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The Study of Serum Aminotransferase Levels in Dengue Fever and it’s Correlation with Clinical ProfileMURLIDHAR, SARVESHWAR SHARAN DADHICH, MANGESH BORKAR, SANJIV MAHESHWARI,

MONIKA MAHESHWARI, YAD RAM YADAV

Introduction

Dengue is the most common mosquito borne, endemo-epidemic arbo viral infection in many tropical and subtropical regions of the world. The dengue infection, an arthropod-borne viral hemorrhagic fever, continues to be

Dr. Murlidhar,Dr. Sarveshwar Sharan Dadhich,Dr. Mangesh Borkar, Resident Doctor,Department of Medicine, J.L.N, Medical College,Ajmer (Rajasthan).Dr. Sanjiv Maheshwari, Professor,Department of Medicine,J.L.N. Medical College and Associated Group of Hospitals, Ajmer (Rajasthan).Dr. Monika Maheshwari, Asso. professor,Dr. Yad Ram Yadav, Asst. Professor,Department of Medicine, J.L.N, Medical College,Ajmer (Rajasthan).

Specially Contributed to "The Antiseptic" Vol. 113 No. 8 & P : 8 - 12

Back ground: Dengue infection, the most prevalent arthropod borne viral illness in humans is caused by dengue virus. The involvement of liver in dengue fever is not uncommon. Liver involvement in dengue fever is manifested by the elevation of transaminases representing reactive hepatitis, due to direct attack of virus itself or the use of hepatotoxic drugs.Objectives: To study the serum aminotransferase levels and to assess it’s correlation with the clinical profile in dengue fever.Method: This is a cross sectional, descriptive study carried out in J.L.N. Hospital Ajmer in the duration of 1½ years. In this study all the patients who presented

ABSTRACT

in department of medicine with dengue IgM and/or NS1 positive were included.

Result: A total of 175 patients with serologically positive dengue were included in the study. Patients were classified as classical dengue fever (DF) 80.6%, dengue hemorhagic fever (DHF) 13.7% and dengue shock syndrome (DSS) 5.7%. The mean age was 34.07 years (male : female = 53.7:46.3). The mean Aspartate aminotransferase (AST) observed is 199.3, 344.2 and 1223 U/L in DF, DHF and DSS respectively. The mean Alanine aminotransferase (ALT) were seen is 121.7, 185.8 and 818.8 U/L in DF, DHF and DSS respectively. Hepatic dysfunction

is very common in all forms of dengue infection, with AST rising significantly more than ALT. Serum aminotransferase levels appear to have a directly proportional correlation with grading of dengue infection.(p<0.001)Conclusion: Hepatic dysfunction is very common in all forms of dengue infection and elevated liver enzymes were seen more frequently in DSS followed by DHF and DF patients with AST rising significantly more as compared to ALT. Serum aminotransferase levels appear to have a directly proportional correlation with grading of dengue.Key words: DF, DHF, DSS, AST ALT

a major challenge to public health, especially in South-East Asia.1

In the past 50 years, the prevalence of dengue fever has increased 30 fold with increasing geographic expansion to new countries and in the present decade, from urban to rural setting. It has a wide geographical distribution and can present with a diverse clinical spectrum.2

An estimated 50-100 million dengue infections occur annually and approximately 2.5 billion live in dengue endemic countries. Case fatality rates vary from 1 to 5% but can be <1% with appropriate treatment.3

Although dengue virus is a

non hepatotropic virus, liver injury due to dengue infection is not uncommon and has been described since the 1960s.3 Hepatic involvement can be characterized by manifestations of acute hepatitis, with pain in the right hypochondrium, hepatomegaly, jaundice, and raised aminotransferase levels. In hepatitis, the levels of these enzymes reach a maximum on the ninth day after the onset of symptoms, and they gradually return to normal levels within three weeks.

Although the liver is not the main target organ for this disease, histopathological findings, including centrilobular necrosis,

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malaria, enteric fever, alcololic liver disease, chronic liver disease, hepatitis A, B and C.

All the clinically suspected cases of dengue infection aged >18 years of age as per the WHO guidelines were screened and only serological confirmed cases by dengue IgM capture ELISA and /or NS 1 were included in this study. A detailed history and a thorough clinical examination were done for all the cases. Data was collected in a prewritten proforma. All the cases were subjected to following investigationsDengue serology:

D o n e b y immunochromatographic method and card test.Liver function test:

AST and ALT was estimated by IFCC without pyridoxal phosphate activation. Total bilirubin, total protein, albumin and ALP were estimated by colorimetric assay.Routine investigations:

Hemoglobin, total cell count, ESR, Packed cell volume, Platelet count, PT and APTT, blood urea, serum creatinine, blood sugar, MP, Widal test – by tube method, Anti HAV, HbSAg, Anti HCV and Ultrasound abdomen and thorax was done.

Statistical analysis:

Cross sectional, descriptive statistical analysis has been carried out in this study. Results on continuous measurements are presented on Mean SD (Min-Max) and results on categorical measurements are presented in Number (%).

Analysis of variance (ANOVA) has been used to find the significance of study parameters between three or more groups of patients, Chi-square/ Fisher Exact test has been used to find the significance of study parameters.Statistical software:

The Statistical software namely SAS 9.2, SPSS 16.0 etc. were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc.Result

There was 175 Dengue IgM antibody and/or NS-1 antigen positive patients were included in the study after they had fulfilled the inclusion and exclusion criteria. Mean age of dengue infection patients was 34.07±12.43 years with male to female ratio (53.7:46.3).

Table 1: Diagnosis of dengue infection

No. of patients NS1 or IgM PositiveDiagnosis Cases %Dengue Fever (DF) 141 80.6%Dengue Hemorrhagic Fever (DHF) 24 13.7%Dengue Shock Syndrome (DSS) 10 5.7%Total 175 100%Table 1: As per WHO classification, 141 (80.6%) patients were classified as dengue fever, 24 (13.7%)

as dengue hemorrhagic fever, and 10 (5.7%) as dengue shock syndrome.Table 2: Symptomatology in dengue subgroups

Complaints DF DHF DSS p value [n=141] % [24] % [n=10] % Fever 141 100.0 24 100.0 10 100.0 1.00Headache 116 82.3 16 66.7 10 100.0 0.43

fatty alterations, hyperplasia of the Kupffer cells, acidophil bodies and monocyte infiltration of the portal tract have been detected in patients with dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). In most cases, hepatic involvement prolongs the clinical course of this self-limiting viral infection, but it does not constitute a sign of worse prognosis.2,4 The liver dysfunction could be a direct viral effect or an adverse consequence of dysregulated host immune response against the virus.2 Several outbreaks of dengue infection have been reported from India. However, large clinical studies documenting hepatic involvement in dengue infection, especially in adults, are scarce.Material and Methods

The study was performed on patients admitted for dengue fever in J. L. N. hospitals, Ajmer. Total duration of the study was 1½ years.Inclusion criteria:

Dengue IgM and/or NS-1 antigen positive.Exclusion criteria:

The patients age <18 years associated infections known to cause hepatic involvement like

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Retroorbital pain 20 14.2 12 50.0 2 20.0 0.003Arthralgia 66 46.8 19 79.2 10 100.0 <0.001Myalgia 69 48.9 18 75.0 10 100.0 <0.001Vomiting 48 34.0 19 79.2 7 70.0 <0.001Pain abdomen 26 18.4 17 70.8 6 60.0 <0.001Bleeding manifestation 44 31.2 24 100.0 10 100.0 <0.001Fever and headache was present in all the dengue subgroups. Occurrence of retro-orbital pain, arthralgia,

myalgias, vomiting, pain abdomen and hemorrhagic manifestation were statistically significant in DHF and DSS compared to classical dengue fever patients.Table 3: Comparison of signs and symptoms in dengue subgroups:

Diagnosis DF [n=141] % DHF [n=24] % DSS [n=10] %Jaundice 1 0.7 0 0.0 8 80.0Pallor 4 2.8 1 4.2 0 0.0Icterus 1 0.7 0 0.0 10 100.0Hepatomegaly 9 5.1 8 33.3 7 70.0Ascites 0 0.0 1 4.2 3 30.0Pleural Effusion 1 0.7 0 0.0 6 60.0The jaundice is 0.7% in DF and 80% in DSS. The hepatomegaly is 5.1% in DF, 33.3% in DHF and

70% in DSS. The pleural effusion is 0.7% (DF) and 60% (DSS).Table 4: Comparison of clinical signs in DF, DHF and DSS

Parameters DF [n=141] DHF [24] DSS [n=10] p value Mean ±SD Mean ±SD Mean ±SD Age (Yrs) 33.87 12.780 32.79 9.592 38.70 14.008 0.78Temperature 98.43 7.592 98.65 0.078 99.67 0.932 0.72Pulse 80.07 9.568 85.33 11.552 108.80 8.854 <0.001R.R 18.21 2.273 18.96 1.488 20.80 1.398 0.001S.B.P 117.77 9.237 110.92 9.762 81.60 7.168 <0.001DBP 74.88 6.138 70.08 6.606 55.60 8.262 <0.001On comparison of the DF, DHF and DSS groups, table 4 shows that the mean value of pulse was

significantly different in these groups. Whereas vital parameters were deranged more significantly in the DSS group as compared to the DF and DHF groups.Table 5: Comparison of Laboratory parameters in dengue subgroups

Class Diagnosis DF [n=141] DHF [24] DSS [n=10] P Value Mean S. D. Mean S.D. Mean S.D. Hb 12.79 1.734 13.21 1.970 12.72 0.694 0.52HCT 41.74 3.251 47.46 3.821 47.84 4.409 <0.001ESR 14.26 7.483 22.08 10.116 14.40 5.125 <0.001Total Platelet 36370.77 30292.18 17604.58 13974.11 15000 3597.22 <0.001PT 12.45 1.544 15.65 0.750 16.82 0.512 <0.001APTT 34.44 2.996 48.53 4.552 66.52 4.855 <0.001S. Creatinine 0.90 0.204 0.99 0.123 1.12 0.204 0.001

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Table 5 shows that HCT was significantly increased in DHF and DSS group when compared to DF group. ESR and platelet count was significantly more deranged in the DHF group as compared to the DF group. PT and APTT were significantly deranged in DSS and DHF patients as compared to DF group.Table 6: Liver function tests

Parameters No. of Patients (n=175) % Mean ± SDAST(U/L) 12-38 1 0.6 277.69±279.498 >38 174 99.4 ALT(U/L) 7-41 5 2.9 170.36±181.823 >41 170 97.1 ALP(U/L) 33-96 59 33.7 126.78±65.238 >96 116 66.3 Table 6 shows the hepatic dysfunction, raised AST in 99.4% (174/175), raised ALT in 97.1% (170/175)

and raised ALP in 66.3% (116/175) patients. The mean AST levels were 277.69 ± 279.498 U/L and were significantly higher than ALT levels (170.36±181.823U/L) and ALP levels (126.78±65.238).Table 7: Comparison of liver function tests in dengue subgroups.

DF [n=141] DHF [24] DSS [n=10] Mean ± SD Mean ± SD Mean ± SD p valueT. Bilirubin 0.96 0.367 1.78 0.270 3.84 0.313 <0.001D. Bilirubin 0.50 0.245 0.95 0.265 2.89 0.247 <0.001T. Protein 6.88 0.520 5.19 0.136 5.19 0.137 <0.001Albumin 3.60 0.396 3.3 0.191 2.70 0.133 <0.001AST 199.33 77.167 344.17 80.79 1223.00 547.81 <0.001ALT 121.74 49.982 185.83 40.99 818.80 301.87 <0.001ALP 115.93 52.687 141.61 87.53 244.30 41.78 <0.001

Table 7 shows the Hyperbilirubinemia, elevated transaminases, hypoproteinaemia, and hypoalbuminaemia were seen in higher frequency in DHF and DSS as compared to classical DF. Most of the patients had modest elevation of liver enzymes in dengue subgroups. Liver dysfunction was more severe in DHF and DSS.

Discussion

The biochemical impact of dengue virus on liver function was studied in 175 serologically confirmed cases of dengue IgM and/or NS-1 antigen infection.

In our study the mean age of patients was 34.07 ± 12.43 years, with male to female ratio being (M: F = 53.71:46.29). In a recent study done by Rajoo et al.5 mean age was 31.6 years with predominant male patients (M: F = 3.3:1).

In this study, DF, DHF and DSS were present in 80.6%, 13.7% and 5.7% patients respectively. The results are comparable of

in 13.7% patients as compared to17.6%– 20.4% in other Indian studies.7, 8 Although liver size does not correlate with disease severity, an enlarged liver is observed more frequently in shock than in non shock cases2. In our study, hepatomegaly was more frequent in the DSS as compared to DF (70 % and 5.1% respectively).

The liver dysfunction, as increased transaminases, was found in most of the patients in our study 97.1% - 99.4%, similar to the results of Rajoo et al.5 (93.9%–97.7%) and other studies.7,8,9,10 The aspartate aminotransferase (AST) levels in dengue infection tend to be greater

a recent study done by Makroo et al.6 (DHF and DSS in 9.3% and 2.2% respectively) and Rajoo et al.5 (DHF and DSS in 13.6% and 5.1% respectively).

In our study hyperbilirubinemia was significantly more common in patients with DSS and DHF when compared to DF patients. Rajoo et al.5 found Hyperbilirubinemia to be significantly more common in patients with DSS, DF patients with hemorrhage and in non-survivors. Thus, observations support the fact that high bilirubin may act as a bad prognostic marker in patients with dengue infection.5

Hepatomegaly was observed

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than alanine aminotransferase (ALT) levels.11,12 In our study too, aspartate aminotransferase (AST) levels (277.69±279.498 U/L) tend to be greater than alanine aminotransferase (ALT) levels (170.36±181.823 U/L). The increased level of AST and ALT more in DHS and DSS as compare to DF. The mean AST in DF, DHF and DSS is 199.33, 344.17 and 1223 U/L respectively and mean ALT in DF, DHF and DSS is 121.74, 185.83 and 818.8 U/L respectively.

Kuo et al.13, in an evaluation of 270 dengue patients, observed abnormal levels of AST and ALT in 93.3% and 82.2%, respectively. WAHID et al., in a study of 50 serologically confirmed cases (25 cases of classic dengue and 25 of DHF), also found that the serum levels of AST and ALT were significantly greater among patients with the hemorrhagic form of the disease14.

Mohan et al. evaluated 61 children with clinical suspicion of dengue, with 37 cases of classic dengue, 16 of DHF and 8 of DSS, and observed that 96% of the children had abnormal transaminase levels. These values were higher in the DHF and DSS 15.

This preferential elevation of liver enzymes, with AST being significantly higher than ALT was also noted in study done by Rajoo et al.5 and Itha et al.9. This pattern is similar to that we see in alcoholic hepatitis but differs from that seen in other viral hepatitis. The exact cause of this is uncertain, but it has been suggested that it may be due to excess release of AST from damaged myocytes during dengue infection.10 This abnormality may act as an early indicator of dengue infection. The severity of hepatic dysfunction in dengue infection has been associated with disease

severity. Indeed, liver injury has been proposed to be a good positive predictive factor for the development of DHF.12

We noted a greater degree of hepatic injury in the DHF & DSS group as compared to the DF group, suggesting that the degree of liver injury may be related to the severity of dengue infection. Similar data have been suggested by Souza et al.16 However, in two other studies, the degree of elevation of liver enzymes in the DF and DHF groups was not significantly different.9,17

In our study, the mean bilirubin, AST, ALT, total protein, albumin and coagulation profile values were significantly deranged in patients with hemorrhage as compared to those without and in patients with sequential dengue infection as compared to those with primary infection. CONCLUSION

Hepatic dysfunction is very common in all forms of dengue infection, with AST rising significantly more than ALT. A greater degree of hepatic injury is observed in DHF group and DSS group as compared to the DF group.

Serum aminotransferase levels appear to have a directly proportional correlation with grading of dengue.

Therefore, the use of liver tests to evaluate the degree of liver damage is of great importance, and markers such as AST and ALT may be used as parameters to evaluate severity.REFERENCES

1. World Health Organization. Dengue hemorrhagic fever: diagnosis, treatment, prevention and control. 2ndedition. Geneva: WHO, 1997:1-83.

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4. Rico-Hesse R: Molecular evolution and distribution of dengue virus type 1and type 2 in nature. Virology 1990; 174:479-493.

5. Rajoo Singh Chhina, OmeshGoyal, DeepinderKaurChhina, PrernaGoyal, Raj Kumar, SandeepPuri. Liver function tests in patients with dengue viral infection. Dengue Bulletin, 2008; Volume 32:110-117.

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12. Kalayanarooj S, Vaughn DW, Nimmannitya S, Green S, Suntayaorn S, Kunentrasai N, Viramitrachai W, Ratanachu-eke S, Kiatpolpoj S, Innis BL, Rothman AL, Nisalak A, Ennis FA. Early clinical and laboratory indicators of acute dengue illness. J Infect Dis. 1997; 176(2): 313-321.

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15. Mohan B., Patwari A.K., Anand V.K., et al. Hepatic dysfunction in childhood dengue infection. J Trop Pediatrics 2000;46:40-3.

16. Souza, L.J., Alves, J.G., Nogueira, R.M.R., Neto, C.G., Bastos, D.A., da Siva Siqueira, E.W., SoutoFilho, J.T.D., Cezario, T.A., Soares, C.E., Carneiro, R.C., 2004. Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1585 cases. Braz. J. Infect. Dis. 8, 156—163.

17. Wahid, S.F., Sanusi, S., Zawawi, M.M., Ali, R.A., 2000. A comparison of the pattern of liver involvement in dengue hemorrhagic fever with classic dengue fever. Southeast Asian J. Trop. Med. Public Health 31, 259—263.