Relative frequency of acute pancreatitis from dengue outbreaks as a late complication, in Egypt

Abstract

Patients with dengue virus infection have a different symptoms range from asymptomatic to sever form depending on primary and secondary immune status of host, infecting genotype and patient’s age. The current study aimed to describe the clinical and laboratory profile of dengue fever outbreak and acute pancreatitis as a late complication, in Egypt, as two case reports only were available in literature regarding this issue. This prospective cohort study was carried out on 100 patients confirmed to have dengue disease out of 200 clinically suspected patients. Clinical, laboratory (serology for dengue specific IgM, real-time PCR for dengue virus, serum amylase and lipase) and abdominal multi-slice CT were done to all included patients. All patients presented with fever, headache and fatigue, which are the main clinical manifestations of dengue fever. The mean age of studied patients was 40.34 ± 15.74 years. Thirteen patients (13%), with their mean age 44.57 ± 11.53, presented after 3 months with typical clinical, laboratory and radiological manifestations of acute pancreatitis with positive serum dengue virus IgM, antibodies and negative serum dengue virus PCR. So, acute pancreatitis as a late complication of dengue fever disease should be keep in mind for its early diagnosis and management, thus minimize the morbidity and mortality from dengue fever.

Introduction

Dengue fever is widely spreading mosquito-borne viral disease. In the last years, its incidence showed marked increase with appearance of the disease in new countries in both urban and rural areas [28]. Frequent, large sized dengue outbreaks were existed in Africa as far back as 1926 [4]. In October 2015, an outbreak of dengue fever in Egypt in Dayrout discrete of Assiut governorate (http://www.who.int/csr/don/12-november-2015-dengue/en/), where 235 cases admitted due to acute febrile illness, to Dayrout Fever Hospital, with no fatalities or complications [1]. In October 2017, dengue fever cases were reported by Egypt’s Ministry of Health in both the Upper Egypt’s Qena governorate and in Red Sea City of Qusair, Egypt (http://english.ahram.org.eg/News/278071.aspx) [1].

Dengue virus (DEN) is a single-stranded RNA Flavivirus, have four serotypes (DEN-1 to -4) [19]. Dengue virus transmitted to humans by the bites of infected female Aedes mosquitoes. Several species of Aedes mosquitoes were responsible for dengue outbreaks includes: Aedes aegypti, Aedes albopictus, Aedes polynesiensis and several species of the Aedes scutellaris complex. Each species of these mosquitoes has different ecology, behaviour and geographical distribution [29].

After the incubation period, the illness has three phases: febrile, critical and recovery phase [23]. The febrile phase usually continue from 2 days to 1 week and often associated with facial flushing, skin erythema, generalized body ache, myalgia, arthralgia, Anorexia, nausea and vomiting, tender hepatomegaly, progressive decrease in total leucocytic count, positive tourniquet test and headache [13]. Mild bleeding tendency as petechiae and mucosal membrane bleeding may also occur, however, uncommonly massive vaginal bleeding and bleeding from gastrointestinal tract may occur [3].

During the acute phase of dengue, the laboratory diagnosis can be performed by detection of the antigen using ELISA or real time-PCR, while during the recovery, diagnosis can be approached by detection of IgM using ELISA method [15].

Acute pancreatitis is a common cause of acute abdomen; however, acute pancreatitis due to infective causes is relatively uncommon. In addition, pathogenesis of pancreatitis following viral infections remains unknown [5]. So, the current study aimed to describe one of the rare complications of dengue fever which is, acute pancreatitis, and to identify the relative frequency, the clinical profile and laboratory findings of those patients.

Materials and methods

Study design and participants

This prospective cohort study was carried out on 100 out of 200 patients with clinical suspicion, proved to have dengue fever, recruited from El-Kosier country, Red-Sea Government whom referred to outpatient clinic of Tropical Medicine & Gastroenterology department, Qena University Hospital. The study period was from October 1, 2017, to April 1, 2018. All enrollees gave written informed consents. The study has been approved by the Ethics committee of Faculty of Medicine-South Valley University-Egypt and was done in accordance with the Declaration of Helsinki.

All patients, at any age, presented with fever, headache and fatigue with or without development of acute severe boring upper abdominal pain radiating to the back were included in the study, after obtaining an informed written consent. Those who proved to have concurrent viral, bacterial or parasitic infections were excluded.

The diagnosis of dengue virus infection was confirmed by combination of clinical data and laboratory dengue virus RT-PCR. Patients were followed up 3 months later and those with acute pancreatitis were diagnosed by clinical picture, radiological, laboratory findings and Dengue-specific IgM antibodies.

 Biochemical and molecular assays and radiological workup

Sampling

We obtained 10 ml of venous blood under complete aseptic precautions using one EDTA containing vacutainer (for CBC) tube and 2 plane vacutainer tubes. The plane tubes were centrifuged after clotting and the sera were isolated aseptically into two sterile tubes, one used for the chemical investigations and serological tests and another one kept at − 80 C until the time of RT PCR assay.

Complete blood count (CBC) was done using Celtac hematology analyzer (Nihon Kohden, Japan). The liver function tests (Bilirubin, AST, ALT and albumin) were performed by BT 1500 full automatic chemistry analyzer (Biotechnica, Italy). Colorimetric assays of serum amylase and lipase were performed by a spectrophotometer (Chem-7, Erba Diagnostics Mannheim GmbH, Germany), using colorimetric assay kits supplied by Spectrum Diagnostics, Egypt with their catalog numbers ( 219 001-D and 281 001 respectively). 

Dengue virus RT-PCR

RNA extraction was done using QIAamp RNA extraction kit (QIAGEN) and according to the pamphlet of the kit. Real time PCR (Applied Biosystem) detection was done using RealStar^® Dengue RT-PCR Kit 2.0 (altona Diagnostics, Germany) and according to the included pamphlet. As regard programming and setup of the basic data we used the manual of the step one instrument with technical support. The procedure used two fluorescent detector dyes, FAM™ and JOE™ dyes. The FAM dye detects the Dengue virus RNA and the JOE dye detected in the negative control. The results then were expressed qualitatively as positive, negative or invalid (the invalid result when both dyes were not detected.

Serological test

Dengue virus IgM was estimated using Human anti Dengue virus IgM ELISA kit (Abcan, United Kingdom) and according the pamphlet of the kit. The assays were done using microplate ELISA reader (EMR-500, Labomed,Inc, USA).

Abdominal multi-slice CT (MSCT)

After insertion of 18 gaugue cannula and using automatic injector (Medrad, Vistron injector system, USA). Triphasic CT of the abdomin was performed to all patients. Contiguous 5 mm-thick axial CT scans were obtained with (Aquilion 64; Toshiba Medical Systems Corporation, Otawara, Japan), Unenhanced images were acquired, as well as dual-phase-contrast-enhanced images using power injection of 100–150 mL of Omnipaque 350 mg I/mL. The abdomin was scanned three time, first at 20 s (arterial phase), second at 60 s (portal phase) following the initiation of contrast material injection.

Statistical analysis

Data were analyzed using IBM SPSS Statistics for Windows version 22. Quantitative data were expressed as mean ± standard deviation. Qualitative data were expressed as number and percentage.

Results

Out of 200 patients with positive clinical criteria, only 100 patients have been proved to have dengue viral infection by positive RT-PCR, upon whom the study has been conducted.

Their mean age was 40.34 years ± 15.74 SD, with 51 (51%) males and 49 (49%) females, with female to male ratio 1:1.04. The presenting clinical manifestations and their frequencies were shown in (Table 1). With fever, headache and fatigue were the main symptoms, complained by all patients (100%).

Table 1.

Demographic and clinical data, at presentation, of patients with dengue fever

Variables	N. % (n = 100)
Number	100
Age (years) (Mean ± SD)	40.34 ± 15.74
Sex (N. %)
Male	51 (51%)
Female	49 (49%)
Presenting clinical manifestations (N. %)
Fever	100 (100%)
Headache	100 (100%)
Fatigue	100 (100%)
Arthralgia	95 (95%)
Myalgia	94 (94%)
Retro-orbital pain	92 (92%)
Nausea	52 (52%)
Vomiting	26 (26%)
Diarrhea	11 (11%)
Rash	2 (2%)
Bleeding tendency	1 (1%)
Hepatomegaly	9 (9%)
Splenomegaly	10 (10%)
Palpable lymph nodes	3 (3%)

Regarding arthralgia, myalgia, retro-orbital pain, and nausea, they were detected in 95%, 94%, 92% and 52%, of patients respectively. While vomiting, diarrhea and rash (in the form of small petechiae or maculopapular) were found in 26%, 11% and 2% of patients respectively. With the bleeding tendency was the least presenting symptom (1%) found in one patient only who presented with bleeding gum and unilateral epistaxis. Tender hepatomegaly was frequent in 9(9%) patients and 10 (10%) patients showed mild splenomegaly, while lymphadenopathy was frequent in 3 (3%) patients (Table 1).

As regards the laboratory findings of the included patients with dengue infection, 20(20%) patients showed raised AST, 33(33%) patients showed within twofolds raised ALT and 6(6%) patients showed raised serum total bilirubin (Table 2).

Table 2.

Frequency of abnormal laboratory parameters of the include patients with dengue infection

Abnormal laboratory parameters	N. % (n = 100)
Liver function parameters
AST (u/l) > 45 IU/l	20 (20%)
ALT (u/l) > 55 IU/l	33 (33%)
S. total bilirubin >  2 mg/dl	6 (6%)
Complete blood count parameters
Anemia (Hemoglobin < 11 g/dl)	28 (28%)
Leucopenia (WBCs < 4000/mm3)	3 (3%)
Thrombocytopenia (Platelets < 150/mm3)	22 (22%)

Regarding complete blood count parameters, 28 (28%) patients showed mild anemia, 22 patients (22%) patients presented with thrombocytopenia, 3 (3%), patients presented with leucopenia (Table 2).

The relative frequency of patients with dengue viral infection and presented by pancreatitis as a late complication were 13% of the included patients, 10 (10%) of cases were diagnosed as having mild focal acute pancreatitis and the remaining 3 (3%) have severe acute pancreatitis). Males were 7 (54%) and 6 (46%) were females with their mean age 44.57 ± 11.53, presented after 3 months with typical clinical and laboratory manifestations of acute pancreatitis with their mean serum amylase and lipase 417.09 ± 85.53 and 419.96 ± 59.71 respectively together with positive serum dengue virus IgM antibodies and undetectable viremia by dengue virus PCR (Table 3).

Table 3.

Demographic and laboratory data of patients with dengue viral infection and complicated by late onset pancreatitis

Variables	N. % (n = 13)
Sex
Male	7 (54%)
Female	6 (46%)
Positive IgM specific for dengue viral infection	13 (100%)
Raised serum amylase >  600 U/l	13 (100%)
Raised serum lipase >  550 U/l	13 (100%)

Their abdominal CT findings were in the form of focal or diffuse focal pancreatic enlargement with changes in density due to edema. Obscuring of the pancreatic margins due to inflammation, retroperitoneal fat stranding, necrosis of pancreatic parenchyma and abscess formation (Fig. 1).

Fig. 1.

Abdominal MSCT with picture of acute pancreatitis, a showed enlarged pancreas; b showed fluid in lesser sac with necrosis of the body and tail (a and b showed picture of severe acute pancreatitis); c showed focal hypodense area at pancreatic head; d showed minimal fluid at lesser sac (c and d represent picture of focal mild acute pancreatitis)

Discussion

Dengue infection is a public health problem in both developed and developing countries [30].

The current study describes the clinical presentations, laboratory data and outcome of dengue fever outbreak which has been appeared in Red-sea governorate, Egypt. The mean age of our included patients was 40.34 years ± 15.74. This come in agreement with Mawahib et al. study in which all patients were more than 18 years old with 51.7% were young and 46.3% were old patients [7]. Also Azhar et al. have reported that age group of 21–30 years had the prevalence of 29.8% and age group of 31 to above 61 year contributes to 37.1% of all included cases [2]. A slight male predominance has been noticed in our study. This comes in agreement with Anjali et al. who found in their study male to female ratio 1.33:1 [20]. Also all patients included in study of Khan et al. were males [16]. At the same time Mawahib et al. study on 701 randomly selected patients from 10 localities in Sudan found that 45% of patients were females and 49.4% were males [7].

In this study, all our included patients were presented with fever, headache and fatigue with more than 90% of patients presented with arthralgia, myalgia and retro-orbital pain and more than half of patients presented with nausea. This come in agreement with that reported by WHO [31], that consider fever with flushed face, headache, retro-orbital pain, myalgia, arthralgia and anorexia were typical symptoms of non-complicated dengue fever. Also, Shah and Jainl [24], reported similar findings. Opposite to our results Anjali et al. found in their study on 196 children patients (one to 5 years old) that moderate fever was reported in (54%) of patients, myalgia in (36%) and headache in (34.6%) [20]. This can be explained by age effect on disease severity and presentation.

In our study vomiting, diarrhea, rash and bleeding tendency were less frequent. With our results, Ramos et al. reported similar findings [22]. Against our results Khan et al. [16], and Singh et al. [25], they reported higher frequency of vomiting, hemorrhagic manifestations in the form of (gum bleeding, epistaxis, hematemesis and melena) and skin rashes in their patients. In our opinion, it may be related to infection with another more virulent genotype of dengue virus.

As regard the frequency of hepatomegaly, splenomegaly and lymphadenopathy detected in our patients at time of presentation, this come in agreement with Singh et al. reported hepatomegaly in 10% and splenomegaly 5% of their cases respectively [25]. Opposite to our results, Anjali et al. noticed in their study on 196 children patients, hepatomegaly in (46%), ascites in (28%) and jaundice in (4%) of their included patients [20]. This can be explained by effect of age on disease severity as the younger the age at presentation, the more the Dengue disease severity.

In the current study, raised ALT was more frequent than raised AST and total bilirubin. With our results, Shilpi et al. reported in their study that no one of patients with dengue fever without warning sign develop raised transaminases (ALT, AST) or raised bilirubin, however 15.9% patients who have dengue fever with warning signs develop hyperbilirubinemia with total bilirubin > 3 mg/dl and without elevation in liver enzymes [10].Additionally, Shah and Jain [24], reported similar findings.

Opposite to our results, Souza et al. [26], and Trung et al. [27], who found in their studies raised AST levels was more frequent than the raised ALT frequency in their included patients. As regard hyperbilirubinemia, in Souza et al. [26], no patients presented with raised bilirubin, while Trung et al. [27], found raised bilirubin in 1.7% of patients. This can be related to dynamic change in AST and ALT levels during the course of disease where AST peaked at the 6th day of illness,while ALT reach its maximum level at the 7th day followed by rapid decrease in AST and ALT levels [8]. In addition, infection by different genotype may be responsible.

In this study as regard abnormality detected in the complete blood count at time of presentation, the relative frequencies of anemia, thrombocytopenia and leucopenia were similar to those of Shah and Jain [24] and Jain et al. [11], studies. Also in the studies done by Shilpi et al. [10], and Lin et al. [18], leucopenia was reported in 20.1% and 56.6% of patients respectively, at the same time 71.1% and 62.6% of patients have thrombocytopenia respectively.

The pathogenesis of pancreatic disease in dengue is unknown. Direct invasion of pancreatic tissues by the virus itself or an autoimmune mechanism to pancreatic cells leads to development of inflammation, damage of pancreatic cell and edema of the ampulla of Vater [14]. Acute pancreatitis was considered by many studies, as acute, rare and atypical manifestations presented within days of dengue virus infection disease [6, 9, 12]. Surprisingly in this study, we firstly recorded the relative frequency of acute pancreatitis as a late complication of dengue infection outbreaks in Egypt and we reported 13(13%) patients presented with acute pancreatitis 3 months post recovery from dengue viral infection as confirmed by RT-PCR and serological tests. No studies are available in the literature on Dengue fever and late onset acute pancreatitis except for two case reports. Rajesh et al. reported another one case report, girl 16-year-old presented with acute pancreatitis, 3 weeks following dengue virus infection [21]. Additionally, Krithika and Ramya [17] reported a case study of male child 11 years old presented by acute pancreatitis about 10 days following complete cure of dengue virus infection. This may be related to involvement of immune mechanism to dengue virus in pathogenesis of late onset acute pancreatitis.

Dengue fever has many clinical presentations which is of important diagnostic value. Acute pancreatitis could be occurring as a late complication, so its early recognition could lead to decreased morbidity and mortality via proper management.

Study limitations

The relatively low frequency of cases that require larger-scale studies to confirm our findings. The lack of correlations of the viral load with the dengue disease severity and the occurrence of late onset pancreatitis as the performed RT-PCR was qualitative and not quantitative assay.

Compliance with ethical standards

Conflict of interest

The authors report no conflicts of interest in this work.