38 

A Chairulfatah D Setiabudi R Agoes R Colebunders Thrombocytopenia and Platelet Transfusions in Dengue Haemorrhagic Fever and Dengue Shock SyndromeDengue Bull20032713843

39 

David W. Vaughn Sharone Green Siripen Kalayanarooj Bruce L. Innis Suchitra Nimmannitya Saroj Suntayakorn Dengue viremia titer, antibody response pattern, and virus serotype correlate with disease severityJ Infect Dis2000181129



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