Complication Of Dengue Research Articles

Abstract 10196: A History of Dengue Infection is Associated with Lower Global Longitudinal Strain by Speckle Tracking Echocardiography in Men from the Amazon Basin

Background: Studies have shown that infection with dengue virus may affect the heart in the acute phase, and that men possibly have a higher risk of severe dengue complications. No studies have investigated if dengue infection also may affect long-term cardiovascular function. Hypothesis: We hypothesized that adults from the general population with a self-reported history of dengue infection had lower myocardial strain compared to controls. Furthermore, that strain could be even lower in men with a history of dengue. Methods: We enrolled individuals from the general population in the Amazon Basin. History of self-reported dengue infection and cardiovascular risk factors were collected by questionnaires. All persons underwent physical examination and bedside echocardiography. We analyzed global longitudinal strain (GLS) and circumferential strain (GCS). Results: We included 529 individuals (mean age 39±15 years, 39% men) of which 49% (n=259) had a history of dengue infection. A history of dengue infection was not associated with lower GLS (Figure A). However, when stratifying the population by sex, dengue infection in men was significantly associated with lower GLS (OR 1.13 per 1% decrease [95%CI 1.02 to 1.24], P=0.014) and GCS (OR 1.06 per 1% decrease [95%CI 1.01 to 1.12], P=0.030), whereas no relationship was found for women (Figure A). In multivariable models adjusted for age, blood pressure, heart rate, creatinine, smoking habits, diabetes and income, the association with GLS (OR 1.13 [95%CI 1.02 to 1.25], P=0.016) and GCS (OR 1.07 [95%CI 1.01 to 1.14], P=0.015) remained significant in men (Figure B and C). We found no significant relationship with left ventricular ejection fraction. Conclusion: Dengue may potentially have long term effects on left ventricular systolic function as measured by strain in men. This calls for further studies to assess long-term cardiac sequelae and subclinical myocardial impairment in individuals with a history of dengue.

Dengue and the heart.

Dengue is a neglected viral arthropod-borne tropical disease transmitted by the bite of infected Aedes spp. mosquitoes. It is responsible for a significant global burden of disease and corresponding socio-economic implications. There are four different virus serotypes, all of which are found predominantly in countries with tropical climates. Patients with dengue may present with cardiovascular (CV) manifestations, contributing to associated death and disability. A systematic review was conducted to identify CV manifestations of dengue, wherein 30 relevant studies were identified in the MEDLINE and PubMed databases. CV complications of dengue include rhythm abnormalities, hypotension, myocarditis, pericarditis and deterioration in myocardial function. Prompt recognition and treatment of CV complications of dengue are essential to reduce morbidity and mortality in these patients, who are at risk of progressing to cardiogenic shock and heart failure.

Plasma leakage in dengue: a systematic review of prospective observational studies

Plasma leakage is a precursor to life-threatening complications of dengue, but this group is poorly defined and not often reported in literature. Patients with Dengue haemorrhagic fever (DHF) as defined in the 1997 World Health Organization classification are often reported, and they all have plasma leakage, but some patients with plasma leakage do not meet the definition of DHF. The study aims to estimate the frequency of plasma leakage and DHF (as a surrogate of plasma leakage) in dengue and its variations based on virus serotype, geography, patient gender and pre-existing immunity to dengue. PUBMED, Scopus, EMBASE, CINAHL and Web of Science were searched for prospective observational studies reporting on plasma leakage or DHF. Quality of data was assessed using the NIH quality assessment tool for cohort studies. Forty-three studies that recruited 15,794 confirmed dengue patients were eligible. Cumulative frequency of plasma leakage was 36.8% (15 studies, 1642/4462, 95% CI 35.4–38.2%), but surprisingly the estimated cumulative frequency of DHF was higher (45.7%, 32 studies, 4758/10417, 95% CI 44.7–46.6%), indicating that current medical literature over-reports DHF or under-reports plasma leakage. Therefore, a reliable estimate for the proportion of dengue patients developing plasma leakage cannot be derived from existing medical literature even after applying rigorous inclusion criteria to select homogenous studies. Plasma leakage is an important marker of “at-risk” dengue patients and standardizing its definition, diagnosis and reporting should be a priority in research and global policy.

The relationship between platelet count and the onset of leaking phase in dengue patients

Introduction: The complications of dengue are related to reduced intravascular volume following plasma leakage. Thrombocytopenia or platelet dysfunctions are detected in all stages of the illness and are related to the clinical outcome. The main objective of the study was to correlate absolute platelet count to the onset of leaking phase in dengue patients who had entered into leaking phase after the hospital admission. Methods: One hundred and sixteen patients (age range 14-74 years, median age 33 years) who entered the leaking phase after admission were recruited to the study. Dengue infection in patients was confirmed with either the presence of positive NS1 or positive IgM antibodies. Serial ultrasonography was done from admission until the leaking phase is detected. Platelet counts were assessed twice per day just prior to the ultrasonography. Results: There were 47 (40.5%) females and 69 (59.5%) males among the recruited patients. The mean number of days at which leaking was detected following onset of fever was 4.9 ± 0.9 days. The mean platelet count at the onset of leaking phase was 30,051 ± 17,023 /μL. Age and the platelet count at the time of onset of leaking phase was significantly negatively correlated (whole group r = -0.323 p < 0.001; in females r = -0.369, p = 0.011; males r = -0.280 p = 0.020). Platelet count at the time of onset of leaking phase was significantly lower in the patients older than 30 years of age (27,577.5 ± 17,361.4) compared to those of the patients younger than 30 years (33,955.6 ± 15,888.8) (p=0.032). Upper limit of the range of platelet count at the onset of leaking phase was 77, 000/ μL which was slightly lower in females. Conclusions: According to this study, the value of platelet count as a predictor of the progression of dengue infection depends on the age of the patients. Young patients are more prone to develop leaking phase with higher platelet counts than the older patients.

P-OT025. A rare case of dengue encephalopathy in pregnant woman

Introduction . Dengue fever has been known for more than two decades as a tropical endemic infection caused by the dengue virus that affected from Aedes aegypti . Complications of dengue fever are common and usually related to renal and hepatic dysfunction. Encephalopathy is a rare complication. Here we report an unusual case of pregnant woman with dengue encephalopathy. Results . A 28-year-old female, G1P0A0, consulted by the anesthetic division with loss of consciousness. Prior to that, she had acute fever with history of acute progressive cephalgia and positive results of IgG and IgM dengue antibody. She was 20 weeks of pregnancy. On examination she was stuporous (E2V2M5). Lateralization, pathological reflex, and meningeal signs were not found. Laboratory examination showed thrombocytopenia 23 × 10 3 /µl, increased transaminase enzyme, hypokalemia 2.53 mmol/L, and hypoalbuminemia 2.35 gr/dL. Head CT Scan showed cerebral edema. During hospital care, she was monitored closely. Careful fluid management was carried out with additional treatment consisted of thiamine 100 mg/12 h, piracetam 800 mg/12 h, folic acid 2 × 1 mg, and transfusion of albumin and premix KCL. Patient condition was improved after 7 days of hospital care. The encephalopathy lasted for 5 days. Patient was discharged with full of consciousness and the baby was safe. Conclusion . Encephalopathy is a rare manifestation of DHF. However, it is a significant diagnostic challenge when it presents in atypical form, especially during pregnancy. It was first reported in 1976, and worldwide literature search shows the various incidence of dengue encephalopathy from 0.5% to 6.2% with a mortality rate up to 40%. The complications of dengue in pregnancy have been scarcely studied. There are increased risks of maternal hemorrhage, preterm labor and stillbirths. Dengue should be the differential diagnosis even a pregnant women presents with fever and altered sensorium especially in endemic areas like Indonesia.

Neurological Manifestations of Dengue Fever.

Background:Dengue is a common endemic infection in India. Neurological complications involving various parts of the neuro-axis have been reported. We report neurological complications amongst dengue patients admitted to a tertiary hospital in Western India.Materials and Methods:Patients admitted in a tertiary hospital in Western India with dengue infection and having neurological symptoms were included in this study. Their history, physical examination, laboratory investigations and imaging studies were obtained from the inpatient records and analysed.Results:Between January 2014 to December 2019, a total of 5821 patients were diagnosed with dengue. Of these, 154 (2.64%) had neurological manifestations. Encephalopathy in a setting of multisystem involvement was seen in 31.2% patients, encephalitis with focal features, abnormal imaging and/or abnormal cerebrospinal fluid (CSF) examination was seen in 15.6%, syncope in 27.3% and acute symptomatic seizure in 11.0%. Less common presentations were intracranial haemorrhage (4.5%), Guillain-Barre syndrome (GBS) (3.2%), optic neuritis (1.9%), myositis (1.3%), hypokalemic paralysis (1.3%), ischemic stroke (0.6%), posterior reversible encephalopathy syndrome (PRES) (0.6%), myoclonus (0.6%) and brachial plexopathy (0.6%).Conclusions:In this study of patients admitted with dengue, neurological complications due to dengue were seen in 2.64%. Encephalopathy, encephalitis and syncope were the commonest manifestations, followed by acute symptomatic seizures, intracranial haemorrhage and GBS. The entire neuroaxis can be involved in dengue infection. To the best of our knowledge, this is the largest reported study of neurological complications of dengue.

A Dengue Virus Serotype 1 mRNA-LNP Vaccine Elicits Protective Immune Responses.

Dengue virus (DENV) is the most common vector-borne viral disease, with nearly 400 million worldwide infections each year concentrated in the tropical and subtropical regions of the world. Severe dengue complications are often associated with a secondary heterotypic infection of one of the four circulating serotypes. In this scenario, humoral immune responses targeting cross-reactive, poorly neutralizing epitopes can lead to increased infectivity of susceptible cells via antibody-dependent enhancement (ADE). In this way, antibodies produced in response to infection or vaccination are capable of contributing to enhanced disease in subsequent infections. Currently, there are no available therapeutics to combat DENV disease, and there is an urgent need for a safe and efficacious vaccine. Here, we developed a nucleotide-modified mRNA vaccine encoding the membrane and envelope structural proteins from DENV serotype 1 encapsulated in lipid nanoparticles (prM/E mRNA-LNP). Vaccination of mice elicited robust antiviral immune responses comparable to viral infection, with high levels of neutralizing antibody titers and antiviral CD4+ and CD8+ T cells. Immunocompromised AG129 mice vaccinated with the prM/E mRNA-LNP vaccine were protected from a lethal DENV challenge. Vaccination with either a wild-type vaccine or a vaccine with mutations in the immunodominant fusion loop epitope elicited equivalent humoral and cell-mediated immune responses. Neutralizing antibodies elicited by the vaccine were sufficient to protect against a lethal challenge. Both vaccine constructs demonstrated serotype-specific immunity with minimal serum cross-reactivity and reduced ADE in comparison to a live DENV1 viral infection.IMPORTANCE With 400 million worldwide infections each year, dengue is the most common vector-borne viral disease. Forty percent of the world's population is at risk, with dengue experiencing consistent geographic spread over the years. With no therapeutics available and vaccines performing suboptimally, the need for an effective dengue vaccine is urgent. Here, we develop and characterize a novel mRNA vaccine encoding the dengue serotype 1 envelope and premembrane structural proteins that is delivered via a lipid nanoparticle. Our DENV1 prM/E mRNA-LNP vaccine induces neutralizing antibody and cellular immune responses in immunocompetent mice and protects an immunocompromised mouse from a lethal DENV challenge. Existing antibodies against dengue can enhance subsequent infections via antibody-dependent enhancement (ADE). Importantly our vaccine induced only serotype-specific immune responses and did not induce ADE.

The The Effect of Carica Papaya Leaf Extract on Increasing Platelet Count Among Dengue Fever Patients: A Meta-Analysis

Objective: Hemorrhagic fever is a very serious complication of dengue, which remains a major public health concern in the Philippines. On average, there are 170, 503 symptomatic dengue infections and 750 deaths reported in 4 years, with an incidence of around 180 dengue episodes per 100, 000, and a case fatality rate of approximately 0.44%, owing mostly to bleeding secondary to thrombocytopenia, with reported mortalities occurring among individuals less than 20 years of age. In most rural areas in the country, a health care institution is often inaccessible and most patients cannot afford the high cost of hospitalization and transfusion. In a local study of the knowledge, attitude, and practices on dengue, herbal medicines including “tawa-tawa” and papaya are often used as an alternative supportive treatment due to easy availability and low cost. Animal studies also support a potential therapeutic effect. The objective of this review is to assess the effects of C. papaya leaf extract as an adjunct treatment among patients with dengue hemorrhagic fever using a systematically searched and synthesized meta-analysis.
 Materials and Methods: Six randomized clinical trials with a total of 988 subjects involving the efficacy of C. papaya leaf extract in increasing platelet count in dengue patients were searched through PubMed, Google Scholar, Scopus, and Science Direct and selected after assessing the eligibility and validity of the articles through a standard criterion. Mean difference of platelet counts from days 1 to 5 were pooled together and analyzed by Review Manager (RevMan) software 5.3.
 Results: Pooled estimates revealed significant increase in platelet count at Day 3 (MD=12.18; CI 10.28-14.08), Day 4 (MD=31.30; CI 27.77-34.83), and Day 5 (MD=13.23; CI 9.90-16.55). Random effects model at Day 5 also showed significant increase in platelet count. Likewise, a subgroup analyses of studies based on route of administration, frequency, and dosage were performed and showed significant increase in platelet count.
 Conclusion: Based on this meta-analysis, supplementation with C. papaya leaf extract in patients with dengue shows a beneficial effect in increasing platelet count.

Rescue therapy with intravenous immunoglobulin in severe refractory dengue: A pilot study

BackgroundSevere dengue causes more than 22,000 deaths annually worldwide. Complicated dengue has high mortality of 44–72%. Disordered immune system with capillary leak and thrombocytopenia are hallmark of complicated dengue. Intravenous immunoglobulin (IV Ig) therapy has shown to be effective in complicated dengue in pediatric age group with refractory shock, but studies in adults are lacking. Its immunoresuscitative role is not yet fully explored in critically ill patients with severe dengue. MethodsThis is retrospective observational study of patients with complicated dengue fever who were administered IV Ig therapy in a tertiary care hospital of southern India from 01 Jan 2018 to 31 Dec 2019. ResultsA total of 999 patients with dengue were admitted; 754 (75.47%) were males, and 245 (24.53%) were females. A total of 402 (40.24%) patients presented with warning signs. Bleeding was seen in 121 patients (12.11%); 102 (10.21%) had shock; 29 (2.90%) had acute kidney injury and 24 (2.40%) had adult respiratory distress syndrome. Overall, four people died (mortality rate: 0.40%). IV Ig in the dose of 0.4 g/kg for 5 days was used in 13 critically ill patients where standard therapy failed, 9 patients with refractory shock (which included three with myocarditis with refractory shock), 2 with encephalitis, 2 in hemophagocytic lymphohistiocytosis. Two patients died, one with myocarditis with refractory shock and another with refractory shock. ConclusionIV Ig therapy in critically ill patients with complicated dengue can be used as a rescue therapy.

Is there any association between body mass index and severity of dengue infection?

Dengue, an acute infectious disease caused by a flavivirus, is a threat to global health. There is sparse evidence exploring obesity and the development of more severe dengue cases in adults. With increasing prevalence of obesity in areas with a high risk of dengue infection, obesity may increase the burden and mortality related to dengue infection. Our study aimed to determine the association between obesity and the development of more severe dengue infection in primary healthcare settings and whether these associations were modified by dengue fever phase. A cohort study was conducted among laboratory-confirmed dengue patients aged >18 y in the central region of Peninsular Malaysia from May 2016 to November 2017. We collected demographic, clinical history, physical examination and laboratory examination information using a standardized form. Dengue severity (DS) was defined as either dengue with warning signs or severe dengue. Participants underwent daily follow-up, during which we recorded their vital signs, warning signs and full blood count results. Incidence of DS was modeled using mixed-effects logistic regression. Changes in platelet count and hematocrit were modeled using mixed-effects linear regression. The final multivariable models were adjusted for age, gender, ethnicity and previous dengue infection. A total of 173 patients were enrolled and followed up. The mean body mass index (BMI) was 37.4±13.75 kg/m2. The majority of patients were Malay (65.9%), followed by Chinese (17.3%), Indian (12.7%) and other ethnic groups (4.1%). A total of 90 patients (52.0%) were male while 36 patients (20.8%) had a previous history of dengue infection. BMI was significantly associated with DS (adjusted OR=1.17; 95% CI 1.04 to 1.34) and hematocrit (%) (aβ=0.09; 95% CI 0.01 to 0.16), but not with platelet count (x103/µL) (aβ=-0.01; 95% CI -0.84 to 0.81). In the dose response analysis, we found that as BMI increases, the odds of DS, hematocrit levels and platelet levels increase during the first phase of dengue fever. Higher BMI and higher hematocrit levels were associated with higher odds of DS. Among those with high BMI, the development of DS was observed during phase one of dengue fever instead of during phase two. These novel results could be used by clinicians to help them risk-stratify dengue patients for closer monitoring and subsequent prevention of severe dengue complications.

English

BACKGROUND Dengue Fever is a major contributor to morbidity and mortality among all communicable diseases in Kerala. Delay in seeking care is significantly associated with complications. Understanding health seeking behaviour of persons with risk of infection, helps in improving health care delivery. METHODS A cross sectional study was done among 100 dengue fever patients listed under Integrated Disease Surveillance Programme (IDSP) of Thiruvananthapuram district, Kerala state. Data regarding their health seeking behaviour during the course of the disease was collected using a structured questionnaire. RESULTS Inappropriate health seeking behaviour indicated by delay in seeking care and self medication was found in 22 % (95 % CI; 13.9 - 30.1) of subjects. Mean (SD) of delay in seeking health care was 3.01 (1.3) days. Treatment was initiated from government health facility by 63 % of patients. Primary level health care facility was sought by 61 % patients whereas 30 % opted for a secondary level facility. Proximity of the location of health facility to the patient’s dwelling was the factor influencing choice of treatment facility in 70 % of patients, followed by perceived quality of facility (15 %) and patient perceived competency of the physician (9 %). Male gender (p = 0.03) and educational status less than secondary level (p = 0.008) were significant risk factors for self-medication and delay in seeking health care. CONCLUSIONS Inappropriate health seeking behaviour in patients with suspected Dengue Fever is comparatively less in Kerala. Majority are seeking care from Government facilities and access to health care is influencing health seeking behaviour. Awareness generation in general and specific interventions targeting those with lower education status can further improve health seeking behaviour and reduce complications of dengue. KEYWORDS Health Seeking Behaviour, Dengue Fever, Self-Medication, Delay in Seeking Care, Healthcare Access, Kerala

To Study the Effectiveness of Platelet Transfusion in Management of Dengue Patients in Tertiary Care Hospital

Background: Dengue has been emerging as rapidly spreading and dreaded mosquito borne disease caused by the bite of Aedes Aegypti Mosquito. Clinical features are variable and presents with Dengue fever or Dengue Hemorrhagic fever or more severe Dengue shock syndrome. Thrombocytopenia is presenting feature in in all Dengue cases and some often presents with bleeding. Platelet transfusions are given in patients with haemorrhagic symptoms. Present study thus aims to study the effectiveness of platelet transfusion in management of Dengue patients with Dengue haemorrhagic fever and Dengue shock syndrome. Results: In present study, a total of 20 patients were diagnosed as dengue confirmed cases by serological testing methods. Out of 20, 12 (60%) patients had dengue fever with platelet count in range of 50,000-80,000 per μl. Two patients with Dengue fever had Petechial spots with platelet count in range of 50,000 per μl and were given prophylactic Single Donor Platelet Transfusions. Eight patients (40%) presented with Dengue Haemorrhagic fever and platelet count of < 20,000 per μl. These patients were given single donor platelet transfusions. Six patients responded good with CCI of > 30,000 per μl and 2 patients recorded as non-responders. Conclusion: This study suggests that 25% Platelet transfusions are inappropriate. Platelet transfusions are more effective when it is given to patients with platelet count <20,000 per μl. Platelet transfusion should be given based on platelet count and hemorrhagic manifestations, as this decreases hospitalization of patients and complications of dengue.

Dengue fever complicated with acute ST elevation myocardial infarction - a therapeutic conundrum: our experience from two cases

Dengue fever has a wide range of clinical manifestations from asymptomatic disease to complicated dengue haemorrhagic fever and dengue shock syndrome. Bleeding manifestations in dengue is well known but thrombotic events complicating dengue is uncommon. ST elevation myocardial infarction during dengue is rare and poses important management dilemma. At present, there is no consensus on how to manage this situation. We present two patients with dengue fever developing ST elevation myocardial infarction and our experience in the management. We suggest case-based management of acute coronary syndrome in dengue, guided by the degree of thrombocytopaenia and bleeding risk. Further studies are needed to include this into existing dengue management guidelines.

Liver function in dengue and its correlation with disease severity: a retrospective cross-sectional observational study in a tertiary care center in Coastal India.

Introductiondengue, the most important arthropod- borne disease is transmitted to humans by mosquitos of the Aedes family. Liver dysfunction in dengue varies from mild injury with elevation of transaminases to severe hepatocyte injury. The aim of our study was to assess the prevalence of hepatic dysfunction in patients with dengue and to correlate between the severity of the disease with the extent of hepatic dysfunction.Methodsretrospective cross-sectional observational study including 120 patients with confirmed dengue serology admitted in Medicine Department of Father Muller Medical College during November 2018-December 2019. Patient demographics, presenting symptoms, clinical signs, laboratory parameters such as complete blood count, serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), alkaline Phosphatase (ALP), total and direct bilirubin; serum albumin and globulin levels were collected. Patients were categorized based on the modified WHO classification of 2009 into dengue with or without the warning signs and severe dengue. Comparison of multiple means across disease severity was performed using One Way-ANOVA with post hoc analysis using least significant difference. Pearson's correlation coefficient test was used to calculate the correlation between transaminases and platelet count. P-value <0.05 and CI 95% were considered in all analyses.Resultsserum glutamic-oxaloacetic transaminase was elevated in 66.7%, 78.6% and 91.7% patients of dengue without warning signs, warning signs and severe dengue respectively. Serum glutamic-pyruvic transaminase was elevated in 42.4%, 52.4% and 91.7% patients of dengue without warning signs, warning signs and severe dengue respectively. Patients with elevated SGOT (93.8%) and SGPT (81.2%) had a higher incidence of bleeding manifestations. Hypoalbuminemia (50.8%) and A: G ratio reversal (27.3%) was significantly more in severe dengue (p<0.0001). Serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase levels negatively correlated with platelet count (p<0.0001).Conclusionliver involvement in the form of elevated transaminases was found in 74.2% dengue patients. Serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase level increases with increase in dengue severity which is indicated by fall in platelet count as they are negatively correlated with each other. Liver damage is one of the common complications of dengue and transaminitis, hypoalbuminemia and reversal of A: G ratio should be used as biochemical markers in dengue patients to detect and monitor hepatic dysfunction.

SPECTRUM OF COMPLICATED DENGUE FEVER IN RAWAL INSTITUTE OF HEALTH SCIENCES ISLAMABAD: A CROSS SECTIONAL STUDY

ABSTRACT&#x0D; BACKGROUND &amp; OBJECTIVE: Pakistan has been facing frequent dengue fever epidemics for the last decade. The current study aims at various complications of dengue fever and their association with age, gender, serology, duration, and symptoms.&#x0D; METHODOLOGY: This cross-sectional study was conducted at the Medicine department, RIHS Islamabad, over eight months of duration after ethical approval. The dult indoor dengue fever cases were selected by consecutive sampling and informed consent obtained. Cases with malaria co-infection, hematological disease, and severe systemic illness were excluded. The symptoms, hematological counts, serology (dengue NS-1, IgG, and IgM), liver function tests, coagulation profile, pneumonia, and pericardial effusion, were documented. Data were analyzed by SPSS V-22.&#x0D; RESULTS: Among 75 cases, 19(25%) were females and 56(75%) males. The mean age was 33.5+12.7. The mean duration of symptoms was 5.4+2.0 days. Dengue NS-1 was positive in 45(60%), IgM in 22(29%), and IgG in 8(11%). Symptoms observed were fever 97%, headache 53%, pain abdomen 35%, vomiting 48%, rash 17%, and body aches 39%. Complicated Dengue fever was seen in 21(28%). Complications include gum bleed 12%, liver impairment 6.6%, gastrointestinal bleed 5%, per-vaginal bleed 4%, epistaxis 4%, hematuria 3%; pleural effusion, ascites and pneumonia 2.6% each, pericardial effusion 1.3% and one expiry. Age, gender, dengue serology, and hematological profile wasn’t found to be associated with complications.&#x0D; CONCLUSION: Complications are frequent in indoor dengue cases that include hemorrhagic complications, liver impairment, effusions, and pneumonia. Early presentation to the hospital may be helpful to screen for impending complications with improved morbidity and better patient care.

A case of cerebellar hemorrhage in a patient with severe dengue

Background: Degue is the most rapidly spreading mosquito-borne viral infection in the world with various symptoms and clinical presentation. Neurological complication of dengue is rare (0.5 to 7.4%) and its pathophysiological basis of is not fully understood. Data on cerebellar hemorrhage as a complication of severe dengue is rare. Case Description: This is a case of a 25 y old female, household helper presented with a 5 d history of fever, headache, nausea, vomiting and diarrhea. She consulted a physician, diagnosed was acute gastroenteritis, advised supportive care. Workups showed leukopenia, thrombocytopenia, positive dengue NS1Ag. She was hydrated intravenously at home. In 2 d, platelet count further decreased and transaminases were elevated. On the 5th day of illness, fever and diarrhea resolved, but was noted disoriented. At the ER, vital signsBP 100/70 mmHg, CR 78, RR 26, temperature 36.5C, GCS13 (E3V4M6) with petechiae on both upper extremities. Manual muscle and sensory testing were normal but unable to do finger to nose test, no meningeal and Babinski signs. Repeat workups showed leukocytosis (22.70 x 109/L), thrombocytopenia (47.00 x 109/L). She was hydrated with PNSS and started on cefepime and moxifloxacin to cover for a possible pneumonia. She was noted to be unresponsive and was intubated. ET secretion was frothy. Other workups: 12LECG sinus tachycardia with anterior wall ischemial; chest X-ray pulmonary edema; cranial CT scan showed cerebro-cerebellar edema with uncal herniation, non-communicating hydrocephalus with possible subarachnoid hemorrhage. Her blood pressure decreased requiring vasopressors. She was to be transfused with platelet concentrate, when she had cardiac arrest and attempted resuscitation 3 times. Patient eventually expired. Post-mortem examination showed pulmonary congestion (right lung 700 g, left lung 750 g); pleural effusion (right 300 mL light red, thin fluid), cerebellar hemorrhage and gastric pinpoint hemorrhages. Discussion: Prevalence of hemorrhage on dengue, especially in the central nervous system, especially in the cerebellum is rare. Further studies may be done to determine certain risk factors that may be predict such complications. Conclusion: We were able to present a case of severe dengue presenting with cerebellar hemorrhage and circulatory collapse and exemplified that these cases possessed high mortality despite early diagnosis.

Análise espacial dos casos de dengue e correlação com dados pluviométricos em São Paulo no período de 2015 a 2016

O vírus da dengue é um arbovírus da família dos flavivírus. Há quatro tipos de vírus: DEN (1, 2, 3 e 4), sendo o DEN3 o mais grave. É transmitido pelo Aedes aegypti. As formas clínicas são: a Dengue Clássica, Dengue com Complicações e a Febre Hemorrágica da Dengue. O Brasil é responsável por 70% dos casos da doença nas Américas. O objetivo deste trabalho foram demarcar as localidades que apresentam o maior número de casos de dengue correlacionando com dados pluviométricos no estado de São Paulo no período de 2015 a 2016. A prevalência foi calculada nos munícipios que registraram os maiores números de casos associados aos índices pluviométricos. Para edição de mapas foi utilizado o programa Q GIS 2.18. O estado de São Paulo foi o que apresentou o maior número de casos no país no período de 2015 a 2016 (1.688.688). As maiores prevalências relacionadas com os dados pluviométricos foram registradas em Onda Verde (17.989,9/1445,9mm); São Paulo (17.965,9/1819,4mm); Rio Claro (10.804,7/1435,0mm); Catanduva (8.915,2); Sorocaba (8.815,6/1476,3mm) e Campinas (5.766,2/1793,5mm). Os municípios com os maiores números de casos registrados foram: Onda Verde, São Paulo, Rio Claro, Catanduva, Sorocaba e Campinas. A associação entre a pluviosidade e sorotipo viral provavelmente colaboraram para a elevada prevalência da doença em 2015. Naquele ano a região Sudeste apresentou uma crise hídrica e as pessoas armazenaram água das chuvas em recipientes improvisados aumentando assim a oferta de criadouros do mosquito. Desta forma é muito importante que ocorra o incremento das políticas públicas de prevenção e a conscientização da população ao respeito de medidas para prevenção de criadouros do mosquito vetor. Palavras Chaves: Dengue. Aedes aegypti. Prevalência.

Manual Partial Exchange Transfusion a Cost Effective Life Saving Intervention in Sickle Cell Crisis: Single Centre Retrospective Data Analysis

Introduction: Sickle cell disease (SCD) poses a considerable health burden in lower middle income country (LMIC) like India. One ICMR survey reported about 20% of children with SCD died by the age of two years and 30% of children with SCD amongst the tribal community in India died before they reached adulthood. Data on mortality rate in the adult population with SCD is sparse. Our centre data shows that despite the availability of Hydroxyurea and supportive care, almost one-third of hospitalized Sickle Cell Crisis patients develop life threatening complications. Manual Partial Exchange Transfusion is a cost-effective intervention to decrease mortality in Sickle Cell Crisis. But perhaps, it is an underutilized therapy. In India, the cost incurred for each session of exchange transfusion, if done by the RBC apheresis machine, is $420. Whereas Manual Exchange Transfusion costs only $70(including the cost of the central venous catheter) for the first session followed by $15 for each subsequent session. Aim: A single centre retrospective data analysis to evaluate the outcome of Sickle Cell Crisis patients undergoing Manual Partial Exchange Transfusion during hospitalization. Material and Method: A total of 553 SCD patients on regular follow up at the Haemato Oncology Care Centre (HOCC) from July 2012 to July 2020 were evaluated.169 patients were hospitalized for treatment of Sickle Cell Crisis at the Bhailal Amin General Hospital and Sterling Hospital Vadodara. The data was retrieved after the IRB/Apex committee approvals for retrospective analysis. The indication for exchange transfusion was Acute Chest Syndrome 19(35%), Hepatic cell crisis 11(20%), Vaso Occlusive Crisis not responding to the conservative line of therapy in 48 hours of treatment 11(20%), Cerebrovascular Accident (CVA) 5 (9%), Avascular Necrosis of Femur with excruciating pain 3 (6%), Complicated Dengue with Multi-organ failure 3 (6 %), Priapism 1 (2%) and Splenic Sequestration 1 (2%). Central venous access was secured with a central venous catheter or dialysis catheter. Simple packed cell volume was transfused to 11(20%) patients and 5(9%) patients received platelet transfusion. The cut-off values for HB and Platelet count were 8 gm% and 50000/cumm, respectively at the time of the Manual Partial Exchange Transfusion procedure. Blood volume withdrawn was 5 to 10 ml /kg, followed by an equal volume of packed cell volume transfusion at every session. The procedure was repeated every 12 hr or 24 hr depending on the clinical condition of the patient. HbS value was reassessed post 4 sessions with repeat testing done after 2 to 4 sessions if the observed HbS value was more than 30% or more than 10% (for CVA) after 4 sessions. The endpoint was clinical recovery with HbS less than 30% or no clinical recovery despite the achievement of HbS less than 10%. In CVA the endpoint was HBS less than 10%. Results: Manual Partial Exchange Transfusion was carried out in 54/169 (32 %) hospitalized patients. The median age was 25yrs (range 5 yrs to 69 yrs), with male predominance [Males 42(77%) and females 12(23%)].Pre procedure HbF value was &amp;lt;10% in 13(24%), 10 to 20% in 23 (43%) and &amp;gt;20% in 18(33%). A total of 50 out of 54 (93%) patients recovered completely. 28 (52%) patients were hemodynamically stable with normal SPO2 on room air at the time of Manual Partial Exchange Transfusion with an average of 7 days of hospitalization. All of these patients recovered completely with less than 5 sessions of Manual Partial Exchange Transfusion. 26(49%) patients were critically ill and had an average of 12 days of hospitalization. They were on Ventilator and Inotrope support at the time of Manual Partial Exchange Transfusion. 14/26(54%) critically ill patients recovered completely with an average of 6 sessions of Manual Partial Exchange Transfusion. 12/26(46%) critically ill patients succumbed even though post exchange HBS value decreased to less than 10%. The overall mortality rate of SCD patients in this analysis was 12/553 (2.1%), significantly lower than what was historically reported as 30% in the ICMR survey. Underlying Dengue viral infection associated with Multi-organ dysfunction and Fulminant hepatic failure were risk factors for mortality observed in our study. Conclusion: Manual Partial Exchange Transfusion is highly effective in reducing mortality in Sickle Cell Crisis. It is feasible and cost-effective in small centres lacking apheresis machine facility. Disclosures No relevant conflicts of interest to declare.

P.668 Lysergic acid diethylamide (LSD) modulates social behavior and neuronal activity of pyramidal neurons in the medial prefrontal cortex

Dengue fever, transmitted by Aedes aegypti mosquitoes, is one of the most common vector-borne disease. Its incidence is increasing steadily worldwide, becoming a major public health problem in the tropical and subtropical zone. Neurological manifestations after dengue are not very common and acute disseminated encephalomyelitis (ADEM) following dengue infections is rare with a few cases documented in literature. Clinical characteristics and typical lesions of ADEM on magnetic resonance imaging (MRI) of brain along with serologic positivity for dengue usually confirm the diagnosis. We report a case of ADEM which developed as a neurological complication of dengue during an epidemic in a 39-year-old woman.

Cardiac manifestations of dengue fever in pediatrics age group

Background: Dengue infection is a serious public health concern in tropical and subtropical regions of the world. Cardiac involvement is a known but rare complication of dengue. Electrocardiogram (ECG) and 2D echocardiogram (ECHO) are preferred non invasive instant diagnostic tool to evaluate the status of heart in dengue infection. Objectives: The present study was carried out to confirm the cardiac manifestation in dengue fever, along with its correlation with the severity of the disease. Materials and Methods: A total of 60 subjects were included over a period of 1-year time from inpatient and outpatient departments presenting with clinical features suggestive of dengue and further confirmed by positive serology test of IgM and/or NS1 antigen by rapid and/or by ELISA method. Cardiac manifestations were analyzed with the help of ECG and 2D ECHO in all serologically confirmed cases. Results: 16 out of 60 cases had cardiac findings in the form of tachycardia, bradycardia, and myocarditis. ECG showed some nonspecific findings like sinus tachycardia followed by sinus bradycardia. Myocarditis diagnosed by ECHO as ejection fractions &lt;50% was observed in four cases of dengue with warning sign and in one of severe dengue, while mild TR was seen in three cases of dengue with a warning sign, two cases of probable dengue, and one case of severe dengue. Conclusion: This study showed that cardiac involvement of dengue infections runs a benign course without any complications. Early diagnosis, strict monitoring, and prompt supportive management reduce the mortality rate in dengue.