Heart and liver are infected in fatal cases of dengue: three PCR based case studies

Background

Dengue is a global problem mainly in the tropics. Meticulous clinical management of cases has reduced the death rate significantly, but large numbers of people still succumb to severe complications of the infection. Presence of myocarditis is often overlooked leading to a poor outcome. Clinical management guidelines of dengue do not stress the importance of myocarditis as a manifestation in dengue infection. Severe hepatic dysfunction also needs emphasis.

Case presentation

We present three patients who had come to hospital on the 3rd day of fever. Two of them (case 1 and 3) were in shock on admission and case 2, who was stable on the3^rd day, went into the critical phase and developed shock while in the hospital on the 4^thday. All three had tachycardia on admission that got worse with time. The clinical course was unstable with fluctuations in urine output and deterioration of organ function. Despite frequent monitoring and life support they survived only 2–3 days in hospital. All three patients had myocarditis during the critical phase. In the first case, myocarditis was confirmed by troponin estimation and echocardiogram. In the second and third cases, histopathology confirmed myocarditis. Haemorrhagic necrosis of the liver was found in case 2 and 3 with exponential rise of transaminases. In all three cases, viral RNA was detected in both heart and liver tissues by PCR amplification.

Conclusions

We stress that detection of myocarditis and liver involvement in any dengue patient is important from the onset of the illness where treatment should be tailored to prevent development of hypotension. Our findings are novel as PCR and histology are rarely done on tissues of deceased dengue patients in the world. Studies are needed to find therapeutic interventions to reverse cardiac and hepatic dysfunction in dengue infection.

Impact of molecular structure on the physicochemical properties of starches isolated from different field pea (Pisum sativum L.) cultivars grown in Saskatchewan, Canada

The objective of this study was to determine the molecular structure and properties of recently released cultivars of field peas [CDC Golden (CDCG), Abarth (ABAR), CDC Patrick (CDCP) and CDC Amarillo (CDCA)] grown at different locations in Saskatchewan, Canada. Starch yield (on whole seed basis), apparent amylose, total lipid and specific surface area were in the range 34-37%, 38.2-42.6%, 1.07-1.38% and 0.31-0.38m2/g, respectively. The proportion of short (DP 6-12) amylopectin chains, amylopectin branching density, molecular order, crystallinity, crystalline heterogeneity, gelatinization transition temperatures, pasting temperatures, peak viscosity, extent of acid hydrolysis, and resistant starch content were higher in CDCG and ABAR. However, amylopectin long chains (DP 13-26), average chain length and thermal stability were higher in CDCP and CDCA. The results of this study showed that differences in physicochemical properties among cultivars were mainly influenced by amylopectin chain length distribution, amylopectin branching density and co-crystallization of amylose with amylopectin.

Metabolic and polycystic ovary syndromes in indigenous South Asian women with previous gestational diabetes mellitus

OBJECTIVE

To determine the risk of metabolic syndrome (MS) and polycystic ovary syndrome (PCOS) in a cohort of indigenous South Asian women with a recent history of gestational diabetes mellitus (GDM).

DESIGN

Case-control study.

SETTING

Department of Obstetrics & Gynaecology, University of Colombo, Sri Lanka.

SAMPLE

Two hundred and seventy-four indigenous Sri Lankan women with previous GDM and 168 ethnically matched controls. Of these, 147 with previous GDM and 67 controls not taking hormonal contraception participated in an in-depth endocrine study.

METHODS

Assessing the prevalence of MS and PCOS based on clinical features, biochemistry and ovarian ultrasound examination at 3 years postpartum.

MAIN OUTCOME MEASURES

Prevalence of MS and PCOS.

RESULTS

Women with previous GDM and controls were studied at a mean (range) of 34.6 (13.4-84.1) and 46.5 (17.5-78) months postpartum, respectively. Those with previous GDM had a larger mean +/- 95% confidence interval waist circumference (90.9 +/- 1.3 versus 81.2 +/- 2.8 cm, P = 0.0004) and were more likely to have hypertension (17.6 versus 7.4%, P = 0.001), glucose intolerance (51.7 versus 10.4%, P = 0.00001), hypertriglyceridaemia (16.3 versus 5.9%, P = 0.02) and a lower level of high-density lipoprotein (70 versus 56.7%, P = 0.04) than the controls. Of the women who had GDM, 72 (49%) had MS, 86 (58.5%) had polycystic ovaries and 59 (40%) had PCOS, significantly more than the control women-4 (6%), 9 (13%) and 2 (3%), respectively (P = 0.00001).

CONCLUSIONS

The prevalence of MS and PCOS in indigenous Sri Lankan women 3 years postpartum is significantly higher in those with previous GDM compared with ethnically matched controls. This confirms an association between GDM and subsequent PCOS and MS.

Dengue infections during pregnancy: A case series from Sri Lanka and review of the literature

BACKGROUND

Dengue is a major public health problem in several countries. Few reports document presentations and outcomes of dengue during pregnancy. In many endemic countries as the average age of getting dengue infections is shifting upwards, dengue in pregnancy is likely to be encountered more frequently. Patterns of dengue in patients from different regions are needed if we are to draft evidence based management guidelines.

OBJECTIVES

To document clinical and laboratory findings in a cohort of hospitalised patients with dengue during pregnancy in Sri Lanka and compare their presentation and outcomes with previously published cases.

STUDY DESIGN

Clinical, laboratory, maternal and fetal outcomes and demographic information were collected from patients with confirmed dengue infections during pregnancy treated in a Maternity Hospital in Sri Lanka from 1 January 2000 to 30 June 2004. The Medline database was searched to identify reports relating to dengue infection during pregnancy since 1965.

RESULTS

Twenty-six patients [mean (S.D.) age: 29 (4.2) years] were studied. One (3.8%), 2 (7.7%) and 20 (77%) presented in the first, second and third trimesters of pregnancy, and 3 (11.5%) in the immediate post-partum period. Seventeen (65.3%) had primary and nine (34.7%) secondary dengue infections. Ten (38.5%) had DF, 6 (23.1%): DHF grade I and 10 (38.5%): DHF grade II. Five (19.2%) and three (11.5%) patients who first presented with cough/breathlessness or vaginal bleeding, were initially managed as having a pulmonary embolism or a primary obstetric cause for their vaginal bleeding. Bradycardia was noted in three of the four patients who had a cardiac arrhythmia. Seven (26.9%) needed admission to an ICU. Raised AST and ALT levels were seen in 81.2% and 43.7% of 16 patients in whom liver function tests results were available. No fetal malformations were seen in any of the babies born. The single patient who developed DHF in the first trimester had an abortion while having acute symptoms of dengue.

CONCLUSIONS

Awareness of clinical and laboratory manifestations of dengue in pregnancy should allow its early recognition and institution of appropriate treatment. Reports on dengue in pregnancy from different regions should allow more evidence-based guidelines to be formulated for optimum evaluation and care of such patients. Our data contributes towards this goal.