Background: India experienced a massive outbreak of dengue fever in the 2012-2013 period and this outbreak shows significantly different distribution across India. It also envisaged the hidden weakness of prevention and control program of vector-borne diseases. Aim and Objective: This study was designed to characterize the clinical and demographical profiles of this outbreak in a tertiary-level hospital of greater Kolkata. Materials and Methods: A descriptive hospital-based observational study was conducted among diagnosed dengue fever patients admitted at a tertiary-level hospital during the dengue outbreak in the 2012-2013 period. The clinical, biochemical, and demographic data of those patients were collected and recorded in a planned structured format. Results: The data of a total 382 dengue patients were analyzed. Out of these 382 patients, 67.8% are males and 42.1% belongs to 20-40 years age group. The mean and median ages of the study group were 37.39 (±17.70) years and 35 years, respectively. The mean (±SD) duration of hospital staying was 4.9 (±1.90) days. Out of these patients, 19.4% had hemorrhagic rash throughout the body, 13.2% presented with hemorrhage, and 8.6% were comorbid with typhoid immunoglobulin M (IgM) positive. Clinical shock, peripheral edema, and pulmonary edema were documented in 6.3%, 2.6%, and 5.3% of the patients, respectively. Ultrasonography (USG) abdomen test revealed that 15% of the patients had thick-walled gallbladder, while 11.27% had ascites. Out of the 382 patients, 26.3% (101) presented with pleural effusion, and 10.5% patient’s platelet count went below 35,000. The alanine transaminase (ALT), alkaline phosphatase, and lipase level were abnormally increased in 82.7%, 17.1%, 29.6% patients, respectively. Conclusion: Suburban as well as rural area’s people, mainly the young males, were mostly affected in this outbreak. Enteric fever was found with comorbid infection among a few dengue patients. Some patients documented with deferent complications, which were managed by early diagnosis and supportive treatment.
Keywords: Complication, dengue fever, Kolkata
|How to cite this article:
Acharyya A, Ghosh K, Bhattacharyya A, Ghosh M, Chakraborty S, Ghosh S, Pal M. The dengue fever and its complication: A scenario in a tertiary-level hospital of greater Kolkata. Ann Trop Med Public Health 2016;9:92-6
|How to cite this URL:
Acharyya A, Ghosh K, Bhattacharyya A, Ghosh M, Chakraborty S, Ghosh S, Pal M. The dengue fever and its complication: A scenario in a tertiary-level hospital of greater Kolkata. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Aug 6];9:92-6. Available from: https://www.atmph.org/text.asp?2016/9/2/92/177375
Dengue fever is a vector-bone disease emerging and widely spreading throughout the world. It is an increasingly prevalent tropical arbovirus infection with significant morbidity and mortality.  Over 2.5 billion people, 40% of the world population, are at risk of dengue fever.  According to the National Vector Borne Diseases Control Programme (NVBDCP), the number of cases in India has intensified steadily, from 3,306 in 2001 to 50,222 in 2012; deaths have increased from 53 in 2001 to 242 in 2012.  In West Bengal, 3,306 confirmed dengue cases were reported from 1 January 2012 to 30 September 2012, of which nearly 2,000 cases were recorded from the Kolkata Metropolitan Corporation areas. 
Dengue fever is a recurrent major communicable life-threating disease along with malaria, chikungunya, and Japanese encephalitis in West Bengal. It was first documented in Kolkata (Calcutta) in the year 1824, and several outbreak occurred in this city during the years 1836, 1906, 1911, and 1972 (affecting 40% of the city people).  In India, dengue hemorrhagic fever (DHF) was first reported in Kolkata between 1963 and 1964.  Thereafter several outbreaks occurred in the Kolkata metropolitan city and in its adjoining areas. In 2012-2013, dengue fever outbreak spread in districts (mainly rural areas) nearest to Kolkata – Howrah, Medinipur, Hooghly, Burdwan, etc. The good transport system, increased movement of people from urban to rural areas, and environmental changes may be the main cause of increasing the number of dengue fever patients in rural area. This study was conducted to find the framework of demographic characteristics of the dengue fever patient and to describe the clinical and biochemical markers of changes that occurred during this time period.
|Materials and Methods|
An observational descriptive hospital-based study was conducted in the in patient department (IPD) of General Medicine and Pediatric Department of Sanjiban Hospital in Howrah district in the 2012-2013. A total of 602 dengue patients were admitted in this hospital among of them 382 patient’s preliminary blood tests were completed during the hospital stay time. The patients were admitted from the nearest area of Howrah, Hooghly, Midnapore, and Burdwan district. Febrile illness was associated with myalgia, arthralgia, headache, retro-orbital pain, rash, and hemorrhagic manifestations suggestive of dengue fever. Dengue fever (suspected dengue case) was defined as acute febrile illness of 2-7 days’ duration, with two or more of the following symptoms: Headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, or leukopenia. A confirmed case of dengue was also associated with one or more of the following: Supportive serology [reciprocal hemagglutination-inhibition antibody titer, comparable immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) titer] or positive monoclonal immunoglobulin M (IgM) antibody capture (MAC-ELISA) test in a serum specimen from the late acute or convalescent phase.  Clinically suspected dengue cases were tested with a rapid test kit such as NS1 antigen (nonstructural antigen 1 rapid diagnostic) test kit. All the blood tests were done at the Pathological Department of Sanjiban Hospital. The NS1 ELISA and IgM ELISA (MAC-ELISA) tests were recommended by the West Bengal government for the confirmation of dengue at public health laboratories at that time.
The patients were clinically examined and screened properly, and then were followed up every 12 h by the clinical assistant, register, and consultants. In each visit, the documentation was filled for each case. The preliminary investigation, such as complete hemogram, urea, creatinine, liver function tests, malaria dual antigen, typhoid IgM, chest X-ray, ECG, and along with serum amylase, lipase, ultrasound of abdomen and cerebrospinal fluid (CSF) study, were indicated.
The data were analyzed with Statistical Package for the Social Sciences (SPSS) software (version 11.5) (SPSS-Inc., Chicago, IL). Only descriptive statistic were performed with total number and frequency of clinical and biochemical data.
A total of 382 dengue patients admitted at Sanjiban Hospital who completed all the preliminary tests were only included in this observational study. According to the residence, 193 (50.5%), 115 (30.1%), 60 (15.7%), 8 (2.1%), and 2 (0.5%) patients were from Howrah, Purba Medinipur, Paschim Medinipur, Hooghly, and Burdwan district, respectively [Table 1]. A total of 308 (71%) patient were admitted in the year of 2012 and rest of the patients (74) were included in 2013. Among those patients, 259 (67.8%) were male and rest were female. The mean (±SD) and median ages of the patients were 37.39 (±17.70) years and 35 years, respectively [Table 2]. According to the age group, 42.1% (161/382) were in the 21-40 years age group, 25.7% (98/382) were in the 41-60 years age group, 19.1% (73/382) were in the 1-20 years age group, and only 13.1% (50/382) from the above 60 years age group. The age of patient varied from 1 year to 81 years [Table 1].
|Table 1: Distribution of demographic variables
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|Table 2: Central tendency of variables
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The mean (±SD) and median durations of hospital stay were 5 (±2) days and 5 days, respectively. The hospital bed occupancy range was 12 days; minimum 1 day and maximum was 13 days [Table 2].
The maximum patients have fever, headache, myalgia, and arthralgia. This study was concentrated on life-threating complication of dengue fever. It was reported that 19.4% (74) of the patients had hemorrhagic rash throughout the body and 13.2% (50) patients presented with hemorrhage. Gastrointestinal (GI) tract bleeding in form of melena was one of the frequently reported bleeding manifestation, while four cases were found with intracranial hemorrhage and they did not survived. Seven dengue patients (1.83%) were not survived in this time period at Sanjiban Hospital. A few cases of hematuria, epistaxis, disseminated intravascular coagulation (DIC), and gum bleeding were also reported. Only 6.3% (24) patients turned to clinically shock condition. Peripheral edema and pulmonary edema were found in 2.6% (10) and 5.3% (20) patients, respectively, among all dengue patients. They all survived by urgent standard intensive care unit (ICU) managements. Volume replacement and platelet transfusion (if serum platelet count <10,000) are the main management technique of dengue fever. A few patients with volume replacement therapy developed left ventricle function (LVF). But they were managed by standard ICU treatments. It was also very interesting, 8.6% (32) patients were also comorbid with typhoid IgM positive [Table 3].
|Table 3: Distribution of clinical markers
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USG report found that 15% (57/382) patients had thick-walled gallbladder, while 11.27% (43/382) had ascites. In total, 10% (39/382), 13% (50/382), 10% (39/382) patients had splenomegaly, hepatomegaly, and hepatosplenomegaly, respectively. No case of splenic rupture was found. By USG-guided examination, 26.3% (101/382) of the patients were found with pleural effusion [Table 3].
The mean (±SD) and median platelet counts at the time of admission were 1.45 (0.86) lakh and 1.4 lakh, respectively. The minimum and maximum platelet counts at the time of admission were 25,000 and 4,55,000, respectively [Table 2]. During hospital stay, the mean (±SD) and median value of least platelet count were 1.20 (0.80) lakh and 1.1 lakh, respectively. Total 36.9% (141) cases had platelet count between 36,000 and 1,00,000; while 10.5% (40) patients platelet count went below 35,000 [Table 2].
The alanine transaminase (ALT) and alkaline phosphatase were abnormally increased to 82.7% and 17.1%, respectively, among patients. It was observed that mean (±SD) and median values of ALT were 119.93 (±131.81) IU and 69 IU, respectively [Table 2]. One patient’s ALT increased to 700 IU. The mean (±SD) and median value of alkaline phosphatase were 110.47 (±138.87) IU and 76 IU, respectively. The maximum value of alkaline phosphatase was 1,089 IU (this patient was also diagnosed with cholelethiasis. Raised level of serum lipase was noticed among 29.6% (113) of the patients and it increased maximum upto 821 mg/dL [Table 2].
Dengue fever is one of the most rapidly emerging diseases of tropical and subtropical regions, affecting both urban and peri-urban areas. In 2012, India experienced a massive outbreak of dengue fever. Tamil Nadu reported the highest number of cases of dengue (9,249) in the country , followed by West Bengal that reported 6,067 cases. Other states that also reported increased number of dengue cases were Maharashtra, Kerala, Karnataka, Odisha, Delhi, Gujarat, Puducherry, Haryana, and Punjab.  The geographical distribution of the disease has greatly expanded and the number of cases has increased dramatically in the past 30 years.  Before this outbreak, the dengue cases were normally distributed in urban areas, but this outbreak was also widespread in semi-urban and village areas (near to Kolkata). This study finding is similar with Chatterjee et al.  from West Bengal and Ukey et al.  from Maharashtra study reports. This hospital’s catchment area were Howrah, Purbo Medinipur, Paschim Medinipur, Hooghly and Kolkata districts that reflect the limitation of this study, as it was not able to cover all the districts of West Bengal. All the patients were from the outskirts of Kolkata. Kolkata district has better medical service than any other district of West Bengal. So normally, the patients from Kolkata were getting better treatment in their own district and not need to admit in other district hospital.
Maximum patient were reported from the age group of 21-40 years, and male patients clearly outnumbered the females. Bondopadhya et al.,  Gupta et al.,  Chakravarti and Kumaria  also reported maximum cases in the age group 21-30 years with male dominance.
Fever, headache, myalgia, and arthralgia were the major symptoms of the dengue patients of current study. Additionally, 13.2% dengue patients developed bleeding manifestation and majority of bleeding occurred in GI tract. This current finding is on the track with Chatterjee et al.’s study. But higher (69%) bleeding manifestation was in found in Sharma et al.’s study conducted in Kerala. 
Very interestingly, 8.6% of patient had comorbid of typhoid fever. This finding reveals a new domain of research on typhoid diagnostic kit and association of dengue with typhoid fever as opportunistic infection to each other in this area. It may also reflect the suboptimum manifestation of typhoid fever in the population.
Abdominal tenderness, nausea, and intractable vomiting were frequently observed among dengue patients of this study. Among of them, 10% (39), 13% (50), and 10% (39) patients had splenomegaly, hepatomegaly, and hepatosplenomegaly, respectively. This current finding is concordance with different studies done in India,  Australia,  and Thailand. 
ALT and ALP levels were found to be high among foremost cases and those were increased to 82.7% and 17.1% among patients, respectively. Seventy-two percent of the patients were found with high ALT in Chatterjee et al.’s study that was done in Kolkata.  The current study is also on the track with Chatterjee et al. study regarding the high lipase level.  The recent study and Chatterjee et al.’s study found 29.6% and 35% persons with high lipase level during hospital duration, respectively.
The World Health Organization reported the case fatality rate of untreated dengue fever as 20% and in case of DHF and dengue shock syndrome (DSS) it can be as high as 44%.  But in the IPD of Sanjiban Hospital, this rate was just 1.83%, which is much better than the expectation. The early diagnosis, prompt treatment, availability and affordability of medicines, ICU, blood bank and health-care stuff may be the contributor of this outcome. But further regression model analysis is needed to prove this.
This study finding revealed that younger patients from urban as well as rural areas were predominantly affected with dengue fever. A few patients developed different comorbidities and this hospital setup sufficiently cope up with the burden of this dengue outbreak. Additionally, it was also observed that NS1 positivity had falsely directed to pointless panic and higher center referrals in case of this outbreak.
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[Table 1], [Table 2], [Table 3]