STUDY OF ACUTE HEPATIC DYSFUNCTION ASSOCIATED WITH DENGUE FEVER IN NORTH WEST ZONE OF RAJASTHAN

Abstract

Background: Atypical manifestations of dengue viral fever have been described in recent past, including involvement of the central nervous system, cardiac alterations, and elevations in aminotransferase levels, with reactive hepatitis. Hepatic involvement can be characterized by manifestations of acute hepatitis, with pain in the right hypochondrium, hepatomegaly, jaundice, and raised aminotransferase levels. Although the liver is not the directly targeted organ for dengue virus, histopathological findings, including centrilobular necrosis, fatty alterations, hyperplasia of the Kupffer cells, acidophil bodies and monocyte infiltration of the portal tract have been detected in patients with dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). In most cases, hepatic involvement prolongs the clinical course of this self-limiting viral infection, but it does not constitute a sign of worse prognosis.
 Methods: Hundred confirmed diagnosed inpatient cases of dengue fever were included. Clinical examination and laboratory investigations including liver function tests and serum electrolyte levels were performed regularly at appropriate interval. Viral hepatitis testing was also performed to check for any co-infection or pre-existing viral hepatitis. On the basis of increase in serum aminotransferase levels, patients were divided into two groups; Mild (up to 5 times normal) to Moderate (5- 10 times) acute hepatitis: AST or ALT 45-300 IU/L and severe acute hepatitis: AST or ALT > 300 IU/L or ? 10 times. On basis of serum protein levels, the patients were grouped in two groups, one with hypoalbuminemia; serum albumin <3.0 g/dL and without hypoalbuminemia
 Results: In this study out of total 100 patients 67 were men (67%) and 33 were women (33%). The mean age of the patients was 39 ± 3.1 years. The patients were in the range of age 22-54 years. Maximum number of patients were in third decade of life. All the patients were tested positive for NS1 antigen test. Fever was the most common presenting complaint with mean duration of fever was 6 ± 3.27 days with mean temperature of 38.5 ± 1°C, 21% had abdominal pain, 17% had rash, 3% had jaundice. Liver function tests (LFTs) show the median ALT of 88.50 IU/L with range from 43.25-317.22 IU/L, median AST of 174 IU/L with range from 47-371.5 IU/L. 91% of the patients had elevated AST levels and almost 79% patients had elevated ALT (hepatitis). Normal levels of serum aminotransferase AST and ALT levels were seen in 9% and 21% patients respectively. Mild to moderate increase in AST and ALT levels were seen in 84% and 75% of cases respectively whereas more than 10-fold increase in AST and ALT levels were seen in 7% and 4% patients respectively as shown in Table 1. Mortality was 2% in our study.
 Conclusions: Dengue viral fever contributes significantly to the disease burden in developing countries. Although the disease is self-limiting, but a significant number of cases show signs of organ dysfunction including liver dysfunction. The diagnosis of Dengue may be difficult in some cases due to false negative reports in first few days. It is thus important to investigate all suspected dengue patients with liver function test (serum transaminases levels), so that liver dysfunction can be detected early and proper management can be initiated.
 Keywords: Dengue Viral Fever, Immune Hepatitis, Serum Aminotransferases, Hepatic Dysfunction.