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Year : 2022  |  Volume : 49  |  Issue : 2  |  Page : 186-189

Automated complete blood count profile as a probable indicator of dengue fever severity in children

1 Department of Pathology, DMGMC and H, Purulia, West Bengal, India
2 Department of Pediatrics, Dr. B C Roy PGIPS, Kolkata, West Bengal, India
3 Department of Anatomy, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India

Date of Submission30-Sep-2021
Date of Acceptance19-Apr-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Arijit Majumdar
Vill Duilya, Charaktala, PO – Andul, District Howrah; Pin. 711 302, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jss.jss_135_21

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Background: Dengue is now endemic in more than 100 tropical and subtropical countries. Ninety percent of dengue hemorrhagic fever occurs in children <15 years of age. Leukopenia and thrombocytopenia near the end of the febrile phase are the common findings in dengue fever. Aims and Objectives: (1) To see any significant correlations between various hematological parameters with severity of dengue and (2) to see the shift in the values (increase/decrease) of platelet indices in dengue patients. Materials and Methods: One hundred and twenty patients admitted either with laboratory report of seropositive dengue or with dengue-like symptoms and who were found to be dengue positive after admission were included in the study. Complete hemogram including platelet indices was evaluated by an automated cell counter. Clinical examinations were performed in detail with special reference to the presence of warning signs such as vomiting, lethargy, pain abdomen, bleeding, and ascites. Results: Total leukocyte count, platelet distribution width, and mean platelet volume were not significantly different in patients with warning signs from those without it. The level of mean hematocrit was significantly higher and the mean plateletcrit was significantly lower in dengue with warning signs. Conclusions: Simultaneous measurement of complete blood count and platelet indices can provide us a valid instrument for the measurement of dengue disease severity and an insight into the potential etiology that resulted in change in platelet indices.

Keywords: Automated cell counter, complete blood count, dengue

How to cite this article:
Majumdar A, Kumar A, Biswas S. Automated complete blood count profile as a probable indicator of dengue fever severity in children. J Sci Soc 2022;49:186-9

How to cite this URL:
Majumdar A, Kumar A, Biswas S. Automated complete blood count profile as a probable indicator of dengue fever severity in children. J Sci Soc [serial online] 2022 [cited 2022 Oct 3];49:186-9. Available from: https://www.jscisociety.com/text.asp?2022/49/2/186/354259

  Introduction Top

Dengue fever is a mosquito-borne viral disease caused by 1 of 4 closely related but antigenically distinct serotypes of dengue virus, serotypes DENV-1 through DENV-4.[1] Children are affected as frequently as adults by the classical dengue fever. The presentation ranges from nonspecific febrile illness to life-threatening dengue shock syndrome (DSS). Leukopenia and thrombocytopenia are common findings in dengue fever and are believed to be caused by direct destructive actions of the virus on bone marrow precursor cells. In majority of the cases, the diagnosis is based on the detection of dengue antigens or antibodies.[2] Dengue immunoglobulin M (IgM) and immunoglobulin G enzyme-linked immunosorbent assay (ELISA) kits are widely used for the diagnosis of dengue infection in routine laboratories. An ELISA specific to dengue virus NS1 protein has been developed for the detection of dengue NS1 antigen during the acute phase of disease in patients experiencing primary and secondary infections.[3]

Simultaneous measurement of complete blood count (CBC) along with platelet indices can provide us a valid instrument for measuring disease severity and an insight into the potential etiology that resulted in changes in platelet indices. Increased mean platelet volume (MPV) and platelet distribution width (PDW) suggest that bone marrow produces platelets and rapidly releases them into circulation.[4] A simultaneous reduction of platelet count and plateletcrit (PCT) indicates that platelets have been excessively consumed.

Automated cell counters or hematology analyzers are used to conduct a CBC, which is usually the first test requested by physicians to determine a patient's general health status. A CBC includes red blood cell (RBC), white blood cell (WBC), hemoglobin, and platelet counts, as well as hematocrit levels. Other analyses include RBC distribution width, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentrations, WBC differential count in percentage and absolute value, PDW, platelet mean volume, and large platelet cell ratio.[5]

Blood cell profile analysis by an automated cell counter or hematology analyzer has become a basic investigation nowadays. If we can assess the severity of dengue infection from the measurement of cell count and platelet indices, it would be a great benefit to developing countries like ours. Although some studies had been performed on the adult population, very few reports of the studies on the pediatric population are on record. Hence, this study is undertaken to establish the relationship between hematologic profile and dengue infection severity in children.

  Materials and Methods Top

The study was done in a tertiary care children hospital over a period of 2 years. Written informed consent was obtained from the parents of all enrolled children. The patients having clinical features of dengue with serologically positive dengue infection were included in the study. This was a prospective, cross-sectional study. The sample size was 120. The patients admitted with laboratory diagnosis of seropositive dengue from outside hospital as well as the patients admitted with dengue-like symptoms and found to be dengue seropositive after hospital admission were included in the study. Severity of the infection was considered on the basis of the presence of the following warning signs such as lethargy, vomiting, bleeding, hepatomegaly, ascites, convulsion, and features of shock. Clinical examination in detail and relevant investigation were performed as per requirements in individual cases. The investigations done in all the cases at the time of admission are complete hemogram in an automated cell counter and ESR estimation, dengue NS1 antigen titer by kit (DENV Detect™ NS1 ELISA – InBios), dengue IgM antibody titer by ELISA method (DENV Detect™ IgM capture ELISA InBios), serum urea, creatinine, electrolytes, and liver function tests. The hematological parameters studied are total leukocyte/WBC count, total platelet count, MPV, PDW, PCT, and PDW/platelet count ratio. Statistical analysis of the data was done by SPSS (version 25.0; SPSS Inc., Chicago, IL, USA). P < 0.05 is considered statistically significant.

  Results Top

[Table 1] summarizes the demographic profile of the study population.
Table 1: Demographic characteristics of study population

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Eight (6.7%) children were ≤1 year of age, 35 (29.2%) children were 1.1–5 years of age, 63 (52.5%) children were 5.1–10 years of age, and the rest were more than 10 years of age. More than half (59.2%) of the children were male.

Sixty-seven children had warning signs (ascites, bleeding, convulsion, vomiting, loose stool, lethargy, pain abdomen, and hepatomegaly) and 53 children did not show any sign of severity.

[Table 2] summarizes the distribution of different hematological parameters in patients with or without the presence of warning symptoms.
Table 2: Hematological profile of study population (mean±standard deviation)

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The mean WBC count of patients presented with warning signs was not significantly different from those not presented with the warning signs. In patients without warning signs, the mean hematocrit level was 33.9, whereas it was 35.9 in children having those signs. There is a statistically significant difference (P < 0.0001) in mean platelet count between the children with and without the warning signs. Among the platelet indices, only PCT showed a statistically significant difference in values between the children presented with and without the warning signs. Although the PDW values were not significantly different in those two groups of children, the ratio of PDW-to-platelet count shows a statistically significant difference between them.

  Discussion Top

Dengue is one of the most common arthropod-borne viral illness caused by infection with one of the four serotypes of dengue virus in humans. The illness may range from nonspecific febrile illness to classic dengue fever to the life-threatening dengue hemorrhagic fever (DHF)/DSS.[6] In our study, more than half of the patients (52.5%) are between the age of 5–10 years, which is comparable with the findings of Mishra S et al. and Senthil et al. who obtained, respectively, 11 years and 10 years as the most common age of presentation.[7],[8] Although the boys (59.2%) outnumbered the girls (40.8%) in the present study, there was no significant difference between them regarding the presence of warning signs as depicted in [Table 3].
Table 3: Distribution of warning signs

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In our study, lower platelet count is associated with children presenting with warning signs and it is statistically significant having P < 0.0001 [Table 2]. Similar results were obtained by Navya et al. and Shinde.[8],[9] They showed the association between the severity of the disease and the degree of thrombocytopenia. Chiranth and Avabrata found that 85% of the patients who had warning signs had platelet count <1 lakh/cmm[10] [Table 4].
Table 4: Comparison between different studies regarding low platelet count

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The mean WBC count in the children with warning signs and those without it did not show any significant difference (P value 0.72). The mean hematocrit value in patients having warning signs was found to be significantly raised as compared to patients without those signs in our study as shown in [Table 2]. This finding is consistent with the fact that in dengue patients with warning signs, there is a rise in hematocrit.[11] This is due to increased plasma leakage caused by increase in vascular permeability.

In our study, MPV of the children with warning signs in comparison to that of children without warning signs showed no statistically significant difference (P = 0.85). It shows that the patients affected with dengue showed an increase in MPV irrespective of its severity. Afsar et al. found that MPV was found to be significantly higher in dengue cases when compared to controls[12] due to the activation of platelets in dengue as when platelet production is decreased, young platelets become bigger and more active. During activation, platelets' shapes change from biconcave discs to spherical, and a pronounced pseudopod formation occurs that leads to MPV increase during platelet activation.[13] Mukker and Kiran also showed that the patients having severe thrombocytopenia (platelet count <20,000/cmm) had a statistically significant alteration of platelet indices including MPV compared to those with platelet count more than 1 lakh/cmm.[14] Khatri S et al. (2018) found the value of MPV as 9.01 fl with standard deviation of 0.09, which is close to the value of MPV obtained from our study.[15]

We found a lower PCT value in patients with the warning signs as compared to that in patients without the signs. The difference between these values was statistically significant (P = 0.0117). Chiranth and Avabrata found the similar result in their study, showing that a decreased platelet count and PCT correlate with the severity of infection.[10]

We found a lower PDW in patients with warning signs and no significant difference was found between the PDW of patients with and without warning signs. Navya et al.'s[8] study showed that high PDW (>13%), which is a useful marker for platelet activation, was seen in 92% of cases, of which 84 cases were dengue fever and 8 cases were DHF and the remaining 8% of cases showed low PDW (<13%). We found that the distribution of PDW/platelet in children without warning signs versus those with warning signs was statistically significant (P = 0.031). Purbiya et al. found that PDW/platelet count ratio higher than 0.07 can be considered as an independent predictor of mortality with sensitivity and specificity of 77.1% and 77.5%, respectively.[16]

  Conclusions Top

Classic dengue fever primarily occurs in adults and children, especially younger than 15 years. Leukopenia, lymphopenia near the end of the febrile phase, and thrombocytopenia are common findings in dengue fever and are believed to be caused by direct destructive actions of the virus on the bone marrow precursor cells. 55.8% of patients in our study had warning symptoms such as vomiting, pain abdomen, convulsion, bleeding, ascites, and hepatosplenomegaly at the time of admission or developed during the course of the disease. The value of hematocrit was significantly higher in dengue patients with warning signs compared to those without it. We found that PDW, MPV, and WBC count were not significantly different in both the groups of patients. We found that the mean PCT is significantly lower and PDW/platelet count ratio is significantly higher in patients with warning signs compared to those without warning signs. Hence, high hematocrit, low PCT, and high PDW/platelet may be used as probable indicators for dengue with warning signs and thereby the severity of dengue infection in children.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Centers for Disease Control and Prevention (CDC). Imported dengue-United States, 1997 and 1998. MMWR Morb Mortal Wkly Rep 2000;49:248-53.  Back to cited text no. 1
Gupta E, Ballani N. Current perspectives on the spread of dengue in India. Infect Drug Resist 2014;7:337-42.  Back to cited text no. 2
Shrivastava A, Dash PK, Tripathi NK, Sahni AK, Gopalan N, Lakshmana Rao PV. Evaluation of a commercial Dengue NS1 enzyme-linked immunosorbent assay for early diagnosis of dengue infection. Indian J Med Microbiol 2011;29:51-5.  Back to cited text no. 3
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Sachdev R, Tiwari AK, Goel S, Raina V, Sethi M. Establishing biological reference intervals for novel platelet parameters (immature platelet fraction, high immature platelet fraction, platelet distribution width, platelet large cell ratio, platelet-X, plateletcrit, and platelet distribution width) and their correlations among each other. Indian J Pathol Microbiol 2014;57:231-5.  Back to cited text no. 4
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Chhabra G. Automated hematology analyzers: Recent trends and applications. J Lab Physicians 2018;10:15-6.  Back to cited text no. 5
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Kyle JL, Harris E. Global spread and persistence of dengue. Annu Rev Microbiol 2008;62:71-92.  Back to cited text no. 6
Senthil K, Rajendran NK, Ajith Brabhukumar C. Clinical profile of dengue fever in children: Analysis of 2017 outbreak from Central Kerala, India. Int J Contemp Paediatr 2018;5:2265.  Back to cited text no. 7
Navya BN, Patil S, Kariappa TM. Role of platelet parameters in dengue positive cases – An observational study. Int J Health Sci Res 2016;6:74-8.  Back to cited text no. 8
Shinde PA. Evaluation of platelet count in paediatric patients with dengue fever: A hospital based study. Int J Contemp Med Res 2017;4:1175-7.  Back to cited text no. 9
Chiranth SB, Avabrata KS. Platelet indices and the severity of dengue infection in children. J Pediatr Res 2019;6:242-7.  Back to cited text no. 10
Rothman AL, Ennis FA. Immunopathogenesis of dengue haemorrhagic fever. Virology 1999;257:1-6.  Back to cited text no. 11
Afsar N, Afroze IA, Humaira S, Abid Z. Use of mean platelet volume as an initial diagnostic marker in evaluation of dengue fever. Ann Pathol Lab Med 2017;4:A310-3.  Back to cited text no. 12
Budak YU, Polat M, Huysal K. The use of platelet indices, plateletcrit, mean platelet volume and platelet distribution width in emergency non-traumatic abdominal surgery: A systematic review. Biochem Med (Zagreb) 2016;26:178-93.  Back to cited text no. 13
Mukker P, Kiran S. Platelet indices evaluation in patients with dengue fever. Int J Med Sci 2018;6:2054-9.  Back to cited text no. 14
Khatri S, Sabeena S, Arunkumar G, Mathew M. Utility of platelet parameters in serologically proven dengue cases with thrombocytopenia. Indian J Hematol Blood Transfus 2018;34:703-6.  Back to cited text no. 15
Purbiya P, Golwala ZM, Manchanda A, Sreenivas V, Puliyel JM. Platelet distribution width to platelet count ratio as an index of severity of illness. Indian J Pediatr 2018;85:10-4.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4]


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