Gall Bladder Wall Thickening in Dengue Fever - Aid in Labelling Dengue Hemorrhagic Fever and a Marker of Severity

Evaluation of remote radiologist-interpreted point-of-care ultrasound for suspected dengue patients in a primary health care facility in Colombia

BACKGROUND

Early identification of plasma leakage may guide treatment decisions in dengue patients. This study evaluated the value of point-of-care ultrasound (POCUS) to detect plasma leakage and predict hospitalization or referral to a higher level of care in suspected dengue patients under routine conditions at a primary care facility in Colombia.

METHODS

We conducted a cohort study between April 2019 and March 2020 in a primary care hospital in Cali, Colombia. We prospectively included and followed 178 patients who were at least 2 years old with fever of less than 10 days and clinician-suspected dengue. A trained general practitioner performed a standardized POCUS protocol. Images were quality-rated and overread by an expert radiologist, and her results and those of the general practitioner were compared using the Kappa index. Logistic regression was used to identify factors associated with plasma leakage at enrollment and explore its prognostic value regarding hospital admission or referral to a higher level of care.

RESULTS

Half (49.6%) POCUS images were of suitable quality to be interpreted. The proportion of plasma leakage reported by the radiologist was 85.1% (95% CI: 78.6-90.2%) and 47.2% by the study physician (Kappa = 0.25, 95% CI: 0.15-0.35). The most frequent ultrasound findings were ascites (hepatorenal 87.2%, splenorenal 64%, or pelvic 21.8%) and gallbladder wall thickening (10.5%). Plasma leakage was higher in subjects with thrombocytopenia (aOR = 4, 95% CI: 1.3-12.1) and lower in patients 30-59 years old (aOR = 0.1, 95% CI: 0.0-0.4) than in those 18 years old or younger. POCUS evidence of plasma leakage (aOR = 8.2, 95% CI: 2.2-29.9), thrombocytopenia (aOR = 6.3, 95% CI: 2.4-16.0) and pulse pressure (aOR = 1.1, 95% CI: 1.07-1.2) were associated with hospital admission or referral to a higher level of care.

CONCLUSIONS

Ultrasound is useful to detect plasma leakage in primary care and, challenges remain to guarantee high-quality images and diagnostic accuracy, for which a standardized dengue POCUS protocol and training program is needed.

Predictive Factors for the Complications of Dengue Fever in Children: A Retrospective Analysis

Background and objective Dengue fever (DF) and its complications - dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) - are major public health problems in Southeast Asia. Predicting the development of DHF and DSS using hematological parameters and ultrasonic signs of vascular leakage will help in reducing morbidity and mortality associated with these diseases. Hence, this study aimed to test the association of platelets and packed cell volume (PCV) on day one (D1) of admission with gallbladder wall thickness (GWT) and ascites, which herald the onset of DHF and DSS. Methods The electronic health records of 52 pediatric patients admitted during a mini-outbreak were analyzed to assess platelets and PCV on D1, laboratory and ultrasonography findings, and outcomes. Correlations between D1 hematological parameters and GWT and ascites were tested. Results There was a positive correlation between GWT of more than 5 mm and ascites. However, there was no significant correlation of platelets and PCV on D1 with either GWT or ascites and consequently DHF or DSS. All the patients responded to fluid, blood, and supportive therapy. There were no mortalities. Conclusion Patients who develop GWT after DF are at an increased risk of developing ascites that deteriorate to DHF and DSS. D1 platelets and PCV are not reliable indicators for predicting the progression or worsening of the disease in the pediatric population.

Plasma leakage in dengue: a systematic review of prospective observational studies

Plasma leakage is a precursor to life-threatening complications of dengue, but this group is poorly defined and not often reported in literature. Patients with Dengue haemorrhagic fever (DHF) as defined in the 1997 World Health Organization classification are often reported, and they all have plasma leakage, but some patients with plasma leakage do not meet the definition of DHF. The study aims to estimate the frequency of plasma leakage and DHF (as a surrogate of plasma leakage) in dengue and its variations based on virus serotype, geography, patient gender and pre-existing immunity to dengue. PUBMED, Scopus, EMBASE, CINAHL and Web of Science were searched for prospective observational studies reporting on plasma leakage or DHF. Quality of data was assessed using the NIH quality assessment tool for cohort studies. Forty-three studies that recruited 15,794 confirmed dengue patients were eligible. Cumulative frequency of plasma leakage was 36.8% (15 studies, 1642/4462, 95% CI 35.4-38.2%), but surprisingly the estimated cumulative frequency of DHF was higher (45.7%, 32 studies, 4758/10417, 95% CI 44.7-46.6%), indicating that current medical literature over-reports DHF or under-reports plasma leakage. Therefore, a reliable estimate for the proportion of dengue patients developing plasma leakage cannot be derived from existing medical literature even after applying rigorous inclusion criteria to select homogenous studies. Plasma leakage is an important marker of "at-risk" dengue patients and standardizing its definition, diagnosis and reporting should be a priority in research and global policy.

Predictive analysis on gall bladder wall thickness as a marker for bleeding risk and need of transfusion in dengue patients

Increased gallbladder wall thickening (GBWT) is one manifestation of increased capillary permeability caused by severe dengue. This study was carried out to link the severity of GBWT with the bleeding risk and the need for transfusion. It was conducted retrospectively including all the patients with a diagnosis of dengue infection either via Dengue nonstructural protein-1 (NS-1) antigen or IgM antibody. Pearson's correlation, linear regression and receiver operating characteristic (ROC) curves were used for predictive analysis of GBWT with event of bleeding and need for transfusion of platelets during the hospital stay. A total of 177 participants met the inclusion criteria with a mean age of 33.17 ± 13.63 years. Mean GBWT was found to be 0.37 ± 0.15 cm, with 46.3% of patients had a thickness greater than 0.30 cm. A total of 16 patients were documented with bleeding events out of which 7.3% had minor bleeding and 1.7% had a major bleeding event. Linear regression analysis showed increased GBWT was found associated with decreased platelet count on admission (p=0.002) and lowest platelet counts (p=0.004). GBWT was found predictive of bleeding event and transfusion of platelets at higher sensitivity and specificity than platelet count on admission and lowest platelet counts.