Dengue Hemorrhagic Fever Grade Research Articles

HEMATOLOGY PROFILES AND DISEASE SEVERITY OF PEDIATRIC DENGUE VIRUS INFECTION AT A TERTIARY HOSPITAL IN SURABAYA, INDONESIA

Highlights Dengue virus infections exhibit a spectrum of clinical manifestations, ranging from asymptomatic cases to severe disease, with the potential for fatalities if not managed effectively. Hematology factors significantly contribute to the severity of dengue virus infection. Abstract Background: The escalating incidence of dengue cases in Surabaya, Indonesia, underscores the imperative to comprehend the hematology profiles and disease severity in pediatric patients affected by dengue virus infections (DVI). As the prevalence of DVI continues to surge, understanding the nuanced clinical manifestations becomes paramount for effective management and mitigation of the disease burden. Objective: This study aimed to characterize the hematology profiles and the disease severity of dengue virus infections (DVI) among pediatric patients hospitalized at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia throughout 2019. Material and Method: A retrospective descriptive cross-sectional study was conducted using secondary data from medical records. Pediatric patients aged six months to 18 years were enrolled. A total sampling method comprised 67 patients meeting the inclusion criteria. Result: Severe thrombocytopenia was most commonly observed in dengue hemorrhagic fever (DHF) III cases (36.4%), while leukopenia was predominant in DF cases (42.2%). High hematocrit levels were more prevalent in DHF III cases (27.3%), and high hemoglobin levels were most frequently identified in DHF II and DHF III cases (33% in each case). Significant differences in DVI severity were observed in platelets and hemoglobin levels (p=0.0002 and p=0.0066, respectively) but not in leukocyte and hematocrit levels. Conclusion: Mild thrombocytopenia was prevalent in Dengue Fever (DF), while severe thrombocytopenia was most prevalent in Dengue Hemorrhagic Fever (DHF) grade III. Leukopenia was prominent in DF patients, and platelets and hemoglobin levels varied across severity of DVI. These findings provide insights for improved clinical management and diagnostic criteria refinement.

Analysis of Platelet Lymphocyte Ratio on Severe COVID-19 and Dengue Hemorrhagic Fever Grade IV

Thrombocytopenia can occur in severe COVID-19 or grade IV DHF. In COVID-19, lymphopenia occurs gradually due to Angiotensin Converting Enzyme-2 as the primary response to SARS-CoV-2 and cytokines that can damage lymphocytes. Contrastingly, lymphocytosis occurs in dengue virus infection. Platelet-to-lymphocyte ratio (PLR) is a new inflammatory marker in predicting the severity of both diseases. This study aimed to analyze differences in PLR values in severe COVID-19 and grade IV DHF and determine the cut-off values. Retrospective research of a cross-sectional approach was carried out using medical record data of patients diagnosed with severe COVID-19 and grade IV DHF by clinicians at Dr. Wahidin Sudirohusodo Hospital from January 2017 to October 2021. The platelet-to-lymphocyte ratio was obtained from the complete blood count results using the flow cytometry method at the beginning of hospitalization. Mann-Whitney test and Receiver Operating Characteristics (ROC) curve were used for statistical analysis. A total of 74 severe COVID-19 and 33 grade IV DHF patients were involved; PRL of severe COVID-19 in dead patients was higher than in recovered patients (p>0.05). The platelet-to-lymphocyte ratio value was significantly lower in grade IV DHF patients who died compared to those who recovered (p<0.001). Platelet to-lymphocyte ratio cut-off of 48.30 for severe COVID-19 was obtained with an Area Under the Curve (AUC) of 0.631 (sensitivity of 54.3%, specificity of 78.6%) and cut-off of 0.715 for grade IV DHF with an AUC of 0.989 (sensitivity of 94.4%, specificity of 100%). There was a difference in PLR value in severe COVID-19 and grade IV DHF. Severe COVID-19 patients who died had higher PLR, whereas grade IV DHF patients had lower PLR values. Values above the PLR cut-off of 48.30 for severe COVID-19 and 0.715 for grade IV DHF can predict the severity of the disease.

Effectiveness of platelet transfusion in dengue fever: Rangpur community medical college and hospital experience at Rangpur, Bangladesh

Background: Dengue fever, caused by the dengue virus and transmitted by mosquitoes, is a global health concern, causing mild to severe illness. Severe cases lead to thrombocytopenia, a low platelet count that can cause bleeding. Platelet transfusion is debated as a treatment strategy; some studies support its use to prevent bleeding, while others raise concerns about side effects. The aim of the study is to see the effectiveness of platelet transfusion in dengue patients who has a very low platelet count. Methods: This single-center study was conducted at The Department of Medicine, Rangpur Community Medical College and Hospital, Bangladesh. A total of 52 patients were enrolled and analyzed in this study from March to August 2023. Results: Most cases are Dengue Fever (86.54%), followed by Dengue Hemorrhagic Fever Grade 1 (7.69%) and Dengue Shock Syndrome (5.77%). Bleeding occurred in 15.38% of enrollment. Common symptoms include fever (78.85%), headache (57.69%), cough (67.31%), and myalgia (55.77%). Health parameters include blood pressure (110/70 mm Hg), pulse rate (86.5±12.8 bpm), and temperature (100.5±2.8°F). Investigation findings show S. bilirubin (0.61 mg/dl), S. creatinine (0.94 mg/dl), RBS (120.5 mg/dl), HB% (13.78 g/dl), and PCV (39.75). Platelet counts varied in different conditions, with most responders to platelet transfusion (94.23%) showing no deaths but adverse outcomes related to transfusion reactions (5.77%). Conclusions: The prevalence of dengue fever in Bangladesh necessitates a comprehensive understanding of effective treatment modalities. By examining the outcomes and implications of platelet transfusion in this context, the research seeks to shed light on its effectiveness, thereby informing evidence-based medical practices and improving patient care.

Vitamin D Deficiency (VDD) and Susceptibility towards Severe Dengue Fever-A Prospective Cross-Sectional Study of Hospitalized Dengue Fever Patients from Lahore, Pakistan.

Dengue is a mosquito-borne flaviviral serious febrile illness, most common in the tropical and subtropical regions including Pakistan. Vitamin D is a strong immunomodulator affecting both the innate and adaptive immune responses and plays a pivotal role in pathogen-defense mechanisms. There has been considerable interest in the possible role of vitamin D in dengue viral (DENV) infection. In the present prospective cross-sectional study, we assessed a possible association between serum vitamin D deficiency (VDD) and susceptibility towards severe dengue fever (DF) illness. Serum vitamin D levels were measured at the time of hospitalization in 97 patients diagnosed with dengue fever (DF), dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) at Mayo Hospital, King Edward Medical University, Lahore, PK, from 16 November 2021 to 15 January 2022. In terms of disease severity, 37 (38.1%) patients were DF, 52 (53.6%) were DHF grade 1 and 2, and 8 (8.2%) were DSS. The results revealed that most patients (75 (77.3%)) were vitamin-D-deficient (i.e., serum level < 20 ng/mL), including 27 (73.0%) in DF, 41 (78.8%) in DHF grade 1 and 2, and 7 (87.5%) in DSS. The degree of VDD was somewhat higher in DSS patients as compared to DF and DHF grade 1 and 2 patients. Overall, serum vitamin D levels ranged from 4.2 to 109.7 ng/mL, and the median (IQR) was in the VDD range, i.e., 12.2 (9.1, 17.8) ng/mL. Our results suggest that there may be a possible association between VDD and susceptibility towards severe dengue illness. Hence, maintaining sufficient vitamin D levels in the body either through diet or supplementation may help provide adequate immune protection against severe dengue fever illness. Further research is warranted.

Association between nutritional status and dengue severity in Thai children and adolescents.

Most cases of dengue virus infection are mild, but severe cases can be fatal. Therefore, identification of factors associated with dengue severity is essential to improve patient outcomes and reduce mortality. The objective of this study was to assess associations between nutritional status and dengue severity among Thai children and adolescents. This retrospective cross-sectional study was based on the medical records of 355 patients with dengue treated at the Hospital for Tropical Disease (Bangkok, Thailand) from 2017 to 2019. Subjects were Thai children aged less than 18 years with dengue virus infection confirmed by positive NS1 antigen or IgM. The 1997 and 2009 World Health Organization (WHO) dengue classifications were used to define disease severity and body mass index for age while the WHO growth chart was used to classify nutritional status. The proportions of patients with dengue fever who were underweight, normal weight, and overweight were 8.8%, 61.5%, and 29.7%, respectively. The proportions of patients with dengue haemorrhagic fever (DHF) who were underweight, normal weight, and overweight were 10.2%, 66.1%, and 23.7%, respectively. The proportions of patients with non-severe dengue who were underweight, normal weight, and overweight were 8.6%, 60.9%, and 30.5%, respectively; the same proportions of patients with severe dengue were 10.5%, 67.1%, and 22.4%, respectively. Higher proportions of patients with severe plasma leakage (DHF grade III and IV) were overweight compared with those with mild plasma leakage (DHF grade I and II) (45.5% vs. 18.8%). No difference in nutritional status was observed in patients with different dengue severity.

A Patient with Typhoid Hepatitis

Typhoid hepatitis is typhoid fever accompanied by symptoms of jaundice, hepatomegaly and abnormal liver function tests. The incidence varies between 0.4% -26% of typhoid fever patients. We report a case of a 34-year-old male, presented with fever, epistaxis, gastrointestinal symptoms, thrombocytopenia and elevated AST/ ALT, thus the patient was first diagnosed as dengue hemorrhagic fever grade II. On day 9th the signs and symptoms were persisted, Ig M and Ig G Dengue was negative. Then we evaluated the virus marker for hepatitis and blood culture. The results were negative for HBsAg, anti HCV and Ig M anti HAV, but Salmonella typhi detected on blood culture. The patient was treated with ceftriaxone 1000mg bid iv and get better then discharged from hospital.

Perbandingan antara Rasio Neutrofil Limfosit dan Trombosit pada Kebocoran Plasma Anak

Background: Dengue virus infection is a global health problem. Dengue Hemorrhagic Fever (DHF) has become a global attention because of children death due to plasma leakage. Plasma leakage is a symptom of critical phase in children that occurs on the 3rd to 5th day. Neutrophil lymphocyte (NL) ratio and platelet count change can be seen in critical phase of plasma leakage which can help process of patient’s therapy.&#x0D; Objective: This study aimed to compare the NL ratio and platelets count on plasma leakage in children with DHF.&#x0D; Methods: This study was an analytical study with cross-sectional design. The sample was children with DHF at RSUD Dr.Pirngadi Medan. The data of this study were analyzed by computer software, used an unpaired t test with p &lt;0.05.&#x0D; Results: This study found that the most age of DHF was 6-10 years old, most gender are male and DHF grade 1. Unpaired t test found the average difference between NL ratio and platelet with value of p = 0.043 (p&lt;0.05).&#x0D; Conclusion: Plasma leakage average on NL ratio is higher than plasma leakage average on platelets that occurs in children with DHF at RSUD Dr.Pirngadi Medan.

Karakteristik Klinis dan Virologis Penderita Demam Berdarah Dengue di Kota Bandar Lampung

Abstract. Clinical symptoms of dengue virus (DENV) infection range from asymptomatic mild dengue fever(DF), more severe dengue hemorrhagic fever (DHF) up to dengue shock syndrome. One of the determinantsof dengue infection severity was virus virulence. This study aimed to determine the clinical and virologicalcharacteristics of dengue virus infection patients based on the severity degree. A cross-sectional study wasconducted in RSUD Dr. H. Abdul Moeloek, Lampung Province between July-November 2016 with 56 denguepatients as samples selected using purposive sampling. The serological test was done using a rapiddiagnostic test. Blood samples for DENV serotype identification were examined using reverse-transcriptionpolymerase chain reaction. Classification of DENV infection severity was obtained from the patient’s medicalrecord. The results showed that the most common clinical manifestations were fever, headache, and retroorbitalpain, appearing in all patients from every degree of severity. There were Grade I DHF patients whoexperienced Myalgia (15.6%) and petechiae (22.2%). Laboratory results showed that thrombocytopeniaappeared in every grade, even though 13.3% of grade I patients did not experience it. Secondary infectionwas found in 92.9% of samples, and all DENV serotype can be detected in 39.2%samples: DENV-1 (46.7%),DENV-2 (6.7%), DENV-3 (26.7%), and DENV-4 (20%). This study concluded that the majority of clinicalcharacteristics in DHF patients are in line with the degree of severity, with the bleeding as the dominantmanifestation in patients with grade II-IV. Virological characteristics of DENV-1 are dominant in all patientswith DHF grade I-IV.Keywords: dengue virus, serotype, severity, secondary infection, Bandar Lampung

Severity of hepatitis & it's correlation with dengue hemorrhagic fever: Experience from a tertiary care hospital

Background: Dengue fever and dengue hemorrhagic fever is one of the most frequent febrile viral infections in our community as well as among patients admitted in Internal Medicine Department. This study examined the extent of hepatic involvement in dengue hemorrhagic fever&#x0D; Objectives: To evaluate the incidence of hepatic involvement and its correlation in dengue syndromes.&#x0D; Design: This Cross-sectional observational study done in Internal Medicine Department of BIRDEM General Hospital.&#x0D; Method: A total 50 patients were included in this study who was serologically positive dengue fever patients (IgM ± IgG). These patients were admitted to Internal Medicine Department of BIRDEM General Hospital from July, 2011 to December 2011. Hepatic transaminases (AST and ALT) of these patients were measured and correlation was seen by standard methods. Informed written consent was taken from patients.&#x0D; Results: Total number of patients was 50; their mean age was 45.98±18.37 years. Male: Female ratio was 1:1.85. Common co-morbidities were DM (48%) and hypertension (26%), CKD (8%) and bronchial asthma (6%). Among the 50 patients 23 had CD (Classical Dengue), 20 had DHF (Dengue Hemorrhagic Fever) grade 1, six had DHF grade 2 and one had DHF grade 3. Mean AST among CD and Grade 1, 2, 3 DHF were 58.48±8.99, 96.65±9.06, 217±31.82, 296.00 respectively. Mean ALT among CD and grade 1, 2, 3 DHF were 52.39±9.08, 88.10±13.14, 181.67±12.11 respectively. There was significant difference between AST (P value ˂0.001) and ALT (P value ˂0.001) in each group of patients. It was observed that rise of AST and ALT was significantly higher in grade 1, 2 and 3 when compared with CD. AST and ALT was higher in grade 2 then grade 1 DHF patients.&#x0D; Conclusion: Rise of hepatic transaminases is common in patients with dengue syndromes. There is significant rise in AST then ALT. The rising pattern of these enzymes correlates with severity of dengue syndromes&#x0D; Bangladesh Crit Care J September 2020; 8(2): 76-80

Daily Dengue Severity Score to Assess Severe Manifestations.

The study aimed to develop dengue severity score to assess severe manifestations among hospitalized patients with dengue infection. Children and adolescents with serologically confirmed dengue infection admitted at Ramathibodi Hospital from 2004 to 2018 and treated by an expert multidisciplinary team were recruited. Medical records were retrospectively reviewed and 14 items, related to clinical parameters and managements during hospitalization, were obtained daily as dengue severity score. A total of 191 patients with a mean age of 10.7 years from 2004 to 2013 were recruited. They were classified as dengue fever (35), dengue hemorrhagic fever (DHF) I (53), II (50), III (37) and IV (16). The analysis of 593 daily records revealed the range of daily severity score among patients with DHF grades III (10-20) and IV (31-47) were significantly higher than those of other groups (dengue fever, 5-13; DHF I, 2-10; DHF II, 6-11) with P-values of 0.0001. Using a validity test, a total daily score of ≥12 was an assessment tool for dengue shock syndrome with sensitivity, 86% and specificity, 84%. An additional 51 hospitalized patients with DHF grades II, III and IV with similar ages from 2014 to 2018 were recruited. The number of patients with severe manifestations, having daily score of ≥12, was significantly higher than those without severe manifestations starting from Day -3 to Day +1 of illness. Daily dengue severity score of ≥12 was an accurate assessment tool for severe manifestations.

The Correlation Between Blood Parameters as Early Detection on Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) in Children

Background: Dengue Shock Syndrome (DSS) is a severe manifestation of Dengue Hemorrhagic Fever (DHF) and affects more children and young adults. The age of susceptibility to DSS is 5-15 years old, due to an imperfect immune system. DHF patients with manifestations of DSS have propensity that can affect the platelet and hematocrit values as an initial laboratory parameter.&#x0D; Objective: This study is intended to find out the most effective platelet and hematocrit blood parameters and to find the correlation between platelet values and hematocrit on the incidence of DHF in Wirosaban Hospital of Yogyakarta Municipality in the period f March 2015 to July 2016. The data used were secondary data from medical records of pediatric patients aged 5-15 years old. Material and Methods: The research method used was to determine the correlation between platelet values and hematocrit on the incidence of DHF and DSS in children. Data analysis used chi-square to determine the correlation between platelet values and hematocrit on the incidence of DHF and DSS in children.&#x0D; Results and Discussion: In this study, the number of samples that fulfilled the inclusion and exclusion criteria was 74 on platelet examination while in the hematocrit examination there were 77 that met the criteria. The results of chi-square test for platelet examination obtained p value&gt; 0.05, which means there was no significant correlation between platelet counts and the incidence of DHF, DHF grade II, and DSS. The results of the chi-square test analysis on hematocrit examination obtained p &lt;0.05, which means that there was a significant correlation between hematocrit values and the incidence of DHF and DSS and it obtainedd r = 0.707.&#x0D; Conclusions: In this study the increase in hematocrit is one of the parameters to detect DHF with propensity to DSS.&#x0D; Bangladesh Journal of Medical Science Vol.19(2) 2020 p.273-277

A study of complications in dengue fever among paediatric patients

The first major epidemics of severe and fatal form of disease, dengue hemorrhagic fever (DHF), occurred in Southeast Asia as a direct result of this changing ecology. The dramatic global geographic expansion during the last 25 years of 20th century, epidemic DF/DHF occurred, facilitated by unplanned urbanization in tropical developing countries, modern transportation, lack of effective mosquito control and globalization. During 21st Century, epidemic DF/DHF is one of the most important infectious disease affecting tropical urban areas. It has been estimated that 50 100 million of dengue infections, 5,00,000 cases of DHF were hospitalized and 20,000 25,000 deaths occurred mainly in children. Detailed history of patients with dengue and NS1 positive or IgM positive serological findings were enrolled into the study after obtaining parental consent. The presenting signs and symptoms that were observed among the cases who meet the inclusion criteria are: fever, headache, retro orbital pain, myalgia, arthralgia, appearance of rashes, any bleeding manifestation (epistaxis, melena, hematemesis), decreased urinary output, breathlessness and yellowish discoloration of eyes. About 73.1% of the cases without complications were diagnosed as DHF grade I, 26.9% as grade II and none as grade III in this study. The patients with complications had noted that 7.4% were diagnosed as grade I, 88.9% as grade II and 3.7% as grade III in this study at the time of admission.

Restrictive versus Liberal Fluid Resuscitation in Children with Dengue Shock Syndrome: the differences in Clinical Outcomes and Hemodynamic Parameters

Background: Fluid resuscitation is the mainstay of treatment to counteract massive plasma leakage in dengue shock syndrome. We aimed to determine the differences in clinical outcomes and hemodynamic parameters of children with dengue shock syndrome post restrictive and liberal fluid resuscitation. Materials and Methods: A retrospective observational study of pediatric patients who were between one month to 18 years old, presented with clinical criteria for dengue hemorrhagic fever (DHF) grade III and IV based on WHO classification of dengue fever in 2011, and admitted to the Saiful Anwar General Hospital, Malang- Indonesia, from January 2016 to December 2016. Patients were divided in two groups: resuscitated with either 40ml/kg BW (liberal group) solutions; then we analyzed the clinical outcomes and hemodynamic parameters between two groups. Results Among 100 patients, 92 patients were classified as DHF grade III and 8 patients were DHF grade IV. 74 patients were in the restrictive group and 24 patients were in the liberal group. Median age at diagnosis was 6 years old, and 56% of patients were female. No significant differences were observed between length of stay in pediatric intensive care unit (P=0.09), and duration of ventilator use (P=0.68). The restrictive group had 53% lower mortality compared to the liberal group (P=0.18). This study also showed that there were no significant differences in hemodynamic parameters between two groups based on measurement with USCOM which were preload component (SVV) (P=0.89), inotropy components (SMII) (P=0.07), SVRI (P=0.85) as well as the cardiac index (P=0.66). Conclusion This study showed that there is no difference in clinical outcomes (length of mechanical ventilation and length of PICU stay), and hemodynamic parameters (preload, inotropy, afterload, and cardiac index) in Dengue Shock Syndrome patients who receive restrictive or liberal fluid resuscitation.

Hyperventilation in Children with Dengue Hemorrhagic Fever (DHF)

Many studies of Dengue Hemorrhagic Fever (DHF) have been done but only a few revealed the respiratory status. Respiratory problems arise because of plasma leakage through the damaged capillaries, causing lung edema and in turn result in hypoxemia. This later on will be compensated by a hyperventilation state. During a 6-month-period (May to September 1988), two aspects were studied in 85 patients hospitalized with DHF. First, the ventilatory pattern and second, the result of giving oxygen support in improving the respiratory disturbance, in this case alveolar hyperventilation. The incidence of alveolar hyperventilation in DHF grade II (DHF II) and Dengue Shock Syndrome (DSS) differed significantly. Hypoxemia occurred in DHF II and DSS with no significant differences. The difference of the incidence of metabolic acidosis in DHF II and DSS were significant. In DHF II patients having had hyperventilation state, oxygen therapy decreased respiration rate significantly and increased the PaCO2 though not significantly.

&lt;p&gt;An open-label, randomized prospective study to evaluate the efficacy and safety of &lt;em&gt;Carica papaya&lt;/em&gt; leaf extract for thrombocytopenia associated with dengue fever in pediatric subjects&lt;/p&gt;

ObjectiveThrombocytopenia in dengue fever (DF) is a well-known complication in both adults and pediatric subjects. Management of DF primarily includes symptomatic and intensive supportive care. There are studies available on the efficacy and safety of Carica papaya leaf extract (CPLE) in adult patients with DF. However, there are no published studies available on the efficacy and safety of CPLE in the pediatric age group. Hence, this study was conducted.MethodologyA prospective, open-label, randomized controlled study was conducted in subjects aged between 1 and 12 years having thrombocytopenia associated with DF (NS-1 antigen positive) or dengue hemorrhagic fever (DHF) grades I and II. All participants were randomized into the intervention group (n =147, CPLE syrup + standard therapy) and the control group (n=147, received only standard therapy). All subjects were followed up daily for 5 days with monitoring of blood counts.ResultsA total of 285 subjects were finally evaluated for efficacy, and nine dropped out (seven in the control group and two in the intervention group). However, all 294 subjects were evaluated for safety. CPLE (Caripill) syrup increased the platelet count significantly compared to the control group (P<0.05). In the intervention group, the platelet count increased from day 3 onward: platelet count on day 3 (mean platelet count =89,739.31, P=0.030), day 4 (mean platelet count =120,788.96, P=0.019), and day 5 (mean platelet count =168,922.75 P=0.023). Two children complained of nausea in the intervention group. Overall, Caripill syrup was well tolerated.ConclusionCPLE syrup significantly increases the platelet count in pediatric DF patients and is well tolerated.

Comparação da gravidade dos casos de dengue segundo a classificação antiga e a classificação revisada

Introdução: Existem duas classificações que estratificam os casos de dengue pelo quadro clínico laboratorial: a classificação proposta nos anos 50 e a revisada pela Organização Mundial de Saúde, adotada em janeiro de 2014 no Brasil. Compará-las quanto à capacidade de identificar a gravidade do caso representa nosso objetivo. Métodos: Estudo observacional e transversal com análise e comparação dos casos de dengue de 2011 a 2013 de um hospital terciário de referência da cidade de Natal/RN, de acordo com a classificação antiga e a classificação revisada. As correspondências adotadas foram: Dengue Clássica e Febre Hemorrágica da Dengue (DHF) grau I com Dengue; DHF grau II com Dengue com sinais de alarme; DHF grau III e IV com Dengue grave. Resultados: 2.318 fichas foram analisadas, com a população predominantemente adulta, média de idade 30,32 anos ± 17,89, sendo 39% do sexo masculino, 61% do sexo feminino. A partir das correlações designadas, 428 casos foram concordantes, 699 discordantes e 1191 “sem classificação” (casos cujos dados dos prontuários não possibilitaram sua classificação). Conclusões: As duas classificações foram equivalentes no manejo clínico quando os casos de dengue foram graves. A classificação antiga evita a superestimação de casos leves e moderados por utilizar mais aspectos clínicos e laboratoriais que a classificação revisada. Sangramento de mucosa, dor abdominal e vômitos não representaram sinais que evoluíram para gravidade, demonstrando como a utilização dos sinais de alarme de maneira imprecisa pode superestimar os dados.

Abstract PD-016: MYOCARDIAL DEPRESSION IN PEDIATRIC DENGUE HEMORRHAGIC FEVER: A PROSPECTIVE OBSERVATIONAL STUDY

Aims & Objectives: In addition to plasma leakage, myocardial depression is thought to contribute in the pathogenesis of Dengue Hemorrhagic Fever (DHF), but its role remains unclear. We aim to compare hemodynamic parameters and myocardial inotropy among 4 grades of DHF. Methods Children (1 month – 18 years old) with DHF admitted to the emergency room (ER) or pediatric intensive care unit (PICU) were recruited between January 2016 and March 2017. Diagnosis of DHF (grade I to IV) was based on World Health Organization (WHO) criteria (2012). We excluded patient who had received fluid resuscitation or inotropes, or had congenital heart disease. Stroke volume index (SVI), Smith-Madigan Inotropy Index (SMII), Cardiac Index (CI), and Systemic Vascular Resistance Index (SVRI) was measured at first admission. Trans-jugular measurement using Ultrasonic Cardiac Output Monitor (USCOM 1A®) was performed by pediatric intensivist or trained-chief resident. Results Two hundred eight out of 230 patients were included. The SVI, CI, and SVRI were comparable among all groups (p=0.40; p=0.75; and p=0.88, respectively). However, most of grade III and IV patients had low SVI (82%), low CI (52%), and high SVRI (63%). The SMII was significantly lower in grade IV (0.96 [0.4–2.2] W/m2) than grade I (1.20 [0.7–1.8] W/m2; p<0.001), grade II (1.10 [0.9–1.8] W/m2; p=0.03), and grade III (1.10 [0.4–2.5] W/m2; p=0.005). Conclusions The most DHF grade III and IV patients were low-output and high-resistance. Myocardial depression was contributed to this condition, especially in DHF grade IV.

AKTIVITAS FOSFOLIPASE-A2 SEKRETORIS PLASMA TROMBOSITOPENIA DEMAM BERDARAH DENGUE

Infected macrophages by dengue virus will produce phospholipase-A2 (PLA2) enzyme, that can promote arachidonic acidmetabolism that produce inflammatory mediators, causing endhothelial damage and severe plasma leakage. Capillary endothelialdamage can cause platelet adhesion and aggregation, so that many platelets will be consumed. The role of sPLA2 (secretoryphospholipase-A2), which is a part of PLA2 in dengue and thrombocytopenia up to now has not been widely studied. The objective ofthe study is to analyze the association between the activity of plasma secretory phospholipase-A2 and the degree of thrombocytopeniain DHF adult patients. the study is carried out by a cross sectional, observational analytical study on 45 hospitalized adult patientssuffering dengue hemorrhagic fever in the Tropical Infection Ward, Department of Internal Medicine, Dr. Soetomo Hospital Surabaya,which has been conducted from February–December 2009. The diagnosis of Dengue Haemorrhagic Fever (DHF) was based on the1997 World Health Organization (WHO) criteria, that minimally had one positive serology marker of dengue. Venous blood wastaken from the patient for examining the activity of secretory phospholipase-A2 by correlated enzyme assay method, and plateletcount using automated hematology analyzer. The results of the secretory phospholipase-A2 activity and degree of thrombocytopeniawere analyzed by Pearson correlation test to determine the correlation between the two variables. In this study so far was foundthat the secretory phospholipase-A2 activity in DHF patients was 36.9–195.6 unit/mL (mean 97.49 unit/mL, SD 30.06 unit/mL).The mean of secretory phospholipase-A2 activity was increased according to the degree of thrombocytopenia severity. The mean ofsecretory phospholipase-A2 activities were 91.65 unit/mL, 98.94 unit/mL, and 110.47 unit/mL. The degree of thrombocytopeniawas divided into mild, moderate, and severe. Most of the patients showed mild thrombocytopenia. The sPLA2 activity in this studywas increased in DHF patients with second day of fever, and then decreased at the third and forth day of fever, and increased inDBD patients suffering fifth day of fever. The statistical analyzes show a non significant correlation between secretory phospholipaseA2 activity and degree of thrombocytopenia (p = 0.579). This result may be caused by several factors which influencing thethrombocytopenia in DHF, such as bone marrow suppression, dengue viral serotype, influence of cytosolic phospholipase-A2 (cPLA2)activity, and other proinflammatory cytokines which in this study could not be controlled. Statistical analyzes show a significantcorrelation between sPLA2 activity and the day of fever (p = 0.04). Further studies should have to be carried out in order to knowthe pattern of sPLA2 activity in DHF grade I, II, III, and IV, and to know the influence of other proinflammatory cytokines and viralserotypes in sPLA2 activities.

PERAN ANTIGEN NS1 DENGUE TERHADAP PENGHITUNGAN TROMBOSIT DAN PENAMPAKAN (MANIFESTASI) KLINIS PENJANGKITAN/PENULARAN (INFEKSI) VIRUS DENGUE

Dengue virus infection has become the major health problem in Indonesia. Dengue haemorrhagic fever is a part of dengue virus infection. 95% of this disease commonly affects children less than 15 years. However, in the last five years the incidence of DHF hasalso increased in adults. In 2008, the case fatality rate of DHF was 0.99% in East Java and 0.47% in Surabaya. The diagnosis of DHFis based on the 1997 WHO criteria. Thrombocytopenia is a haematological abnormality occurring in DHF. There is a hypothesis aboutthe role of non-structural 1 antigen (NS1 antigen) during initial virus replication leading to immunological reaction manifestationin thrombocytopenia. To analyze the role of NS1 antigen dengue to platelet count and clinical manifestations to know the degree ofdengue virus infection. This study used a cross-sectional design. The samples are comprised of 52 patients with dengue fever anddengue haemorrhagic fever grade I until III hospitalized at Tropical Disease Ward, Dr.Soetomo Hospital, and Surabaya. Data wereanalyzed using Mann-Whitney test, t-two sample test (p = 0.05). The result of this study using Mann-Whitney test show no difference between NS1 antigen dengue with the clinical manifestations in dengue virus infection (p = 0.882). Analysis using t-two sample test showed a significant difference between NS1 antigen dengue positive and NS1 antigen dengue negative with a change in platelet count (p = 0.006). Although, the test showed no significant difference between NS1 antigen dengue and the platelet count in dengue virusinfection (p = 0.062). There were found no significant association between NS1 dengue antigen with platelet count and clinicalmanifestations in dengue virus infection.

The worsening factors of dengue hemorrhagic fever (DHF) based on cohort study with nested case-control in a tertiary hospital

The clinical pathway of DHF has a broad pathophysiological and pathogenesis spectrum. Clinical and laboratory characteristics are some of the parameters to determine the factors that contribute to the worsening of the disease. The objective of this study is to determine the clinical and laboratory characteristics which contribute to the worsening of DHF. The study had been conducted from January 2012-December 2014 at the general ward of the Internal Medicine Department, Indonesia Army Central Hospital Gatot Soebroto. There were 101 male patients (64.7%) and 55 female patients (35.3 %) ages ranging from 14 - 62 years old. The diagnosis was divided into: 124 patients DHF grade I, 6 DHF grade II, 20 DHF grade III and 6 with dengue shock syndrome (DSS) patients. Clinically and statistically, there were 4 variables apparently found with the severity of DHF, as follows: decreased appetite with p = 0.007 (OR 4.87), hepatomegaly with p = 0.009 (OR 27.00), systolic blood pressure with p = 0.037 (OR 0.95), and initial thrombocyte with p = 0.000 (OR 0.97). This cohort and nested case-control study found that worsening of DHF is related with decreased appetite, hepatomegaly, systolic blood pressure and initial thrombocyte count.