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Original Research (Original Article) 


Mohammad Alzahrani et al, 2020;4(3):695–699.

International Journal of Medicine in Developing Countries

Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia

Mohammed S Alzahrani1,2*, Riyadh M Alloqmani3, Mohammed H Alharbi3, Mohammed A Allihyani3, Mohammad M Alofi3, Abdulrahman M Alganawi3, Saleh M Alloqmani4, Sultan S Alam3, Ahmed A Alzahrani3

Correspondence to: Mohammad Alzahrani

*King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia.

Email: zahranim01 [at] ngha.med.sa

Full list of author information is available at the end of the article.

Received: 04 January 2020 | Accepted: 09 January 2020


ABSTRACT

Background:

Dengue fever (DF) affects approximately 390 million every year, of which 96 million manifests clinically. This study aims to explore the common clinical presentations and laboratory findings of DF with the outcome of hospitalized patients at King Abdulaziz medical city in Jeddah.


Methodology:

An observational cross-sectional study was carried which includes adults 18 years and older who were serologically confirmed the cases of DF and fulfilled the inclusion and exclusion criteria. Data were retrieved by using the electronic clinical information system (BestCare) and electronic laboratory information system (CERNER) at King Abdulaziz Medical City in Jeddah from Jan 2012 to Dec 2017.


Results:

A total of 110 patients were studied, 64 (58.2%) were males and 46 (41.8%) were females, 107 (97.3%) were Saudis and 3 (2.7%) patients were non-Saudis with a median age of 39-year old. Serology tests showed six different patterns of the 110 patients. The most common serology pattern was IgM and IgG positive. The most common clinical presentations were fever (107 patients 97.3%), headache (78 patients 70.9%), myalgia (69 patients 62.7%), vomiting (39 patients 35.5%), and nausea (25 patients 22.7%). The most common lab findings were thrombocytopenia (86 patients), leucopenia (86 patients), aspartate aminotransferase was elevated in 72 patients, and alanine aminotransferase (ALT) was elevated in 61 patients. 106 patients were diagnosed with DF, 3 patients diagnosed with hemorrhagic fever, and only 2 patients were diagnosed with dengue shock one of them was admitted to intensive care unit. Regarding the comorbidities, 30 patients were diabetic and 1 patient was pregnant.


Conclusion:

Fever and thrombocytopenia were the most common clinical and laboratory findings, while confusion and bleeding were the least findings. The overall mortality of DF was found low.


Keywords:

Dengue fever, dengue manifestation, dengue hemorrhagic, dengue shock, clinical profile, Non-structural protein 1.


Introduction

Dengue fever (DF), caused by a mosquito-transmitted flavivirus, is one of the world's major re-emerging infections [1]. DF is considered as a serious infection that costs a patient's own life [2]. DF burden on public health is incompletely defined. In 2013, a systematic review study conducted by Bhatt et al. [2] showed an estimation of 390 million dengue infection cases per year, whereas 96 million of those cases had clinical manifestations. This total number of dengue infections is three times more than the estimated burden reports by the world health organization (WHO) all over the world [2]. The reasons for the emergence of DF are complex and not fully understood; however, the demographic, social, and public health infrastructure changes during the past decades have contributed greatly to this phenomenon [3].

Dengue virus (DENDENV) is the causative agent of DF and dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) and consists of four distinct serotypes DEN-1, DEN-2, DEN-3, and DEN-4. (DENV1–4) [1]. It is a major cause of morbidity throughout tropical and subtropical regions of the world and continues to spread alarmingly. The risk of infection is increased more by rainfall, temperature, and grade of urbanization [13]. DENV infection in humans is asymptomatic but can cause a different variety of clinical manifestations to range from fever, headache, retro-orbital pain, myalgia, arthralgia, and rash to a more severe form of the disease which is DHF [2,4]. DHF is defined by an increase in vascular permeability (“plasma leakage”), hemorrhagic manifestations, and decreased platelet levels near the time of defervescence [5]. DHF can also progress to DSS, which is associated with hypotension or narrow pulse pressure and clinical signs of shock [6]. Although the different DENV serotypes can lead to varying clinical and epidemiologic profiles, defining precisely which clinical characteristics are associated with the distinct serotypes has been elusive. Several reports have indicated that DENV-2 and DENV-3 may cause more severe disease than the other serotypes and that DENV-4 is responsible for a milder illness [6,7]. Certain genotypes within particular serotypes have been associated with epidemics of DHF versus classic dengue, but no correlation with specific clinical features has been reported [8]. In Saudi Arabia, the dengue virus (DEN-2 serotype) was first isolated from a fatal case of DHF in Jeddah, a port city on the Red Sea, in 1994 [1]. Surveillance from 1994 to 2002 at a referral laboratory in Jeddah city reported 319 confirmed patients of dengue viral infection; most of whom (91%) were detected during the 1994 epidemic. DEN-2, DEN-1, and DEN-3 serotypes were identified in that order of frequency [9]. In 2004, Makkah city has the first outbreak of Dengue infection. The isolated serotypes were DENV-1 and DENV-3 [10]. During 2005–2006, an outbreak has occurred in Jeddah again. Later, a thorough plan was executed all over the endemic area of Dengue infection [11]. In 2008, an outbreak has occurred in Medina city with following isolated serotypes DENV-1 and DENV-2 [12]. A total of 3,350 cases were reported by the Saudi Ministry of Health at the year of 2009 [13]. The persistent recurrent infection of Dengue in Saudi Arabia was contributed by a growing grade of urbanization, international trading, and travel [14]. The common clinical manifestations of DF in Saudi Arabia were fever, myalgia. As well, the common Laboratory manifestations were thrombocytopenia and leukopenia in addition to aminotransferases elevation [15]. For more understanding of clinical and laboratory manifestations of DF, this study aims to represent the common clinical and laboratory features of the infection, in addition to the outcome of hospitalized patients at King Abdulaziz medical city in Jeddah, during the years from 2012 to 2017.


Subjects and Methods

This is a cross-sectional study where the data of patients infected with DF who fulfill the inclusion and exclusion criteria will be retrieved and included in this study. Datasheets were used to collect information from the electronic clinical information system (BestCare), electronic laboratory information system (CERNER), and the retrieved Data inpatient medical records department in the ACC building at King Abdulaziz Medical City (see Appendices). Datasheets were used to collect the information from the medical records. Data were retrieved regarding the date of the diagnosis, virus Serological findings, clinical presentation, lab findings, other comorbidity, and the outcome of the included patients. Data were included for any patients who have positive IgM, IgG, and non-structural protein-1 (NS1) serology tests for Dengue from January 2012 to December 2017. Also, age at the time of diagnosis was more than 18 years. We excluded patients who were pediatric age groups less than 18 at the time of diagnosis. The population of the study was 110 DF diagnosed patients who were selected through consecutive non-probability sampling techniques from Jan 2012 to Dec 2017. Frequency and percentage were presented for qualitative data. Also, median and range were measured for quantitative data. All statistical analysis was conducted through the SPSS program.


Results

Of 110 patients diagnosed with dengue, 64 (58.2%) were males and 46 (41.8%) were females, 107 (97.3%) were Saudis and 3 (2.7%) patients were Non-Saudis. Most of the patients were young adults age 18–64 years (84.5%) the median age was 39 years (range 18–86 years) (see Table 1).

Table 1. Gender, nationality, and age groups.

Gender Male 64 58.2%
Female 46 41.8%
Nationality Saudi 107 97.3%
Non-Saudi 3 2.7%
Age groups Adults 93 84.5%
Elderly 17 15.5%

Serology tests showed six different patterns of the 110 patients, there were 29 (26%) of 110 patients were showing a pattern of IgM positive and Both IgG and NS1 were negative. Also, a pattern of both IgM and IgG positive but NS1 negative in 34 (31%) patients. Moreover, eight patients showed a pattern of all 1gM, IgG, and NS1 positive. Furthermore, a pattern of IgM positive and IgG negative but NS1 was positive were showed in 17 (16%) and a pattern of IgM negative but both IgG and NS1 positive were showed in 4 (4%). Last, a pattern of both IgM and IgG negative but NS1 positive were showed in 18 (16%) patients (see Table 2).

The most common clinical symptoms were seen in 110 patients diagnosed with DF were fever (107 patients 97.3%), headache (78 patients 70.9%), myalgia (69 patients 62.7%), vomiting (39 patients 35.5%), and nausea (25 patients 22.7%). The least common symptoms were skin rash (12 patients 10.9%), Bleeding (7 patients 6.4%), confusion (2 patients 1.8%), and hypotension (2 patients 1.8%( one of them expressed bleeding and signs and symptoms of bleeding and shock (see Table 3). Of the 110 patients, 99 patients were admitted to the hospital. The median length of stay for those who were admitted was 3 days (range: 1–8 days). Only one patient of those who showed signs and symptoms of bleeding and shock was admitted to intensive care unit. The most common laboratory manifestations of the 110 patients diagnosed with DF were thrombocytopenia which was presented in 86 patients (78.2%), leucopenia was in presented 81 patients (73.6%), aspartate aminotransferase (AST) were presented in high level in 72 patients (66.1%) and alanine aminotransferase (ALT) were also presented in high level in 61 patients (56.5%) (see Table 4).

Most of the patients were diagnosed as DF (106 patients 96.4%). There were three (2.7%) patients diagnosed with dengue hemorrhagic fever and there was one patient (0.9%) diagnosed with dengue shock (see Table 5).

Table 2. Serology.

Pattern of serology IgM IgG NS1 Number of patients (%)
1 + - - 29 (26%)
2 + + - 34 (31%)
3 + + + 8 (7%)
4 + - + 17 (16%)
5 - + + 4 (7%)
6 - - + 18 (16%)
Total n / (%) 110 (100%)

Table 3. Clinical manifestation.

Fever 107 97.3%
Headache 78 70.9%
Myalgia 69 62.7%
Vomiting 39 35.5%
Nausea 25 22.7%
Rash 12 10.9%
Bleeding 7 6.4%
Confusion 2 1.8%
Hypotension 2 1.8%
Seizure 0 0.0%

Table 4. Laboratory manifestations.

Platelets Low 86 78.2%
WBC Low 81 73.6%
AST High 72 66.1%
ALT High 61 56.5%

Table 5. DF type.

DF Type Dengue fever 106 96.4%
Dengue hemorrhagic 3 2.7%
Dengue shock 1 0.9%

The morbidity of our patients included 30 patients (27.3%) with diabetes millets, one case was a pregnant woman. All patients who were diagnosed and received conservative management in King Abdulaziz Medical city from January 2012 to December 2017 were cured of DF.


Discussion

This study documents the common clinical and laboratory manifestation for Dengue Virus-infected patients confirmed by serological blood tests (IgM, IgG, and NS1 assays), Who presented to King Abdulaziz Medical City (KAMC) in Jeddah from January 2012 to December 2017. Previous studies from Saudi Arabia that had documented Dengue Virus infection in Jeddah [8], common clinical and laboratory manifestation in Makkah [10]. In KAMC, Department of Infectious Diseases had used NS1 assay in addition to IgM and IgG assays. NS1 assay approved to be a useful tool in the detection of an early Dengue Virus infection Kumarasamy et al. [16]. The clinical manifestations were comparable to some extent with what had been reported in the study was done in Makkah [10]. Dengue Hemorrhagic fever was found in three patients (2.7%) and Dengue Shock was found in one patient (0.9) in our study. Compared to 13 (8%), out of 160 patients having Dengue Hemorrhagic fever and 4 (3%) out of 160 were having Dengue Shock in the study was done in Makkah [10]. No case has developed seizure in our study compared to three cases developed tonic-clonic seizure reported in the study was done in Makkah. As reported the patients who had secondary Dengue virus infection will have more severe symptoms and a more severe prognosis than those who had a primary infection [17]. This variation in symptoms severity and disease prognosis of DF to DHF to furthermore DHS in our study compared to other studies is because most of our patients had primary Dengue virus infection. The laboratory manifestations were mostly similar to the studies was done in Jeddah and Makkah (Ayyub 'et al, 2006); [10]. The mortality was preventable with the introduction of conservative management as described in (WHO, 2011). The outcome of Dengue Virus-infected patients was similar to what reported in (Ayyub 'et al, 2006); [10] which was no mortality and All patient were cured.


Conclusion

Fever and thrombocytopenia were the most common clinical and laboratory findings, while confusion and bleeding are the least findings. The overall mortality of DF is low if treated appropriately. The awareness of health care professionals and the public regarding preventive strategies is essential to fight against this disease and to prevent hemorrhagic complications. Finally, several important limitations need to be considered. First, compared to other studies conducted in Saudi Arabia, this study has a smaller source population in one year. Second, the study was conducted at a national guard hospital which is mainly limited to military personnel.


List of Abbreviations

DF Dengue fever
WHO World health organization

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

The study was done after approval of national guard hospital. RYD-81-417780-141366.


Author details

Mohammed S Alzahrani1,2, Riyadh M Alloqmani3, Mohammed H Alharbi3, Mohammed A Allihyani3, Mohammad M Alofi3, Abdulrahman M Alganawi3, Saleh M Alloqmani4, Sultan S Alam3, Ahmed A Alzahrani3

  1. King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
  2. Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
  3. College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
  4. College of Medicine, Umm Al-Qura University, Makkah, Saudia Arabia

References

  1. Ahmed MM. Clinical profile of dengue fever infection in King Abdul Aziz University Hospital Saudi Arabia. J Infect Dev Ctries. 2010;4(08):503–10. https://doi.org/10.3855/jidc.1038
  2. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature. 2013;496(7446):504. https://doi.org/10.1038/nature12060
  3. Alhazmi SA, Khamis N, Abalkhail B, Muafaa S, Alturkstani A, Turkistani AM, et al. Knowledge, attitudes, and practices relating to dengue fever among high school students in Makkah, Saudi Arabia. Int J Med Sci Public Health. 2016;5:930–7. https://doi.org/10.5455/ijmsph.2016.15012016330
  4. Alves M, Fernandes P, Amaro F, Osório H, Luz T, Parreira P, et al. Clinical presentaion and laboratory findings for the first autochthonous cases of Dengue fever in Madeira island, Portugal, 2012. Euro Surveill. 2013;18(6):pii:20398.
  5. El-Gilany A-H, Eldeib A, Hammad S. Clinico-epidemiological features of dengue fever in Saudi Arabia. Asian Pac J Trop Med. 2010;3(3):220–3. https://doi.org/10.1016/S1995-7645(10)60013-2
  6. Kalakatawi MH, Kalakatawi MM, Nasser HH, Elrefae NM. Atypical dengue meningitis in Makkah, Saudi Arabia. Saudi J Health Sci. 2012;1(3):162. https://doi.org/10.4103/2278-0521.106088
  7. Zailayee A, Ismaeel A, Almahmeed A, Azhar E. Dengue virus infection in the western region of Saudi Arabia. Int J Infect Dis. 2008;12:328–9. https://doi.org/10.1016/j.ijid.2008.05.879
  8. Zaki A, Perera D, Jahan SS, Cardosa MJ. Phylogeny of dengue viruses circulating in Jeddah, Saudi Arabia: 1994 to 2006. Trop Med Int Health. 2008;13(4):584–92. https://doi.org/10.1111/j.1365-3156.2008.02037.x
  9. Jamjoom GA, Azhar EI, Kao MA, Radadi RM. Seroepidemiology of asymptomatic dengue virus infection in Jeddah, Saudi Arabia. Virol Res TreaTmenT. 2016;7:1. https://doi.org/10.4137/VRT.S34187
  10. Khan NA, Azhar EI, El-Fiky S, Madani HH, Abuljadial MA, Ashshi AM, et al. Clinical profile and outcome of hospitalized patients during first outbreak of dengue in Makkah, Saudi Arabia. Acta Trop. 2008;105(1):39–44. https://doi.org/10.1016/j.actatropica.2007.09.005
  11. Ministry of Health: Department of Statistics. Health statistical year book 2007. Riyadh, KSA: Saudi Ministry of Health.
  12. El-Badry AA, El-Beshbishy HA, Al-Ali KH, Al-Hejin AM, El-Sayed WS. Molecular and seroprevalence of imported dengue virus infection in Al-Madinah, Saudi Arabia. Comp Clin Pathol. 2014;23(4):861–8.
  13. Ministry of Health: Department of Statistics. Health statistical year book 2009. Riyadh, KSA: Saudi Ministry of Health. https://doi.org/10.1007/s00580-013-1704-x
  14. Egger JR, Ooi EE, Kelly DW, Woolhouse ME, Davies CR, Coleman PG. Reconstructing historical changes in the force of infection of dengue fever in Singapore: implications for surveillance and control. Bull World Health Organ. 2008;86(3):187–96. https://doi.org/10.2471/BLT.07.040170
  15. Alhaeli A, Bahkali S, Ali A, Househ MS, El-Metwally AA. The epidemiology of Dengue fever in Saudi Arabia: a systematic review. J Infect Public Health. 2016;9(2):
    117–24.
  16. Kumarasamy V, Wahab AA, Chua SK, Hassan Z, Mohamad M, Chua KB. Evaluation of a commercial dengue NS1 antigen-capture ELISA for laboratory diagnosis of acute dengue virus infection. J Virol Methods. 2007;140(1–2):75–9. https://doi.org/10.1016/j.jviromet.2006.11.001
  17. Thomas L, Verlaeten O, Cabié A, Kaidomar S, Moravie V, Martial J, et al. Influence of the dengue serotype, previous dengue infection, and plasma viral load on clinical presentation and outcome during a dengue-2 and dengue-4 co-epidemic. Am J Trop Med Hygiene. 2008;78(6):990–8. https://doi.org/10.4269/ajtmh.2008.78.990


How to Cite this Article
Pubmed Style

Alzahrani MS, Alloqmani RM, Alharbi MH, Allihyani MA, Alofi MM, Alganawi AM, Alloqmani SM, Alam SS, Alzahrani AA. Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia. IJMDC. 2020; 4(3): 695-699. doi:10.24911/IJMDC.51-1577581131


Web Style

Alzahrani MS, Alloqmani RM, Alharbi MH, Allihyani MA, Alofi MM, Alganawi AM, Alloqmani SM, Alam SS, Alzahrani AA. Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia. http://www.ijmdc.com/?mno=79806 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1577581131


AMA (American Medical Association) Style

Alzahrani MS, Alloqmani RM, Alharbi MH, Allihyani MA, Alofi MM, Alganawi AM, Alloqmani SM, Alam SS, Alzahrani AA. Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia. IJMDC. 2020; 4(3): 695-699. doi:10.24911/IJMDC.51-1577581131



Vancouver/ICMJE Style

Alzahrani MS, Alloqmani RM, Alharbi MH, Allihyani MA, Alofi MM, Alganawi AM, Alloqmani SM, Alam SS, Alzahrani AA. Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia. IJMDC. (2020), [cited March 29, 2020]; 4(3): 695-699. doi:10.24911/IJMDC.51-1577581131



Harvard Style

Alzahrani, M. S., Alloqmani, . R. M., Alharbi, . M. H., Allihyani, . M. A., Alofi, . M. M., Alganawi, . A. M., Alloqmani, . S. M., Alam, . S. S. & Alzahrani, . A. A. (2020) Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia. IJMDC, 4 (3), 695-699. doi:10.24911/IJMDC.51-1577581131



Turabian Style

Alzahrani, Mohammed S, Riyadh M Alloqmani, Mohammed H Alharbi, Mohammed A Allihyani, Mohammad M Alofi, Abdulrahman M Alganawi, Saleh M Alloqmani, Sultan S Alam, and Ahmed A Alzahrani. 2020. Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 695-699. doi:10.24911/IJMDC.51-1577581131



Chicago Style

Alzahrani, Mohammed S, Riyadh M Alloqmani, Mohammed H Alharbi, Mohammed A Allihyani, Mohammad M Alofi, Abdulrahman M Alganawi, Saleh M Alloqmani, Sultan S Alam, and Ahmed A Alzahrani. "Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia." International Journal of Medicine in Developing Countries 4 (2020), 695-699. doi:10.24911/IJMDC.51-1577581131



MLA (The Modern Language Association) Style

Alzahrani, Mohammed S, Riyadh M Alloqmani, Mohammed H Alharbi, Mohammed A Allihyani, Mohammad M Alofi, Abdulrahman M Alganawi, Saleh M Alloqmani, Sultan S Alam, and Ahmed A Alzahrani. "Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia." International Journal of Medicine in Developing Countries 4.3 (2020), 695-699. Print. doi:10.24911/IJMDC.51-1577581131



APA (American Psychological Association) Style

Alzahrani, M. S., Alloqmani, . R. M., Alharbi, . M. H., Allihyani, . M. A., Alofi, . M. M., Alganawi, . A. M., Alloqmani, . S. M., Alam, . S. S. & Alzahrani, . A. A. (2020) Clinical and laboratory manifestations of dengue fever with the outcome of the hospitalized patients at King Abdulaziz Medical City in Jeddah, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 695-699. doi:10.24911/IJMDC.51-1577581131