Impact of COVID-19 on Guillain-Barre Syndrome in India: A Multicenter Ambispective Cohort Study.

Introduction/Aims: Studies conducted during the coronavirus disease 2019 (COVID-19) pandemic have reported varied data regarding the incidence of Guillain-Barre syndrome (GBS). The present study investigated demographic and clinical features, management, and outcomes of patients with GBS during a specified period of the COVID-19 pandemic, and compared these features to those of GBS in the previous year. Methods: A multicenter, ambispective cohort study including 26 centers across India was conducted. Data from a pre-COVID-19 period (March 1 to August 31, 2019) were collected retrospectively and collected ambispectively for a specified COVID-19 period (March 1 to August 31, 2020). The study was registered with the Clinical Trial Registry India (CTRI/2020/11/029143). Results: Data from 555 patients were included for analysis: pre-COVID-19 (n = 334) and COVID-19 (n = 221). Males were more commonly affected during both periods (male:female, 2:1). Gastroenteritis was the most frequent antecedent event in 2019 (17.4%), whereas fever was the most common event in 2020 (10.7%). Paraparesis (21.3% versus [vs.] 9.3%, P = 0.001) and sensory involvement (51.1% vs. 41.3%; P = 0.023) were more common during COVID-19 in 2020, whereas back pain (26.3% vs. 18.4%; P = 0.032) and bowel symptoms (20.7% vs. 13.7%; P = 0.024) were more frequent in the pre-COVID period. There was no difference in clinical outcomes between the two groups in terms of GBS disability score at discharge and 3 months after discharge. Independent predictors of disability in the pre-COVID period included areflexia/hyporeflexia, the requirementfor intubation, and time to bulbar weakness; in the COVID-19 period, independent predictors included time from onset to admission, intubation, and intubation requirement. The mortality rate was 2.3% during the entire study period (13/555 cases). Discussion: Results of this study revealed an overall reduction in the frequency of GBS during the pandemic. The lockdown likely reduced the risk for antecedent infections due to social distancing and improved hygiene, which may have resulted in the reduction of the frequency of GBS.

Pontomesencephalic Atrophy and Postural Instability in Wilson Disease.

BACKGROUND AND PURPOSE: The MR Parkinsonism index helps in differentiating progressive supranuclear palsy from Parkinson disease and multisystem atrophy. Pontomesencephalic involvement is common in neurologic Wilson disease, but there is no prior study evaluating the MR Parkinsonism index and its indices in Wilson disease. We report the MR Parkinsonism index and its indices in Wilson disease and correlate these changes with clinical severity and postural reflex. MATERIALS AND METHODS: Thirteen individuals with neurologic Wilson disease were included, and their clinical details, including neurologic severity, postural reflex abnormality, and location of signal changes on MR imaging, were noted. The 3D BRAVO T1 sequence was used for measurement of the MR Parkinsonism index and its indices. The MR Parkinsonism index and its indices were also obtained in 6 age- and sex-matched controls. The morphometric parameters in Wilson disease were compared with those in with healthy controls and among the patients with and without abnormal postural reflex. RESULTS: The midbrain area was reduced in patients with Wilson disease compared with controls (112.08 ± 27.94 versus 171.95 ± 23.66 mm2, P = .002). The patients with an abnormal postural reflex had an increased MR Parkinsonism index and pons-to-midbrain ratio compared with controls, whereas these parameters were equivalent in patients with normal postural reflex and controls. The patients with abnormal postural reflex had more severe illness, evidenced by higher Burke-Fahn-Marsden scores (51.0 ± 32.27 versus 13.75 ± 12.37, P = .04) and neurologic severity grades (2.57 ± 0.53 versus 1.67 ± 0.82, P = .04). CONCLUSIONS: An increase in the MR Parkinsonism index in Wilson disease is mainly due to midbrain atrophy and it correlates with neurologic severity and abnormal postural reflex.

Spectrum of hyperosmolar hyperglycaemic state in neurology practice.

BACKGROUND & OBJECTIVES: Hyperosmolar hyperglycaemic state (HHS) is a medical emergency, but there is a paucity of studies reporting the spectrum of neurological manifestations of HHS. We, therefore, report the neurological spectrum, triggering factors and outcome of HHS in general neurology practice. METHODS: The records of the patients with HHS were extracted from computerized hospital information system and those managed currently were prospectively included. The demographic, clinical manifestations, duration of diabetes and precipitating events such as infection, stress and stroke were noted. Patients with HHS were categorized into seizure, movement disorder and encephalopathy groups. Their electroencephalography, magnetic resonance imaging (MRI) findings and outcome were noted. RESULTS: There were 17 patients with HHS (age range 40 and 75 yr) and seven were females. Seven patients were diabetic for five years, one for four years, one for one year and four were diagnosed after the occurrence of HHS. Four patients had epilepsia partialis continua persisting for 72-360 h, one patient had focal seizures and his MRI revealed T2 hyperintensity in frontal region in one patient and cerebellar vermian hyperintensity in another. All the five patients improved, but two had neurological deficits on discharge. Nine patients had encephalopathy which was precipitated by stroke in six patients, urinary infections in two and meningitis in one. Three females had hemichorea-hemiballismus syndrome, which was triggered by infections. Abnormal movements lasted 5-10 days and responded to correction of hyperosmolarity. Nine out of 17 patients improved completely whereas the remaining eight had partial recovery, these patients had stroke, ventilator-related complications or meningoencephalitis. INTERPRETATION & CONCLUSIONS: The most common presentation of HHS was encephalopathy (9) followed by seizure (5) and hemichorea-hemiballismus syndrome (3) which responded to the correction of hyperosmolar state.

Spectrum and outcome of acute infectious encephalitis/encephalopathy in an intensive care unit from India.

PURPOSE: To evaluate the spectrum of acute infectious encephalitis/encephalopathy syndrome (AIES) in intensive care unit (ICU) and the predictors of mechanical ventilation (MV) and outcome of these patients. METHODS: AIES patients diagnosed on the basis of fever, altered sensorium, seizure and cerebrospinal fluid pleocytosis admitted to the neurology ICU were prospectively included. The demographic and clinical details, hematological, biochemical, MRI and etiological findings of the patients were noted. Need of MV, death in hospital and 3-month functional outcome were analyzed. RESULTS: One hundred sixty-four out of 258 (64%) AIES patients needed ICU admission. Their median age was 35 (2-85) years and 71 (43%) were females. The etiology was viral in 44 (herpes and Japanese encephalitis in 12 each, dengue in 17, mumps, measles and varicella in 1 patient each), non-viral in 64 (scrub typhus in 48, falciparum malaria in 6, leptospira in 3 and bacterial in 7) and undetermined etiology in 56 (34%) patients. Sixty-nine (42%) patients needed MV. On multivariate analysis, Glasgow Coma Scale (GCS) score, Sequential Organ Failure Assessment (SOFA) score and raised intracranial pressure were independent predictors of MV. Forty-three (26%) patients died, and all were in the MV group. Higher SOFA score and untreatable etiology were independent predictors of mortality. At 3-month follow-up, 14% had poor and 86% had good outcome. Low GCS score, focal weakness and status epilepticus independently predicted poor outcome. CONCLUSION: Twenty-six percent patients with AIES died in ICU, and 86% had good recovery at 3 months. Admission SOFA scores and untreatable etiology predicted mortality.

Possible role of transforming growth factor ß in tuberculous meningitis.

BACKGROUND: Transforming growth factor ß (TGF-ß) is an anti-inflammatory cytokine and its role in hydrocephalus and stoke has been suggested. Tuberculous meningitis (TBM) is associated with exudates, stroke, hydrocephalus and tuberculoma, but the role of TGF-ß has not been evaluated in relation to these changes. AIM: To evaluate the cerebrospinal fluid (CSF) TGF-ß level in the patients with TBM, and correlate these with clinical findings, MRI changes, paradoxical response and outcome at 6months. METHODS: TBM patients diagnosed on the basis of clinical, CSF and MRI criteria were prospectively included. The clinical details including duration of illness, seizures, focal motor deficit, Glasgow Coma Scale (GCS) score and stage of TBM were noted. Presence of exudate, hydrocephalus, tuberculoma and infarction in MRI was also noted. MRI was repeated at 3months and presence of paradoxical response was noted. Cerebrospinal fluid TGF-ß was measured using ELISA on admission and repeated at 3months and these were compared with 20 controls. RESULTS: TGF-ß level was significantly higher in TBM compared to the controls (385.76±249.98Vs 177.85±29.03pg/ml, P<0.0001). TGF-ß correlated with motor deficit, infarction and tuberculoma on admission but did not correlate with CSF abnormalities, drug induced hepatitis, paradoxical response and outcome. TGF-ß level at 3months was significantly lower than the baseline but remained higher than the controls. CONCLUSION: CSF TGF-ß levels are elevated in TBM and correlate with infarction and tuberculoma.

Safety and efficacy of additional levofloxacin in tuberculous meningitis: A randomized controlled pilot study.

BACKGROUND: Levofloxacin is an effective bactericidal category III antitubercular drug. There is paucity of studies comparing the role of additional levofloxacin to standard antitubercular regimen in the patients with tuberculous meningitis (TBM). AIMS: To compare the safety and efficacy of adding levofloxacin to standard four drug ATT regimen (RHZE). SUBJECTS AND METHODS: The patients with TBM diagnosed on the basis of clinical, cerebrospinal fluid (CSF) and MRI criteria were included. Children below 15 years, patients with pregnancy, seizures, liver failure, kidney failure and malignancy were excluded. The baseline clinical, CSF and MRI characteristics were noted and consciousness was evaluated by Glasgow Coma Scale (GCS). The patients were randomized to RHZE (rifampicin, isoniazid, pyrazinamide and ethambutol) and RHZEL (RHZE and levofloxacin) groups. Outcome was defined at 6 months. Primary outcome was death and secondary outcomes were disability as assess by Barthel Index score and adverse events. RESULTS: Out of 110 TBM patients screened, 57 fulfilled the inclusion criteria. Their median age was 35 (15-75) years. 29 patients received RHZEL and 28 RHZE. The baseline clinical, biochemical and MRI characteristics were similar in the two groups. At 6 months, 11 (19.3%) patients died, 38 (66.7%) had good and 7 (12.3%) poor outcome. There was insignificant survival benefit in RHZEL group compared to RHZE (HR-2.61, 95% CI 0.73-9.36, P = 0.14), 25% patients died in RHZE where as 13.8% in RHZEL group. The disability was not significantly different between the two groups. The composite side effects were also similar between the two groups except for a higher frequency of seizure in RHZEL group (5 Vs 0) which resulted in withdrawal of levofloxacin. CONCLUSION: There was insignificant survival benefit in RHZEL which was associated with high frequency of seizures.

Is VEGF a marker of severity of scrub typhus infection?

Vascular endothelial growth factor (VEGF) and its receptors have been reported as severity markers of septicemia. Scrub typhus (ST) results in multi-organ dysfunction but the role of VEGF has not been evaluated. We report VEGF and its receptors in ST and its correlation with severity, outcome and laboratory findings. Thirty patients with ST diagnosed by solid phase immune chromatographic assay and Weil-Felix tests were included. Their clinical details, Glasgow Coma Scale (GCS), SOFA and modified Rankin Scale (mRS) scores and laboratory findings were noted. VEGF, VEGFR1 and VEGFR2 were done by ELISA at admission and repeated at 1 month. Outcome was defined at 1 month. Serum VEGF and VEGF-R1 levels were significantly higher and VEGFR2 was significantly lower in the ST patients compared to the controls. These levels significantly improved at 1 month. VEGF level correlated with SOFA score (p = 0.05) and SGPT (p = 0.04). VEGFR1 correlated with hemoglobin (p = 0.04), platelet count (p = 0.03), serum CK (p = 0.001), weakness (p = 0.04) and mRS score (p = 0.04). VEGFR2 did not correlate with any clinical or laboratory parameters. All the patients recovered with doxycycline. Serum VEGF and VEGFR1 levels increased in ST and suggest disease severity but do not predict outcome.

VehiHealth: An Emergency Routing Protocol for Vehicular Ad Hoc Network to Support Healthcare System.

Survival of a patient depends on effective data communication in healthcare system. In this paper, an emergency routing protocol for Vehicular Ad hoc Network (VANET) is proposed to quickly forward the current patient status information from the ambulance to the hospital to provide pre-medical treatment. As the ambulance takes time to reach the hospital, ambulance doctor can provide sudden treatment to the patient in emergency by sending patient status information to the hospital through the vehicles using vehicular communication. Secondly, the experienced doctors respond to the information by quickly sending a treatment information to the ambulance. In this protocol, data is forwarded through that path which has less link breakage problem between the vehicles. This is done by calculating an intersection value I v a l u e for the neighboring intersections by using the current traffic information. Then the data is forwarded through that intersection which has minimum I v a l u e . Simulation results show VehiHealth performs better than P-GEDIR, GyTAR, A-STAR and GSR routing protocols in terms of average end-to-end delay, number of link breakage, path length, and average response time.

Outcome of tuberculous meningitis patients requiring mechanical ventilation.

PURPOSE: There is paucity of information about the outcome of tuberculous meningitis (TBM) patients on mechanical ventilation (MV). In this communication, we report the clinical characteristics, predictors of MV, and outcome of TBM patients requiring MV. METHOD: Thirty-eight (18%) of 205 patients with TBM requiring MV were included; and their demographic, clinical, cerebrospinal fluid, and magnetic resonance imaging finding at admission and follow-up were noted. The ventilator-related and systemic complications, hospital death, and 3-month functional outcome were noted. The predictors of need of MV were derived by multivariate regression analysis. RESULTS: There were 38 MV and 36 non-MV TBM patients who were matched for age, sex, and stage of meningitis on admission. The requirement of MV was independently related to leukocytosis, seizure, and cerebrospinal fluid pleocytosis on admission. Patients on MV had higher frequency of septicemia (9 vs 2), bedsores (6 vs 0), and gastric hemorrhage (4 vs 0) compared with non-MV patients. Only 29% of MV patients survived and had poor outcome at 3 months; but in the non-MV group, all the patients survived, and only 11% had poor outcome. CONCLUSION: Mechanical ventilation was needed in 18% TBM patients because of TBM-related or systemic complications. Those requiring MV had high mortality and may be categorized separately.

A study of MRI changes in Wilson disease and its correlation with clinical features and outcome.

OBJECTIVE: To evaluate the sensitivity of different MRI sequences in Wilson disease (WD) with neurological manifestations and its correlation with clinical features and outcome. METHODS: 34 WD patients with neurological manifestation with a median age of 14 years were included. Their Mini Mental State Examination (MMSE) score, movement disorders and laboratory findings were noted. Cranial MRI in T1, T2, FLAIR and DW sequences were done. Outcome at 6 months was categorized into improved (>1 grade improvement), static or worsening. RESULTS: MRI was abnormal in all and revealed involvement of putamen in 29 (85.3%), caudate in 23 (67.6%), brainstem and globus pallidus in 21 (61.8%) each, thalamus in 20 (58.8%), cerebral cortex in 9 (26.5%), subcortical white matter in 8 (23.5%), and cerebellum in 2 (5.9%) patients. The overall sensitivity of T2 and FLAIR was 97.1% each, DWI 38.2% and T1 31.4%. None had contrast enhancement and 4 had reduced ADC value. Choreoathetosis correlated with thalamic, pallidal and putaminal lesions; MMSE with subcortical white mater. MRI load correlated with age, tremor, psychiatric disorder, choreoathetosis, and severity of WD. At 6 months 9 (26.5%) patients improved, 18 (52.9%) remained static and 6 (17.6%) deteriorated. CONCLUSION: In neurologic WD, putaminal involvement is the commonest; T2 and FLAIR sequences have similar sensitivity and number of MRI lesions correlated with disease severity but not with outcome.

VEGF and its receptors in dengue virus infection.

Vascular permeability determines the severity of dengue virus infection. Vascular endothelial growth factor (VEGF) and its (receptor 1) R1 and (receptor 2) R2 receptors may provide insight about the neurological complications of dengue. We report VEGF and its R1 and R2 receptors level in dengue patients and correlate these with neurological complications. Consecutive patients with dengue were subjected to clinical and neurological evaluations. Their blood counts, serum chemistry, including liver and kidney function tests, serum creatine kinase (CK), and albumin were measured. VEGF, VEGFR1 and VEGFR2 were measured by ELISA in the patients and 16 matched controls. Twenty four patients with dengue were included whose ages ranged between 15 and 67 years, and nine of whom were females. Serum VEGF level was insignificantly lower in dengue patients whereas VEGFR1 was significantly higher (P = 0.01) and VEGFR2 was significantly lower (P = 0.005) compared to controls. VEGFR2 correlated with systolic blood pressure, coagulopathy, and serum CK levels. None of the other clinical and biochemical parameters correlated with VEGF and VEGFR1 levels. VEGFR1 and R2 normalized at 1 month. VEGFR2 correlates with the clinical severity of dengue and muscle dysfunction.

An open labeled randomized controlled trial of pregabalin versus amitriptyline in chronic low backache.

BACKGROUND: There is no head on comparison of amitriptyline (AMT) and pregabalin (PG) in relieving pain and disability in chronic low backache (CLBA). This randomized controlled trial reports the efficacy and safety of AMT and PG in CLBA. METHODS: Patients with CLBA, 15-65 years of age without specific cause and significant neurological deficit were included. Severity of pain was assessed by Visual Analogue Scale (VAS) and disability by Oswestry Disability Index (ODI). Patients were followed up at 6 and 14 weeks and their VAS score, ODI and side effect were noted. Primary outcome was pain relief (>50% improvement in VAS score) at 14 weeks and secondary outcome were reduction in ODI (>20%) and side effects. RESULTS: 200 patients with CLBA were randomized to AMT (n=103) and PG (n=97) using random numbers. The VAS score and ODI improved significantly following AMT and PG at 6 and 14 weeks compared to baseline. The improvement in pain (57.3% Vs 39.2%; P=0.01) and disability (65% Vs 49.5%; P=0.03) however was more in AMT group. The composite side effects were similar in both groups. CONCLUSION: AMT and PG are effective in CLBA but AMT reduced pain and disability significantly compared to PG.

Safety and efficacy of levofloxacin versus rifampicin in tuberculous meningitis: an open-label randomized controlled trial.

OBJECTIVES: We report the efficacy and safety of levofloxacin versus rifampicin in tuberculous meningitis (TBM). PATIENTS AND METHODS: In this open-label, randomized controlled trial from India, patients with TBM diagnosed on the basis of clinical, MRI and CSF findings were included. Patients with hepatic or renal dysfunction, organ transplantation, malignancy, pregnancy, lactation, allergy, seizure, age <15 years and antitubercular treatment ≥1 month were excluded. Sixty patients each were randomized to levofloxacin (10 mg/kg, maximum 500 mg) or rifampicin (10 mg/kg, maximum 450 mg). They also received isoniazid, pyrazinamide, ethambutol, prednisolone and aspirin. The primary outcome was death and secondary outcome measures were 6 month disability, repeat MRI changes and serious adverse events (SAEs). RESULTS: The median age of the patients was 34.5 (16-75) years. The baseline clinical and MRI findings were similar between the two groups. At 6 months, 13 out of 60 (21.7%) patients in the levofloxacin arm and 23 out of 60 (38.3%) patients in the rifampicin arm had died (P = 0.07). On Cox regression analysis, survival in the levofloxacin group was significantly better than in the rifampicin group (hazard ratio 2.13, 95% CI 1.04-4.34, P = 0.04). The functional outcome (P = 0.47) was, however, not significantly different between the two groups. On intention-to-treat analysis, 10 out of 47 (21.3%) in the levofloxacin arm and 5 out of 37 (13.5%) in the rifampicin arm had poor recovery. Repeat MRI findings did not differ between the groups. Levofloxacin was discontinued more frequently than rifampicin due to SAEs (16 versus 4, P = 0.01). CONCLUSIONS: Levofloxacin is superior to rifampicin in reducing 6 month death in TBM but not disability. Levofloxacin may be used in TBM especially in those patients with hepatotoxicity and without seizure.

Amitriptyline vs divalproate in migraine prophylaxis: a randomized controlled trial.

OBJECTIVE: This study compares efficacy and safety of divalproate extended release (DVA-ER) and amitriptyline (AMT) in migraine. MATERIALS AND METHODS: Three hundred migraineurs having >4 attacks monthly were randomized into DVA-ER or AMT. The primary end points were >50% reduction in frequency, ≥1 grade improvement in the severity, and >50% improvement in a visual analogue scale (VAS). Secondary end points were functional disability, rescue medication, and adverse events. RESULTS: The median age was 32 years, and 241 were women. 150 patients each received DVA-ER and AMT. At 3 months, 74.7% in DVA-ER and 62% patients in AMT group improved in headache frequency (P = 0.02) and at 6 months, 65.3% and 54%, respectively (P = 0.90). At 3 months, the VAS score improved by >50% in 80.7% in DVA-ER and 64% in AMT (P = 0.005). At 6 months, there was no significant difference between the two groups in VAS score (69.3% vs 56%; P = 0.47) and other outcome parameters. The composite side effects were also not different between the two groups (68% vs 81%); however, hair fall, menstrual irregularity, polycystic ovary, and weight gain were commoner in DVA-ER group. CONCLUSION: Divalproate extended release is more effective at 3 months than AMT; however, at 6 months, both are equally effective in migraine prophylaxis.

Comparative study of thyrotoxic periodic paralysis from idiopathic hypokalemic periodic paralysis: An experience from India.

OBJECTIVE: There is paucity of reports on thyrotoxic periodic paralysis (TPP) from India. We report the patients with TPP and compare them with idiopathic hypokalemic periodic paralysis (IHPP). MATERIALS AND METHODS: Patients with hypokalemic periodic paralysis (HPP) treated during the past 11 years were evaluated retrospectively. Their demographic parameters, family history, clinical features, precipitating factors, severity of weakness, laboratory parameters and rapidity of recovery were recorded. The demographic, clinical and laboratory parameters of TPP and IHPP were compared. RESULTS: During the study period, we managed 52 patients with HPP; nine (17.3%) of whom had TPP and 27 (52%) had IHPP. The demographic, precipitating factors, number of attacks and severity of limb weakness were similar between the TPP and IHPP groups, except in the IHPP group, bulbar weakness was present in four and respiratory paralysis in six, needing artificial ventilation in two patients. Serum potassium was significantly lower in TPP (2.21 ± 0.49) compared with IHPP (2.67 ± 0.59, P = 0.04). Four patients with TPP had subclinical thyrotoxicosis and two had subclinical hyperthyroidism. Rebound hyperkalemia occurred in both TPP and IHPP (three versus eight patients). The recovery was faster in IHPP (26.7 ± 15.4 h) compared with TPP (34.0 ± 14.0 h), but was statistically insignificant. CONCLUSION: TPP constitutes 17.3% of HPP, and absence of clinical features of thyrotoxicosis and subclinical hyperthyroidism in TPP is not uncommon. Clinical features, demographic profile and rebound hyperkalemia are similar in both TPP and IHPP. The serum potassium level is significantly low in the TPP compared with the IHPP group.

Sonographic evidence of ascites, pleura-pericardial effusion and gallbladder wall edema for dengue fever.

INTRODUCTION: Radiographic findings of dengue fever have not yet been clearly elucidated in relation to clinical and serological findings, despite the fact that two-fifths of the world population lives in areas where the virus is endemic. The current study is a retrospective analysis of ultrasonographic (USG) features of patients presenting with probable dengue fever during the outbreak of DF of 2006 in North India. METHODS: Case records of a 169 patients with probable dengue fever were included. Ten individual sonographic parameters were reviewed vis-à-vis ascites, hepatomegaly, splenomegaly, gall bladder wall edema (GBWE), pleural effusion (right or left or both), pericardial effusion, pericholecystic collection, perinephric collection. Subjects who had GB wall thickness >3 mm as measured on ultrasound were identified as positive for GBWE. The cases were analyzed in view of their serological profile. RESULTS: The mean age of the subjects was 27.9 +/- 13.4 years. The mean value of the platelet count was 57.4 +/- 22.3 x 103/cmm. The most common ultrasonographic feature was ascites (126, 74.6%) followed by gall bladder wall edema (122, 72%), hepatomegaly (78, 46.2%), splenomegaly (66, 39.1%) and pericholecystic collection (63, 37.3%); 48 (28.4%) subjects demonstrated evidence of pleural effusion on the right side, while 19 (11.2%) had bilateral effusion. None of the subjects had an isolated left pleural effusion. Twenty-seven (16%) subjects reported bleeding manifestations in the form of petechiae and five (3%) developed renal dysfunction. Presence of pleural and pericardial effusions was found to be specific while ascites and GBWE were identified as highly sensitive markers for seropositive Primary DF. CONCLUSIONS: Ultrasonographic evidence of ascites, pleuro-pericardial effusion, and gallbladder wall edema are rapidly acquired, non-invasive markers of dengue and can be helpful before serological investigations become available. These findings may indicate severity and may herald the onset of bleeding (petechiae) or predict the development of acute renal dysfunction.