Table of Content - Volume 9 Issue 1 - Januray 2018
Study of clinico-serological profile of dengue fever in a tertiary care hospital
Sanjay Thorat1, Tejas Rane2, Aniket Avhad2*, Akshay Kulkarni2
1Professor, 2Junior resident, Department of Medicine, KIMSDU, Malkapur, Karad, INDIA. Email: dr.tejasrane@gmail.com
Abstract Background: In India, dengue epidemics are becoming more frequent (WHO, 2008). The majority of dengue viral infections are self-limiting, but complications may cause high morbidity and mortality. Dengue is the most rapidly spreading mosquito-borne viral disease of mankind, with a 30-fold increase in global incidence over the last five decades. Aim: To study the clinico-serological profile of dengue in a Tertiary Care Hospital. Materials and methods: A observational study was carried out among 350 patients showing symptoms of dengue fever. Laboratory test were done on those patients. Informed consent was taken priory. Results: Most common age group was between 20-29 years, mean age being 28.6 years with M: F ratio was 2.1:1. Majority had NS1 Ag+ve test result. High significance was seen between serological findings and platelet count. Conclusions: The study draws attention to susceptibility of the male, young adult age group. Serologically positive findings will help in early diagnosis and treatment. Key Word: Dengue fever, NS1, platelet count.
INTRODUCTION In India, dengue epidemics are becoming more frequent (WHO, 2008). The majority of dengue viral infections are self-limiting, but complications may cause high morbidity and mortality. Dengue is the most rapidly spreading mosquito-borne viral disease of mankind, with a 30-fold increase in global incidence over the last five decades.1 If intervention occurs early, mortality is less than 1%. The disease is also endemic in many parts of India, especially the metropolitan cities and towns. Outbreaks are now reported quite frequently from different parts of the country like rural areas of Haryana, Maharashtra, and Karnataka. Till date, more than 80 outbreaks have been reported from 16 States/Union Territories, the largest one being in 1996, when a severe outbreak of dengue/DHF occurred in Delhi, wherein about 10 252 cases and 453 deaths were reported.2 During 2010, a total of 28292 cases were reported, which increased to 50222 in 2012 and 75808 in 2013-the highest since 1991. The case fatality ratio (CFR-deaths per 100 cases) has declined from 3.3% in 1996 to 0.4% in 2010 after the national guidelines on clinical management of DF/DHF/dengue shock syndrome (DSS) were developed and circulated in 2007. This further declined to 0.3% in 2013.3 Recently DENV non structural antigen (NSI antigen) has evolved as a new biomarker for early diagnosis of DENV infection. Dengue NSI antigen, a highly conserved glycoprotein is abundant is serum of patients during early stages of DENV infection and can be detected before the formulation of antibodies. Currently NSI antigen capture ELISA and rapid NSI antigen commercial kills for detection of NSI antigen have been developed and evaluated. Its use has been suggested for early diagnosis of dengue infection after the onset of fever representing a new approach for diagnosis of acute dengue infection.4 Thus present study was carried out to study the serological profile of dengue fever.
METHODOLOGY An observational study was carried out among 350 patients. All probable cases that had high grade fever, lymphadenopathy, hepatomegaly, features of shock or haemorrhage, and so forth and were admitted with provisional diagnosis of dengue fever to the Department of Medicine of a Tertiary Care Hospital. Serological test was done among them like positive dengue tests, either NS1 antigen, IgM, IgG antibody rapid serological test kit. Other laboratory blood test like TLC, Platelet count, Hb, haematocrit, and so forth were calculated for each patient and recorded. Ultrasonography was also carried out for hepatomegaly, splenomegaly. The results were tabulated and correlated. The outcomes were recorded. All data was collected and complied in Microsoft excel. The clinical manifestations and laboratory findings like haemoglobin estimation, total platelet count, haematocrit estimation, NS1 antigen, and IgM antibody of each group of illness were compared using chi square test for proportions and student t test was applied for quantitative data. Microsoft excel and SPSS version 20.0.0.0 software were used for data entry and analysis. Value below 0.05 was considered significant. Written consent was taken from the patients before enrolling in the study. Ethical committee clearance was taken from the institute before starting this study.
RESULTS
Table 1: Symptoms among the study population (multiple response)
One patient had one or more than one symptom.
Table 3: Hb count among the study population
Average Hb count 13.1+2.6 gm% Laboratory indices showed that 10 % of the population was anemic. Out of those 10 %, 4 % had Hb of less than 7 g %. 6 % of the theanalysed data had hemoglobin levels of 7.1 to 10 g % (Table 3). However, haemoglobin levels were not consistently related with Hct.
Table 4: Platelet count among the study population
Thrombocytopenia was evident in 53.7 % of the population. Platelet count was as low as 20000 or below, in 1.7 % patients. (Table 4). It decreased further during first three to four days of hospitalization. Platelet transfusion in the form of SDP and RDP was also given (Table 2). Considering the need for the same, it was observed that total of 70 patients were given transfusion. 75.72% or 53 patients opted for SDP and 17 patients i.e. 24.28% opted for RDP.
Table 2: Platelet Transfusion among the study population (n=70)
Splenomegaly was documented in 33 % of the male cohort, whereas 67 % females had splenomegaly on USG.
Table 5: Association between Dengue serology and platelet count
Applying chi square test, p 0.10, shows no statistical significance.
Figure 1: Gender distribution. Figure 2: Dengue Type NS1/IgM/IgG. Figure 3: Symptoms among the study population
Figure 4: TLC count among the study population Figure 5: Splenomegaly on USG among Figure 6: Hepatomegaly on USG among the study population the study population
Based on the following parameters, an analysis of total 350 patients was done for this study. Majority of the patients were young males. Females formed 30 % of the population. In our study of 350 patients, 245 i.e 70 % were males and 105 i.e 30 % were females. The study revealed serology detection of dengue non- structural protein 1 (NS1), anti-dengue IgM, IgG in the blood samples. 65 % cases i.e 228 patients were NS 1 +ve , while 23 % cases i.e 81 patients were IgM +ve. A total of 42 patients were IgG +ve. The most common presentation was fever (90 %) followed by headache (85 %). In an unusual scenario 35 % of the patients had hematemesis and 45 % had rash on day 1 of admission. Myalgia was also an important finding in 75 % of the total cases. (Table 1, figure 3). Average TLC count was 4164.64+2447.75 cells per cubic millimeter of blood The total white cell count was found to be <5000/cmm in 259 patients (74%). A normal cell count between 5000 to 10000 was noted amongst 88 patients (25%) during hospital stay. 4 patients had a count of more than 10000 during their admission. Hepatomegaly on USG among the study population, among males 37 % whereas among females 63 % females had hepatomegaly on USG. Correlating serological outcome with the platelet count, severe thrombocytopenia was observed in 6 cases where 4 of them were NS1 +ve. A total of 112 patients had platelets between 20000 to 50000. 162 patients had a normal platelet count of more than 100000.
DISCUSSION Dengue is an important emerging disease in the tropical and sub-tropical areas. An observational study of serologically positive cases for 1 year revealed the following features. Sex: The overall male predominance was observed (figure 1). Findings were in accordance with other study in Kerala (M: F=1.08:1)5 Symptoms: In our study we noticed that most common presentation is of fever and headache seen in similar studies conducted in different parts of India. In Kerala study and in Northeast India study also fever was a most common symptom observed in 96.8% and 98.1% cases respectively.5,6. Myalgia was observed in 75% of cases in this study. Ina study conducted in Northeast India, myalgia was observed in 81.3% cases.6 We have also observed that hematemesis as a symptom was seen in 35%, unlike other studies where the incidence was low. Serology: Patients were diagnosed as dengue fever based on detection of dengue non- structural protein 1 (NS1), anti-dengue IgM, IgG in the blood samples. Maximum cases showed serology test which was positive for NS1 in 65%, positivity for IgM in 23% patients and 12% patients had mixed positivity (figure 2). Abnormal laboratory findings: 74% of patients had borderline leucopenia, whereas the incidence of thrombocytopenia was only 53.7% (figure 4, table 4) unlike in Ageep AK et al, Mittal H et al and Seema A et al where thrombocytopenia was a most common laboratory finding, observed in 88%, 92.6% and 84% cases respectively.7,8,10 Mortality: In present study mortality rate was not there. In Kerala study mortality rate was 3.2% and in Gupta et al study mortality rate was 4.14%.5,9
CONCLUSION The study draws attention to susceptibility of the male, young adult age group. Serologically positive findings will help in early diagnosis and treatment. Dengue fever cannot just be simply considered as a viral infection, especially in a scenario where so many atypical presentations are seen. There are so many aspects which are manifested differently which when noticed promptly can help in reducing complications of DHF and DSS. Lastly use of mosquito control measures should not be underestimated because it forms the baseline of the treatment in in urban as well as rural population
REFERENCES 1. Shubhankar Mishra, Ramya Ramanathan, and Sunil Kumar Agarwalla. Clinical Profile of Dengue Fever in Children: A Study from Southern Odisha, India. Scientifica. 2016.
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