|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Clinical and Haematological Profile of Dengue during 2021 Epidemic at a Tertiary Care Centre, Western Uttar Pradesh, India: A Cross-sectional Study |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Payal Mittal, Shehraz Firoz, Neetipriya Pandey, Digvijay Ghangas, Sonia Bhatt 1. Assistant Professor, Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India. 2. Associate Professor, Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India. 3. Junior Resident, Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India. 4. Junior Resident, Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India. 5. Professor and Head, Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Correspondence Address : Dr. Shehraz Firoz, Associate Professor, Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India. E-mail: dr.shehrazfiroz@gmail.com |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ABSTRACT |  | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
: Introduction: Incidence of dengue fever has significantly increased in the last few years in developing countries. Its clinical presentation may be variable in paediatrics with high-risk of complications. Dengue fever causes high mortality and morbidity at the paediatric age group. Aim: To evaluate the clinical features and haematological parameters of dengue in paediatric cases at a tertiary care hospital. Materials and Methods: A cross-sectional observational study was conducted in the Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India, on patients diagnosed with dengue fever from August 2021 to November 2021. All cases were subjected to detailed clinical history, examination and relevant investigations (laboratory parameters and clinical features). Data was collected in predesigned proforma, entered in Microsoft Excel sheet and analysed. Results: Out of 801 patients, 486 (60.67%) were males and 315 (39.33%) were females. The commonest symptoms were fever (n=779, 97.25%) followed by body pain/ arthralgia (n=700, 87.39%), flushing (n=622, 77.65%), abdominal pain (n=437, 54.55%), and vomiting (n=428, 53.43%). Highest number of cases (n=399, 49.82%), were from dengue with warning signs. Of total, 759 (94.75%) cases had thrombocytopaenia. Common complications were pleural effusion (26.8%) and ascites (11.88%). Of total, 611 (76.27%) cases got cured while 81 (10.11%) patients expired. Conclusion: Dengue fever is more common in paediatric age group with high rate of complications and disease severity, which has high mortality rate. High clinical suspicion and early fluid management are the only measures to reduce the mortality and morbidity. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Keywords : Aspartate aminotransferase, Immunochromatographic test, Paediatrics | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
DOI and Others :
DOI: 10.7860/IJNMR/2022/58951.2365
Date of Submission: Jul 21, 2022 Date of Peer Review: Aug 31, 2022 Date of Acceptance: Sep 27, 2022 Date of Publishing: Dec 31, 2022 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was Ethics Committee Approval obtained for this study? Yes • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. NA PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Jul 28, 2022 • Manual Googling: Sep 22, 2022 • iThenticate Software: Sep 26, 2022 (14%) Etymology: Author Origin |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| INTRODUCTION |
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The dengue virus is of the Flavi virus genus and Flaviviridae family, responsible for the vector-borne illness, dengue (1). The four serotypes of dengue virus are DENV1, 2, 3 and 4. The primary vectors are two species of Aedes mosquitoes: Aedes aegypti and Aedes albopictus (1). Aedes aegypti is the principal vector and largely responsible for large scale epidemics globally (2). Over the last three decades, dengue has an increasing global incidence with large periodic epidemics in endemic regions (3). According to the World Health Organisation (WHO), the number of dengue cases reported has increased eight-fold in the past two decades from 505,430 cases in 2000 to 5.2 million cases in 2019. The number of reported deaths has increased in the past two decades. Demographic shift has also been noted with an increasing distribution among paediatric age groups (4). India being the second most populated country in the world with rapid and haphazardly expanding urban spaces, is the perfect medium for rapid transmission (5). This has made dengue, a leading public health problem for India (6). The WHO classifies dengue into three major categories: dengue Fever (DF), dengue with warning signs and severe dengue (7). The average incubation period is 4-10 days with symptoms lasting 2-7 days. In 50-90% of the cases, infection is asymptomatic, however, in others, it can manifest with the symptoms of classical DF. Symptoms consist of rapid onset high fever (40°C/104°F) with diffuse body and joint pain, headache, retro-orbital pain, weakness, vomiting, sore throat, lymphadenopathy and a centrifugal maculopapular rash among others (8). Fever, along with any two of the above mentioned symptoms should be suspected to be dengue fever. Warning signs include: severe abdominal pain, persistent vomiting, rapid breathing, bleeding gums, fatigue, restlessness and blood in vomitus (9). Patients who present with bleeding manifestations and endothelial leakage are classified as dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS), also termed as severe dengue (9),(10),(11). Laboratory investigations play a critical role in definitive diagnosis and proper management of dengue. In endemic regions, positive tourniquet test and leucopenia {White Blood Cells (WBC) ≤5000 cells/mm3)} can help in making early diagnosis {Positive Predictive Value Value (PPV): 70-80%)}. Mild thrombocytopenia (100,000 to 150,000 cells/mm3) is common and about half of all DF patients have platelet count below 100,000 cells/mm3; but severe thrombocytopenia (<50,000 cells/mm3) is rare. Haematocrit rise (˜10%) may be found as a consequence of plasma leakage. Serum biochemistry is usually normal but liver enzymes {AST (Aspartate aminotransferase), ALT (Alanine Transaminase)} may be elevated (7). As the management of dengue fever is mainly supportive, early diagnosis helps in the prevention of various complications. Early diagnosis is possible by a combination of clinical features and haematological parameters, as well as, serology. The gold standard is detection of viruses by viral nucleic acid, antibodies or antigen or a combination of these (10). During the 2021 dengue epidemic, Uttar Pradesh witnessed one of the biggest outbreaks with a 10-fold increase in the number of reported cases (over 20,000), since 2020 (12). With each epidemic, it has been observed the clinicohaematological profile and demographics have been changing. With a shift in target population to paediatric age groups, children under the age of 15 years are most susceptible to developing DHF (4). The purpose of the current study was to identify these changes in clinical presentations, laboratory manifestations and complications for early diagnosis and better management of dengue fever in paediatric patients admitted in a tertiary care hospital, Agra, India. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Material and Methods |
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The present observational, cross-sectional study was done on patients diagnosed with dengue fever admitted in Department of Paediatrics, FH Medical College, Agra, Uttar Pradesh, India between August 2021 to November 2021. Ethical approval was obtained from Institutional Ethical Committee (FHMC/IEC/R.Cell/2022/18) and informed consent was obtained from all the subjects. Inclusion criteria: All confirmed dengue cases between one to 18 years of age admitted at FH Medical College, Agra, India confirmed based on the presence of NS1 antigen and/or IgM antibody demonstration serological test by rapid Immunochromatographic Test (ICT) and Enzyme-linked Immunosorbent Assay (ELISA) test were included in the study. Exclusion criteria: Coinfections with other confirmed cases of enteric fever, malaria, typhus, chikungunya, etc., patients not willing to participate in the study were excluded fron the study. Study Procedure All confirmed dengue cases were classified as per WHO guidelines 2009 into three groups (7). • Dengue • Dengue with warning sign • Severe dengue Data collected from the patients included demographic data, clinical profile of dengue patients, complications and outcomes. Clinical examination included haemodynamic parameters, general and systemic examinations. Haemoglobin, leucocyte count, platelets, haematocrit and other relevant investigations were carried out daily until discharge. Clinical fluid accumulation was considered when pleural effusion or ascites was detected on chest radiography or ultrasonography. Various criterias were used to define laboratory parameters and clinical features (Table/Fig 1) (8),(13),(14),(15). Statistical Analysis The data was collected in Microsoft Excel sheet, analysed and represented in the form of numbers and percentages. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Results |
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
In the present study, a total of 801 dengue patients were included as per the inclusion criteria. Among them, 486 (60.67%) were males and 315 (39.33%) were females. Most cases were in between the age group 10-18 years (38.45%) followed by the age group 5-10 years (34.83%). Only 56.55% cases were from urban areas, while 43.44% cases were from rural area (Table/Fig 2). Distribution: According to WHO classification, most cases (49.82%) were dengue with warning signs followed by 28.3% cases of severe dengue and 21.84% cases of dengue without warning signs (Table/Fig 3). Clinical features: The commonest symptom was fever (97.25%) followed by body pain/arthralgia (87.39%), flushing (77.65%), abdominal pain (54.55%) and vomiting (53.43%). Bleeding (nasal bleeding, gastrointestinal bleeding, and intracranial bleeding) was present in 45.69% cases and 15.60% cases had hypotension. 46.81% cases had hepatomegaly and 47.19% cases had splenomegaly. A total of 31.21% cases had cough, while 12.48% cases had respiratory failure due to pleural effusion or pulmonary oedema. A total of 18.15% cases had altered sensorium and 6.74% cases had seizures, which might have been due to dengue encephalitis or intracranial bleeding (Table/Fig 4). Haematological features: A total of 78.15% cases were NS1 antigen positive, 41.44% were IgM positive. Laboratory findings reveal that leucopenia was seen in 22.09% patients, whereas 25.46% patients had leucocytosis. A total of 94.75% cases had thrombocytopenia. The lowest platelet count noted in the present study was 4000/ mm3. Haematocrit was increased in 39.45% cases. AST and ALT were raised in 44.81% and 46.24% cases, respectively (Table/Fig 5). Radiological features: Chest X-ray was done in 250 cases, out of these 14% had bilateral pleural effusion and 12.8% had unilateral pleural effusion. USG abdomen was done in 101 cases, out of these 11.88% had ascites and 6.93% had acalculous cholecystitis. Neuroimaging was done in 21 cases, out of these 33.33% had infraction and 1.69% had cerebral oedema (Table/Fig 5). Mortality: Out of 801 patients admitted, 76.27% were cured, 10.11% expired and 13.6% went on leave against medical advice (Table/Fig 6). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discussion |
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
A vast majority of dengue cases are asymptomatic or mild and self-managed, and hence, the actual numbers of dengue cases are under-reported. Many cases are also misdiagnosed as other febrile illnesses (16). In the present study, a wide range of manifestations were observed with approximately 27% of patients diagnosed as severe dengue and a number of these patients had atypical manifestations. Most of the patients affected were males between the ages of 10 to 18 years, which was similar to other studies carried out in India. This may have been due to more exposure of male children in outdoor activities during the day timings (17). In present study, most organ systems were affected by dengue virus, from cutaneous manifestations to neurological illnesses. The clinical manifestations of dengue fever are quite variable depending upon the age of the patient and the type of infecting strain of virus (18). Fever was the most common symptom, present across the spectrum of non severe and severe dengue in 97% of the patients admitted. This finding is correlated by all studies on dengue (6),(9),(10). Dengue cutaneous manifestations range from maculopapular rash to petechial and flushing. In the present study, the prevalence of rash and flushing were 49.93% and 77.65%, respectively. This was comparatively similar to data reported by Sud R and Nair V, and Majeed IA et al., (10% and 44% of maculopapular and flushing, respectively) (6),(10). In the present study, large (64.91%) number of patients developed complaints of itching, which was significantly higher (28.6%) than that found in a meta-analysis by Nguyen DK et al., (19). Itching is caused by inflammatory cell infiltration and dermal oedema due to increased vessel permeability; cytokines released from the damaged blood vessels during the host and virus interaction, and suggestive of a vigorous immune response (20). Pleural effusion and ascites are the complications of dengue fever resulting from the plasma leakage into the pleural cavity (21). The present study showed pleural effusion in 26.8% cases, and ascites in 11.88%. Shabbir M et al., found 12.6% cases of pleural effusion as opposed to Kumar A et al., who found pleural effusion in 20% cases (22),(23). Rahman MA et al., found a 34% prevalence of ascites in their study (9). Patients also presented with neurological manifestations like headache, altered sensorium and seizures in the present study. Headache occurred due to inflammatory markers and is a commonly reported symptom. In the present study, headache was present in 29.21% of children, while Laul A et al., and Avasthi S et al., reported headache in 87% and 9% respectively (24),(25). After headaches, altered sensorium (18.35%) was the next most common Central Nervous System (CNS) manifestation followed by seizures (9%). Mehta VK et al., found altered sensorium in 90% and seizures in 51% of their dengue encephalitis cases (26). Abdominal pain and vomiting are cardinal in dengue. The present study showed a prevalence of abdominal pain and vomiting 54.55% and 53.43% respectively, which were higher in comparison to Majeed IA et al., (24.61% and 39.23%, respectively and Dhobale RV et al., (43% and 37%, respectively) (10),(17). It is due to more hepatic involvement by dengue virus in the paediatric age group. On examination, 46.81% and 47.91% of patients had hepatomegaly and splenomegaly respectively. Studies by Majeed IA et al., also showed 46.15% and 11.53% prevalence of hepatomegaly and splenomegaly respectively however Dhobale RV et al., only found an 11% prevalence of hepatomegaly (10),(17). Collaborating with the complaint of abdominal pain and finding of hepatosplenomegaly (with or without tenderness), hepatic transaminase levels were monitored. In the present study, 44.81% and 46.24% cases showed elevated AST and ALT levels, respectively. Study by Prasanna N et al., also reported a statistically significant number (ALT in 31% and AST in 22%) of patients who had elevated transaminases (27). All patients were confirmed with serodiagnosis. In the absence of Polymerase Chani Reaction (PCR) viral detection, serodiagnosis tools are an effective and economical means to establish a diagnosis. In the present study NS1Ag, Dengue IgM and Dengue IgG were positive in 78.15%, 35.7% and 41.44% cases, respectively. The NS1Ag test has a sensitivity of 77.3% (15 mins), 80.5% (30 mins) and specificity of 100% (15 and 30 mins post testing) (28). The presence of IgG in 41.44% of patients indicated previous dengue infection which contributed to the large numbers of DSS/DHF patients. Study of Dhobale RV et al., showed antigen positivity rates of 20, 31, 23% of NS1Ag, Dengue IgM, IgG, respectively (17). Thrombocytopenia and leucopenia are common findings in dengue fever, especially lymphopenia is found near the end of the febrile phase. A platelet count of 100,000/mm3 is usually found between day 3 and day 8 of illness. Cytopenias are believed to be caused by direct destructive actions of the virus on bone marrow precursor cells. The resulting active viral replication and cellular destruction in the bone marrow, are believed to cause the bone pain (20). In the present study, thrombocytopenia was seen in 94.75% cases and leucopenia in 22.09% cases. Kulkarni RD et al., showed thrombocytopenia in 68.75% patients (29). Thrombocytopenia may lead to bleeding. A total of 45.69% (366) patients had bleeding manifestations in the form of: gum bleed, epistaxis, haematemesis and melena. Study by Avasthi S et al., demonstrated 8% patients had bleeding episodes, while 26% patients had platelet count below 20,000/mm3 and 84% had platelet <100,000/mm3 (25). While according to Laul A et al., haemorrhagic manifestations: hematemesis, melena and epistaxis were found in 21% however, only 12.85% cases had platelet count <70,000/mm3(24). In study by Khan AH et al., only 5% patients had bleeding, while 40% had thrombocytopenia (30). These findings show thrombocytopenia is very common in dengue, but not every child with thrombocytopenia has bleeding manifestation. To maintain body haemostasis, clotting factors and platelets are required. In the present study, the Prothrombin Time (PT)/ International Normalised Ratio (INR) of 636 patients was done with 24.6% having deranged PT/INR warranting administration of vitamin K injection and/or transfusion of fresh frozen plasma. Adane T and Getawa S, meta-analysis reported PT/INR derangement in 13.4% of paediatric cases (31). Higher incidence of coagulopathy in present study, might be due to more cases of reinfection. A key parameter to watch in haemogram of dengue patients is raised haematocrit, as it suggests increased risk of third space loss of intravascular fluid in effect increasing the viscosity of the blood, causing stasis. Thus, requiring judicious fluid management with intravenous fluid therapy. In the present study, 39.45% cases had raised haematocrit which is comparable to 36%, reported by Prasanna N et al., (27). The present study also showed leucopenia in 22.9% patients, as compared to 31% seen in the study by Prasanna N et al., (27). The present study had a mortality of 10%, which is comparable to 13.75%, reported by Prasad D and Bhriguvanshi A (32). This is largely attributed to many patients presenting to the hospital, in the later stages of the DSS/DHF with atypical manifestations like dengue encephalitis. Due to the outbreak, sample size was large enough to represent the paediatric population. The present study presents the latest trends in clinical and laboratory parameters of dengue in the paediatric age group. Limitation(s) The limitation of the present study was that, virus serotyping investigation was not done. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Original article / research
|
Full Version