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Campana V, Inizan C, Pommier JD, Menudier LY, Vincent M, Lecuit M, Lamballerie XD, Dupont-Rouzeyrol M, Murgue B, Cabié A. Liver involvement in dengue: A systematic review. Rev Med Virol 2024; 34:e2564. [PMID: 38923215 DOI: 10.1002/rmv.2564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
Liver involvement is an unusual yet frequently overlooked dengue complication. Pivotal for an efficient clinical management, the early diagnosis of dengue-associated liver involvement relies on an accurate description of its clinical and biological characteristics, its prognosis factors, its association with severe dengue and its clinical management. We conducted a systematic review by searching PubMed and Web of Science databases for original case reports, cohort and cross-sectional studies reporting the clinical and/or biological features of dengue-associated liver involvement. The study was registered in PROSPERO (CRD42021262657). Of the 2552 articles identified, 167 were included. Dengue-associated liver involvement was characterised by clinical features including abdominal pain, hepatomegaly, jaundice, nausea/vomiting, and an echogenic liver exhibiting hepatocellular necrosis and minimal inflammation. Elevated Aspartate Aminotransferase and Alanine Aminotransferase but also elevated bilirubin, Alkaline Phosphatase, gamma-glutamyl transferase, increased International Normalised Ratio, creatinine and creatine kinase, lower albumin and prolonged prothrombin and activated partial thromboplastin time were prevalent in dengue-associated liver involvement. Cardiovascular and haematological systems were frequently affected, translating in a strong association with severe dengue. Liver involvement was more common in males and older adults. It was associated with dengue virus serotype-2 and secondary infections. Early paracetamol intake increased the risk of liver involvement, which clinical management was mostly conservative. In conclusion, this systematic review demonstrates that early monitoring of transaminases, clinical assessment, and ultrasound examination allow an efficient diagnosis of dengue-associated liver involvement, enabling the early identification and management of severe dengue.
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Affiliation(s)
- Valentine Campana
- CIC Antilles Guyane, INSERM CIC1424, Fort-de-France, France
- PCCEI, Université de Montpellier, INSERM, Etablissement Français du Sang, Université des Antilles, Montpellier, France
| | - Catherine Inizan
- Unité Dengue et Arboviroses, Institut Pasteur de Nouvelle-Calédonie, Pasteur Network, 110, Boulevard Joseph Wamytan, Dumbéa-sur-Mer, Noumea, New Caledonia
| | - Jean-David Pommier
- Intensive Care Unit, Guadeloupe Teaching Hospital, Antilles - Guyane University, Chemin de Chauvel, Les Abymes, France
| | | | | | - Marc Lecuit
- Institut Pasteur, Université Paris Cité, Inserm U1117, Biology of Infection Unit, Paris, France
- Necker-Enfants Malades University Hospital, Department of Infectious Diseases and Tropical Medicine, APHP, Paris, France
| | - Xavier De Lamballerie
- Unité des Virus Emergents (UVE: Aix-Marseille Université - IRD 190 - Inserm 1207), Marseille, France
| | - Myrielle Dupont-Rouzeyrol
- Unité Dengue et Arboviroses, Institut Pasteur de Nouvelle-Calédonie, Pasteur Network, 110, Boulevard Joseph Wamytan, Dumbéa-sur-Mer, Noumea, New Caledonia
| | - Bernadette Murgue
- Unité des Virus Emergents (UVE: Aix-Marseille Université - IRD 190 - Inserm 1207), Marseille, France
| | - André Cabié
- CIC Antilles Guyane, INSERM CIC1424, Fort-de-France, France
- PCCEI, Université de Montpellier, INSERM, Etablissement Français du Sang, Université des Antilles, Montpellier, France
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Gupta A, Sontakke T, Kumar S, Acharya S, Pradeep U. Navigating the Complexity: A Comprehensive Review of Hemophagocytic Lymphohistiocytosis Associated With Dengue Infection. Cureus 2024; 16:e61128. [PMID: 38919247 PMCID: PMC11198985 DOI: 10.7759/cureus.61128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 05/26/2024] [Indexed: 06/27/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) associated with dengue infection presents a unique challenge in clinical practice due to its rarity, rapid progression, and overlapping clinical features. This comprehensive review navigates the complexity of HLH-dengue syndrome by examining its pathophysiology, clinical manifestations, diagnostic criteria, and therapeutic strategies. HLH, characterized by uncontrolled immune activation and cytokine dysregulation, can occur as a secondary complication of dengue infection, leading to severe multiorgan dysfunction and high mortality if not promptly recognized and treated. The review underscores the significance of early diagnosis through vigilant clinical monitoring and appropriate diagnostic tests, such as bone marrow examinations and genetic studies. Collaboration between infectious disease specialists, hematologists, and critical care teams is essential for optimal management. Despite advancements in understanding HLH-dengue syndrome, further research is needed to elucidate its underlying mechanisms and explore novel treatment approaches. This review provides insights into the clinical implications of HLH-dengue syndrome and emphasizes the importance of a multidisciplinary approach to improve patient outcomes in this challenging clinical scenario.
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Affiliation(s)
- Aman Gupta
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tushar Sontakke
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sunil Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Utkarsh Pradeep
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Clinical and Laboratory Characteristics of Hemophagocytic Lymphohistiocytosis in Children With Severe Dengue During the 2019-2020 Outbreak in Southern Colombia. Pediatr Infect Dis J 2023; 42:e204-e211. [PMID: 36916863 DOI: 10.1097/inf.0000000000003887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is characterized by uncontrolled activation of inflammatory cells and an exaggerated release of cytokines. It can be triggered by different factors, including viruses, such as dengue. The objective of this study was to characterize the clinical and laboratory profiles of children with severe dengue and HLH, and to identify the risk factors for this clinical complication. METHODS An analytical study was conducted in children with severe dengue who were treated in an intensive care unit between January 2019 and March 2020. Clinical and laboratory factors were compared between patients with and without HLH. RESULTS HLH represented 13.4% (15/112) of children with severe dengue. Patients with HLH had a long-lasting fever (10.1 vs. 5.8 days; P = 0.012), low hemoglobin levels (7.6 vs. 10.8 g/dL; P = 0.000) and high aspartate aminotransferase values (4443 vs. 1061 U/L; P = 0.002), alanine transaminase (1433 vs. 487 U/L; P = 0.004), partial thromboplastin time (80.6 vs. 51.8 seconds; P = 0.010), prothrombin time (23.5 vs. 19.6 seconds; P = 0.024), triglycerides (333.7 vs. 223.2 mg/dL; P = 0.005), lactate dehydrogenase (4209 vs. 1947 U/L; P = 0.006), soluble CD25 (3488 vs. 1026 pg/mL; P = 0.014), and presented with higher frequency of myocarditis (66.7% vs. 38.3%; P = 0.048), hepatitis (5.3% vs. 1.3%; P = 0.014), bacterial coinfection (73.3% vs. 26.7%; P = 0.010) and fatal outcome (26% vs. 5%; P = 0.037). CONCLUSIONS HLH is a serious life-threatening clinical complication of dengue virus infection that must be considered, particularly during outbreaks.
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Chia PY, Thein TL, Ong SWX, Lye DC, Leo YS. Severe dengue and liver involvement: an overview and review of the literature. Expert Rev Anti Infect Ther 2020; 18:181-189. [PMID: 31971031 DOI: 10.1080/14787210.2020.1720652] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Two billion population are at risk of dengue fever and by 2080, over six billion population will be at risk. Hepatitis is common in dengue and the liver is invariably involved in severe cases. We conducted a literature review using the PubMed database on articles covering a broad range of issues related to dengue and hepatitis.Areas covered: This article overviews available literature on changes in the definition of severe dengue, pathogenesis of liver involvement in dengue, clinical manifestations, and predictors of mortality in severe dengue with liver involvement, impact of viral hepatitis co-infections and hepatotoxic drugs, and hemophagocytic lymphohistiocytosis.Expert commentary: Hepatitis is commonly seen in dengue however the degree of elevation of transaminases did not correlate well with severity of illness in observational studies, except in the elderly. The underlying pathogenesis of liver injury is still being elucidated and further studies are required to fully understand the cellular pathways. Acute or chronic viral hepatitis does not appear to affect dengue outcomes. Commonly used medications such as paracetamol and statins may influence dengue outcomes.
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Affiliation(s)
- Po Ying Chia
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Tun-Linn Thein
- National Centre for Infectious Diseases, Singapore, Singapore
| | - Sean Wei Xiang Ong
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
| | - David Chien Lye
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yee Sin Leo
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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Bhattacharya D, Angurana SK, Nallasamy K, Iyer R, Jayashree M. Severe Dengue and Associated Hemophagocytic Lymphohistiocytosis in PICU. Indian J Pediatr 2019; 86:1094-1098. [PMID: 31353429 DOI: 10.1007/s12098-019-03040-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/10/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To study the clinico-laboratory profile and outcome of children with severe dengue and dengue-associated hemophagocytic lymphohistiocytosis (HLH). METHODS In this retrospective study, 22 children with laboratory confirmed severe dengue admitted to pediatric intensive care unit (PICU) were enrolled. Clinical features, laboratory parameters, and outcome were noted and compared between cases fulfilling HLH-2004 criteria and those without HLH. RESULTS Median (IQR) age was 8 (5-10.3) y. Fever was present for mean (SD) duration of 5.3 (2.1) d. Vomiting, respiratory distress, pain abdomen and hepatomegaly were other clinical features. Thrombocytopenia, anemia and elevated serum transaminases were noted in 91%, 41% and 30% respectively; coagulopathy and hypoalbuminemia were seen in 36% each. Half (n = 11, 50%) had dengue shock syndrome. Acute respiratory distress syndrome (ARDS) (n = 7, 32%) and acute kidney injury (AKI) (n = 6, 28%) were other major organ dysfunctions. Mean (SD) duration of PICU stay was 3.6 (1.5) d with 13.6% mortality. HLH was noted in 7 (32%) cases at a median (IQR) hospital stay of 5 (2-8) d. Children with HLH had significantly higher Pediatric Index of Mortality 2 (PIM 2) score at admission and higher frequency of pain abdomen, anemia, hypoalbuminemia, elevated alanine aminotransferase (ALT) and ARDS. Length of PICU stay (5.1 vs. 2.9 d) and mortality (28.6% vs. 6.7%) were higher in HLH group, however the difference was not statistically significant. Steroids were used in 4 cases with HLH and all survived, whereas among 3 who did not receive steroids, 2 died (p = 0.23). CONCLUSIONS Severe dengue presents with life-threatening organ dysfunctions. HLH is increasingly recognized in dengue infection and maybe considered as a differential diagnosis in children with lower hemoglobin, hypoalbuminemia, elevated ALT and severe organ dysfunction.
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Affiliation(s)
- Deepanjan Bhattacharya
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Suresh Kumar Angurana
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Karthi Nallasamy
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India.
| | - Rajalakshmi Iyer
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
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Rajapakse S, Wattegama M, Weeratunga P, Sigera PC, Fernando SD. Beyond thrombocytopaenia, haemorrhage and shock: the expanded dengue syndrome. Pathog Glob Health 2018; 112:404-414. [PMID: 30507366 DOI: 10.1080/20477724.2018.1552645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Dengue infection classically presents with fever, thrombocytopaenia, and varying degrees of plasma leakage, giving rise to shock. However, a myriad of other manifestations, involving the cardiovascular system, the nervous system, the liver, the kidneys, the gut and the haematological system have been reported in dengue. This review summarizes these varied presentations.
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Affiliation(s)
- Senaka Rajapakse
- a Department of Clinical Medicine, Faculty of medicine , University of Colombo , Colombo , Sri Lanka
| | - Milanka Wattegama
- b Department of Endocrinology , North Colombo Teaching Hospital , Ragama , Sri Lanka
| | - Praveen Weeratunga
- a Department of Clinical Medicine, Faculty of medicine , University of Colombo , Colombo , Sri Lanka
| | - P Chathurani Sigera
- c Department of Parasitology, Faculty of medicine , University of Colombo , Colombo , Sri Lanka
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Incidence and Risk Factors for Developing Dengue-Associated Hemophagocytic Lymphohistiocytosis in Puerto Rico, 2008 - 2013. PLoS Negl Trop Dis 2016; 10:e0004939. [PMID: 27556807 PMCID: PMC4996422 DOI: 10.1371/journal.pntd.0004939] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/01/2016] [Indexed: 12/03/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal disorder characterized by fever, pancytopenia, hepatosplenomegaly, and increased serum ferritin. HLH is being increasingly reported as a complication of dengue, a common tropical acute febrile illness. Methodology/Principal Findings After a cluster of pediatric dengue-associated HLH patients was identified during the 2012–2013 dengue epidemic in Puerto Rico, active surveillance and a case-control investigation was conducted at four referral hospitals to determine the incidence of HLH in children and identify risk factors for HLH following dengue. Patients with dengue-associated HLH (cases) were matched by month of illness onset and admission hospital to dengue patients that did not develop HLH (controls). During 2008–2013, a total of 33 HLH patients were identified, of which 22 (67%) were associated with dengue and 1 died (dengue-associated HLH case-fatality rate: 4.5%). Two patients with dengue-associated HLH had illness onset in 2009, none had illness onset during the 2010 dengue epidemic, and 20 had illness onset during the 2012–2013 epidemic. Frequency of infection with either dengue virus (DENV)-1 or DENV-4 did not differ between cases and controls. Cases were younger than controls (median age: 1 vs. 13 years, p < 0.01), were hospitalized longer (18 vs. 5 days, p < 0.01), and were admitted more frequently to pediatric intensive care units (100% vs. 16%, p < 0.01). Cases had co-infection (18.2% vs. 4.5%, p = 0.04), recent influenza-like illness (54.5% vs. 25.0%, p = 0.01), and longer duration of fever (7 vs. 5 days; p < 0.01). Cases were more likely to have lymphadenopathy, hepatomegaly, splenomegaly, anemia, and elevated liver transaminases (p ≤ 0.02). Conclusions/Significance During this cluster of dengue-associated HLH cases that was temporally associated with the 2012–2013 epidemic, most patients with dengue-associated HLH were infants and had higher morbidity than dengue inpatients. Physicians throughout the tropics should be aware of HLH as a potential complication of dengue, particularly in patients with anemia and severe liver injury. Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal medical condition that can occur after a patient has an infection. While HLH is most commonly associated with Epstein-Barr virus infections, it has been reported as a complication of dengue, a common mosquito-borne, acute febrile illness. After a cluster of pediatric dengue-associated HLH patients was identified in Puerto Rico, active surveillance and a case-control investigation was conducted to determine the rate of HLH in children and identify risk factors for HLH following dengue. During 2008–2013, a total of 33 HLH patients were identified, of which 22 (67%) were associated with dengue and 1 died (dengue-associated HLH case-fatality rate: 4.5%). Most (91%) dengue-associated HLH patients had illness onset during the 2012–2013 epidemic, however, HLH was not found to be associated with a particular type of dengue virus. Dengue-associated HLH cases were younger than dengue inpatient controls, were hospitalized longer, and were admitted more frequently to the pediatric intensive care unit. Cases had longer duration of fever, and were more likely to have anemia, hepatomegaly and elevated liver transaminases than controls. Physicians in the tropics should be aware that HLH may complicate dengue, and they should evaluate dengue patients who develop anemia and severe liver injury.
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