SUDANESE JOURNAL OF PAEDIATRICS

2023; Vol 23, Issue No. 2

ORIGINAL ARTICLE

Clinical, biochemical and outcome profile of dengue fever in hospitalised children in Eastern Uttar Pradesh, India

Ankur Singh(1), Abhishek Abhinay (1), Rajniti Prasad (1), Om Prakash Mishra (1)

(1) Department of Paediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Correspondence to:

Professor Ankur Singh

Department of Paediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.

Email: ankur [at] bhu.ac.in

Received: 24 December 2020 | Accepted: 17 November 2023

How to cite this article:

Singh A, AbhinayA, Prasad R, Mishra OP. Clinical, biochemical and outcome profile of dengue fever in hospitalised children in Eastern Uttar Pradesh, India. Sudan. Sudan J Paediatr.2023;23(2):171–176.

https://doi.org/10.24911/SJP.106-1608787494

ABSTRACT

Dengue fever is an important cause of acute febrile illness in the postmonsoon season in India. This study was done to record the incidence of dengue in admitted patients with acute febrile illness in a hospital setting. The study also intends to record the clinical, biochemical and outcome profile of paediatric dengue cases admitted in tertiary centres in Eastern Uttar Pradesh, India. It was a prospective case record analysis at a tertiary care research hospital in Eastern Uttar Pradesh. The study recruited fifty-53 children (<18 years) with serology-proven diagnosis of dengue disease. Disease was confirmed by doing Ns1Ag, IgM antibody test by ELISA method. Six hundred children were screened and 53 met the inclusion criteria. The incidence of dengue disease in hospitalised acute febrile illness was 8.8%. There were thirty-one males. The mean age of presentation of the study population was 9.32 ± 5 years with a range of 0.25 – 17 years. Fever (94%), nausea and vomiting (59 %), abdominal pain (55%), persistent vomiting (49%), thrombocytopenia (<100,000 [66%]), and petechiae and purpura (43%) were the important clinical manifestations. Six required intensive care monitoring. There was only one death. Dengue fever is an important cause of acute febrile illness in children. Case fatality rate can be minimised with proper World Health Organisation classification and protocol-based management of cases.

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KEYWORDS

Dengue fever; Children; Outcome; Eastern Uttar Pradesh; India.

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INTRODUCTION

Dengue is the most prevalent Flavivirus infection in tropical and subtropical countries. It is caused by mosquito vectors: Aedes aegypti and Aedes albopictus [1,2]. Dengue has become endemic to every region in India due to unplanned urbanisation and poor water sanitation services. There have been published reports of dengue infection from all over India, mainly from metropolitan cities [3–7]. Dengue has become an important cause of acute febrile illness in postmonsoon season in small cities too. There has been a lack of studies on the dengue profile of paediatric patients in this eastern part of Uttar Pradesh. To address this knowledge gap, we undertook this study to know the incidence of dengue disease in acute (fever <5 days) febrile illness in the paediatric age group in hospitalised children. A secondary objective was to enlist the age profile, clinical, biochemical and outcome profiles in the paediatric age group.

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MATERIALS AND METHODS

The present study was conducted at the Department of Paediatrics between periods from September to December 2018. It was a prospective observational study of all dengue cases, admitted to the paediatric ward of less than 18 years of age. The primary objective was to study the incidence of dengue disease in acute febrile illness in hospitalised paediatric patients. All relevant demographic, clinical and biochemical information was recorded in predesigned performa. The case of dengue was defined by the presence of compatible clinical symptoms with positive serology test by ELISA method (either of Ns1Ag, IgM). Cases were further classified based on the World Health Organisation (WHO) criteria [8]. Cases were managed according to the latest WHO protocol [8]. Laboratory parameters were recorded at admission and discharge. Parameters were compared among cases based on their severity. Frequencies for qualitative variables were recorded. Quantitative variables were summarised with mean and SD. Comparison among quantitative variables was made using the student t test, analysis of variance-one-way. A nonparametric test of Wilcoxon was used for a paired data set where the SD was too high. The chi-square test was used for comparison among groups. The nonparametric test Kruskal – Wallis was used to compare means among groups where data was NonGaussian. Significance was taken as p < 0.05.

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RESULTS

A total of 600 children less than 18 years of age were screened for dengue serology and disease. There were 8.8% confirmed cases of dengue. We recruited 53 dengue disease cases with 31 males and 22 females (Table 1). The majority of cases (49/53) belonged to Varanasi urban and semi-urban areas. The mean age of presentation of the study population was 9.32 ± 5 years with a range of 0.25 – 17 years. There were 43 cases of nonsevere dengue (probable dengue=4, dengue with warning signs=39) and 10 cases of severe dengue. The prominent clinical manifestations were: fever (94%), nausea and vomiting (59%), abdominal pain (55%), persistent vomiting (49%), lethargy and headache (40%), body pain and anorexia (36%), rash (28%), and eye pain (23%).

Other less common manifestations were: cough, diarrhoea, convulsion, nasal bleeding, blood in stool, vaginal bleed, mucosal bleed, bleeding gums, and blood in the urine. -66% of cases had low platelet count (<100,000) at the time of presentation. Petechiae and purpura were present in 43% of cases. The mean duration of hospital stay was 4.58 ± 2.85 days in the study population. There was a significant difference in haemoglobin, platelet and haematocrit parameters at admission and discharge in the dengue with warning signs group (Table 2). On the contrary, severe dengue cases had significant differences in total leucocyte count and platelet at admission and discharge (Table 2).

There was a significant difference among the three groups based on hospital stay. This difference was more significant between probable dengue versus dengue with warning signs and probable dengue versus severe dengue (Table 3). There was no significant difference in mean age at presentation in all three groups. There were only six cases that required paediatric intensive care admission. The successful discharge rate was 93%. The case fatality rate was (1.8%). There were two cases that were left against doctors’ advice (LAMA).

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DISCUSSION

Dengue fever is one of the most common causes of acute febrile illness in postmonsoon season in India. The present study recruited 53 cases with 32 males and 22 females. Slight male preponderance has been found in various Indian studies too [3–7]. The mean age of presentation was 9.32 ± 5.0 years, slightly higher than previously reported studies [3–7]. This might be due to early reporting of symptoms by elderly children, increased awareness among the general public about the disease, and better availability of diagnostic and therapeutic services in the region. Common symptoms of fever, cough and coryza may be attributable to other common upper respiratory symptoms in younger children by treating clinicians; thereby leading to underdiagnosis of dengue in the younger population. Fever, vomiting and abdominal pain were the consistent features of the disease (Table 1). This finding is in congruence with previous published Indian studies [3–7]. The presence of thrombocytopenia was not associated with bleeding manifestation. Children showed bleeding manifestations even at >50,000 platelet counts. There were children who did not bleed even at <10,000 platelet count. This finding shows that there are other mechanisms that are responsible for bleeding in dengue disease [9–12]. These are suppression of haematopoiesis directly by the dengue virus, indirect immune injury, consumptive coagulopathy, platelet function defect, and damage of vascular endothelial cells. Newer WHO classification of dengue fever has facilitated in early diagnosis and protocol-based treatment of dengue fever. Children with warning signs are admitted and hydrated well so they do not enter the phase of critical illness or complication (severe dengue). In this study, our maximum number of patients were from the category of nonsevere dengue (probable dengue −4; dengue with warning signs −39). Advantages of the new WHO classification are: the children are picked up early in disease progression, get protocol-based treatment and platelet infusions are discouraged, leading to less morbidity and mortality. All previous studies had shown mortality of 1% – 2%; similar findings in our study population [3–7]. Few studies have compared the previous WHO Classification (1997) with the present WHO classification (2009) [13]. They have found better sensitivity and specificity of the present WHO classification over the previous one in the Indian population too. The better outcome in the present study is supported by our biochemical parameters. There has been a significant change in monitoring parameters of disease at the time of admission and at discharge. Nonsevere dengue disease has shorter hospital stays as compared to severe dengue disease. This is due to developing complications in severe disease; leading to longer hospital stays. Only a few patients required paediatric intensive care management. This suggests that patients can be managed in a normal ward if proper classification of disease is done at the time of diagnosis. This will also reduce the financial burden on patients and hospitals. It will further reduce the demand for intensive care.

Table 1. Demographic, clinical and outcome characteristics of study group (n=53).

Parameter		N
Gender	Male	31 (58.49%)
	Female	22 (41.50%)
Locality	Varanasi	49 (92.45%)
	Jaunpur	1 (1.88%)
	Bhabhua	1 (1.88%)
	Bhadohi	1 (1.88%)
	Rohtas	1 (1.88%)
Outcome	Discharge	49 (92.45%)
	Death	1 (1.88%)
	LAMA	2 (3.77 %)
Requiring PICU Admission	Yes	6 (11.32%)
Fever lasting for 2–7 days		50 (94.33%)
Fever at the time of presentation		12 (22.64%)
Persistent vomiting		26 (49.05%)
Nausea and vomiting		31 (58.49%)
Abdominal pain		29 (54.71%)
Lethargy/restlessness		21 (39.62%)
Rash		15 (28.30&)
Headache		21 (39.62%)
Eye pain		12 (22.64%)
Body pain		19 (35.84%)
Anorexia		19 (35.84%)
Liver enlargement (>2 cm )		21 (39.62%)
Vomit with blood		1 (1.88%)
Blood in stool		3/51 (5.88%)
Nasal bleed		5/52 (9.61%)
Bleeding gums		2/52 (3.84%)
Blood in urine		1 (1.88%)
Vaginal bleed		3 (5.66 % )
Haematuria		1/34 (2.94%)
Diarrhoea		7 (13.20%)
Cough		9 (16.98%)
Convulsion or coma		6 (11.32%)
Mucosal bleeding		3 (5.66 % )
Platelet count <100,000 at time of presentation		35 (66.03%)
Petechiae		10/52 (19.23%)
Purpura		13 (24.52%)
Capillary leak (pleural effusion/ascites)		6 (11.32%)
Probable dengue		4 (7.54%)
Dengue with warning signs		39 (7.35%)
Severe dengue		10 (18.86%)

LAMA, Left against medical advice; PICU, Paediatric Intensive Care Unit.

Table 2. Summary characteristics of quantitative variables (n=53).

Parameter	Mean ± SD or median (IQR)
Age (years )	9.32 ± 5.0
Parameter ---------------------------------------------- Hospital stay (days)	Mean ± SD or median (IQR) ------------------------------------- 4.58 ± 2.85
Hb at admission (gm/dl)	11.63 ± 2.15
Hb lowest (gm/dl)	10.55 ± 1.92
Hb highest (gm/dl)	12.23 ± 2.04
Hb at discharge (gm/dl)	11.00 ± 1.58
TLC at admission (cells/µl)	6,430 (5,995)
TLC lowest (cells/µl)	4,185 (3,715)
TLC highest (cells/µl)	7,195 (5,060)
TLC at discharge (cells/µl)	6,230 (3,780)
Platelet at admission (cells/µl)	47,000 (119,000)
Platelet lowest (cells/µl)	36,500 (84,000)
Platelet highest (cells/µl)	130,000 (70,000)
Platelet at discharge (cells/µl)	119,000 (80,000)
Hct at admission (%)	35 ± 5.74
Hct lowest (%)	31.39 ± 4.51
Hct highest (%)	36.61 ± 5.40
Hct at discharge (%)	32.56 ± 4.18
Urea (mg/dl)	27.35 (15.9)
Creatinine (mg/dl)	0.7 ± 0.25
Sodium meq/l)	136.28 ±6.08
Potassium (meq/l)	4.55 ± 0.71
SGOT (IU/l)	116 (136.5)
SGPT (IU/l)	60.9 (71.1)
Total bilrubin (mg/dl)	0.54 ± 0.62
Direct bilirubin (mg/dl)	0.34 ± 0.60
Indirect bilirubin (mg/dl)	0.20 ± 0.13
Total protein (gm/dl)	6.0 ± 0.84
Albumin (gm/dl)	3.4 ± 0.48
Alkaline phosphatase (IU/l)	214.85 (201.5)

Hb, Haemoglobin; Hct, Haematocrit; IQR, Interquartile range; SD, Standard deviation; SGOT, Serum glutamic oxaloacetic transaminase; SGPT, Serum glutamic pyruvic transaminase; TLC,Total leucocyte count.

Table 3. Number of hospital days based on dengue severity.

Dengue severity	Hospital stay (days) Median (IQR)	p-value
Probable dengue	2 (1,3)
Dengue with warning signs	4 (3,5)	0.004
Severe dengue	6 (5,8)

IQR, Interquartile range.

The present study has a limitation of small sample size. We studied only hospitalised children. Out-patient nonsevere dengue cases were not taken. This important limitation underestimates the actual burden of the problem in this region. Serotyping and genotyping of prevalent dengue strain was not done. Therefore, there is a need to study the prevalent dengue strain in this region. This will help to develop vaccine design and deployment strategies for the disease.

This study has brought up important points. It constitutes the first study in this Varanasi region focussing on an estimate of the burden of problems faced by children of this region. Public health policymakers should improve preventive and therapeutic services in the region to combat vector-borne diseases during postmonsoon season.

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Conflict of interest

The authors declare that they have no competing interests.

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FUNDING

None.

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ETHICAL APPROVAL

Institute ethical clearance was taken from the Institute Ethical Committee (Dean/2019/EC/1017) (dated: 18/01/2019). Written informed consent was obtained from parents of children included in the study.

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