|Year : 2017 | Volume
| Issue : 4 | Page : 129-133
Hematological changes among children with dengue fever in Saudi Arabia
Marwa H Abdel Hamed
Paediatric Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||05-Sep-2017|
|Date of Acceptance||02-Oct-2017|
|Date of Web Publication||9-Feb-2018|
Marwa H Abdel Hamed
Paediatric Department, Faculty of Medicine, Ain Shams University, Cairo, 11566
Source of Support: None, Conflict of Interest: None
Background Dengue fever is Vector born viral infections endanger billions of people. About 50 million cases of dengue infection every year all-over the whole world has been estimated by World Health Organization (WHO). DF occurs primarily in tropical areas around the world affecting both children and adults. It is endemic in certain cities of Saudi Arabia, such as Jeddah and Makkah. Dengue fever has nonspecific symptoms and signs, so laboratory confirmation of dengue infection is mandatory.
Objectives To assess hematological changes of patients with dengue fever in pediatric age group among Saudi children.
Design Descriptive retrospective study.
Patients and Methods All data were collected from the medical records of 90 children aged from 2 to 15 years who had diagnosed to have dengue fever in Jeddani Group Hospital. The presenting clinical features were collected and analyzed. The laboratory results analyzed were blood count including Hemoglobin level, hematocrit level, lecucocytic count and platelet count.
Results All 90 patients included in the study had both fever and myalgia, 2.2% of children had bleeding (epistaxis, bleeding gum). Mean±SD of Hemoglobin level was 10.82 ± 1.2 g/dl. Thrombocytopenia (platelets <150000/UL) was found in 74.45% of cases, leucopenia (<4000/UL) was detected in 66% of cases.
Conclusion Dengue fever is mosquito transmitted viral infection, it needs accurate physical examination and proper follows up of hematological changes, this will lead to decrease morbidity and mortality among children.
Keywords: dengue fever, leukocytes, platelets
|How to cite this article:|
Abdel Hamed MH. Hematological changes among children with dengue fever in Saudi Arabia. Egypt J Haematol 2017;42:129-33
| Introduction|| |
Dengue is considered a human arbovirus disease caused by virus of the Flaviviridae family, which is transmitted by the female mosquito of the Aedes aegypti . There are four serotypes of the dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4 .
Primary infection with certain serotype provides life-long lasting immunity to this serotype only but increases the severity later on .
The name ‘dengue’ is derived from ‘Ki dengapepo’ meaning a sudden seizure. It was also called ‘Break Bone Fever’ during Philadelphia epidemic in 1780 .
Dengue fever (DF) was first discovered in 1779 in Batavia, and a pandemic occurred in Philadelphia (USA), 1 year later .
WHO estimates 50–100 million cases of classic DF and more than 300000 cases of dengue hemorrhagic fever (DHF) each year, which leads to 24 000 deaths per year .
The clinical presentation of classic DF is characterized by the abrupt onset of headache, bone aches, myalgia, and high fever, in addition to arthralgia, retro-orbital pain, and hemorrhagic manifestations .
| Patients and methods|| |
This is a descriptive retrospective study. All needed data were collected from the medical records of 90 children aged from 2 to 15 years who were diagnosed as having DF in Jeddani Group Hospital (Jeddah, Saudi Arabia). They were diagnosed to have DF if they had positive serology result for dengue using the ELISA IgM captures method. Approval of the ethical committee of the hospital was acquired for conducting the study. Any child with fever, but seronegative for DF, were excluded from the study.
The exclusion criteria included children proved to have malaria, cancer, tuberculosis, HIV, and bacterial and parasitic illnesses, and those who were on any medications (antibiotics, antipyretics, anti-inflammatory) for the past 2 months.
Our patients were diagnosed with DF and DHF according to 2009 WHO classification criteria .
The criteria were designed to classify cases of severe dengue into three specific subcategories: severe vascular leakage, severe bleeding, and severe organ dysfunction. These criteria could allow clinicians to evaluate progression of disease or pathogenesis in a more focused way, allowing new fields of scientific research .
Hematological investigation data including complete blood counts using fully automated hematology analyzer and peripheral smear stained with Leishman stain were collected from all patient records or files. Moreover, serological investigation data were taken in such patients.
Hemoconcentration was seen as raised hemoglobin (Hb) or red blood corpuscles count. Leukopenia was considered if white blood cell (WBC) count was less than 4000×103/µl and thrombocytopenia was less than 150×103/µl. The data of our patients fulfilling mentioned inclusion and exclusion criteria were collected from case files and entered into the Microsoft Excel (Microsoft Corp., Redmond, WA, USA). All demographic data and clinical manifestations were categorized into frequency, whereas mean±SD for laboratory results.
| Results|| |
Children who had DF in this study included 51 (56.7%) males and 39 (43.3%) females. Their ages ranged from 2 to 15 years. The average age at presentation was 10.5±4.4 years ([Table 1]).
Patients in this study presented with various clinical features. All (100%) children presented with fever for around 2–5 days and also experienced myalgia, six (6.67%) patients only had skin rashes, 15 (16.67%) patients had retro-orbital pain, few cases complained of bleeding, three (3.34%) cases had hematuria, and only one (1.1%) case had epistaxis sorghum bleeding ([Table 2]).
|Table 2 Different clinical presentations of children with dengue fever (n=90)|
Click here to view
Regarding hospital stay, mean±SD of hospital stay was 5.35±1.7. All children were discharged from the hospital ([Table 1]).
All were subjected to investigations including complete blood count and serology tests for dengue.
Only those patients with positive serology result for dengue were included in the present study.
The most common hematological changes found were thrombocytopenia, leucopenia, and increased in differential count of WBC distribution.
The Hb levels ranged between 6.8 and 14.2 g/dl, with mean±SD of 10.82±1.2 g/dl. The lowest Hb level was 6.8 g/dl; however, the highest Hb value was 14.2 g/dl ([Table 3] and [Table 4]).
The hematocrit levels were raised in 40% of cases. The total WBC count was less than 4000×103/µl in 66% of cases ([Table 5]). Mean±SD of total leukocyte count was 3552.47±2152 ([Table 3]). The differential WBC count (monocytes, eosinophils, and basophils) was found to be raised in 54% of the cases.
Regarding platelets count, 74.45% of cases had platelet countless than 150 000/µl, of which 20% had platelet counts of 40 000–80 000/µl ([Table 6]).
| Discussion|| |
DF was first discovered in Jeddah in the form of a fatal case of DHF, but the first outbreak was in Jeddah (Saudi Arabia) in 1994 (http://www.cdc.gov/dengue/dengue…/Dengue) .
There are many risk factors that help spread of this virus such as travelling of some persons from endemic areas such as India, Pakistan, Yemen, and other tropical or subtropical regions, and also rain falling, increased humidity, and presence of water collection sites which help breeding of mosquitoes.
Early diagnosis based on laboratory investigations and management of DF is mandatory, and it should be a priority for not only patients but also for the entire public health.
Diagnosis of dengue virus infection based on clinical symptoms and signs is not reliable and should be confirmed by laboratory studies .
Our data showed sex differences regarding DF, with a male predominance. This may be because of young males being exposed to mosquitoes more than young females as they are more involved in outdoor activities. This is in agreement with many literature studies , and also Rashmi and Hamsaveena , who stated that 68% of the studied cases of dengue were in males, with male to female ratio of 1.6 : 1, and Arshad et al.  who found that males outnumbered females, but these results disagreed with the study done by Raimunda et al. .
The most common clinical feature of dengue in our study was high fever (100%). In other studies conducted by Avarebeel et al. , Achalkar  and Patel et al. , similar results were found. Moreover, Jakribettu et al. , stated that fever was found in 100% of cases. These results disagreed with previous studies where 85%  and 33%  of patients presented with fever.
In our study, myalgia was seen in 100% of case. This is near to the results of previous studies done by Pervin et al.  where they found 84% of infected cases had myalgia; on the contrary, Jakribettu et al.  showed that only 42% of cases had myalgia.
This difference in frequency of clinical presentations may be because of different viral serotypes and different age groups.
In this study, 5.45% of children experienced bleeding. This is consistent with Potts and Rothman  who observed increased frequency of hemorrhage, but this was in adult. However, Hammond et al.  reported that the frequencies of melena and hematemesis were significantly higher in children with dengue but not in adults.
The results of this work showed that mean±SD of Hb level was 10.82±1.2 g/dl, and lowest Hb level was 6.8 g/dl. This is similar to the results of Ramandeep et al.  who showed that patients with dengue had low Hb values compared with healthy controls, that is, Hb ranging from 5.4 to 12.7 g/dl in patients with dengue and 10.6–15.0 g/dl in healthy controls. These results disagree with Jakribettu et al.  who found that Hb levels were more in patients with DF owing to increased intravascular permeability especially in children who have more baseline microvascular permeability than adults, so they are more liable to DHF or dengue shock syndrome.
Leucopenia was detected in 66% of the children. This result is similar to other published results such as those by Kittigul et al. , Potts and Rothman , and Patel et al.  who stated that decrease in WBCs was present in cases with DF when compared with patients with other febrile illness, and this result also agrees with the study done by Arshad et al.  who reported that 49% of infected cases had leucopenia. However, in studies done by Rusmawati et al. , the incidence of leucopenia was less than 33.3%.
This could be explained that there is impairment of the proliferative responses of peripheral blood mononuclear cell to mitogen and recall antigen and to phytohemagglutinin stimulated T-cell responses of patients with dengue .
It was found that classic dengue began with leukocytosis, and leukopenia appeared later .
Thrombocytopenia was found in 74.45% of our cases, and this result is in agreement with other studies, especially on DHF ,,. Moreover, these findings are similar to Wilder-Smith et al. , who concluded that platelets count was less than 140×109/l and WBC count was less than 5×109/l, which are highly suggestive of DF. Similar findings were observed by Rashmi and Hamsaveena  who detected that platelets count was less than 150 000/µl in 80% of dengue cases, whereas Banerjee et al.  found that platelets count ranged between 40 000 and 100 000 cells/µl in 19% of cases with DF.
The cause of thrombocytopenia in DF may be because of both decreased platelets production owing to bone marrow suppression and increased platelets destruction in DHF, so low platelet count is used as one of the criteria for DF diagnosis . This is caused by the direct infection of the megakaryocytes by the virus itself and presence of antibodies against platelets . However, Deparis et al. , argued that these laboratory measures are not dengue specific in the early stages of the disease.
The inflammatory responses to dengue are caused by immune complex formation, complement activation and the release of cytokines into the circulation before the most serious forms of the disease. There are multiple mechanisms underlying the bleeding in DHF including vasculopathy, thrombopathies, and disseminated intravascular coagulopathy (DIC) .
Children are at a high risk of getting infected by DHF than adults because it has been suggested that baseline microvascular permeability in children is greater than that of adults .
Hemoconcentration was seen in more than 40% of the patients. A study carried out by Achalkar  showed hemoconcentration in more than 50% of the patients.
Thrombocytopenia (platelets<100 000/mm3) was seen in 74.45% of patients, which was similar to the studies by Avarebeel et al.  and Achalkar .
| Conclusion|| |
DF is a viral infection caused by transmission of the virus through mosquitoes, and accurate physical examination and proper follow-up of hematological changes are needed to decrease morbidity and mortality among children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]