Serum Lactate as a Predictor of Severity in Dengue Infection

Background Dengue infections caused by the four antigenically distinct dengue virus serotypes (DENV1, DENV2, DENV3, DENV4) of the family Flaviviridae are the most major arboviral diseases in humans in terms of geographic spread, morbidity, and mortality. Objective: The study was conducted to assess serum lactate in cases of dengue and correlate it with severity in dengue infection. Methodology: A prospective observational study was carried out among indoor patients admitted to the general medicine department of the tertiary care hospital SMIMER Surat. The study's duration was 15 to 18 months. Result: our study found out of total 154 cases; majority of cases were belonged from 83(53.90%) cases were from less than 30 years. male was contributed 96 (62.34%), majority of cases had duration of fever 39(25.32%), 66 (42.66%) case had high LDH, comparison of serum lactate dehydrogenase with severity of dengue mean lactate dehydrogenase of dengue without severity was mean was 148.45 and SD 11.81, while in severe dengue mean serum lactate dehydrogenase 388.23 and SD 99.47 with p value 0.001 which was statically significant. Conclusion According to this study, it is preferable to monitor serial lactate levels as opposed to using a single lactate number.

Whether Platelet Count Really Influences the Outcome of Dengue Patients? A Study Done at Tertiary Care Centre in North Karnataka Region

In many parts of India, Dengue has become a major public health problem and Kalaburagi District in North Karnataka region was previously not known to be an endemic area for dengue. Three clinical syndromes, classic dengue fever, dengue haemorrhagic fever and dengue shock syndrome are seen with dengue virus infection. This present study was undertaken to find out whether platelet count really influences the outcome of dengue patients in a tertiary health care centre in Kalaburagi, Karnataka.METHODSAbout hundred patients admitted in our hospital with positive Dengue NS1 and Dengue IgM were selected. The follow up of patients is done from the onset of fever to up to twelve days or until their recovery according to discharge criteria of WHO whichever of them is earlier.RESULTSIn this study, 100 cases were studied, out of which Dengue fever was seen in 73 cases, Dengue Hemorrhagic Fever in 17 cases and Dengue Shock Syndrome in 10 cases was seen based on WHO criteria. In this study, 99 percent patients had fever. In this study 73 percent of patients were Dengue NS1 Positive and 27 percent of patients were Dengue IgM Positive. In present study, continuously increasing pattern of platelet count was seen in 55 percent cases; initial fall then rise of platelet count was seen in 38 percent cases and persistently low pattern of platelet count was seen in 7 percent cases. This study showed that 30 percent of patients had bleeding manifestations and bleeding manifestations were maximum in patients having low platelet counts. In the present study, 92% cases improved and 8% cases expired.CONCLUSIONSAmong the three clinical syndromes, Dengue fever was more common than dengue haemorrhagic fever and dengue shock syndrome. It was found that platelet count influenced the outcome of dengue patients. Management of dengue case is mainly supportive

Clinico-epidemiological study of dengue fever in Ajmer region

Background: Dengue infection is a major challenge to public health, especially in South-East Asia. It present with a diverse clinical spectrum. Estimates suggest that annually over 50 million cases of dengue hemorrhagic fever (DHF) occur in Asian countries with a case fatality rate of less than 5%. Of those with DHF, at least 90% are children younger than 15 years old. In humans, dengue infection causes a spectrum of illness ranging from relatively mild, non-specific viral syndrome known as Dengue fever (DF) to severe hemorrhagic disease and death. Definitive early Dengue diagnosis requires laboratory tests and those suitable for use at this stage of illness are either costly, such as RT-PCR for Dengue; not sufficiently rapid, such as virus isolation. Currently test available are NS1 antigen detection and ELISA for dengue, IgM and IgG antibodies. Objective of this study is to study clinico-epidemiological and haematological features of Dengue infection.Methods: Prospective observational study involving initial 100 registered cases who were serologically confirmed dengue infection for a period of one year.Results: DF, DHF and DSS were found in 41%, 53% and 6% patients respectively. Most common presenting complaint and bleeding manifestation were fever and petechiae. Uncommonly altered sensorium and icterus were found in severe dengue infection. 6% patients had coagulopathy, 37 patients had hepatic involvement and 2 patients had deranged renal function who had DSS. Fever was present in (100%) cases of DF, DHF and DSS. 26% patients had their platelet count <50000/mm3.Conclusions: Dengue is a common disease in the India with wide spectrum of clinical presentations, affecting 5-15 years age group children commonly. It is one of the dreaded fevers but early diagnosis and management according to recent WHO guidelines can decrease case fatality rate significantly.

Clinical profile of Dengue fever in an urban tertiary care hospital in South India

Background: Dengue is among the most common flavivirus infections in the world. Today dengue ranks as the most important mosquito- borne viral disease in the world. Current estimates report that, at least 112 countries are endemic for Dengue and about 40% of the world populations (2.5-3 billion people) are at risk in tropics and subtropics. Annually 100 million cases of dengue fever and half a million cases of DHF occur worldwide. The clinical features are noted to be different in varying demographics of the world outlining the importance of bringing out data from different parts of the world, so clinicians are better equipped to anticipate the problems associated with clinical dengue.Methods: The study was conducted over a period of 2 years at a tertiary care hospital in urban Bengaluru, India. A cross sectional study of a total of 250 patients was done. They were diagnosed to be positive for dengue serology (NS1 or IgM) before including them in the study. Clinical features, haematological, biochemical and radiological parameters were assessed.Results: Out of 250 patients with dengue fever, the most common symptoms were fever (100%), headache (94.4%) and myalgia (97.2%). Bleeding manifestations were noted in 11.6% of the patients. Bradycardia was noted in 14.8% of the study population. Leukopenia was noted in 36% of the study population. Increased SGOT was seen in 59.6% and increased SGPT in 52.8% of the 250 subjects. The clinical outcome of the 250 patients of dengue fever was classical dengue fever in 86.8%, DHF in 11.6%, DSS in 0.8% and death in 0.8%.Conclusions: All patients with dengue fever present with fever. Other common features noted were headache, myalgia. Bleeding manifestations are to be looked out for. Rare but important features that a clinician must be vigilant to look for are bradycardia and leucopenia.

Immature platelet fraction in children infected with dengue fever

Background: Millions are infected with dengue every year.' Early diagnosis of dengue infection is important for proper treatment of DHF and DSS to avoid fatal outcome. Thrombocytopenia is a common hematological abnormality in dengue, which demands platelet transfusion in most of the severe dengue cases. Platelet transfusion though life-saving has its own hazards. Hence, we can use some new parameter like immature platelet fraction (IPF) which is a measure of reticulated platelets that reflects the rate of thrombopoiesis. The risk of platelet transfusion may be decreased by rapid identification of immature platelet fraction. This study was performed to establish reference of IPF values for the assessment of thrombopoiesis.Methods: Blood samples from 150 children were obtained on day of illness 3, 5 and 7. The IPF is identified by sysmex XE2100 hematology analyser in the reticulocyte channel using a fluorescent dye and a carefully designed gating system and counted by a special software termed IPF master7. IPF values against platelet count were assessed separately on day 3, 5 and 7.Results: The reference intervals of IPF > 8 % and IPF < 8 % were assessed against platelet count. Increase in IPF favored increase in platelet count on day 5 which was statistically significant with the p value <0.001.Conclusions: A rapid and inexpensive automated measurement of IPF can be integrated as a standard parameter to evaluate the thrombopoietic state of the bone marrow. From the study it can be concluded that IPF is an important predictor of increase in platelet count.' Increase in IPF>8 % suggests that platelet count will be increased in next 24 to 48hrs indicating that further blood transfusion will not be required.

Status of circulating immune complexes, IL8 titers and cryoglobulins in patients with dengue infection.

Dengue, a serious viral infection caused by the mosquito vector, Aedes aegyptii, affects about 390 million people annually from more than 125 countries across the globe. However, until now, there is no reliable clinical or laboratory indicator to accurately predict the development of dengue severity. Here, we explored critical pathophysiological determinants like IL8, circulating immune complex (CIC) and cryoglobulin in dengue-infected patients for identification of novel dengue severity biomarker(s). Totally, 100 clinically suspected dengue cases were tested by NS1 ELISA and MAC ELISA for dengue virus aetiology. For control, 49 healthy volunteers were included. Blood profiling (complete hemogram and liver function test) of patient population were done using automated cell counter and standard auto analyzer based biochemical analysis. Serum CIC was quantified by PEG precipitation. Serum cryoglobulins were estimated by Folin assay. Levels of serum IL-8 were assessed by standard sandwich ELISA kits. Patient CIC were further characterized by SDS Gel electrophoresis. Forty per cent of the cases tested positive, of which 11 patients had severe clinical manifestation. The mean ±SEM of cryoglobulin concentration for DHF, DF, and HC were 1.30±0.31, 0.59±0.08 and 0.143±0.009 μg/μl, respectively. Thus, DHF and DF patients have shown 9- and 2.2-fold increase in cryoglobulin levels; and 18- and 5-fold increased CIC, respectively compared to HC patients. The mean ±SEM of CIC-PEG index for DHF, DF and HC were 491±41.22, 146±14.19 and 27.98±2.56, respectively. Raised levels of IL8 titers were also found in all 11 DHF patients. Peak levels of CIC, cryoglobulin and IL8 titers were associated with thrombocytopenia. SDS PAGE analysis of CIC from DHF revealed the presence of at least six protein bands that were not observed in samples from DF and HC. Prediction efficacy of IL8, CIC and cryoglobulin for DHF was determined using the receiver operator characteristic curve (ROC). The area under the curve was 1.00 for IL8, 0.99 for CIC and 0.74 for cryoglobulins. Overall, the results suggest that CIC, IL-8 and cryoglobulins may serve as important laboratory parameters to monitor dengue infection progression.

Dengue hemorrhagic fever/ dengue shock syndrome in a patient with hereditary spherocytosis

BACKGROUND: Dengue Hemorrhagic Fever/Dengue Shock Syndrome (DHF/DSS) occurs only in a small number of dengue fever (DF).This condition,when coupled with a form of congenital hemolytic nemia called Hereditary Spherocytosis (HS), will turn a relatively manageable case of DF into a complicated condition with very poor prognosis. CASE PRESENTATION: Here we report a case of a 19-year-old male student from Manila who came in with fever,jaundice, and dengue warning signs. He was also diagnosed with HS. This compounding infection initiated a hemolytic crisis of his HS, causing severe bleeding and multiple organ failure on top of DHF/DSS. The progression of the disease started with bleeding, and later on with altered sensorium (encephalopathy), respiratory failure, and ultimately, demise. CONCLUSION: DHF/DSS together with HS may cause a hemolytic crisis. High RBC turnover and heightened erythroid marrow activity in HS makes a patient vulnerable to develop aplastic crisis due to dengue virus infection. Erythroid marrow failure may result in profound anemia, heart failure, hypoxia, cardiovascular collapse, and death.

The role of NS-1 antigen in early diagnosis of Dengue hemorrhagic fever in Yangon Children Hospital.

Detection of dengue virus NS1 antigen in patients’ sera serves as a supplementary assay for early diagnosis of dengue cases. This study evaluated the usefulness of NS-1 antigen for early diagnosis of dengue infection in children by use of a commercial immunochromato-graphic based SD Dengue Duo rapid test. The accuracy of SD Dengue Duo NS-1 antigen test was compared against a gold standard RT-PCR test in 117 children with suspected dengue infection attending YCH. All the children included in this study were tested for blood for complete picture and platelet count together with SD Dengue Duo rapid test. Among 117 samples, 65 serum samples were randomly selected and tested by RT-PCR. The sensitivity of SD Dengue Duo NS1 antigen assay was 40% (95% confidence interval) and specificity was 80% (95% confidence interval) as there were more secondary dengue cases in study population.The accuracy of NS1 antigen assay against RTPCR in patients with reduced platelet count showed that the sensitivity of NS1 antigen assay was 100% (95% confidence interval) and specificity was also 100% (95% confidence interval) when the platelet count was below 40,000.The result of this study demonstrated that the sensitivity and specificity of NS-1 antigen assay, at the time of low platelet count below 40,000, when specimens were collected within 5 days of fever, were relatively high compared to sensitivity and specificity of antibody detection. With the considerations for limitations such as NS1antigen assay being less sensitive in secondary dengue cases, in children, for diagnosis of dengue in early stage, with thorough clinical history and examination and also with platelet count, NS1 assay deserves inclusion in the diagnostic evaluation.

Clinical implications and treatment of dengue

Dengue is a common pathogenic disease often proving fatal, more commonly affecting the tropics. Aedes mosquito is the vector for this disease, and outbreaks of dengue often cause mass damage to life. The current review is an effort to present an insight into the causes, etiology, symptoms, transmission, diagnosis, major organs affected, mitigation and line of treatment of this disease with special emphasis on drugs of natural origin. The disease has a potential to spread as an endemic, often claiming several lives and thus requires concerted efforts to work out better treatment options. Traditional medicine offers an alternative solution and could be explored as a safer treatment option. Development of a successful vaccine and immunization technique largely remains a challenge and a better antiviral approach needs to be worked out to complement the supportive therapy. No single synthetic molecule has found to be wholly effective enough to offer curative control and the line of treatment mostly utilizes a combination of fluid replacement and antipyretics-analgesics like molecules to provide symptomatic relief.

Seroprevalence of dengue virus in a tertiary care hospital, Andhra Pradesh, South India.

Background: Dengue fever and Dengue Haemorrhagic fever (DF/DHF) is an acute viral disease caused by Dengue virus. The infection is transmitted by the bite of an infected female mosquito- Aedes aegypti. The Dengue virus causes significant morbidity and mortality in many parts of the world, including India, where it was first isolated in Calcutta, West Bengal during 1945. This study was conducted to know the seroprevalence of Dengue virus in a tertiary care hospital, Hyderabad Methods: Blood for serological studies are carefully collected taking due universal precautions from suspected DF/DHF cases (a) as soon as possible after hospital admission or attendance. All the patients were screened for anti-Dengue IgG and IgM antibodies By Enzyme Immunoassay. The study period was 18 months from 2012. Results: From a total of 1327serum samples tested were screened for Dengue IgM and IgG among which 706(53.2%) were positive. 125(17.7%) were only IgM positive and 198(28.05%) of the tested samples showed only IgG positive. 383(54.25%) of the tested samples revealed positive for both IgM and IgG antibodies. Conclusion: Surveillance is prerequisite for monitoring the dengue situation in the area and should be carried out regularly for early detection of an impending outbreak and to initiate timely preventive and control measures.

Dengue in India.

Dengue virus belongs to family Flaviviridae, having four serotypes that spread by the bite of infected Aedes mosquitoes. It causes a wide spectrum of illness from mild asymptomatic illness to severe fatal dengue haemorrhagic fever/dengue shock syndrome (DHF/DSS). Approximately 2.5 billion people live in dengue-risk regions with about 100 million new cases each year worldwide. The cumulative dengue diseases burden has attained an unprecedented proportion in recent times with sharp increase in the size of human population at risk. Dengue disease presents highly complex pathophysiological, economic and ecologic problems. In India, the first epidemic of clinical dengue-like illness was recorded in Madras (now Chennai) in 1780 and the first virologically proved epidemic of dengue fever (DF) occurred in Calcutta (now Kolkata) and Eastern Coast of India in 1963-1964. During the last 50 years a large number of physicians have treated and described dengue disease in India, but the scientific studies addressing various problems of dengue disease have been carried out at limited number of centres. Achievements of Indian scientists are considerable; however, a lot remain to be achieved for creating an impact. This paper briefly reviews the extent of work done by various groups of scientists in this country.

Dengue Infections And Circulating Serotypes In Negeri Sembilan, Malaysia

This study observed the pattern of reported dengue infections, clinical manifestations, and circulating dengue serotypes in Negeri Sembilan, Malaysia. The aim of this study was to determine the co-circulation of the four different dengue virus serotypes in Negeri Sembilan. We analyzed the surveillance data (VEKPRO) from Negeri Sembilan State Health Department and National Public Health Laboratory, Malaysia on reported dengue infections from 1st January 2010 to 31st December 2010. There were 1466 reported dengue infections, 1342 (91.5%) cases were dengue fever (DF) and 124 (8.5%) were dengue hemorrhagic fever (DHF). The mean age was 32.2± 15.8 years old and most were young adults, aged 15 years old and older. Males (p < 0.05), and those residing in Seremban district (p < 0.05) were more likely to get dengue infections. Symptoms presented upon admission were fever (100%), headache (99.9%), myalgia and arthralgia (98.8%), rash(24.2%), petechiae (16.0%),bleeding tendencies (7.0%) and neurological deficits(1.2%). All four dengue serotypes (DEN 1 – 4) were present, the pre-dominant serotype was DEN-3, noted in January, then existed together with DEN-2 until around May. DEN-1 was the most pre-dominant circulating dengue serotype afterwards, reaching a peak in December 2010. Dengue affected all age groups particularly young adults and males. Most cases reported were in urban areas and Seremban district. Most of the dengue infections occurred in the first half of the year, with the DEN-2 and DEN-3 serotypes being the most predominant.

Dengue disease status in Chennai (2006-2008): A retrospective analysis.

Background & objectives: Dengue is one of the most important Arboviral diseases in man with outbreaks in Southeast Asia and India. We report a retrospective analysis of the dengue positivity in the referred samples for three years period (2006 to 2008) at the Department of Virology, King Institute of Preventive Medicine, Chennai, Tamil Nadu, India. Methods: Serum samples from 1593 suspected cases (968 male and 625 female) were obtained. Of the 1593 cases screened, 1204 (75.5%) were paediatric cases and 389 (24.4%) adults. The samples were subjected to MAC ELISA and IgG ELISA. Results: Of the 968 patients, 686 (43.0%) were positive, of which 579 (84.0%) were in the paediatric age group (<14 yr) and 107 (15.5%) were adults. The IgM positivity being 356 (36.7%) in males and 330 (52.8%) in females. Of the 686 positives, 113 (16.47%) were positive for both IgM and IgG denoting secondary infection. There was a noticeable increased occurrence during the cooler months and during the monsoon and post-monsoon months. Interpretation & conclusions: The dengue IgM seropositivity among the suspected cases indicates active dengue virus activity. Increase in the probable secondary infections especially in a country like ours where multiple serotypes are prevalent raises concern over probable increase in the incidence of the more serious DHF/DSS. Studies need to be done to identify circulating serotypes of dengue virus to design preventive strategies.

Relationship between Plasma Thyrotropin and Brain Natriuretic Peptide in Elderly Patients with Diastolic Heart Failure / 中国康复理论与实践

@#ObjectiveTo investigate the relationship between thyrotropin (TSH) levels and B-type natriuretic peptide (BNP) in elderly patients with diastolic heart failure (DHF). MethodsPlasma levels of TSH and BNP were measured in 93 elderly patients diagnosed DHF clinically. ResultsThe BNP was (1011.07±238.27) pg/ml and (769.36±169.55) pg/ml in patients with high TSH level（>5.5 μIU/ml, n=46) and normal TSH level (0.35～5.5 μIU/ml, n=47) (P<0.05), respectively. ConclusionHigh TSH levels might promote the plasma BNP secretion in elderly patients with diastolic heart failure.

Dengue serosurveillance in Kolkata, facing an epidemic in West Bengal, India.

Background & objectives: A dengue outbreak occurred throughout West Bengal, India starting from August 2005. The objectives of this study were: (i) documentation of suspected cases, confirmed by MAC ELISA; (ii) a longitudinal serosurveillance of dengue in Kolkata by detecting denguespecific IgG and IgM antibodies in suspected cases and to note the seasonal incidence; (iii) to get information about proportion of primary, secondary and old dengue cases and persons free from dengue in the population tested; and (iv) to get some idea to forecast advent of dengue and dengue epidemic/precipitation of DHF. Methods: The epidemiological data were collected from different sources including Calcutta School of Tropical Medicine and Government of West Bengal. For serosurveillance in Kolkata, serum of each suspected patient was examined for detection of IgG and IgM antibodies using the microwell ELISA dengue fever kit. Results: Altogether, 6293 ELISA IgM reactive cases were documented out of 12,059 persons (52.18%) tested in the whole of West Bengal, involving 18 districts with 34 deaths. Serosurveillance of 1668 persons from August 2005 to December 2007 in Kolkata showed that only 18.1% (302) suffered from dengue, 6.03% (101) from primary, 12.03% (201) from secondary dengue, 20.44% (341) were not sufferers of dengue and 61.45% (1025) were old dengue cases. Though stray dengue cases were found perennially, most of the cases occurred in the post-monsoon season, with a peak in September. Of dengue patients, 63.24% (191) were males. Secondary dengue cases outnumbered primary dengue cases. So, possibility of DHF would remain in all age groups and in those persons who suffered from dengue on earlier occasion. Dengue cases drastically reduced in two subsequent post-epidemic years (2006 and 2007). Interpretation & conclusion: Dengue serosurveillance studies may give some idea about advent, intensity, transmission season, seasonal incidence, waxing and warning, and impending epidemic of dengue and DHF. A large-scale active longitudinal serosurvey along with the study of vector capacity and vector competence would provide more correct information.