Use of intravenous N-acetylcysteine in acute severe hepatitis due to severe dengue infection: a case series.

BACKGROUND: Dengue fever is a common mosquito borne viral infection. Severe dengue fever associated severe hepatitis carries high mortality. Based on the beneficial effect of N-acetylcysteine (NAC) in paracetamol poisoning and non-acetaminophen induced liver failure, it is used in dengue fever associated hepatitis in clinical practice. We aim to study the reversal of liver enzymes with NAC in the setting of severe hepatitis due to severe dengue infection. METHODS: A retrospective analysis was conducted on hospitalized 30 adults with severe dengue fever with severe hepatitis. These 30 patients had aspartate transaminase (AST) and alanine transaminases (ALT) more than 500 U/L and/or PT INR (prothrombin time and international normalized ratio) more than 1.5. They were treated with NAC infusion of 100 mg/h for 3 to 5 days. RESULTS: The mean age of the group was 49.9 ± 11.46 years and 18 (60%) patients were males. Nineteen patients (63%) developed dengue shock. Of them 12 patients (40%) developed hepatic encephalopathy. Median AST on the day of administration of NAC was 1125 U/L interquartile range (IQR) 1653.25 while median ALT was 752 (IQR 459.25). There was a statistically significant reduction of both ALT (p = 0.034) and AST (p = 0.049) from day 1 to 4 after NAC infusion. Rise of platelet count between day 1 and day 4 also showed statistically significant difference (p = 0.011) but the reduction of prothrombin time and international normalized ratio (PT/INR) from 1 to day 4 did not show statistical significance difference. Mean duration of treatment with NAC was 3.61 ± 0.75 days while mean length of hospital stay was 6.2 ± 1.27 days. Only one patient died (3.3%). None of the patients reported adverse drug reaction due to NAC. CONCLUSION: Majority of patients demonstrated marked clinical and biochemical improvements and they recovered fully. We observed faster and significant recovery of liver enzymes following administration of NAC. Based on the above findings, this study provides preliminary evidence for the beneficial effect of NAC in severe hepatitis in dengue infection with greater survival benefits.

[Takotsubo syndrome in dengue patient]. / Síndrome de Takotsubo en paciente con dengue.

Takotsubo syndrome, was described in Japan in 1990, it is a stress cardiomyopathy, predominantly in women, usually postmenopausal. Cardiac hypokinesia occurs, with involvement of multiple coronary territories. In intensive care unit (ICU), it is considered underdiagnosed. Manifestations of severe dengue fever include cardiovascular involvement, mainly arrhythmias and systolic dysfunction. A case of a 72-year-old man is presented, who was hospitalized in ICU for dengue fever, with plateletopenia (15000 cells/mm3) and dehydration. After fluid management the patient reported respiratory discomfort, auscultating crackling rales. A pulmonary ultrasound was made where bilateral B lines were found with B7 pattern compatible with interstitial syndrome and pulmonary edema. Basal hyperkinesia, medial and apical hypokinesia with an image consistent with apical ballooning were observed in the transthoracic echocardiogram. The electrocardiogram showed complete right bundle branch block. Chagas serology was negative and quantitative troponin I was increased. In the context of severe dengue, a Takotsubo syndrome was diagnosed. The patient evolved favorably. After discharge, a normalization of the cardiac function was stated in ultrasound images. The case is of clinical importance due to the low association of these two diseases and the need to screen for cardiac involvement in severe dengue.

El síndrome de Takotsubo, fue descripto en Japón en 1990, se trata de una miocardiopatía por estrés, predominante en mujeres, generalmente postmenopáusicas. Se produce una hipoquinesia cardiaca, con compromiso de múltiples territorios coronarios. En las unidades de terapia intensiva (UTI), se considera subdiagnosticada. En las manifestaciones del dengue grave, se encuentra el compromiso cardiovascular, principalmente arritmias y disfunción sistólica. Se presenta el caso de un hombre de 72 años, internado en UTI por dengue, con plaquetopenia (15000 células/mm3) y deshidratación. Luego de la administración de fluidos refirió disconfort respiratorio, auscultándose estertores pulmonares. Se realizó ecografía pulmonar donde se apreció líneas B bilaterales con patrón B7 compatible con síndrome intersticial y edema pulmonar. En el ecocardiograma transtorácico se objetivó hiperquinesia basal, hipoquinesia medial y apical con imagen compatible con balonamiento apical. En el electrocardiograma se evidenció bloqueo completo de rama derecha. La serología para Chagas fue negativa y la troponina I cuantitativa se detectó aumentada. Se diagnosticó síndrome de Takotsubo en el contexto de dengue grave. El paciente evolucionó favorablemente. Posterior al alta, se constató normalización de la motilidad cardíaca, en las imágenes ecográficas. El caso es de importancia clínica por la baja asociación de las dos enfermedades y la necesidad de pesquisar el compromiso cardíaco en el dengue grave.

An effective pan-serotype dengue vaccine and enhanced control strategies could help in reducing the severe dengue burden in Bangladesh-A perspective.

Dengue is an important vector-borne disease occurring globally. Dengue virus (DENV) infection can result in a potentially life-threatening disease. To date, no DENV-specific antiviral treatment is available. Moreover, an equally effective pan-serotype dengue virus vaccine is not available. Recently, two DENV vaccines, Dengvaxia and Qdenga, were licensed for limited use. However, none of them have been approved in Bangladesh. DENV is transmitted by Aedes mosquitoes, and global warming caused by climate change favoring Aedes breeding plays an important role in increasing DENV infections in Bangladesh. Dengue is a serious public health concern in Bangladesh. In the year 2023, Bangladesh witnessed its largest dengue outbreak, with the highest number of dengue cases (n = 321,179) and dengue-related deaths (n = 1,705) in a single epidemic year. There is an increased risk of severe dengue in individuals with preexisting DENV-specific immunoglobulin G if the individuals become infected with different DENV serotypes. To date, vector control has remained the mainstay for controlling dengue; therefore, an immediate, strengthened, and effective vector control program is critical and should be regularly performed for controlling dengue outbreaks in Bangladesh. In addition, the use of DENV vaccine in curbing dengue epidemics in Bangladesh requires more consideration and judgment by the respective authority of Bangladesh. This review provides perspectives on the control and prevention of dengue outbreaks. We also discuss the challenges of DENV vaccine use to reduce dengue epidemics infection in Bangladesh.

A Case of Emergency Pericardial Drainage for Cardiac Tamponade Due to Dengue Fever.

Dengue fever is a febrile viral disease transmitted by mosquitoes. The symptoms of dengue fever are numerous and varied; however, cardiac tamponade is a particularly rare and atypical complication. This study describes a case of a 30-year-old male who presented with acute respiratory distress and chest pain on the ninth day after diagnosis of dengue fever. On admission, a computed tomography scan revealed a large pericardial effusion. The patient went into shock and was urgently treated with pericardial drainage, which resulted in rapid improvement of his symptoms. Emergent management of this rare but potentially fatal complication of dengue fever resulted in a favorable outcome in this case.

A Study on the Clinical Profile of Patients Presenting With Dengue Fever and the Precision Prediction of Dengue Severity Using Platelet Count at Presentation.

Background The most prevalent arbovirus infection in the world, dengue, has become a serious public health issue. This study aims to examine the clinical characteristics of individuals who present with dengue fever and use platelet count prediction to estimate the severity of dengue. Materials and methods This observational, cross-sectional study was conducted at Dr. D. Y. Patil Medical Hospital, Pune, Maharashtra, India, from February 2022 to May 2024. A total of 100 patients older than 12 years old who had dengue fever (presenting within three days of the first symptom) and were dengue NS1 antigen-positive in the laboratory were included. Patients under 12 years of age and pregnant women were excluded. Also excluded were patients with a history of prior dengue infection and patients on medications causing thrombocytopenia, such as antiplatelets (aspirin). Written informed consent was obtained from each patient. For adolescent boys and girls aged 13-18, consent was obtained from a parent or legal guardian along with the adolescent's assent. Data were collected through physical examinations and laboratory investigations. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York), with descriptive statistics and tests for nonparametric data, setting the significance at p<0.05. Results The average age of the study participants was 29.48 ± 10.62 years, with 24% in the 0-20 year age group, 36% in the 21-30 age group, 24% in the 31-40 age group, 12% in the 41-50 age group, 3% in the 51-60 age group, and 1% in the 61-70 age group. Men comprised 65% of the population, with 35% being women. Weakness was the most prevalent symptom, followed by nausea and fever with chills. Patients with dengue fever without warning indications had a median platelet count of 114,000/µL upon admission; those with dengue fever with warning signs had a median count of 35,500/µL; and those with severe dengue had a median count of 25,000/µL. These distinctions attained statistical significance, underscored by p-values of <0.001. The predictive model for severe dengue using platelet count on presentation demonstrated a robust capacity to anticipate severe dengue with a noteworthy association (p<0.04), indicating an increased risk of severe dengue with a lower platelet count (<25,000/µL, odds ratio (OR) 7.5). Conclusion Dengue was more common in the young population, with a predominance of male patients. Weakness was the most common symptom. Patients with a platelet count less than 25,000/µL had 7.5 times more odds of developing severe dengue.

Integrated Approach to Severe Dengue Complicated by Guillain-Barré Syndrome and Multi-organ Failure.

This report details the case of a female patient who was admitted with severe dengue, which was further complicated by bilateral pneumonia and multiple organ involvement. The patient also developed quadriparesis, a neurological complication, and had a recent history of vaccination with the COVISHIELD COVID-19 vaccine. A nerve conduction study later determined the condition to be acute motor axonal neuropathy, a variant of Guillain-Barré syndrome (GBS). While neurological complications, such as GBS, are rare in dengue cases, they can significantly affect patient outcomes. Treatment with intravenous immunoglobulin (IVIG) has proven to be an effective disease-modifying therapy for GBS. IVIG therapy is recognized for its anti-inflammatory and immunomodulatory effects, making it beneficial in certain autoimmune conditions, including those involving the nervous system. However, its use in severe infections or sepsis remains controversial. In this case, IVIG therapy was administered alongside broad-spectrum antibiotics. The patient's favorable response to IVIG therapy and subsequent clinical improvement highlight the importance of early recognition and targeted intervention for neurological complications in dengue cases.

Comparison of clinical and laboratory parameters of primary vs secondary dengue fever in travellers.

BACKGROUND: Dengue fever (DF), caused by the dengue virus (DENV), is the most common arboviral disease in travellers worldwide. It is hypothesized that compared with primary DF, secondary DF may result in antibody-dependent enhancement of the immune response, resulting in more severe disease. We aimed to compare clinical and laboratory parameters in travellers with primary and secondary DF to determine whether secondary DF is associated with markers of severe disease. METHODS: We conducted a retrospective cohort study, which included all patients diagnosed with DF at the Central Virology Laboratory of the Israeli Ministry of Health during 2008-19. Clinical, laboratory and virological data were extracted from laboratory and patient records. A diagnosis of DENV infection was based on a positive nonstructural protein 1 (NS1) test, polymerase chain reaction or serology testing for immunoglobulin M (IgM) and immunoglobulin G (IgG). Primary and secondary infections were classified based on travel history, NS1 result and IgM/IgG ratio. Severe DF was defined according to WHO classification. RESULTS: We identified 245 DF cases: 210 (86%) primary and 35 (14%) secondary. Whilst fever duration was significantly longer in secondary compared with primary infections (6.4 vs 5.3 days, P = 0.027), mean Aspartate aminotransferase levels were significantly higher in primary compared with secondary cases (146 vs 65 U/L, P < 0.001), and no other clinical or laboratory parameter differed significantly between the groups. Of note, only four patients had severe DF, all had primary infections and none died. CONCLUSIONS: In a cohort of returning travellers with DF, secondary infection, compared with primary infection, was not associated with a consistent trend towards greater severity of the clinical and laboratory markers examined in this study.

Corrigendum: Clinical Characteristics and Risk Factors for Severe Dengue Fever in Xishuangbanna, During the Dengue Outbreak in 2019.

[This corrects the article DOI: 10.3389/fmicb.2022.739970.].

Clinical Characteristics and Risk Factors for Severe Dengue Fever in Xishuangbanna, During the Dengue Outbreak in 2019.

Background: Dengue poses a large burden on the public health systems worldwide. severe dengue (SD) could lead to more serious clinical symptoms and even death. This study aimed to identify the cause of SD in a clinical trial during the dengue outbreak in Xishuangbanna in 2019, and could provide new insights into the pathogenic mechanisms of SD. Methods: Mosquito-borne viral (DENV, JEV, and CHIKV) infections were identified. The epidemiological factors and clinical symptoms of inpatients in Xishuangbanna were recorded. The IgG and IgM levels in the serum of dengue inpatients were evaluated, and secondary infections were identified. Then, the structural proteins (C/PrM/E) were sequenced and compared with those of the same type of DENV in the same area as before, and their structures were predicted by the SWISS-MODEL (expasy.org). The full-length viral genomes were sequenced and aligned with representative strains by BioEidt or MEGA 5.0. Results: In this outbreak, the clinical symptoms were more serious in SD. The proportion of SD inpatients of male and Han nationality was larger than that of dengue fever (DF) inpatients (p < 0.05). DENV-2 infection was the majority in DF, with 45 inpatients. However, DENV-1 infection was the most common SD, with 54 inpatients. There were 3 DENV-3-positive inpatients in the DF group and 6 ZIKV-positive inpatients in the SD group. A secondary infection accounted for 76.47% (78 cases) of SD inpatients, but secondary infections were only in 20% (17 cases) of DF inpatients. In the three-dimensional structure of protein analysis, the C/PrM/E of DENV-1 and DENV-2 showed more stability than previous epidemic strains, while DENV-3 in 2019 showed a looser spatial structure. After a complete genome sequencing and analysis, all six DENV-2 strains belonged to cosmopolitan, five of which clustered into one branch. The GC/AT of the five strains decreased from 2014 to 2018. Compared with DF strains, SD strains had no mutations of commonness. Conclusions: SD may related to secondary heteromorphic dengue in Xishuangbanna in 2019. The coinfection of ZIKV could be another related factor for SD. The currently datas were very limited and only suggestive.

First report of epidemic dengue fever and malaria co-infections among internally displaced persons in humanitarian camps of North Darfur, Sudan.

OBJECTIVES: This study aimed to investigate an outbreak of a non-malaria, undifferentiated febrile illness, among internally displaced persons (IDPs) living in humanitarian camps in North Darfur, Sudan, in 2019. METHODS: An investigation team was deployed to North Darfur to identify suspected cases and collect blood samples, and clinical and demographical data. Blood samples were examined microscopically for Plasmodium spp and tested for dengue (DENV) and yellow fever viruses by reverse transcriptase-quantitative polymerase chain reaction. RESULTS: Between September 7 and December 18, 2019, we clinically identified 18 (24%), 41 (54%), and 17 (22%) cases of dengue fever, dengue with warning signs, and severe dengue, respectively. Blood samples were collected from 22% of patients, and 47% of these tested positive for DENV-1 RNA. We confirmed 32 malaria cases with 5 co-infections with DENV. This outbreak of dengue was the first among IDPs in the humanitarian camps. CONCLUSIONS: Our findings indicate that dengue has become endemic or that there has been a new introduction. Further epidemiological, entomological, and phylogenetic studies are needed to understand disease transmission in the area. An early warning and response system and an effective health policy are crucial for preventing and controlling arboviruses in Sudan.

"Honeycomb" pattern of gallbladder wall thickening - A forward step in early diagnosis of "Severe Dengue Fever".

AIMS AND OBJECTIVES: To study "Honeycomb" pattern of gallbladder wall thickening (GBWT) in dengue fever (DF) and to assess its clinical significance in early diagnosis of severe DF. MATERIALS AND METHODS: A total 244 patients of DF were studied, 84 patients were classified as severe DF, 61 patients as DF with warning signs, and 99 patients as DF without warning signs. Abdominal ultrasound was performed for assessment of GBWT patterns, hepatomegaly, splenomegaly, pancreatic enlargement, ascites, pleural effusion, and other additional findings were recorded in severe DF cases. Statistical comparison between "Honeycomb" pattern of GBWT and clinically severe DF was done using Pearson correlation test. RESULTS: Out of 244 patients, 145 patients were males and 99 patients were females, belonging to various age groups ranging from 1 to 81 years and 14.34% (35 patients) among them included in pediatric group. In total, 65.57% (160 patients) were non-severe DF cases and 34.42% (84 patients) were severe DF cases. A total of 84 patients of severe DF, 92.85% patients showed GBWT, and out of which, 71.42% patients had "Honeycomb" pattern, whereas a total of 160 patients of non-severe DF patients, 45% patients had GBWT and out of which, only 5.6% patients showed "Honeycomb" pattern. "Honeycomb" pattern of GBWT shows sensitivity of 71.4%, 94.37%, Positive predictive value of 86.95%, and Negative predictive value of 86.28% in severe DF. CONCLUSION: "Honeycomb" pattern of GBWT is significant finding in severe DF. Its sensitivity and specificity are high in severe DF with significant statistical correlation. It can aid in early diagnosis of severe DF.

Síndrome de Takotsubo en paciente con dengue / Takotsubo syndrome in dengue patient

Resumen El síndrome de Takotsubo, fue descripto en Japón en 1990, se trata de una miocardiopatía por estrés, predo minante en mujeres, generalmente postmenopáusicas. Se produce una hipoquinesia cardiaca, con compromiso de múltiples territorios coronarios. En las unidades de terapia intensiva (UTI), se considera subdiagnosticada. En las manifestaciones del dengue grave, se encuen tra el compromiso cardiovascular, principalmente arrit mias y disfunción sistólica. Se presenta el caso de un hombre de 72 años, inter nado en UTI por dengue, con plaquetopenia (15 000 cé lulas/mm3) y deshidratación. Luego de la administración de fluidos refirió disconfort respiratorio, auscultándose estertores pulmonares. Se realizó ecografía pulmonar donde se apreció líneas B bilaterales con patrón B7 compatible con síndrome intersticial y edema pulmonar. En el ecocardiograma transtorácico se objetivó hiperqui nesia basal, hipoquinesia medial y apical con imagen compatible con balonamiento apical. En el electrocardio grama se evidenció bloqueo completo de rama derecha. La serología para Chagas fue negativa y la troponina I cuantitativa se detectó aumentada. Se diagnosticó síndrome de Takotsubo en el contexto de dengue grave. El paciente evolucionó favorablemente. Posterior al alta, se constató normalización de la moti lidad cardíaca, en las imágenes ecográficas. El caso es de importancia clínica por la baja asocia ción de las dos enfermedades y la necesidad de pesqui sar el compromiso cardíaco en el dengue grave.

Abstract Takotsubo syndrome, was described in Japan in 1990, it is a stress cardiomyopathy, predominantly in women, usually postmenopausal. Cardiac hypokinesia occurs, with involvement of multiple coronary territories. In in tensive care unit (ICU), it is considered underdiagnosed. Manifestations of severe dengue fever include cardio vascular involvement, mainly arrhythmias and systolic dysfunction. A case of a 72-year-old man is presented, who was hos pitalized in ICU for dengue fever, with plateletopenia (15 000 cells/mm3) and dehydration. After fluid management the patient reported respiratory discomfort, auscultating crackling rales. A pulmonary ultrasound was made where bilateral B lines were found with B7 pattern compatible with interstitial syndrome and pulmonary edema. Basal hyperkinesia, medial and apical hypokinesia with an im age consistent with apical ballooning were observed in the transthoracic echocardiogram. The electrocardiogram showed complete right bundle branch block. Chagas serol ogy was negative and quantitative troponin I was increased. In the context of severe dengue, a Takotsubo syn drome was diagnosed. The patient evolved favorably. After discharge, a normalization of the cardiac function was stated in ultrasound images. The case is of clinical importance due to the low as sociation of these two diseases and the need to screen for cardiac involvement in severe dengue.

Severe Dengue Fever with Haemolytic Anaemia-A Case Study.

Dengue fever, the most common arthropod-borne viral infection in South East Asia, is increasing in prevalence due partially to increased awareness and better diagnostic methods. While haematologic complications, such as cytopeniae and bleeding, may occur in severe dengue infection due to a variety of aetiologies, reports of haemolytic anaemia in dengue fever are scant. We report a case of severe dengue fever with haemolytic anaemia following the critical phase of infection.

El dengue, la arbovirosis más relevante de venezuela / Dengue, the most important arboviruses of Venezuela

Se actualiza el dengue mediante una revisión de la literatura médica disponible, por considerarla como la arbovirosis más relevante que registra el sistema de vigilancia de enfermedades notificables venezolanas. En los últimos 20 años se ha comportado como una endemoepidemia nacional con elevaciones y disminuciones en el número de casos registrados anualmente en la república. En el año 2010, con 123 000 casos notificados representó el mayor número registrado en el devenir histórico de la epidemiología venezolana y pasando a más de 30 000 en el 2011. En el artículo se revisa la etiología de esta enfermedad infecciosa viral, su modo de transmisió, la patogenia con sus hipótesis explicativas de la enfermedad, la nueva propuesta de clasificación clínica en dengue moderado y dengue severo que sustituye a la de dengue clásico y hemorrágico, los parámetros bioanalíticos para el diagnóstico de certeza, la conducta terapéutica necesaria a seguir y las posibilidades de encontrar, en los próximos años, una vacuna con la efectividad adecuada, que pueda conducir a la prevención definitiva de esta virosis considerada como un problema de salud en las regiones tropicales.

By means of reading the medical literature available, we are updating dengue fever the most lelevant arovirosis registred in the notificable disease system in venezuela. During the last 20 years, dengue fver behavior has been a national endemic-epidemic with rises and downs in the number of registered cases per year in the republic. The year 2010 with 123 000 cases notifed, was the bigger number registered all over the history of venezuelan epidemiology and going to more than 30 000 in 2011. The paper includes revision of the etiology of this infectious viral disease, its way of transmission, the pathogenesis with its different hypothesis wich would explain the disease, the new proposal for the clinical classification as moderate and severe dengue fever that substitutes the prevous classic and hemorrhagic dengue fever, laboratory studies for diagnosis confirmation, therapeutics to be followed and the possibility of finding during the years coming, a vaccine that could lead to the definite prevention of this viral disease, considered as a public health problem in tropical regions.