CLINICAL, HEMATOLOGICAL,BIOCHEMICAL AND RADIOLOGICAL PREDICTORS OF SEVERITY AND OUTCOME IN DENGUE INFECTION.

In present study ELISA IgM was done in 33 cases and is compared to rapid card test IgM of the same cases. ELISA is more efficacious in detecting dengue IgM with a100% sensitivity and 100% specificity than rapid card test whose sensitivity and specificity are 4.55% and 90.91% respectively. and cases. These NS1 are to by et (62) aspartate aminotranferase(AST) and alanine aminotransferase (ALT), are released into the bloodstream, and as a consequence these enzymes are believed to be sensitive indicators of liver damage. In the acute phase of the disease, an increase occurs in aminotranferases, the levels of which subsequently decrease as the liver recovers. AST may be found in high concentrations in the heart muscle, liver cells and skeletal muscle and, in lower concentrations, in the kidneys and pancreas. ALT is mainly found in the liver and in lower concentrations in the kidney. While majority of the patients have only mild or moderate elevation of these transaminases, some of them have levels elevated by 10-fold or greater. In dengue infections, the levels of serum AST are greater than serum ALT, which is in contrast to the normal finding with viral hepatitis. It has been suggested that this may be due to excess release of AST from damaged myocytes during dengue infection. The elevation of the AST level is usually higher than that of ALT in patients with dengue fever during the first week of infection, with a decrease to normal levels within three weeks. Some studies have suggested that the average levels of transaminases were significantly higher in SD patients than in DF patients.

If the p-value was < 0.05, then the results were considered to be statistically significant otherwise it was considered as not statistically significant. Data were analyzed using SPSS software v. 23  1. Out of 65 cases majority of the cases were under age group 6-10 years (n=26) accounting to 40%. 2. In Dengue fever (DF) cases, out of 25 maximum cases (n=11) are from 6-10 years accounting to 44%. 3. In Dengue fever with warning signs (DFWS) cases, out of 31 maximum cases (n=13) are from 10-14 years accounting to 41.9%. 4. In Severe Dengue (SD) cases, out of 9 maximum cases (n=4) are from 0-5 years accounting to 44.4%. 5. "p value" = 0.012 suggests that there is statistically significant difference among age wise distribution of different types of dengue illness. Out of 25 cases of DF majority of patients are males (n=15) accounting to 60%. Out of 31 cases of DFWS majority of patients are males (n=20) accounting to 64.5%. Out of 9 cases of SD majority of patients are males (n=6) accounting to 66.7%. "p value" = 0.914 suggests no statistical significance in gender distribution among various types of dengue illness i.e no gender is specific to any group.  Out of 65 cases maximum cases (n=31) are of DFWS accounting to 47.7% followed by DF (n=25) accounting to 38.5% and SD (n=9) accounting to 13.8%.   presentation after the onset of illness:  TYPES OF  DENGUE  ILLNESS   DAY OF PRESENTATION OF SYMPTOMS:  TOTAL  n=65   P value  1-2 days  n   3-4 days  n   5-7 days  n   >7days  n  DF  2  15  7  1  25  0.872  DFWS  2  17  9  3  31  SD  1  3  4  1  9 This table shows distribution of cases according to the day of presentation to the hospital after the onset of fever. In present study of 65 cases there is no statistical difference between the three groups of dengue illness according to day of presentation to the hospital (p value = 0.872).

Most common symptoms in dengue illness:
Above figure shows the most common symptoms in dengue, in descending order it is as follows : fever, vomiting, abdominal pain, myalgia, headache, loose stools, arthralgia, cough, cold, rashes, nausea etc.

Most common warning signs in dengue illness:
Above figure shows the most common warning signs in dengue, in descending order abdominal pain (30.7%), hepatomegaly (24.6%), abdomen tenderness (23%), raised hematocrit with reduced platelet count (6%),3% each in ascites & tender right hypochondrium.   In present study ELISA IgM was done in 33 cases and is compared to rapid card test IgM of the same cases. ELISA is more efficacious in detecting dengue IgM with a100% sensitivity and 100% specificity than rapid card test whose sensitivity and specificity are 4.55% and 90.91% respectively.  statistically significant p value. 5. The mean PT value at admission in DF is 15.5 ± 3.5, in DFWS is 16 ±3.4 and in SD is 22.6 ±5.8 with statistically significant p value (<0.001). 6. The mean APTT value at admission in DF is 47.9 ± 14.2, in DFWS is 51.4 ± 22.6 and in SD is 51 ± 25.1 without statistically significant p value. 7. The mean AST value at admission in DF is 82.9 ± 61.1, in DFWS is 140.5 ± 99.7 and in SD is 725.9 ± 600.5 with statistically significant p value (<0.001). 8. The mean ALT value at admission in DF is 31.7 ± 18.9, in DFWS is 80.7 ± 87.1 and in SD is 588.4 ± 728. 3 with statistically significant p value (<0.001). 9. The mean Bilirubin value at admission in DF is 0.4 ± 0.1, in DFWS is 0.7 ± 1.2 and in SD is 1.3 ± 1.8 without statistically significant p value. 10. The mean Albumin value at admission in DF is 3.6 ± 0.3, in DFWS is 3.2 ± 0.6 and in SD is 3.3 ± 1 with statistically significant p value (=0.044). 11. The mean ALP value at admission in DF is 148.1 ± 43.3, in DFWS is 177.7 ± 76.8 and in SD is 217.2 ± 66.9 with statistically significant p value (=0.026).

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12. The mean CPKMB value at admission in DF is 51.3 ± 28.7, in DFWS is 41.4 ± 20.8 and in SD is 100.8 ± 88.6 with statistically significant p value (=0.001).  Chest X-ray findings was mainly consolidation and is seen in 44.4% of severe dengue cases and 6.5% of DFWS cases.
X-ray was normal in 100% cases of DF, 93.5% of DFWS and 55.6% of SD.
Chi square test p<0.001 suggests consolidation is more common & specific in severe dengue over DFWS & DF. Table10:-Roc analysis of selected parameters to detect severe dengue     1. FFP was administered to 2 (6.5%) of 31 DFWS cases , 1(11.1%) out of 9 cases of SD and none of the cases with DF received FFP. 2. Platelets was administered to 6(19.4%) of 31 DFWS cases , 3(33.3%) out of 9 cases of SD and none of the cases with DF received platelets. 3. Whole blood was administered to 1(3.2%) of 31 DFWS cases , 2(22.2%) out of 9 cases of SD and none of the cases with DF received whole blood. 4. There is a statistically significant difference in transfusion of blood components between different types of dengue with p value of 0.0067. ANOVA test shows "p value" of 0.002 suggesting it is statistically significant and states that prolonged duration of stay is specific for severe dengue.

Biochemical findings :
Biochemical findings include Liver function tests (LFT) & CPK-MB levels.Upon injury to the liver, the enzymes, aspartate aminotranferase(AST) and alanine aminotransferase (ALT), are released into the bloodstream, and as a consequence these enzymes are believed to be sensitive indicators of liver damage. In the acute phase of the disease, an increase occurs in aminotranferases, the levels of which subsequently decrease as the liver recovers. AST may be found in high concentrations in the heart muscle, liver cells and skeletal muscle and, in lower concentrations, in the kidneys and pancreas. ALT is mainly found in the liver and in lower concentrations in the kidney. While majority of the patients have only mild or moderate elevation of these transaminases, some of them have levels elevated by 10-fold or greater. In dengue infections, the levels of serum AST are greater than serum ALT, which is in contrast to the normal finding with viral hepatitis. It has been suggested that this may be due to excess release of AST from damaged myocytes during dengue infection. The elevation of the AST level is usually higher than that of ALT in patients with dengue fever during the first week of infection, with a decrease to normal levels within three weeks. Some studies have suggested that the average levels of transaminases were significantly higher in SD patients than in DF patients. Maximum percentage of polyserositis is noted in SD (89.9%) followed by DFWS (87.1%) and least in DF (32%) suggesting with increase in severity frequency of polyserositis increases.

Roc:
Among the 65 cases reviewed, about 9 cases (13.84%) had severe dengue. 1. AST, ALT, BIL, ALP, PT, SGOT 2 /SGPT and total count were found to be good at identification of severe dengue.
In present study the composite index (AST 2 /ALT) was the most accurate (AUC 0.813; 95% CI 0.615 -1.000) when optimal cut off is ≥ 400.4 with highest sensitivity (88.9%) and specificity (76.8%) stating that it may be used as a marker for identification of severe dengue based on admission AST and ALT which is comparable to study done by Sani SS et al (95) . This is followed by AST, ALP, PT, ALT and BILIRUBIN which can be used to predict severity of dengue infection.

Blood products usage in management:
Types  (64) . Out of 65 cases blood products were transfused in 13(20%) cases of which platelets were transfused in 9(13.8%) of 65 cases of which 3(33.3%) cases are from severe dengue group ,FFP was transfused in 1(11.1%) of severe dengue group and three children required whole blood transfusion which is comparable to study by Sujatha R et al (66) in which out of 125(22%) children who received blood products, platelets were transfused in 80 children (14% of 568) out of which 64 (32.9%) were from SD group. Fresh frozen plasma (FFP) was used in 23 children (11.8%) of severe dengue group. Four children required whole blood transfusion.

Limitations of my study:-
1. Patients present to the hospital on different days after the onset of illness which may alter the levels of various parameters at admission. 2. ELISA test for IgM could be done only in 33 cases as Bijapur was proven to be dengue positive region by the district surveillance officers and they didn"t collect samples further. 3. Sample size of the present study is small.