Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases

Dengue induced acute liver failure: A meta summary of case reports

BACKGROUND

Dengue fever is the most common cause of viral hemorrhagic fever, with more than 400 million cases being reported annually, worldwide. Even though hepatic involvement is common, acute liver failure (ALF) is a rare complication of dengue fever.

AIM

To analyze the demographic profile, symptomology, hospital course and outcomes of patients presenting with ALF secondary to dengue infection by reviewing the published case reports.

METHODS

A systematic search was performed from multiple databases including PubMed, Reference Citation Analysis, Science Direct, and Google Scholar. The search terms used were "dengue" OR "severe dengue" OR "dengue shock syndrome" OR "dengue haemorrhagic syndrome" OR "dengue fever" AND "acute liver failure" OR "hepatic failure" OR "liver injury". The inclusion criteria were: (1) Case reports or case series with individual patient details; (2) Reported acute liver failure secondary to dengue infection; and (3) Published in English language and on adult humans. The data were extracted for patient demographics, clinical symptomatology, clinical interventions, hospital and intensive care unit course, need for organ support and clinical outcomes.

RESULTS

Data from 19 case reports fulfilling the predefined inclusion criteria were included. The median age of patients was 38 years (inter quartile range: Q3-Q1 26.5 years) with a female preponderance (52.6%). The median days from diagnosis of dengue to development of ALF was 4.5 d. The increase in aspartate aminotransferase was higher than that in alanine aminotransferase (median 4625 U/L vs 3100 U/L). All the patients had one or more organ failure, with neurological failure present in 73.7% cases. 42.1% patients required vasopressor support and hepatic encephalopathy was the most reported complication in 13 (68.4%) cases. Most of the patients were managed conservatively and 2 patients were taken up for liver transplantation. Only 1 death was reported (5.3%).

CONCLUSION

Dengue infection may rarely lead to ALF. These patients may frequently require intensive care and organ support. Even though most of these patients may improve with supportive care, liver transplantation may be a therapeutic option in refractory cases.

Prediction of severity of dengue infection in children based on hepatic involvement

Background and Aim

To assess the spectrum of hepatic involvement in children with dengue fever (DF) and prediction of severity of dengue infection by early detection of elevated liver enzymes.

Methods

This prospective observational study was conducted at a tertiary care hospital from June 2019 to September 2019. Children admitted with DF were included. Severity of DF was graded as dengue without warning sign (DNWS), with warning sign (DWS), and severe dengue fever (SDF) according to WHO criteria. Liver injury (LI) was defined as alanine aminotransferase (ALT) more than upper limit of normal irrespective of sex.

Results

Of 190 children (male, 109) with DF, 60 had DNWS, 49 had DWS, and 81 had SDF. A total of 100 children (52.6%) had LI. The distribution of hepatic involvement spectrum involves hepatomegaly (26.3%), hepatic tenderness (25.2%), features of acute liver failure (1.5%), raised level of ALT (52.6%), raised level of aspartateaminotransferase (AST) (65.8%), prolonged prothrombin time (7.3%), and reduced level of serum albumin (44.7%) in children. Of them, 5.8% and 6.8% of children had >tenfold increase in ALT and AST values. The degree of liver function derangement significantly (P < 0.05) increased with DF severity. In our study, ALT at 422 IU/L (10 times upper limit of normal [ULN]) and AST 689 IU/L (17 times ULN) had similar sensitivity and specificity as WHO recommended cutoff of 1000 IU/L (25 times of ULN) to detect SDF.

Conclusion

ALT ≥10 times and AST ≥17 times of ULN are as sensitive as ≥25 times (as recommended by WHO) to detect SDF.

Role of N-acetylcysteine in liver injury due to dengue fever

Dengue fever (DF) is a common mosquito-borne viral infection which is endemic in Southeast Asia. Liver involvement may vary from asymptomatic elevation of liver enzymes to fulminant hepatitis. Although the valuable effects of N-acetylcysteine (NAC) in paracetamol toxicity and non-paracetamol liver failure have been extensively studied, its use in DF-associated hepatitis remains unclear. We made a literature search in an online format from libraries such as PubMed, Google Scholar, and EMBASE, and selected 33 articles including original research articles, case reports, and systemic analyses. The majority of the articles reviewed had a positive outcome but treatment strategies involved NAC together with supportive care. Hence, data on sole use of NAC from large randomised control trials remain unclear.

Transaminitis among Patients with Dengue Fever Visiting a Tertiary Care Centre

Introduction

Transaminitis is a condition where serum aspartate transaminase and alanine transaminase increase indicating liver dysfunction. One such disease where liver involvement might be observed is dengue, which is a mosquito-borne viral infection. The aim of the study was to find out the prevalence of transaminitis among patients with dengue fever in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted in a tertiary care centre from 1 November 2022 to 31 March 2023 after obtaining ethical approval from the Institutional Review Committee. Informed written consent was taken before collecting the data. A rapid immunochromatography test was used to confirm dengue infection. Serum aspartate transaminase and alanine transaminase were measured through routine Reitman and Frankel's enzymatic method. Dengue-confirmed patients from the medical outpatient department, fever clinic, and medical ward of the centre were included in the study. Patients with known prior liver diseases or any other chronic diseases, pregnancy, and patients in the hospice unit were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 442 dengue infected patients, the prevalence of transaminitis was 188 (42.53%) (37.92-47.13, 95% Confidence Interval). The highest frequency of dengue positive was observed among the 18-35 years age group, which was 97 (51.59%) with male predominance 134 (71.27%).

Conclusions

The prevalence of transaminitis among patients with dengue fever in a tertiary care centre was found to be lower than other studies done in similar settings.

Keywords

alanine transaminase; aspartate transaminase; dengue.

Dengue hepatitis: Incidence, spectrum and outcome

BACKGROUND AND AIMS

While dengue infection is common in India, there is scarce information on dengue hepatitis. The aim of this study was to analyze the incidence, spectrum and outcome of dengue hepatitis.

METHODS

We retrospectively analyzed consecutive patients, who had hepatitis among those with dengue infection admitted to two tertiary care hospitals in western India from January 2016 to March 2021. Diagnosis of dengue infection was made by serology. Dengue hepatitis was diagnosed and the severity of dengue was categorized by standard criteria.

RESULTS

Of 1664 patients admitted with dengue fever during the study period, 199 patients had hepatitis (i.e. incidence of dengue hepatitis was 11.9%). Of the 199 dengue hepatitis patients (age: 29 [13 - 80] years, median [range], 67% males), 100 patients (50%) had severe dengue, 73 (36%) had severe dengue hepatitis, 32 (16%) had dengue shock syndrome and eight (4%) had acute liver failure. Forty-five patients (23%) had acute lung injury and 32 (16%) had acute kidney injury. The dengue hepatitis patients were treated with standard medical care, including vital organ support, as needed-166 (83%) patients survived, while 33 patients (17%) died (cause of death: multi-organ failure: 24 patients, septic shock: nine patients). The presence of shock independently predicted mortality (odds ratio 6.4, 95% confidence interval: 1.2 - 34). Among patients with dengue hepatitis, mortality rate was higher in those with severe dengue (23%), dengue shock syndrome (47%), severe dengue hepatitis (24%) and acute liver failure (38%).

CONCLUSION

In this large series of hospitalized patients with dengue infection, the incidence of dengue hepatitis was 11.9%. Among 199 dengue hepatitis, 17% died; multi-organ failure was the commonest cause for death and death rate was higher in patients with more severe disease. The presence of shock at presentation independently predicted mortality.

Aminotransferases in Relation to the Severity of Dengue: A Systematic Review

A systematic review was conducted to investigate the relationship between aminotransferases and the severity of dengue infection, which is a prevalent and significant infection in tropical and subtropical regions. Aminotransferases are enzymes that are often elevated in dengue due to the liver's physiological and immunological response to the infection. This review focused on analyzing various studies that examined the correlation between aminotransferase levels and the severity of dengue. Extensive literature searches were performed using ("dengue*" OR "dengue fever*" OR "dengue haemorrhagic fever*" OR "dengue shock syndrome*") AND ("alanine aminotransferase*" OR "aspartate aminotransferase*") on PubMed. The selected articles were thoroughly reviewed, encompassing epidemiology, pathogenesis, and clinical manifestations of dengue. The consistent findings across the studies indicated that aminotransferases can serve as predictive markers for dengue severity. Therefore, early assessment of liver enzyme levels is crucial in dengue cases, and elevated levels should be closely monitored to prevent adverse outcomes.

The association of obesity and dengue severity in hospitalized adult patients

BACKGROUND

Obesity is associated with unfavorable outcomes for infectious diseases. Most researches exploring the association between nutritional status and dengue severity have focused on pediatric populations, with only few studies assessing adult patients.

METHODS

Adult patients with laboratory-confirmed dengue admitted to a tertiary hospital in southern Taiwan between 2014 and 2015 were enrolled retrospectively. Demographics, comorbidities, clinical presentation, laboratory findings, and outcomes were obtained from case-record forms. Patients were categorized into obese group and nonobese group. The obese group comprised patients with a body mass index of ≥27.5 kg/m².

RESULTS

A total of 1417 hospitalized patients with dengue were evaluated. The mean age was 57.9 years (range: 18-92 years). The obese and nonobese groups comprised 333 (23.5%) and 1084 (76.5%) patients, respectively. The obese group included more patients with hypertension (85%, p < 0.001), diabetes mellitus (33%, p < 0.001), and congestive heart failure (6.3%, p = 0.049). Multivariate analysis revealed that the obese group had more petechiae (AOR: 1.353, 95% CI: 1.025-1.786, p = 0.033), more dyspnea (AOR: 1.380, 95% CI: 1.015-1.876, p = 0.040), and more severe hepatitis (AOR: 2.061, 95% CI: 1.050-4.048, p = 0.036). The obese group also had higher peak hematocrit values (44.1%, p < 0.001) and lower nadir platelet count (45.3 × 10³/μL, p = 0.049) than the nonobese group.

CONCLUSION

In adult patients with dengue, obese group had more petechiae, dyspnea, severe hepatitis, lower nadir of platelet count, and higher peak hematocrit level. We observed no difference in severe dengue or mortality between obese and nonobese group.

Blood transfusion in severe dengue infection: a case series

BACKGROUND

Dengue is still a recurrent challenge to the global population, without specific antiviral therapy. Clinical management strategies are aimed to mitigate the deaths. The use of blood products in dengue is recommended mainly in cases of bleeding.

CASE PRESENTATION

We prospectively collected data on Sri Lankan dengue cases in the Teaching Hospital, Peradeniya, Sri Lanka from 2017, and selected ten severe cases where blood transfusions were involved in the management. The series comprises seven females and three males, with a median age of 36 years (range 12-53 years). All patients were critically ill at the time of blood transfusion, with dramatic stabilization of vital parameters after the transfusions. Only one patient had detectable bleeding, while five patients had occult blood loss as indicated by dropping hematocrit. Even though four patients had stable hematocrit, they had metabolic acidosis. Two patients had a very high increase of hepatic transaminases along with acidosis. Two patients had myocarditis with dropping hematocrit, suggestive of occult bleeding.

CONCLUSIONS

Clinical deterioration despite fluid management commonly occurs due to occult bleeding in dengue infection. Blood transfusion is lifesaving in such cases of blood loss, acidosis, and severe hepatic damage. The mechanism of this effect needs an explanation, such as enhanced oxygen delivery to the tissues and hemostasis to hypothesize a few possibilities.

Acute Pancreatitis Secondary to Dengue Fever: An Uncommon Presentation of a Common Endemic Illness

Dengue viral infection is considered endemic in Ecuador. It is more frequent during winter, caused by an RNA virus in the Flavivirus group. Its presentation can range from an asymptomatic state to hemorrhagic fever with shock signs. Acute pancreatitis could be a rare form of acute abdomen presentation associated with dengue virus infection. This case illustrates a 26-year-old man who presents to the hospital with cramp-like pain in the epigastrium and radiation to the right upper quadrant, accompanied by nausea and vomiting. He also endorsed additional symptoms such as throbbing-like headache, myoarthralgias, and fever of 40.4°C (104.72°F). Laboratory tests revealed elevated hematocrit, thrombocytopenia, elevated pancreatic enzymes, transaminitis, elevated alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT). Ultrasonography of the abdomen revealed hepatic steatosis, free fluid in the abdominal cavity, and small bilateral pleural effusions. Additional testing revealed IgM and IgG antibodies positivity to dengue virus. The patient was treated conservatively with intravenous (IV) fluid hydration and bowel rest. Acute pancreatitis should be considered when a patient presents with a suspected acute abdomen in the emergency department, and a detailed medical history is necessary to make a correct approach to the differential diagnosis.

Alpha-mangostin inhibits viral replication and suppresses nuclear factor kappa B (NF-κB)-mediated inflammation in dengue virus infection

Severe dengue virus (DENV) infection results from viral replication and dysregulated host immune response, which trigger massive cytokine production/cytokine storm. The result is severe vascular leakage, hemorrhagic diathesis, and organ dysfunction. Subsequent to previously proposing that an ideal drug for treatment of DENV infection should efficiently inhibit both virus production and cytokine storm, we discovered that α-mangostin (α-MG) from the pericarp of the mangosteen fruit could inhibit both DENV infection and cytokine/chemokine production. In this study, we investigated the molecular mechanisms underlying the antiviral and anti-inflammatory effects of α-MG. Time-of-drug-addition and time-of-drug-elimination studies suggested that α-MG inhibits the replication step of the DENV life cycle. α-MG inhibited polymerization activity of RNA-dependent RNA polymerase (RdRp) with IC50 values of 16.50 μM and significantly reduced viral RNA and protein syntheses, and virion production. Antiviral and cytokine/chemokine gene expression profiles of α-MG-treated DENV-2-infected cells were investigated by polymerase chain reaction array. α-MG suppressed the expression of 37 antiviral and cytokine/chemokine genes that relate to the NF-κB signaling pathway. Immunofluorescence and immunoblot analyses revealed that α-MG inhibits NF-κB nuclear translocation in DENV-2-infected cells in association with reduced RANTES, IP-10, TNF-α, and IL-6 production. These results suggest α-MG as a potential treatment for DENV infection.

Dengue Fever With Fulminant Liver Failure and Fatal Pulmonary Alveolar Hemorrhage: A Case Report

Dengue infection may rarely present with end-organ dysfunction. A 22-year-old male patient presented with a serologically confirmed dengue infection, with clinical manifestations and laboratory pictures suggestive of fulminant hepatitis. The in-hospital disease course was complicated with encephalopathy, recurrent hypoglycemic episodes, coagulopathy, pulmonary alveolar hemorrhage, hypotension, and kidney injury. He was managed with intravenous fresh frozen plasma, platelet concentrate, crystalloids and N-acetyl cysteine (NAC) along with other recommended supportive measures for dengue and fulminant hepatic failure. The patient did not show any improvement in liver function despite therapy and succumbed to his illness on day 6 of hospitalization. In view of the large burden of disease in developing nations and atypical manifestations of dengue infection, research into effective treatment strategies is warranted.

Liver function in dengue and its correlation with disease severity: a retrospective cross-sectional observational study in a tertiary care center in Coastal India

Introduction

dengue, the most important arthropod- borne disease is transmitted to humans by mosquitos of the Aedes family. Liver dysfunction in dengue varies from mild injury with elevation of transaminases to severe hepatocyte injury. The aim of our study was to assess the prevalence of hepatic dysfunction in patients with dengue and to correlate between the severity of the disease with the extent of hepatic dysfunction.

Methods

retrospective cross-sectional observational study including 120 patients with confirmed dengue serology admitted in Medicine Department of Father Muller Medical College during November 2018-December 2019. Patient demographics, presenting symptoms, clinical signs, laboratory parameters such as complete blood count, serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), alkaline Phosphatase (ALP), total and direct bilirubin; serum albumin and globulin levels were collected. Patients were categorized based on the modified WHO classification of 2009 into dengue with or without the warning signs and severe dengue. Comparison of multiple means across disease severity was performed using One Way-ANOVA with post hoc analysis using least significant difference. Pearson's correlation coefficient test was used to calculate the correlation between transaminases and platelet count. P-value <0.05 and CI 95% were considered in all analyses.

Results

serum glutamic-oxaloacetic transaminase was elevated in 66.7%, 78.6% and 91.7% patients of dengue without warning signs, warning signs and severe dengue respectively. Serum glutamic-pyruvic transaminase was elevated in 42.4%, 52.4% and 91.7% patients of dengue without warning signs, warning signs and severe dengue respectively. Patients with elevated SGOT (93.8%) and SGPT (81.2%) had a higher incidence of bleeding manifestations. Hypoalbuminemia (50.8%) and A: G ratio reversal (27.3%) was significantly more in severe dengue (p<0.0001). Serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase levels negatively correlated with platelet count (p<0.0001).

Conclusion

liver involvement in the form of elevated transaminases was found in 74.2% dengue patients. Serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase level increases with increase in dengue severity which is indicated by fall in platelet count as they are negatively correlated with each other. Liver damage is one of the common complications of dengue and transaminitis, hypoalbuminemia and reversal of A: G ratio should be used as biochemical markers in dengue patients to detect and monitor hepatic dysfunction.

Dengue hemorrhagic fever and the liver

Dengue hemorrhagic fever (DHF) is one of the most rapidly emerging infections of tropical and subtropical regions worldwide. It affects more rural and urban areas due to many factors, including climate change. Although most people with dengue viral infection are asymptomatic, approximately 25% experience a self-limited febrile illness with mild to moderate biochemical abnormalities. Severe dengue diseases develop in a small proportion of these patients, and the common organ involvement is the liver. The hepatocellular injury was found in 60%-90% of DHF patients manifested as hepatomegaly, jaundice, elevated aminotransferase enzymes, and critical condition as an acute liver failure (ALF). Even the incidence of ALF in DHF is very low (0.31%-1.1%), but it is associated with a relatively high mortality rate (20%-68.3%). The pathophysiology of liver injury in DHF included the direct cytopathic effect of the DENV causing hepatocytes apoptosis, immune-mediated hepatocyte injury induced hepatitis, and cytokine storm. Hepatic hypoperfusion is another contributing factor in dengue shock syndrome. The reduction of morbidity and mortality in DHF with liver involvement is dependent on the early detection of warning signs before the development of ALF.

Triphala in Traditional Ayurvedic Medicine Inhibits Dengue Virus Infection in Huh7 Hepatoma Cells

Traditional Triphala (three fruits), consisting of Phyllanthus emblica, Terminalia chebula, and Terminalia bellirica, presents a broad range of biological activities. However, its ability to inhibit dengue virus (DENV) infection has not been reported yet. Herein, the authors investigated the efficiency of three different Triphala formulations and its individual extract constituents to inhibit DENV infection. Treatment with T. bellirica extract or Triphala formulated with a high ratio of T. bellirica extract showed remarkable efficiency in significantly lowering DENV infection in Vero cells. Their effects were further studied in Huh7 cells, to address its potential ability in human cells. Treatment with 100 μg/mL of T. bellirica extract or Triphala resulted in an approximate 3000-fold or 1000-fold lowering of virus production, respectively. Furthermore, the treatment diminished IL-6 and CXCL-10 expressions, which are the hallmark of the cytokine storm phenomenon in DENV infection. The HPLC profiling demonstrated gallic acid as a major compound, the treatment by which showed its ability to effectively inhibit DENV infection after virus entry. Molecular docking demonstrated that gallic acid was able to interact with DENV NS5 protein, which could be one of Triphala’s antiviral mechanism. This study offers Triphala formulation and its ingredient, T. bellirica extract, as a natural based pharmaceutical to be used in DENV infection treatment.

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.

Predictive value of hepatic transaminases during febrile phase as a predictor of a severe form of Dengue: analysis of adult Dengue patients from a tertiary care setting of Sri Lanka

OBJECTIVES

Dengue viral infection is an ongoing epidemic in Sri Lanka, causing significant mortality and morbidity. A descriptive-analytical study was carried out using serologically confirmed Dengue patients during a 6 month period. The relationship between the elevation of hepatic enzymes and severity of Dengue was assessed after stratifying recorded maximum AST/ALT (SGOT/SGPT) values 2-15 times elevated and by the phases of the illness. Sensitivity, specificity, predictive values, and ROC curves were assessed using maximum values for AST and ALT.

RESULTS

Out of 255 patients, 107(42%) were females. The majority (52.9%) were in the 20-39 year age group. Only 19.6% had DHF. No statistically significant difference was noticed in the values of maximum transaminases during the febrile phase among DF and DHF patients. Higher sensitivity and low specificity with the 1-5 times elevation range was noticed, and a higher cut-off level of more than 5 times elevation showed low sensitivity and higher specificity. The combination of both transaminases cut-offs with age and sex also does not show clinically significant predictability of severe disease. The AST and ALT elevations are not showing discriminatory predictive value on dengue severity. As different serotypes cause different epidemics, it is important to carry out large-scale specific studies considering the serotypes.

Hepatic Manifestations of Nonhepatotropic Infectious Agents Including Severe Acute Respiratory Syndrome Coronavirus-2, Adenovirus, Herpes Simplex Virus, and Coxiella burnetii

Nonhepatotropic viruses such as adenovirus, herpes simplex virus, flaviviruses, filoviruses, and human herpes virus, and bacteria such as Coxiella burnetii, can cause liver injury mimicking acute hepatitis. Most of these organisms cause a self-limited infection. However, in immunocompromised patients, they can cause severe hepatitis or in some cases fulminant hepatic failure requiring an urgent liver transplant. Hepatic dysfunction is also commonly seen in patients with severe acute respiratory syndrome coronavirus-2 infection. Patients with preexisting liver diseases are likely at risk for severe coronavirus disease 2019 (COVID-19) and may be associated with poor outcomes.

Liver injury in the era of COVID-19

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has undoubtedly revolutionized the whole globe and given a new point of view on respiratory tract infections. Nevertheless, coronavirus disease 2019 (COVID-19) cannot be perceived as a disease limited only to pneumonia with diverse severity. More and more reports have demonstrated a wide range of possible systemic symptoms, including hepatic complications. Liver injury has been observed in a significant proportion of patients, especially in those with a severe or critical illness. COVID-19 might provoke a deterioration of liver function in patients with already diagnosed chronic liver diseases and without pre-existing liver disorders. The deterioration of liver function worsens the prognosis, increases the risk of a severe course of SARS-CoV-2 infection and prolongs the hospital stay. In general, patients who develop liver dysfunction in COVID-19 are mainly males, elderly people, and those with higher body mass index. The underlying mechanisms for hepatic failure in patients infected with SARS-CoV-2 are still unclear, nevertheless liver damage appears to be directly connected with virus-induced cytopathic effects. A liver injury observed during hospitalization might be simultaneously caused by the use of potentially hepatotoxic drugs, mainly antiviral agents. This minireview focuses on a possible relationship between COVID-19 and the liver, potential molecular mechanisms of liver damage, the characteristics of liver injury and suggested factors predisposing to hepatic manifestations in COVID-19 patients.

Gene Expression Signatures in AML-12 Hepatocyte Cells upon Dengue virus Infection and Acetaminophen Treatment

Dengue is an acute viral disease caused by Dengue virus (DENV) and is considered to be the most common arbovirus worldwide. The clinical characteristics of dengue may vary from asymptomatic to severe complications and severe organ impairment, particularly affecting the liver. Dengue treatment is palliative with acetaminophen (APAP), usually known as Paracetamol, being the most used drug aiming to relieve the mild symptoms of dengue. APAP is a safe and effective drug but, like dengue, can trigger the development of liver disorders. Given this scenario, it is necessary to investigate the effects of combining these two factors on hepatocyte homeostasis. Therefore, this study aimed to evaluate the molecular changes in hepatocytes resulting from the association between DENV infection and treatment with sub-toxic APAP concentrations. Using an in vitro experimental model of DENV-2 infected hepatocytes (AML-12 cells) treated with APAP, we evaluated the influence of the virus and drug association on the transcriptome of these hepatocytes by RNA sequencing (RNAseq). The virus-drug association was able to induce changes in the gene expression profile of AML-12 cells and here we highlight and explore these changes and its putative influence on biological processes for cellular homeostasis.

Mechanisms and consequences of COVID-19 associated liver injury: What can we affirm?

Since the first reports of coronavirus disease 2019 (COVID-19) cases in December 2019 in China, numerous papers have been published describing a high frequency of liver injury associated with severe acute respiratory syndrome coronavirus 2 infection, many of them proposing a link between these findings and patient outcomes. Increases in serum aminotransferase levels (ranging from 16% to 62%) and bilirubin levels (ranging from 5% to 21%) have been reported and seem to be more often observed in patients with severe forms of COVID-19. Although absolute changes in these parameters are frequently seen, other variables, such as the ratio above the upper limit of normal, the onset of liver injury as a complication in severe cases and histopathological findings, reinforce that liver changes are of dubious clinical relevance in the course of this disease. Other factors must also be considered in these analyses, such as the repercussions of hemodynamic changes, the presence of thrombotic events, and, mainly, the possible drug-induced liver injury with the current, yet off-label, treatment. This paper aimed to analyze the currently available data on liver injury in patients with COVID-19.

Coronavirus Disease of 2019: a Mimicker of Dengue Infection?

At the beginning of 2020, the national health system and medical communities are faced with unprecedented public health challenges. A novel strain of coronavirus, later identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread globally, marking another pandemic of coronaviruses. This viral disease is responsible for devastating pneumonia, named coronavirus disease of 2019 (COVID-19), and projected to persist until the end of the year. In tropical countries, however, concerns arise regarding the similarities of COVID-19 with other infectious diseases due to the same chief complaint, which is fever. One of the infectious disease of a primary concern is dengue infection, which its peak season is approaching. Others report that there are cases of serological cross-reaction of COVID-19 and dengue infection. In this comprehensive review, we underscore the importance of knowing similar clinical presentations of both diseases and emphasize why excluding COVID-19 in the differentials in the setting of a pandemic is imprudent.

Dengue hepatitis with acute liver failure: Clinical, biochemical, histopathological characteristics and predictors of outcome

BACKGROUND

Hepatitis infection from non-hepatotropic viruses such as dengue virus (DENV) is increasing worldwide. There is increasing recognition of the changing epidemiology and atypical presentations of DENV infection including acute liver failure (ALF). There is paucity of data regarding incidence, disease characteristics, and markers of prognosis in patients who develop DENV-related ALF.

METHODS

We aimed to study the incidence, clinical features, laboratory characteristics, and determinants of outcome in patients of DENV presenting with ALF. We reviewed all patients with DENV infection and focused on DENV-related ALF from 2014 to 2017. Diagnosis of DENV and ALF was confirmed by serological tests and standard criteria, respectively.

RESULTS

Thirty-six patients (20 men, mean age 32.3) developed ALF among 10 108 patients with DENV infection (0.35%). Twenty-one patients died (58.3%). Although bilirubin, aspartate and alanine aminotransferase, and international normalized ratio were markedly elevated in all patients with DENV ALF, there was no statistically significant difference between survivors and non-survivors. Lactate levels, pH at admission, and model for end-stage liver disease (MELD) score were the only predictors of mortality. Lactate levels were significantly higher in non-survivors (11.5 ± 4.2 mmol/L) than survivors (6.3 ± 3.6 mmol/L) (P < 0.001). MELD score in non-survivors (26.7 ± 10.2) was significantly higher than in survivors (20 ± 7.2) (P = 0.039). Receiver operator characteristic curve showed lactate or pH to be a superior prognostic marker than MELD with an area under the curve of 0.80, 0.79, and 0.70, respectively.

CONCLUSION

Dengue hepatitis progressed to ALF in 0.35%. Development of ALF was associated with a high mortality (> 50%). Lactate level, pH, and MELD score at admission were significant determinants of outcome.

Effect of standard dose paracetamol versus placebo as antipyretic therapy on liver injury in adult dengue infection: a multicentre randomised controlled trial

BACKGROUND

Dengue is a common cause of acute liver failure in tropical countries. Paracetamol is the recommended antipyretic for dengue. Related observational studies in dengue have suggested that excessive paracetamol intake is related to hepatic injury. We aimed to evaluate whether standard dose paracetamol as an antipyretic in dengue infection caused transaminase elevation, and to evaluate the efficacy of paracetamol.

METHODS

In this randomised, double-blind, placebo-controlled trial, adult participants (aged ≥18 years) with dengue, as confirmed by either positive NS1 antigen, positive dengue IgM antigen with thrombocytopenia, or positive PCR test, were enrolled at three Royal Thai Army hospitals in Thailand. Key exclusion criteria were baseline AST or ALT concentrations of more than 3 times the upper limit of normal, cirrhosis, indication of paracetamol other than dengue infection, concurrent diagnosis of other causes of fever, or pregnancy. Patients were randomly assigned (1:1), by a computer-generated block randomisation procedure (block size of six), to receive either paracetamol (500 mg) or placebo (500 mg) every 4 h when body temperature exceeded 38°C during hospitalisation. Participants and investigators were masked to treatment assignment. The primary outcome was the proportion of participants with transaminase elevation, defined as serum aspartate transaminase (AST) and alanine transaminase (ALT) concentrations of more than 3 times the upper limit of normal on recovery day, in the intention-to-treat population. Prespecified interim analyses for safety and efficacy were performed with group sequential stopping boundaries. This trial is registered with ClinicalTrials.gov, number NCT02833584.

FINDINGS

Between Sept 1, 2016, and Dec 12, 2017, 125 participants were randomly assigned to receive either paracetamol (n=63) or placebo (n=62). 123 participants were included in the intention-to-treat population. The median daily dose of study medication was 1·5 g (IQR 0·8-2·0). The study was terminated early owing to a higher rate of transaminase elevation in the paracetamol group than in the placebo group (22% vs 10%; incidence rate ratio 3·77, 95% CI 1·36-10·46, p=0·011). The change of AST and ALT concentrations in the paracetamol group was higher than in the placebo group (mean difference 12·43 U/L per day, 7·16-17·71, p<0·0001 for AST; 7·40 U/L per day, 95% CI 3·68-11·13, p=0·0001 for ALT). Three participants in the paracetamol group had severe dengue: two had upper gastric haemorrhage and one had acute kidney injury. No patients died or had liver failure.

INTERPRETATION

Use of standard dose paracetamol in dengue infection increased the incidence of transaminase elevation, and also overall transaminase concentrations in the absence of a counterbalancing reduced fever or pain score.

FUNDING

Phramongkutklao College of Medicine.

Acute Liver Failure in a Patient With Dengue Shock Syndrome

Dengue is an arboviral disease of significant burden in tropical countries. It commonly affects the liver, ranging in presentation from asymptomatic transaminitis to acute liver failure. We present a young woman from India who developed acute liver failure because of dengue shock syndrome and improved without a liver transplant. We review the disease characteristics and management of dengue, with a focus on the natural history of illness and how to approach the possible need for liver transplant in these patients.

Clinical Profile, Liver Dysfunction and Outcome of Dengue Infection in Children: A Prospective Observational Study

BACKGROUND

Liver involvement in dengue illness is common and can lead to acute liver failure (ALF). No single method can effectively identify patients at risk for disease progression and bad outcome. We aimed to determine the relationship between liver dysfunction, kinetics of liver function tests (LFTs) and severity of hepatitis on the outcome in pediatric dengue illness.

METHODS

We conducted a prospective observational study of hospitalized children (1-12 years) with dengue infection (July 2014-July 2015). Serial monitoring of LFTs was done in confirmed dengue cases. Patients were classified into non-severe (NSD) and severe dengue (SD). Severity of hepatitis was graded: mild, moderate and severe hepatitis. Events were noted during hospitalization.

RESULTS

One hundred two children (66, boys), median age 72 (48-96) months, were analyzed (NSD, n = 41; SD, n = 61). Elevated transaminases (92%) was the most common abnormality; aspartate transaminase (AST) and alanine transaminase (ALT) in 87% and 82%, respectively. Maximum abnormalities in LFTs peaked at day 5 (AST, ALT) and day 7 (Alkaline Phosphatase [ALP], gamma-glutamyl transferase) of illness. Elevated transaminases was found to be higher in SD than NSD (100% vs. 80%, P = 0.006). Severe hepatitis developed organ dysfunction such as altered sensorium (P < 0.001), ALF (P < 0.001), acute kidney injury (P < 0.001) and shock (P < 0.001), more commonly than those with mild to moderate hepatitis. Fourteen patients died, two-thirds of whom had severe hepatitis (P < 0.001). Using binary logistic regression, presence of severe hepatitis and shock at presentation was an independent predictor for ALF (odds ratio: 77; 95% confidence interval : 13-457, P < 0.001) and mortality (odds ratio: 55; 95% confidence interval: 4.6-66, P < 0.001), respectively.

CONCLUSIONS

Many children with dengue have liver involvement. Severe hepatitis in dengue is associated with significant organ dysfunction and poor outcome.

Primary Dengue Infection in Patients Requiring Hospitalization During an Outbreak in a Low Incidence Mexican Region

Background: Dengue manifestations can range from subclinical to fatal. The study of factors that influence dengue's clinical severity can provide information to potentially limit or predict severe cases. Secondary infection (SI) with a different dengue serotype has been recognized as an important determinant of severity. However, severe dengue (SD) manifestations, including shock, can happen during primary infection (PI) too and the mechanisms involved are less understood. To characterize the severe manifestations associated to PI, we distinguished between primary and secondary dengue cases in hospitalized patients from a region of low and recent dengue incidence in central Mexico. This region can serve as a model for dengue's behavior as it spreads to new areas worldwide. Methods: Dengue-specific immunoglobulin M (IgM) and IgG concentrations were measured in the serum of 78 hospitalized patients with dengue hemorrhagic fever, and their ratios were used to discriminate between PI and SI, as recommended by World Health Organization. Clinical and laboratory manifestations were compared between PI and SI. Results and Conclusions: PI was detected in 23% of hospitalized dengue cases, a proportion similar to that reported in high-incidence regions in Mexico. PI was more frequent in 16- to 40-year-olds, and was absent in patients older than 60 years. Only dengue with warning signs and SD were present in the studied population of hospitalized patients, and case frequency decreased with clinical severity both in PI and SI groups. No significant differences in demographics, laboratory tests, or symptoms were found between PI and SI, which illustrates that cases requiring hospitalization during outbreaks can be severe, even if they are PI. This information can help plan for sanitary contingencies in places where dengue is recently emergent and numerous PI cases are expected. The mechanisms involved in PI clinical severity need to be studied further.

Relative frequency of acute pancreatitis from dengue outbreaks as a late complication, in Egypt

Patients with dengue virus infection have a different symptoms range from asymptomatic to sever form depending on primary and secondary immune status of host, infecting genotype and patient's age. The current study aimed to describe the clinical and laboratory profile of dengue fever outbreak and acute pancreatitis as a late complication, in Egypt, as two case reports only were available in literature regarding this issue. This prospective cohort study was carried out on 100 patients confirmed to have dengue disease out of 200 clinically suspected patients. Clinical, laboratory (serology for dengue specific IgM, real-time PCR for dengue virus, serum amylase and lipase) and abdominal multi-slice CT were done to all included patients. All patients presented with fever, headache and fatigue, which are the main clinical manifestations of dengue fever. The mean age of studied patients was 40.34 ± 15.74 years. Thirteen patients (13%), with their mean age 44.57 ± 11.53, presented after 3 months with typical clinical, laboratory and radiological manifestations of acute pancreatitis with positive serum dengue virus IgM, antibodies and negative serum dengue virus PCR. So, acute pancreatitis as a late complication of dengue fever disease should be keep in mind for its early diagnosis and management, thus minimize the morbidity and mortality from dengue fever.

Spectrum, Manifestations and Outcomes of Dengue Infection in Individuals with and without Liver Disease

Background and Aims: Dengue infection is a major health burden, which can result in mild self-limited febrile illness to highly fatal hemorrhagic disease. There is paucity of literature describing the manifestations of dengue in patients with underlying liver disease. We studied and compared the manifestations of this tropical infection in patients with and without liver disease. Methods: Patients with serologically-confirmed dengue infection were included in this retrospective study, obtained for over a period of 1 year. Demographic and laboratory variables were compared for the individuals with no underlying liver disease (Group A, n = 71), chronic hepatitis (Group B, n = 12), and cirrhosis (Group C, n = 12). Results: Males predominated the study population (61%), with a higher mean age in the cirrhotic group. The most common clinical manifestation was classical dengue fever, seen in 89 individuals. Two presented as dengue hemorrhagic fever (1 each in Group A and Group B), 1 presented as acute liver failure, and 3 as acute-on-chronic liver failure. Hemoconcentration was less evident in Group C as compared to Group A and Group B (p < 0.001). Patients in Group C had significantly prolonged International Normalized Ratio (INR) and enhanced thrombocytopenia compared to patients in Group A and Group B. Patients in Group C also required prolonged hospital stay (Group A: 4.83 ± 2.88, Group B: 7.33 ± 2.3, Group C: 13 ± 5 days; p < 0.001). Three patients expired in Group C compared to the 1 in Group A and none in Group B (p = 0.01). On univariate analysis, hemoglobin, albumin, INR, and bilirubin predicted development of liver failure. On multivariate analysis, INR and bilirubin predicted development of liver failure. Conclusions: Dengue infection can have varied manifestations, ranging from simple fever to acute-on-chronic liver failure and acute liver failure. Cirrhotic patients lack classical features of dengue and have relatively poor prognosis. Dengue should be suspected as a cause of liver failure in endemic areas, where no etiological cause is discernible.

Predictive factors of dengue severity in hospitalized children and adolescents in Rio de Janeiro, Brazil

INTRODUCTION

Dengue is one of the most important mosquito-borne infections. Severe cases are more frequently observed in adults. However, in 2008, the State of Rio de Janeiro, Brazil, experienced a severe dengue epidemic that primarily affected children and caused many cases of dengue hemorrhagic fever (DHF) and death.

METHODS

A cross-sectional analytical study was conducted to examine laboratory diagnosis and clinical epidemiologic factors for confirmed dengue cases in patients aged less than 16 years, from January to June 2008, at a municipal hospital in the City of Rio de Janeiro, Brazil. Variables associated with severe outcomes and P values less than .05 were evaluated by means of a logistic regression model.

RESULTS

Of the 419 dengue cases studied, 296 were classified as DHF and 123 as classical dengue. Six patients who had DHF died. In multivariate analysis, some laboratory and clinical variables were independently associated with DHF: age 5 years or older (odds ratio [OR], 4.94; 95% confidence interval [CI], 1.30-18.71), abdominal pain (OR, 8.59; 95% CI, 3.17-23.27), hepatomegaly (OR, 15.87; 95% CI, 5.38-46.85), and positive tourniquet test (OR, 10.84; 95% CI, 3.96-29.71). Hypoalbuminemia occurred more frequently than hemoconcentration in DHF cases, and high aminotransferase levels were associated with severity.

CONCLUSIONS

Age greater than 5 years, abdominal pain, painful hepatomegaly, and positive tourniquet test were predictors of DHF. The high frequency of hepatic impairment suggests that acetaminophen should be avoided in severe cases of dengue.

Acute Hepatitis in Infections Caused by Dengue Virus in Southern Punjab, Pakistan

Background

Dengue is the most common vector-borne disease worldwide. It poses a significant health burden in tropical and subtropical countries. Common clinical presentations include retro-orbital pain, fever, headache, nausea, vomiting and aches and pains in the body. A severe form of dengue fever is known as dengue hemorrhagic fever (DHF) that includes signs of hemorrhage. Besides the typical signs and symptoms, atypical presentations of dengue include myositis, hepatitis and encephalitis. Hepatic involvement in dengue has varied presentations. This study aims to highlight the importance of acute hepatitis, an atypical presentation in dengue patients.

Methods 

We conducted a descriptive, cross-sectional study in the Medical Unit-1 of Bahawal Victoria Hospital, Bahawalpur, a tertiary-care hospital serving the area of Southern Punjab, Pakistan. The relevant medical records of 63 patients admitted with dengue-associated hepatitis to the Medical Unit-1 of Bahawal Victoria Hospital, Bahawalpur, between January 1, 2015 and December 1, 2016, were reviewed. Informed consent was given. Information regarding demographic variables and disease course was collected and analyzed.

Results 

This study included 55 men (87.3%) and eight (12.7%) women. Fifty (79.3%) patients were diagnosed with dengue fever (DF). Thirteen patients were managed on the lines of DHF. Out of the total 63 patients, only six were locals. The common clinical presentations in these patients included high fever, retro-orbital pain, severe headache, rash, dark-colored urine, bleeding problems and hepatomegaly. Higher levels of aspartate aminotransferase (AST) were noted in comparison to alanine transferase (ALT). Despite the complicated clinical course in some patients, all patients were managed successfully and discharged, except one.

Conclusion

The frequency of acute hepatitis in dengue patients is high, especially in young men. Early diagnosis and prompt treatment are necessary for better prognosis. Although no specific treatment guidelines are available, supportive treatment in a timely fashion can prevent complications. Transfusion with packed cell volume (PCV) and N-acetyl cysteine (NAC) has produced promising results.

Development of standard clinical endpoints for use in dengue interventional trials

Dengue is a major public health problem worldwide. Although several drug candidates have been evaluated in randomized controlled trials, none has been effective and at present, early recognition of severe dengue and timely supportive care are used to reduce mortality. While the first dengue vaccine was recently licensed, and several other candidates are in late stage clinical trials, future decisions regarding widespread deployment of vaccines and/or therapeutics will require evidence of product safety, efficacy and effectiveness. Standard, quantifiable clinical endpoints are needed to ensure reproducibility and comparability of research findings. To address this need, we established a working group of dengue researchers and public health specialists to develop standardized endpoints and work towards consensus opinion on those endpoints. After discussion at two working group meetings and presentations at international conferences, a Delphi methodology-based query was used to finalize and operationalize the clinical endpoints. Participants were asked to select the best endpoints from proposed definitions or offer revised/new definitions, and to indicate whether contributing items should be designated as optional or required. After the third round of inquiry, 70% or greater agreement was reached on moderate and severe plasma leakage, moderate and severe bleeding, acute hepatitis and acute liver failure, and moderate and severe neurologic disease. There was less agreement regarding moderate and severe thrombocytopenia and moderate and severe myocarditis. Notably, 68% of participants agreed that a 50,000 to 20,000 mm³ platelet range be used to define moderate thrombocytopenia; however, they remained divided on whether a rapid decreasing trend or one platelet count should be case defining. While at least 70% agreement was reached on most endpoints, the process identified areas for further evaluation and standardization within the context of ongoing clinical studies. These endpoints can be used to harmonize data collection and improve comparability between dengue clinical trials.

Dengue is a major public health problem worldwide. Although several drug candidates have been evaluated in randomized controlled trials, none has been effective, and early recognition of severe dengue and timely supportive care remain the only means to reduce mortality. While the first dengue vaccine was recently licensed, and several other candidates are in late stage clinical trials, future decisions regarding deployment of such vaccines or therapeutics will require evidence of product safety, efficacy and effectiveness. Standard, quantifiable clinical endpoints are needed to ensure reproducibility and comparability of research findings. To address this need, we established a working group of dengue researchers, vaccine developers, and public health specialists to develop endpoints. After two working group meetings and discussions at international meetings, the Delphi methodology was used to clarify and further develop endpoints such that 70% or greater agreement was reached on most endpoint definitions including moderate and severe plasma leakage, moderate and severe bleeding, acute hepatitis and acute liver failure, and moderate and severe neurologic disease. The process identified areas for further evaluation and standardization within the context of ongoing clinical studies. The endpoints can be used to harmonize data collection and improve comparability between dengue clinical trials.

Validation of Serum Aminotransferases Levels to Define Severe Dengue Fever in Children

PURPOSE

We aimed to study the pattern of liver-injury in children with dengue fever (DF) and validate serum aminotransferase ≥1,000 IU/L as a marker of severe DF.

METHODS

Children admitted with DF were included. DF was defined by presence of clinical criteria and positive serological or antigen tests in absence of other etiology. DF severity was graded as dengue without or with warning signs and severe dengue. Liver-injury was defined as alanine aminotransferase (ALT) more than twice the upper limit of normal (boys, 30 IU/L; girls, 21 IU/L).

RESULTS

Of 372 children with DF, 144 (38.7%) had liver-injury. Risk of liver-injury and aminotransferase levels increased with DF severity (p<0.001). Recommended ALT and aspartate aminotransferase (AST) cut-off at ≥1,000 IU/L had sensitivity 4.8% (5/105), specificity 99.3% (265/267) for detection of severe DF. In children with ALT and AST <1,000 IU/L (n=365), the area under receiver operating curves for prediction for severe DF, were 0.651 (95% confidence interval [CI], 0.588-0.714; p<0.001) for ALT and 0.647 (95% CI, 0.582-0.712; p<0.001) for AST. Serum ALT at 376 IU/L and AST at 635 IU/L had sensitivity and specificity comparable to ≥1,000 IU/L for defining severe DF.

CONCLUSION

Liver-injury is common in DF. The ALT and AST levels increase with DF severity. ALT and AST levels of ≥1,000 IU/L could be lowered to 376 IU/L and 635 IU/L respectively for defining severe DF.

Lessons learnt from managing a case of dengue hemorrhagic fever complicated with acute liver failure and acute kidney injury: a case report

Background

Dengue is a common arboviral infection with a diverse spectrum of clinical manifestations. Dengue hemorrhagic fever is a more severe form of infection characterized by plasma leak and hemoconcentration. Although hepatic dysfunction is common in dengue illness, massive liver necrosis is rarely reported. Lactic acidosis is a poor prognostic marker in liver failure related to dengue. Management of acute renal injury in dengue hemorrhagic fever due to prolonged shock is challenging as the fluid reabsorption during the recovery phase expands the intravascular volume and precipitates heart failure and pulmonary edema.

Case presentation

We report the case of a 43-year-old Sri Lankan Sinhalese woman with serologically confirmed dengue fever presenting with evidence of plasma leakage developing acute liver failure evidenced by deranged liver functions, coagulopathy, and altered sensorium and acute kidney injury with anuria. She had elevated serum lactate levels. In addition to the “standard care,” she was managed with intravenously administered N-acetyl cysteine and blood transfusions, even in the absence of bleeding or dropping packed cell volume, targeting a higher packed cell volume anticipating a better oxygenation at tissue level. Continuous veno-venous hemodialysis was employed and continued for 138 hours removing the fluids reabsorbed during the recovery phase to prevent her from developing heart failure and pulmonary edema. She made full recovery with no sequelae.

Conclusions

N-acetyl cysteine and packed cell transfusion aiming at a higher packed cell volume to maintain adequate tissue perfusion during shock may be beneficial in acute liver failure due to dengue virus. The use of a continuous form of renal replacement such as continuous veno-venous hemodialysis is of paramount importance in managing fluid states in the recovery phase of dengue hemorrhagic fever in those with renal impairment. Interesting observations made in the fluid dynamics during the reabsorption phase need further studies preferably with an animal model.

Dengue hemorrhagic fever complicated with acute liver failure: a case report

Background

Dengue is a common arboviral infection with a clinically diverse spectrum of presentations. Although hepatic dysfunction is commonly identified in patients will dengue illness, acute liver failure is rare. The etiopathogenesis of hepatic dysfunction is multifactorial and related to direct viral invasion of hepatocytes, immunological factors and hypoxia particularly in cases of shock in dengue hemorrhagic fever. Ideal management of dengue-related hepatic dysfunction and acute liver failure is still debated.

Case presentation

We report a 53-year-old Sri Lankan Sinhalese male with serologically confirmed dengue fever presenting with evidence of plasma leakage developing acute liver failure evidenced by deranged liver functions, coagulopathy and altered sensorium. In addition to the ‘standard care’, the patient was managed with intravenous N-acetyl cysteine and blood transfusions even in the absence of bleeding or dropping packed cell volume (PCV), targeting a higher PCV in anticipation of better oxygenation at tissue level. He made a full recovery with no sequential infections.

Conclusion

N-acetyl cysteine and packed cell transfusion aiming at a higher PCV to maintain adequate tissue perfusion during shock may be beneficial in acute liver failure due to dengue virus. Large randomized trials should be carried out to establish the efficacy of these treatment strategies to support these observations and change the current practice.

RNAi screen reveals a role of SPHK2 in dengue virus-mediated apoptosis in hepatic cell lines

Hepatic dysfunction is a feature of dengue virus (DENV) infection. Hepatic biopsy specimens obtained from fatal cases of DENV infection show apoptosis, which relates to the pathogenesis of DENV infection. However, how DENV induced liver injury is not fully understood. In this study, we aim to identify the factors that influence cell death by employing an apoptosis-related siRNA library screening. Our results show the effect of 558 gene silencing on caspase 3-mediated apoptosis in DENV-infected Huh7 cells. The majority of genes that contributed to apoptosis were the apoptosis-related kinase enzymes. Tumor necrosis factor superfamily member 12 (TNFSF12), and sphingosine kinase 2 (SPHK2), were selected as the candidate genes to further validate their influences on DENV-induced apoptosis. Transfection of siRNA targeting SPHK2 but not TNFSF12 genes reduced apoptosis determined by Annexin V/PI staining. Knockdown of SPHK2 did not reduce caspase 8 activity; however, did significantly reduce caspase 9 activity, suggesting its involvement of SPHK2 in the intrinsic pathway of apoptosis. Treatment of ABC294649, an inhibitor of SPHK2, reduced the caspase 3 activity, suggesting the involvement of its kinase activity in apoptosis. Knockdown of SPHK2 significantly reduced caspase 3 activity not only in DENV-infected Huh7 cells but also in DENV-infected HepG2 cells. Our results were consistent across all of the four serotypes of DENV infection, which supports the pro-apoptotic role of SPHK2 in DENV-infected liver cells.

Análisis descriptivo del compromiso de órganos en niños con dengue grave en Neiva, Colombia

Introducción. La infección por dengue puede comprometer órganos como el miocardio y el hígado. Tal hecho puede agravar la evolución clínica, por ello estos órganos han sido considerados en la clasificación revisada de la Organización Mundial de la Salud (OMS) para esta enfermedad.Objetivo. Describir la presencia de afectación por dengue en órganos como miocardio, hígado y sistema nervioso central (SNC) en niños de Neiva, ColombiaMateriales y métodos. Este estudio analizó 930 niños con diagnóstico de dengue confirmado que ingresaron al Hospital Universitario Hernando Moncaleano Perdomo de Neiva entre enero de 2009 y diciembre de 2010. Para el diagnóstico y estratificación clínica se usó la clasificación revisada de la OMS. La infección por dengue se confirmó por detección plasmática de NS1 o IgM específica. Se realizó seguimiento clínico y paraclínico diario durante toda la hospitalización.Resultados. De los 930 niños, 105 fueron clasificados como dengue grave (DG) y, de estos, 19 presentaron órganos afectados. El miocardio fue el más comprometido (14 casos), seguido por el hígado (4 casos) y el SNC (1 caso).Conclusión. El compromiso clínico del miocardio, el hígado o el SNC se observó en el 18% de los casos de niños con DG. Es necesario un diagnóstico y tratamiento oportuno de esta patología en niños.

Profile of hepatic involvement in dengue infections in adult Pakistani population

OBJECTIVES

To estimate the range of hepatic involvement in dengue infections by assessing clinical and biochemical profile of adult dengue infected patients.

METHODS

Serologically confirmed 220 adult cases of dengue infections admitted to Mayo hospital from June 2013 to November 2013 were classified as having dengue fever, dengue haemorragic fever and dengue shock syndrome. The frequency and range of bilirubin, liver enzymes derangement and presence of liver enlargement in each group was calculated and further stratified according to age and gender. Patients with positive viral serology, chronic liver disease, malaria and typhoid were excluded from the study.

RESULTS

About 60% of DHF patients had hepatomegaly compared to 40% of DF patients. Liver dysfunction was more common in DF compared to DHF (38.15 vs 18.6%). Hyperbilirubinemia was noted in 40 (18.2%) patients, 28 (12.7%) in DF and 12(5.5%) in DHF. The mean serum bilirubin was higher in DHF [0.87+0.33] compared to DF [0.74+0.27]. Bilirubin was higher in male patients and in younger (<20 years) age group. ALT was elevated more frequently in male patients in age group of 31-40 years and in DF patients as compared to DHF [72(32.7% vs 40(18.2%)]. The mean serum ALT level was 103.7 U/l in DHF and 69.2U/l in DF. AST was raised in all DHF patients as compared to DF in which 40% patients had normal AST levels. Alkaline Phosphate was high in all DHF patients with a mean of 278.7. It was raised in most of the DF patients as well and majority of patients were in age group of 31-40 years.

CONCLUSION

Liver involvement is very common in dengue infections and is not limited to elevation of transaminases only. Bilirubin and Alkaline phosphatase are also raised in considerable number of patients. Therefore in adults with fever, jaundice, hepatomegaly and altered liver function tests, the diagnosis of dengue infection should be strongly considered in areas where dengue infection is endemic. List of abbreviations:DF: Dengue Fever DHF: Dengue Hemorrhagic Fever DSS: Dengue Shock Syndrome DIC: Disseminated intravascular coagulation ALT: Alanine transaminase AST: Aspartate aminotransferase.

Evaluation of creatine kinase and liver enzymes in identification of severe dengue

Background

Existing biomarkers such as AST, ALT and hematocrit have been associated with severe dengue but evidence are mixed. Recently, interests in creatine kinase as a dengue biomarker have risen. These biomarkers represent several underlying pathophysiological processes in dengue. Hence, we aimed to assess AST, ALT, CK and hematocrit in identification of severe dengue and to assess the correlational relationship amongst common biomarkers of dengue.

Methods

This was a retrospective cohort study of confirmed dengue patients who were warded in Kuala Lumpur Hospital between December 2014 and January 2015. CK, AST, ALT, hematocrit, platelet count, WBC and serum albumin were taken upon ward admission and repeated at timed intervals. Composite indices based on admission AST and ALT were analyzed. Correlation coefficients and coefficients of determination were computed.

Results

Among the 365 cases reviewed, twenty-two (6%) patients had severe dengue. AST and ALT were found to be good at identification of severe dengue. The AST²/ALT composite index was the most accurate (AUC 0.83; 95% CI 0.73 - 0.93). Optimal cutoff was 402 with a sensitivity of 59.1% (95% CI: 36.4 - 79.3%) and specificity of 92.4% (95% CI: 89.1 - 95.0%). Modified cutoff of 653 had a sensitivity of 40.9% (95% CI: 20.7 - 63.7%) and specificity of 97.4% (95% CI: 95.1 - 98.8%). Our analyses also suggested that several underlying biological processes represented by biomarkers tested were unrelated despite occurring in the same disease entity. Also, markers of plasma leakage were discordant and AST was likely hepatic in origin.

Conclusions

The composite index AST²/ALT may be used as a marker for identification of severe dengue based on admission AST and ALT, with two choices of cutoff values, 402 and 653. AST is most likely of liver origin and CK does not provide additional value.

Analyses of clinical and laboratory characteristics of dengue adults at their hospital presentations based on the World Health Organization clinical-phase framework: Emphasizing risk of severe dengue in the elderly

BACKGROUND/PURPOSE

Dengue clinically dynamically changes over time; the World Health Organization (WHO) dengue classification framework proposed 3 dengue clinical phases-febrile (days 1-3), critical (days 4-6) and recovery (days ≥7) phases. This study aimed to better understand clinical and laboratory characteristics in adults (≥18 years) suffering dengue in different clinical phases at their hospital presentations.

METHODS

A retrospective analysis of adults suffering dengue between 2008 and 2014.

RESULTS

Of the 669 included dengue adults, 146 (21.8%) were elderly (≥65 years), and 27 (4%) suffered severe dengue. When compared with those in febrile phase, significantly higher incidence of ascites, mucosal bleeding, and/or gastrointestinal bleeding; lower white blood cell (WBC) and platelet counts; higher hematocrit, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were found in critical phase. When compared with their younger counterparts, elderly at febrile phase had significantly lower frequencies of bone pain, myalgia, headache and rash; higher frequencies of vomiting, pleural effusion and mucosal bleeding; higher WBC count, AST and ALT levels, and lower platelet count; in critical phase, elderly had significantly higher frequencies of pleural effusion, mucosal bleeding and gum bleeding. Four (0.6%) patients experienced severe dengue in recovery phase. Significantly higher proportions of elderly developed severe dengue in both febrile and critical phases as compared with younger adults.

CONCLUSIONS

Elderly had lower frequency of classical dengue symptoms, yet were at higher risk of development of severe dengue during their early dengue course. A small number of patients developed severe dengue at the WHO-proposed recovery phase.

Serum cytokine/chemokine profiles in patients with dengue fever (DF) and dengue hemorrhagic fever (FHD) by using protein array

BACKGROUND

DENV infection can induce different clinical manifestations varying from mild forms to dengue fever (DF) or the severe hemorrhagic fever (DHF). Several factors are involved in the progression from DF to DHF. No marker is available to predict this progression. Such biomarker could allow a suitable medical care at the beginning of the infection, improving patient prognosis.

OBJECTIVES

The aim of this study was to compare the serum expression levels of acute phase proteins in a well-established cohort of dengue fever (DF) and dengue hemorrhagic fever (DHF) patients, in order to individuate a prognostic marker of diseases severity.

STUDY DESIGN

The serum levels of 36 cytokines, chemokines and acute phase proteins were determined in DF and DHF patients and compared to healthy volunteers using a multiplex protein array and near-infrared (NIR) fluorescence detection. Serum levels of IL-1ra, IL-23, MIF, sCD40 ligand, IP-10 and GRO-α were also determined by ELISA.

RESULTS

At the early stages of infection, GRO-α and IP-10 expression levels were different in DF compared to DHF patients. Besides, GRO-α was positively correlated with platelet counts and IP-10 was negatively correlated with total protein levels.

CONCLUSIONS

These findings suggest that high levels of GRO-α during acute DENV infection may be associated with a good prognosis, while high levels of IP-10 may be a warning sign of infection severity.

Dengue

Dengue is one of the most important mosquito-borne viral infections caused by single-stranded RNA virus that are transmitted by the Aedes aegypti and Aedes albopictus mosquito species. Dengue is endemic in over 140 countries in Asia, the USA, the Eastern Mediterranean, and Africa. The World Health Organization (WHO) estimated that there are more than 2.5 billion people—mainly occurs in children living in tropical and subtropical countries—at risk of dengue infection with one or more dengue viruses. There are estimated nearly 100 million symptomatic dengue infections occurring worldwide annually, nearly 75% in Asia and the Western Pacific region [1]. During the past decades, the outbreaks of dengue infection have been reported throughout the world with increased severity. Ecologic and demographic changes are considered to be the contributing factors to the emergence of dengue infection in the past decades. Dengue has expanded into new countries and into urban settings associated with increased distribution of A. aegypti, population growth, urbanization, development of slums, migration of population, movement of dengue virus by infected travelers, trade development, and improved diagnostic capabilities in medical practice [2, 3]. Increased transmission of dengue virus in tropical urban areas has been created by substandard housing and crowding as well as deterioration in water, sewer, and waste management systems, all of which are intimately associated with unplanned urbanization [4–7]. So it is likely that dengue will expand its geographic reach and become an increasing burden on health resources in affected areas during the next decade. An effective vector-control management is the only means to reduce dengue infection in endemic areas. Because vector control has achieved only limited success so far in reducing the transmission of dengue, the usage of effective dengue vaccine in target population along with the preventive measures already used such as raising public awareness may be the means to effectively control of this disease in endemic area [8].

A Study on Spectrum of Hepatobiliary Dysfunctions and Pattern of Liver Involvement in Dengue Infection

INTRODUCTION

The most common arthropod-borne viral (arboviral) disease in humans is dengue. It is transmitted by female Aedes mosquitoes. These mosquitoes are widely distributed in subtropical and tropical areas of the world. Study of dengue infection and its complications are rare from countries like India.

AIM

In this prospective observational cross-sectional study, we intended to assess the frequency and degree of hepatobiliary dysfunction in adult patients with dengue infection presenting to a tertiary-care medical facility.

MATERIALS AND METHODS

The details of all patients with serologically proved dengue fever admitted to a tertiary care hospital in eastern India from July 2014 to June 2015 were prospectively reviewed. We collected data including routine blood count, Liver Function Test (LFT), Prothrombin Time (PT), Activated Partial Prothrombin Time (APTT), abdominal ultrasonography from 110 patients.

RESULTS

The maximum number of cases were seen in the age group between 46 years and 61 years and of all cases 55.5% were male and 44.5% were female. Pain abdomen and vomiting were the commonest presenting complaints next to fever which was present in all the cases. Elevated liver enzymes, abnormal values of PT and APTT, thrombocytopenia were observed more commonly in Dengue Shock Syndrome (DSS). Gall bladder wall thickening, thrombocytopenia were seen more commonly in both DSS and Dengue Haemorrhagic Fever (DHF). Plasma leakage such as ascites and pleural effusion on USG were seen more frequently in patients with DHF (76.9% and 73.1%) followed by DSS (72% and 68%) and DF (33.9% and 32.2%).

CONCLUSION

Hepatobiliary derangement is seen more commonly in severe case of dengue infection. Early recognition of these parameters can also be used as a predictor for assessing the disease severity.

Dengue score: a proposed diagnostic predictor for pleural effusion and/or ascites in adults with dengue infection

Background

There are several limitations in diagnosing plasma leakage using the World Health Organization (WHO) guidelines of dengue hemorrhagic fever. We conducted a study to develop a dengue scoring system to predict pleural effusion and/or ascites using routine laboratory parameters.

Methods

A prospective observational study was carried out at Cipto Mangunkusumo Hospital and Persahabatan Hospital, Jakarta, Indonesia. Dengue-infected adults admitted on the third febrile day from March, 2010 through August, 2015 were included in the study. A multivariate analysis was conducted to determine the independent diagnostic predictors of pleural effusion and/or ascites and to convert the prediction model into a scoring system.

Results

A total of 172 dengue-infected adults were enrolled in the study. Of the 172 patients, 101 (58.7 %) developed pleural effusion and/or ascites. A multivariate analysis was conducted to determine the independent diagnostic predictors of pleural effusion and/or ascites in dengue-infected adults. The predictors were scored based on the following calculations: hemoconcentration ≥15.1 % had a score of 1 (OR, 3.11; 95 % CI, 1.41–6.88), lowest albumin concentration at critical phase ≤3.49 mg/dL had a score of 1 (OR, 4.48; 95 % CI, 1.87–10.77), lowest platelet count ≤49,500/μL had a score of 1 (OR, 3.62; 95 % CI, 1.55–8.49), and elevated ratio of AST ≥2.51 had a score of 1 (OR 2.67; 95 % CI, 1.19–5.97). At a cut off of ≥ 2, the Dengue Score predicted pleural effusion and/or ascites diagnosis with positive predictive value of 79.21 % and negative predictive value of 74.63 %. This prediction model is suitable for calibration and good discrimination.

Conclusions

We have developed a Dengue Score that could be used to identify pleural effusion and/or ascites and might be useful to stratify dengue-infected patients at risk for developing severe dengue.

Is excessive acetaminophen intake associated with transaminitis in adult patients with dengue fever?

BACKGROUND

Dengue, an endemic infection causing severe flu-like symptoms and fever, is often treated with high-dose acetaminophen that can exceed recommended daily dosages. This leads to hepatotoxicity, although the underlying mechanism is poorly understood. We hypothesised that excessive acetaminophen causes hepatic toxicity in dengue patients.

AIMS

To investigate a correlation between elevated serum transaminases and excessive acetaminophen intake, and other aggravating factors of liver injury in dengue cases.

METHODS

This prospective observational study obtained blood samples from 150 participants with acute febrile illness for dengue serological tests, blood counts, and the detection of serum transaminases and acetaminophen levels. Other factors were determined by questionnaire.

RESULTS

Of 150 participants enrolled, 77 had dengue fever. Abnormally high serum aspartate transaminase and alanine transaminase levels were present in 97.0% and 75.3% of dengue cases respectively. Multivariate analysis of cases with increased serum transaminases more than threefold normal upper limits indicated that male gender (odds ratio (OR) = 3.62, 95% confidence interval (CI) 1.38-9.42) and consuming >8 g acetaminophen orally (OR = 4.62, 95% CI 1.37-13.18) correlated with transaminitis. No correlation was found for other factors such as age, fever day at presentation, body mass index, alcohol intake or dengue severity classification (all P > 0.05). Chronic alcohol consumption was higher in non-dengue (2.6%) versus dengue cases (27.8%) (P < 0.01).

CONCLUSIONS

Most dengue patients had mild-to-moderate transaminitis. Male gender and acetaminophen >8 g were associated with increased serum transaminases. Thus, 1000 mg acetaminophen every 8 h or <3000 mg/day is recommended for dengue cases. Chronic alcohol consumption might be protective against dengue infection.

Differences in Liver Impairment Between Adults and Children with Dengue Infection

Dengue infection (DI) is a major vector-borne disease in southeast Asia and an important cause of morbidity. The complications such as hepatic impairment are common, and because the physiology of the liver differs between children and adults, the DI-associated liver impairments might be expected to differ as well. This study aims to compare the differences in liver impairment between adults and children with DI. We retrospectively studied 158 adults and 79 children with serologically confirmed DI admitted to the Bangkok Hospital for Tropical Diseases from 2008 to 2012. In total, 93% of adults and 87% of children exhibited abnormal liver enzyme levels during hospitalization. Overall, 76 (42.4%) adults and 16 (20.3%) children had dengue hemorrhagic fever (DHF). Compared with children, adults with dengue fever (DF) presented a significantly higher incidence of liver function impairment (alanine transaminase [ALT] > 2 × upper limit of normal [ULN]) (47.1% versus 25.5%), hepatitis (ALT > 4 × ULN) (29.4% versus 12.8%), and severe hepatitis (aspartate transaminase [AST]/ALT > 10 × ULN) (16.5% versus 4.3%). Children with DHF showed a significantly higher incidence of liver function impairment due to AST derangement than did adults (100% versus 73%). There were no differences in the total bilirubin, albumin, or total protein levels between adults and children. Liver enzymes normalized significantly more slowly in adults, and AST recovery was faster than ALT. In conclusion, liver function impairment was more common among adults than children with DF. As the severity progressed to DHF, liver injury became more common in children.

SB203580 Modulates p38 MAPK Signaling and Dengue Virus-Induced Liver Injury by Reducing MAPKAPK2, HSP27, and ATF2 Phosphorylation

Dengue virus (DENV) infection causes organ injuries, and the liver is one of the most important sites of DENV infection, where viral replication generates a high viral load. The molecular mechanism of DENV-induced liver injury is still under investigation. The mitogen activated protein kinases (MAPKs), including p38 MAPK, have roles in the hepatic cell apoptosis induced by DENV. However, the in vivo role of p38 MAPK in DENV-induced liver injury is not fully understood. In this study, we investigated the role of SB203580, a p38 MAPK inhibitor, in a mouse model of DENV infection. Both the hematological parameters, leucopenia and thrombocytopenia, were improved by SB203580 treatment and liver transaminases and histopathology were also improved. We used a real-time PCR microarray to profile the expression of apoptosis-related genes. Tumor necrosis factor α, caspase 9, caspase 8, and caspase 3 proteins were significantly lower in the SB203580-treated DENV-infected mice than that in the infected control mice. Increased expressions of cytokines including TNF-α, IL-6 and IL-10, and chemokines including RANTES and IP-10 in DENV infection were reduced by SB203580 treatment. DENV infection induced the phosphorylation of p38MAPK, and its downstream signals including MAPKAPK2, HSP27 and ATF-2. SB203580 treatment did not decrease the phosphorylation of p38 MAPK, but it significantly reduced the phosphorylation of MAPKAPK2, HSP27, and ATF2. Therefore, SB203580 modulates the downstream signals to p38 MAPK and reduces DENV-induced liver injury.

Acute Undifferentiated Febrile Illness in Patients Presenting to a Tertiary Care Hospital in South India: Clinical Spectrum and Outcome

Background:

Acute undifferentiated febrile illness (AUFI) may have similar clinical presentation, and the etiology is varied and region specific.

Materials and Methods:

This prospective observational study was conducted in a tertiary hospital in South India. All adult patients presenting with AUFI of 3–14 days duration were evaluated for etiology, and the differences in presentation and outcome were analyzed.

Results:

The study cohort included 1258 patients. A microbiological cause was identified in 82.5% of our patients. Scrub typhus was the most common cause of AUFI (35.9%) followed by dengue (30.6%), malaria (10.4%), enteric fever (3.7%), and leptospirosis (0.6%). Both scrub typhus and dengue fever peaked during the monsoon season and the cooler months, whereas no seasonality was observed with enteric fever and malaria. The mean time to presentation was longer in enteric fever (9.9 [4.7] days) and scrub typhus (8.2 [3.2] days). Bleeding manifestations were seen in 7.7% of patients, mostly associated with dengue (14%), scrub typhus (4.2%), and malaria (4.6%). The requirement of supplemental oxygen, invasive ventilation, and inotropes was higher in scrub typhus, leptospirosis, and malaria. The overall mortality rate was 3.3% and was highest with scrub typhus (4.6%) followed by dengue fever (2.3%). Significant clinical predictors of scrub typhus were breathlessness (odds ratio [OR]: 4.96; 95% confidence interval [CI]: 3.38–7.3), total whole blood cell count >10,000 cells/mm³ (OR: 2.31; 95% CI: 1.64–3.24), serum albumin <3.5 g % (OR: 2.32; 95% CI: 1.68–3.2). Overt bleeding manifestations (OR: 2.98; 95% CI: 1.84–4.84), and a platelet count of <150,000 cells/mm³ (OR: 2.09; 95% CI: 1.47–2.98) were independent predictors of dengue fever.

Conclusion:

The similarity in clinical presentation and diversity of etiological agents demonstrates the complexity of diagnosis and treatment of AUFI in South India. The etiological profile will be of use in the development of rational guidelines for control and treatment of AUFI.