INVOLVEMENT OF THE LIVER

IN DENGUE INFECTIONS.

BACKGROUND

DENGUE FEVER / DHF is a reemerging disease in the tropical world .

The disease is caused by 4 closely related dengue viruses which are
transmitted by aedes mosquitoes principally aedes aegypti.

Dengue infection continues to be a major challenge to public health

especially in south east asia .

An average of 20 patients are admitted in our hospital (kims) with

dengue fever per day. As per the latest records 434 patients were
admitted with dengue fever in the month of may in Trivandrum . In the
last 5 months 2174 confirmed dengue fever cases were reported in
kerala .Out of which 1139 were from Trivandrum.

This data clearly depicts the increasing rate of dengue fever in

Trivandrum.

It has a wide geographical distribution and present with diverse clinical

spectrum . DHF and dengue shock syndrome represent the severe end
of disease spectrum which if not properly managed would result in
significant mortality.

Although dengue virus is not a hepatotropic virus , liver injury due to

dengue infection is not uncommon . The degree of liver dysfunction in
dengue fever varies from mild injury with elevation of aminotrasferases
alone to severe injury with jaundice and even fulminant hepatic failure .
The liver dysfunction could be a direct viral effect or a consequence of
dysregulated host immune response against the virus . The severerity of
hepatic dysfunction has been associated with disease severeity. Indeed
liver injury has been proposed to be a good predictive factor for
development of DHF.

Reducing dengue mortality requires an organized process that a

guarantees an early recognition of the disease and its management .
Most patients recover without requiring hospital admission while some
progess to severe disease . simple but effective triage principles and
management can help identify those at risk of developing severe
disease .

Doing a liver function test in the early febrile phase could help predict
the severity and bleeding outcome in dengue infection and if LFT found
raised in the early febrile phase , hepatoprotective drugs may be
considered to prevent liver damage.

Objectives

To assess the degree of liver involvement in dengue patients with either

NS1 or dengue IgM positive .

METHODOLOGY

Study design : Hospital based descriptive study.

Source of Data: inpatients attending KIMS hospital.

Method of collection of data : Purpose of study will be explained to the

patient prestructred proformo will be used to record the relevant
information from individual case selected for the study. 50 cases who
fulfill the following inclusion criteria will be selected for the study.

INCLUSION CRITERIA

Informed consent

Dengue cases with either NS 1 positive or dengue IgM positive.

Age above 13 yrs

Exclusion criteria

Age less than 13 yrs

Associated infections known to cause hepatic involvement like malaria ,

enteric fever , hepatitis.

LIVER INJURY GRADING SYSTEM

The degree of liver damage will be assessed according to the levels of the
liver enzymes

Grade 1 normal levels ( AST 5 -40 units /l , ALT 7 56 units /l )

Grade 2 mild elevation in the liver enzymes not exceeding the three times
the normal value

Grade 3 elevated liver enzymes with levels of enzymes increased to more

than 3 times but less than 10 times the normal value

Grade 4 acute hepatitis with liver enzymes level increased to atleast 10

times the normal value

With the above grading liver damage can be assessed.

Anticipated outcome

LFT (especially AST) may be used to predict the severity and bleeding
outcome in dengue infection .

If LFT found raised in the early febrile phase , hepatoprotective drugs

may be considered to prevent liver damage .

PROFORMA
NAME:
AGE
SEX
ADDRESS
DATE OF ADMISSION :
DATE OF DISCHARGE:
DENGUE IGM:
DENGUE NS 1 ANTIGEN :
CHIEF COMPLAINTS
FEVER /HEAD ACHE /RETRO ORBITAL PAIN /ARTHRALGIA/MYALGIA/VOMITING/ABDOMINAL PAIN/JAUNDICE/ALTERED SENSORIUM
HAEMORRHAGIC MANIFESTATIONS : ECCYMOSIS / BLEEDING GUMS / RASH/EPISTATSIS /HEAMETEMESIS/MALENA/PER VAGINAL BLEEDING
PAST HISTORY DM / HTN /JAUNDICE
PERSONAL HISTORY : ALCOHOL /SMOKING /USE OF HEPATOPROTECTIVE DRUGS
GCS
PALLOR /ICTRUS/CYANOSIS/CLUBBING/LYMPHADENOPATHY/EDEMA
VITAL SIGNS
TEMPERATURE :
HEART RATE :
RESPIRATORY RATE :
BLOOD PRESSURE:
SYSTEMIC EXAMINATION
PER ABDOMEN :
CARDIVASCULAR :
RESPIRATORY :
CENTRAL NERVOUS SYSTEM :
INVESTIGATIONS
LFT
Total bilirubin:
Direct bilirubin:
Total protein :
Albumin:
AST:
ALT :
ALP:
CBC
HB:
PCV:
PLATELET:
PT :
APTT:
VIRAL MARKERS :
WIDAL TEST:
OUTCOME OF THE PATIENT:

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