Abstract
BackgroundDengue fever is a common mosquito borne viral infection. Severe dengue fever associated severe hepatitis carries high mortality. Based on the beneficial effect of N-acetylcysteine (NAC) in paracetamol poisoning and non-acetaminophen induced liver failure, it is used in dengue fever associated hepatitis in clinical practice. We aim to study the reversal of liver enzymes with NAC in the setting of severe hepatitis due to severe dengue infection.MethodsA retrospective analysis was conducted on hospitalized 30 adults with severe dengue fever with severe hepatitis. These 30 patients had aspartate transaminase (AST) and alanine transaminases (ALT) more than 500 U/L and/or PT INR (prothrombin time and international normalized ratio) more than 1.5. They were treated with NAC infusion of 100 mg/h for 3 to 5 days.ResultsThe mean age of the group was 49.9 ± 11.46 years and 18 (60%) patients were males. Nineteen patients (63%) developed dengue shock. Of them 12 patients (40%) developed hepatic encephalopathy. Median AST on the day of administration of NAC was 1125 U/L interquartile range (IQR) 1653.25 while median ALT was 752 (IQR 459.25). There was a statistically significant reduction of both ALT (p = 0.034) and AST (p = 0.049) from day 1 to 4 after NAC infusion. Rise of platelet count between day 1 and day 4 also showed statistically significant difference (p = 0.011) but the reduction of prothrombin time and international normalized ratio (PT/INR) from 1 to day 4 did not show statistical significance difference. Mean duration of treatment with NAC was 3.61 ± 0.75 days while mean length of hospital stay was 6.2 ± 1.27 days. Only one patient died (3.3%). None of the patients reported adverse drug reaction due to NAC.ConclusionMajority of patients demonstrated marked clinical and biochemical improvements and they recovered fully. We observed faster and significant recovery of liver enzymes following administration of NAC. Based on the above findings, this study provides preliminary evidence for the beneficial effect of NAC in severe hepatitis in dengue infection with greater survival benefits.
Highlights
Dengue fever is a common mosquito borne viral infection
Hepatic encephalopathy was present in 12 patients (40%)
Of 30 patients only one (3.3%) died. In this case series, we studied a series of 30 dengue patients with acute severe hepatitis who were treated with NAC
Summary
Dengue fever is a common mosquito borne viral infection. Severe dengue fever associated severe hepatitis carries high mortality. In majority of patients liver enzyme elevation do not cause hepatic dysfunction, but 4–7% of patients develop significant acute hepatitis with tenfold or more rise of aminotransferase levels [2, 3]. It carries a mortality rate of 50% due to complications such as encephalopathy, severe bleeding, renal failure and metabolic acidosis [4]. Acute liver failure warrants costly novel interventions like molecular adsorbent recirculating system (MARS), which is shown to improve transplant free survival, [9] or urgent liver transplantation None of these methods are readily available in resource poor countries
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