Evaluation of biochemical and haematological changes in dengue fever and dengue hemorrhagic fever in Sri Lankan children: a prospective follow up study

Abstract

Background Series of biochemical and haematological changes occur during the course of dengue infection, which vary depending on the clinical disease. The patterns of change are not well documented and identifying these patterns in children with dengue infection would help to anticipate the progression to different clinical stages thus enabling effective management. Methods A prospective follow up study was conducted during the period of July 2013 – April 2014 at Professorial Pediatric unit, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka. Children (5–12 years) admitted within the first 84 h of fever, with a clinical diagnosis of dengue infection were recruited. Children who became positive for dengue IgM were included in the final analysis. Blood was collected on admission for complete blood count, Alanine aminotransferase, Aspartate aminotransferase, albumin, cholesterol and corrected calcium. These tests were repeated at 12 hourly intervals during the hospital stay. Results Data of 130-subjects were analyzed (Dengue fever /Dengue hemorrhagic fever: 100/30). There was a significant difference in the pattern of white cell counts, platelets and haematocrit in the two clinical groups. Both transaminase rose initially in both dengue fever and dengue hemorrhagic fever and a steep rise were seen between 8th and 9th days in hemorrhagic fever. Both albumin and cholesterol decreased significantly at the time of entering into the critical phase. According to Receiver operating characteristic curve analysis, albumin level crossing 37.5g/L (sensitivity 86.7%, specificity 77.8%) and a 0.38 mmol/L reduction in cholesterol level (sensitivity 77.3%, specificity 71.9%) between day 3 and 4 were the best predictors of entering into critical phase. Calcium levels did not show any distinct pattern. Conclusions There is a clear difference in the pattern of change of both hematological and biochemical parameters in dengue fever and dengue hemorrhagic fever. Reduction in albumin and cholesterol levels seen between the completion of day 3 and day 4 were highly valid predictors of entering into critical phase in dengue hemorrhagic fever. Electronic supplementary material The online version of this article (10.1186/s12887-019-1451-5) contains supplementary material, which is available to authorized users.

Management of dengue infection: improving morbidity

“…Data from Sri Lanka showed that in DHF, serum albumin and cholesterol showed a decline with the increase in the haematocrit. In DHF patients, serum albumin showed a negative correlation with the haematocrit from day 3 to day 6 and was significant on day 4 (r=0.49, p=0.006) and day 4.5 (r=0.41, p=0.022) [25]. The best cut off value of serum albumin to predict entry into critical phase was 37.5 g/L (sensitivity of 86.7%; specificity of 77.8%) [25].…”

“…Increase in haematocrit closely reflected the decline of the platelet count in both DF and DHF, which was more distinct and rapid in the latter. The highest haematocrit of DHF was seen on day 4, which denotes the onset of the critical phase [25].…”

“…The main haematological abnormalities are leucopenia and thrombocytopenia caused by direct destructive action of the dengue virus [24]. A Sri Lankan study showed that leucocyte count and platelet count on day 2.5 as predictors of entry into critical phase [25]. Although the predictive power was not as high as some of the biochemical markers, a platelet count <100×10 9 /L had a sensitivity of 76.9% and a specificity of 79.3% while total leucocyte count <2.6×10 9 /L had a sensitivity of 69.2% and a specificity of 82.8%.…”

“…Patients with hypocalcaemia had significantly lower platelet count and serum albumin levels [27]. A study done among Sri Lankan children did not show any distinct pattern of change in calcium levels [25]. This could be due to early administration of oral calcium lactate, 1mmol/kg/d, for all suspected cases of dengue fever as per study protocol.…”

“…In spite of supplementation with calcium lactate, there was no increase in serum calcium during the acute phase, but once acute phase was over, levels began to rise. This indicates that these patients may have leaked out calcium during acute phase and supplementation would have maintained normocalcaemia [25]. Based on this evidence, the author routinely supplement all suspected patients with dengue infection, with 10mg/kg of elemental calcium twice daily, irrespective of the calcium status, and it could be one reason for low morbidity and mortality rates observed.…”