Gall Bladder Wall Thickening in Dengue Fever – Aid in Labelling Dengue Hemorrhagic Fever and a Marker of Severity

Abstract

Introduction Dengue fever is a mosquito-borne viral disease spread by the bite of the Aedes aegypti mosquito. Dengue epidemics have contributed to a great economic burden, especially in SouthEast Asia. This study aimed to determine gall bladder wall thickness (GBWT) in patients with dengue fever, assess its sensitivity and specificity to identify dengue hemorrhagic fever, and also compare gall bladder wall thickening (GWBT) with platelets, hematocrit, and leucocyte count. Materials and methods This prospective observational study was conducted in the dengue ward of Benazir Bhutto Hospital, Rawalpindi, Pakistan, from September 2019 to January 2020, i.e., four months. Patients admitted to the dengue ward diagnosed as seropositive and provided consent were enrolled into the study. Laboratory investigations (blood complete picture, liver function tests, renal function tests) were collected and recorded. Ultrasonography was performed on admission and subsequently during a hospital stay. Patients were divided into two groups: those with gall bladder wall thickness ≤ 3mm and ˃3mm. All data were entered and analyzed on SPSS version 24 (IBM Inc., Armonk, USA). Results Out of 180 patients, 122 (67.8%) were male, and 58 (32.2%) female. The mean age was 33 ± 13 years. One hundred and six patients (58.9%) were diagnosed with dengue fever, 68 (37.8%)-dengue hemorrhagic fever, and six (3.3%)-dengue shock syndrome. The most common finding was gall bladder wall thickness ˃3mm (69/180; 38.3%) followed by ascites (38.1%). Sixty-two patients out of 69 (89.9%) with GBWT ˃3mm were managed as dengue hemorrhagic fever (p=0.000). Alanine transaminase (ALT), platelet, and total leukocyte count (TLC) were associated positively with an edematous gall bladder wall (p<0.005). The mean gall bladder wall thickness for dengue hemorrhagic fever was 6.4mm ± 2.5 mm. A GBWT value of 3.5mm was found to have 94.6% specificity and 91.2% sensitivity. Conclusion Gall bladder wall edema is strongly correlated with dengue hemorrhagic fever. Hence it should be assessed in all patients with dengue fever.

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

“…Forty-three studies met the inclusion criteria [ 8 – 50 ] which included 40 hospital based and 3 community based cohorts that collectively recruited 15,794 patients (Table 1 ). Another ten studies [ 51 – 60 ] initially considered as eligible, were later excluded due to a high probability of reporting on same cohorts in the included studies.…”

“…Fifteen studies reported the proportion of patients with plasma leakage out of all symptomatic and hospitalised patients (Table 2 ), but the method of diagnosis was inconsistent. Six studies predominantly relied on ultrasonography [ 8 , 20 , 32 , 36 , 41 , 42 ] while the remainder used chest X-ray alone, [ 12 ] chest X-ray with ultrasonography, [ 35 ] ultrasonography and a rise in haematocrit > 20%, [ 43 , 49 ] a rise in haematocrit (> 20% or > 15%) with clinical examination [ 18 , 45 , 50 ] or clinical examination alone [ 26 ]. One study did not mention the method of diagnosis [ 14 ].…”

“…Of all studies reporting on plasma leakage, six [ 8 , 12 , 14 , 20 , 32 , 49 ] specifically mentioned no deaths, one (this study mentions a haematocrit rise > 20% rather than a “plasma leakage”) reported eight deaths [ 50 ], while the others did not confirm the presence or absence of deaths. Of all studies reporting on DHF, 26 reported on deaths (9 studies reported 60 deaths, [ 9 , 15 , 16 , 18 , 19 , 21 , 22 , 30 , 43 ] and 17 studies reported no deaths [ 8 , 10 – 12 , 14 , 20 , 23 , 27 – 29 , 32 , 33 , 37 – 39 , 44 , 49 ]). Thirty-five deaths occurred in DHF patients while for 24, it was not mentioned if they had DHF.…”

Early diagnostic markers in predicting the severity of dengue disease

“…Thrombocytopenia is a classical of dengue infection, and this can be caused due to binding of platelets to the activated endothelial cells (Teixeira et al 2008). It was reported that the edema of the gall bladder is associated with the dengue hemorrhagic fever, so every dengue patient should be screened for it (Adil et al 2020). The sensitivity and specificity of the thickness of the gall bladder in assessing the admission to the intensive care unit or general ward were 100% and 62.1% (Ibrahim et al 2022).…”

“…The same radiologist performed all the ultrasound abdomen examinations, to avoid the inter observer bias. The serum ferritin level is considered as high if it is more than 500 ng/ml (Senjo et al 2018) and more than 3 mm of gall bladder wall thickness was considered as the significant edema (Adil et al 2020). This study did not include the controls as the serum ferritin levels, and ultrasound abdomen were not done in other cases of fever, which were negative for the NS1 antigen card test.…”