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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 4  |  Page : 151-156

Clinical profile of dengue and its effect of on biochemical parameters: A hospital-based cross-sectional study


Department of Entomology, Greater Hyderabad Municipal Corporation, Hyderabad, Telangana, India

Date of Submission20-Apr-2021
Date of Decision10-May-2021
Date of Acceptance05-Jul-2021
Date of Web Publication26-Nov-2021

Correspondence Address:
Dr. Rambabu Ayyadevara
10-3-146, Flat No: G2, Sai Amrutha Nilayam Apts, Back Side of Busdepot, Mamilagudem, Khammam - 507 001, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_31_21

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  Abstract 


Background: Dengue affects the overall biochemical parameters and these characteristics can be utilized to monitor the progress of the patients. Hence, more and more studies are required to throw light on how these parameters differ in three different forms of dengue, i.e., dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS). Hence, the present study was carried out.
Objective: The objective of the study was to study the clinical profile of patients with dengue and to study the biochemical parameters in these three forms of the dengue.
Methods: Hospital-based cross-sectional study was carried out among forty cases of dengue. In all these cases, various biochemical tests were carried out and correlated with three forms of dengue. These parameters were compared in three groups of patients, i.e. DF, DHF, and DSS.
Results: Majority (70%) were having classical DF. The most common clinical feature in all three types of dengue was fever. Creatinine, blood urea, total bilirubin, and direct bilirubin mean values were significantly higher in DSS cases compared to DF cases (P < 0.05). Alkaline phosphate was significantly increased, and total proteins were significantly reduced in DSS cases (P < 0.05). Packed cell volume, total white blood cell, and erythrocyte sedimentation rate were significantly more in DHF cases compared to other two groups. The mean platelet values were significantly reduced in DSS group compared to other two groups (P < 0.05).
Conclusion: DF is the most common presentation of dengue. DSS and DHF affect the biochemical parameters significantly and can be used to monitor the progress during the management of cases.

Keywords: Biochemical parameters, clinical profile, dengue, effect, study


How to cite this article:
Ayyadevara R. Clinical profile of dengue and its effect of on biochemical parameters: A hospital-based cross-sectional study. MRIMS J Health Sci 2021;9:151-6

How to cite this URL:
Ayyadevara R. Clinical profile of dengue and its effect of on biochemical parameters: A hospital-based cross-sectional study. MRIMS J Health Sci [serial online] 2021 [cited 2022 Jan 19];9:151-6. Available from: http://www.mrimsjournal.com/text.asp?2021/9/4/151/331240




  Introduction Top


There are four serotypes of dengue virus. It is caused by infection with any one serotype. It is an arthropod-borne viral disease and also called as arboviral disease. The genus is Flavivirus and the family is Flaviviridae.[1],[2] The dengue presents with a wide range of presentation. Most cases are asymptomatic, while majority develop classical dengue fever (DF). Some land into dengue hemorrhagic fever (DHF) and few develop dengue shock syndrome (DSS).[3]

Female Aedes aegypti is the vector which transmits the virus. It is a well-domesticated mosquito, especially in the urban areas.[4]

The dengue virus is transmitted from human beings to the mosquitoes during the viremia phase. Incubation period on an average is 5 days, and the range is 3–15 days. The viremia occurs 24 h before the onset of fever and lasts up to 6 days from the illness. During this period, if the female A. aegypti mosquito bites that person, the mosquito becomes infected and later transmits to other person during biting.[4],[5]

Globally, it has been estimated by the World Health Organization that more than 50 cases of DF occur every year. About 2.5 billion population is exposed to the risk of dengue infection.[6] It has been considered one of the “emergent public health disease.”[7]

The total number of cases of dengue infection in India increased from 99,913 in year 2015 to 157,315 in 2019.[8]

DF is diagnosed if the person presents with fever, joint pains, and intense headache (clinical data); if exposed to the mosquito breeding places in and around the house (epidemiological data) and NS-1 antigen is positive along with decreased platelet count (laboratory data). A variety of laboratory tests including serology, isolation of the virus, and other laboratory tests such as platelet count and liver function tests are used for monitoring the patient condition.[9],[10]

Among the hematological parameters, leukopenia is the most commonly observed parameter. However, there may be initial transient leukocytosis accompanied with neutrophilia. As the DHF progresses, there is rise in the hematocrit (HCT) of about 20% which is found to be associated with thrombocytopenia.[11],[12]

Dengue thus affects the overall biochemical parameters and these characteristics can be utilized to monitor the progress of the patients. Hence, more and more studies are required to throw light on how these parameters differ in three different forms of dengue, i.e., DF, DHF, and DSS. Hence, the present study was carried out to study the clinical profile of patients with dengue and to study the biochemical parameters in these three forms of the dengue.


  Methods Top


Study design

The study was a hospital-based cross-sectional study.

Study period

The study was conducted from July 2012 to December 2012.

Settings

This study was conducted at Government Hospital, Vijayawada.

Sample size

A total of forty cases of dengue were studied who were eligible as per the inclusion and exclusion criteria laid down for the present study.

Ethical considerations

Institution ethics committee permission was obtained. Informed consent was obtained from all eligible cases of dengue.

All those patients who got diagnosed as dengue positive in Government Hospital with symptoms suggestive of DF such as fever, severe headache, joint pains, and bleeding manifestations, shock were investigated with dengue rapid test. Those patients found positive for the test were included in the study, and informed consent was taken from all patients.

A detailed clinical history was obtained from all patients followed by thorough clinical examination of all systems. They were further investigated with other biochemical, hematological, and investigations mentioned in the study protocol.

Inclusion criteria

All the adult patients of either gender with clinical features suggestive of dengue infection, later on, confirmed by dengue rapid test were included in the study.

Exclusion criteria

  • Children below age ten
  • Mixed infections
  • Chronic alcoholics.


Detection of dengue

Detection of dengue infection was estimated by rapid visual test for the identification of dengue NS1 antigen and differential detection of immunoglobulin M (IgM)/IgG antibodies in human serum by dengue Day 1 test (Young, 2000; Guzman, 1996).

Principle

Dengue Day 1 test kit consists of two devices, one device for the detection of dengue NS1 antigen and second device for the differential detection of Dengue IgM/IgG antibodies in human serum/plasma. Dengue NS1 antigen device contains two lines, “C” (Control line) and “1” (Dengue NS1 Antigen detection Test Line). Test line is coated with antibodies anti-dengue NS1 gold colloid conjugate making antigen antibodies complex. This complex migrates along the membrane to the test region and forms the visible pink line at “T” as antibody-antigen-antibody gold colloid forms.

Dengue IgM/IgG test device contains three lines, “C” (Control line), “M” (IgM Test Line), and “G” (IgG Test Line). IgM Test line is coated with antihuman IgM and IgG test line is coated with antihuman IgG. When a sample is added to the device IgG and IgM antibodies in the sample react with antihuman IgM or IgG antibodies coated on the membrane, respectively. Colloidal gold complexes containing dengue1–4 antigens are captured by the bound antidengue IgG and IgM on respective test bands located in the test window causing a pale to dark red band to form at the IgG or IgM region of the test device window. The intensity of the test bands in the respective device will vary depending on the amount of antigen/antibody present in the sample. The appearance of any pink/red color in a specific test region should be considered positive for that particular antigen and/or antibody type (IgG or IgM). A red procedural control line should always develop in the test device window to indicate that the test has been performed properly.

Specimen collection

Serum samples were used to perform the test. If the serum or plasma samples are not tested immediately, the samples should be refrigerated at 2°C–8°C and can be stored for 3 days.

Procedure

Dengue day 1 test kit and sample should be at room temperature before testing. The foil pouch on the test card was removed. The patient's name and identification number were labeled on the test card. Dengue NS1 antigen device: Two drops of sample were added using dengue antigen test sample dropper to the sample well of antigen device. The test card was allowed to complete the reaction in 20 min. Results were read at 20 min.

Positive results may appear as early as 2–10 min but for negative results must be conformed only after 20 min. Dengue IgM/IgG test device: The dengue antibody lower circular part of the sample dropper was filled with the specimen up to the mark on the dropper. Then, the specimen to the sample well was added. Two drops of dengue antibody assay buffer were added to the buffer well “B” on the device. The test card was allowed to complete the reaction in 20 min. Results were read at 20 min. Positive results may appear as early as 2–10 min but for negative results must be conformed only after 20 min.

Other investigations

Random blood sugar was estimated by glucose oxidase method. Other investigation carried out were estimation of alkaline phosphatase (ALP), estimation of alanine aminotransferase (ALT), 2.6 estimation of aspartate aminotransferase (AST), estimation of total protein, estimation of albumin, estimation of cholesterol, estimation of urea by modified Berthelot's method, estimation of creatinine, and estimation of bilirubin. All these investigations were carried out using standard techniques.

red blood cells count, hemoglobin content (Hb), HCT, white blood cell (WBC) count, absolute, and relative counts of WBC populations: lymphocytes, monocytes, neutrophils, eosinophils, and basophils platelets count. For the measurement of the abovementioned parameters, laser scatter technology combined with chemical dye method and flow cytometry are used. Mindray Hematology Analyzer (Mindray BC-2300, Guangzhou Shihai Medical Equipment Co., Ltd, China).

Statistical analysis

The data were entered in the Microsoft Excel worksheet and analyzed using mean and standard deviation values. To compare the mean values in more than two groups, analysis of variance was used. F value was calculated, and P < 0.05 was taken as statistically significant.


  Results Top


[Table 1] shows the categorization of cases into DF, DHF, and DSS. As per the trend, majority (70%) were having classical dengue fever. Nine had DHF and only three had DSS.
Table 1: Categorization of cases into dengue fever, dengue hemorrhagic fever, and dengue shock syndrome

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[Table 2] shows clinical features in dengue infection according to the WHO criteria. The most common clinical feature in all three types of dengue was fever in all cases followed by pain abdomen. [Table 3] shows the comparison of mean values of biochemical parameters in DF, DHF, and DSS. It was found that creatinine, blood urea, total bilirubin, and direct bilirubin mean values were significantly higher in DSS cases compared to DF cases. Cholesterol was significantly reduced in DSS cases compared to DF cases (P < 0.05). [Table 4] shows mean values of liver enzymes and protein levels in DF, DHF, and DSS. ALP was significantly increased in DSS cases, and total proteins were significantly reduced in DSS cases (P < 0.05). The AST and ALT mean values were not found to be significantly different in the three groups. [Table 5] shows mean values of hematological parameters in DF, DHF, and DSS. It was observed that packed cell volume (PCV), total WBC, and erythrocyte sedimentation rate (ESR) were significantly more in DHF cases compared to other two groups. The mean platelet values were significantly reduced in DSS group compared to other two groups (P < 0.05), whereas, Hb, neutrophils, and lymphocytes were comparable in the three groups. [Table 6] shows mean values of electrolytes in DF, DHF, and DSS. The mean values of electrolytes were comparable in all the three groups.
Table 2: Clinical features in dengue infection according to World Health Organization criteria

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Table 3: Comparison of mean values of biochemical parameters in dengue fever, dengue hemorrhagic fever, and dengue shock syndrome

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Table 4: Mean values of liver enzymes and protein levels in dengue fever, dengue hemorrhagic fever, and dengue shock syndrome

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Table 5: Mean values of hematological parameters in dengue fever, dengue hemorrhagic fever, and dengue shock syndrome

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Table 6: Mean values of electrolytes in dengue fever, dengue hemorrhagic fever, and dengue shock syndrome

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  Discussion Top


Forty patients who were positive for dengue infection were included with no other coinfections or metabolic disturbances such as diabetes or who were at the age above 15 years during the study period. As per the trend, majority (70%) were having classical DF. Nine had DHF and only three had DSS. The most common clinical feature in all three types of dengue was fever in all cases followed by pain abdomen. It was found that creatinine, blood urea, total bilirubin, and direct bilirubin mean values were significantly higher in DSS cases compared to DF cases. Cholesterol was significantly reduced in DSS cases compared to DF cases (P < 0.05). ALP was significantly increased in DSS cases, and total proteins were significantly reduced in DSS cases (P < 0.05). The AST and ALT mean values were not found to be significantly different in the three groups. It was observed that PCV, total WBC, and ESR were significantly more in DHF cases compared to other two groups. The mean platelet values were significantly reduced in DSS group compared to other two groups (P < 0.05), whereas Hb, neutrophils, and lymphocytes were comparable in the three groups. The mean values of electrolytes were comparable in all the three groups.

Francisca Azin et al.[13] studied 154 cases of dengue and found that the dengue cases had typical thrombocytopenia and raised levels of transaminases. There was hemoconcentration observed in the dengue cases. These biochemical abnormalities were seen starting from 3rd day and showed a reduction on 11th day of illness. The authors concluded that these markers can be used to monitor the condition of dengue cases.

Shekar and Amaravadi[14] included 100 cases of dengue. The most common presentation was found out to be DF in 81% of the cases which is slightly more than what we found i.e., we observed that 70% were having DF and remaining cases had either DSS or DHF. Fever was the most common presentation in dengue which is also seen in the present study.

Faridi et al.[15] observed that out of 34 cases of dengue, 64.6% were male and all cases had a fever which is similar presentation as the present study where our all cases had fever. 32.4% of the cases had splenomegaly in their study with 17.6% having ascites, but we did not study these aspects. Tourniquet test was positive in 64.7% of their cases and 23.5% of cases had epistaxis. About 56% had significant thrombocytopenia, but there was no association between it and bleeding manifestations. Serum glutamic pyruvic transaminase was increased beyond normal limits in 64.6% of the cases. ALP was increased beyond normal limits in 35.3% of the cases. Serum bilirubin was increased in 8.8% of the cases. Age and sex were not found to be associated with abnormal liver function tests. The authors also noticed that, in DHF cases, the levels of serum enzymes were increased, and we also observed that the mean values of liver function parameters were more in DHF and DSS cases compared to DF cases.

Karoli et al.[16] carried out a cross-sectional study among 356 suspected dengue cases and found that, among them, 39% tested positive for dengue. Majority (58%) were males. The incidence of classical DF was 70% which is exactly similar to the finding of the present study. Thirty percent of the cases in their study had DHF, while this figure was 22.5% in the present study. Forty percent of the cases had bleeding manifestations. Six percent of cases died due to multiorgan failure.

Jayadas et al.[17] examined the blood samples of 150 suspected cases for dengue and found that, among them, 78 were positive. Among these, 37 had classical DF and 41 had a critical issue. Leukopenia and thrombocytopenia were more in the latter group. Patients with severe form of disease had significantly more HCT, Hb, and liver transaminase levels.

Freed et al.[18] studied 102 dengue cases. Fever was universal just like the present study. About 59.8% of the cases had thrombocytopenia and 44.1% of the cases had anemia. AST was raised in 45.1% of the cases and ALT was raised in 17.6% of the cases.

Kularatnam et al.[19] followed 130 cases of dengue. They gave cutoff points of albumin and cholesterol on days 3 and 4 which would decide the risk for critical disease. They gave that, for albumin, it was 37.5 g/l with sensitivity of 86.7% and specificity of 77.8%, while for cholesterol, it was 0.38 mmol/l reduction with a sensitivity of 77.3% and specificity of 71.9%. They did not find any peculiar pattern with calcium.

Patel et al.[20] studied 82 cases of the dengue and found that majority were males (62%). About 86.5% of the cases had thrombocytopenia. About 62.2% had classical DF, and in the present study, we found that 70% had classical DF. The authors noted that DHF was seen in 17.07% of the cases, whereas it was 22.5% in the present study.


  Conclusion Top


DF is the most common presentation of dengue. DSS and DHF affect the biochemical parameters significantly and can be used to monitor the progress during the management of cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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