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Retinal profile: a clinical indicator of severity in dengue fever in a suburban Indian environment Rubii Malhotra, Luxmi Singh, RK Bundela, Pragati Garg, Diva Kant, Ankit Garg and BB Lal Trop Doct 2014 44: 143 originally published online 10 April 2014 DOI: 10.1177/0049475514529759 The online version of this article can be found at: http://tdo.sagepub.com/content/44/3/143
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Original Article
Retinal profile: a clinical indicator of severity in dengue fever in a suburban Indian environment
Tropical Doctor 2014, Vol. 44(3) 143–147 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514529759 tdo.sagepub.com
Rubii Malhotra1, Luxmi Singh2, RK Bundela1, Pragati Garg2, Diva Kant3, Ankit Garg3 and BB Lal4
Abstract Purpose: To study the retinal changes in subjects suffering from dengue fever and check if these changes can be taken as sufficient indicator of severity and progression of the disease. Patients/Methods: A detailed history was recorded of 118 patients on whom ocular examination, including direct ophthalmoscopy, indirect ophthalmoscopy and coloured fundus photography, was performed. Results: Forty-seven percent of patients were found to have posterior segment abnormalities. Retinal vein dilatation or tortuosity was the most common finding followed by changes in the optic disc (8.4% of patients) and background haemorrhage (6.7% of patients). With increasing severity of thrombocytopenia, the proportion of patients with retinal abnormalities increased. In patients with grade I thrombocytopenia, no fundal abnormality was found. In those with grade II thrombocytopenia, fundal abnormality was found in 13.63% patients, whereas in the grade III category it was 27.90%. Conclusions: Severity of thrombocytopenia had a significant association with retinal abnormalities. Occurrence of fundus changes increases with an increase in severity of thrombocytopenia. Fundus changes were found in all patients with grade IV thrombocytopenia.
Keywords Dengue, thrombocytopenia, viral, retinal abnormalities
Introduction Dengue fever, caused by the bite of the vector mosquito Aedes aegypti and resulting flavivirus infection, is the most prevalent mosquito-borne viral disease in humans. The highest incidence is found in tropical zones such as South East Asia, India and its neighbouring countries.1 Each year, more than 100 million people suffer from this disease worldwide. The World Health Organization (WHO) reports that, globally, more than 2.5 billion people are currently at risk of dengue fever.2 Dengue is a disease which has multisystem involvement with associated complications that have also been found to affect the eye. Ocular involvement with dengue fever and dengue haemorrhagic fever has not been commonly reported in the past; however an increasing number of patients of dengue fever with associated ocular complications are now being recorded. This may be the result of an increase in incidence reported from different parts of the world including
India.3,4 This is a result of a rapid upsurgence of Aedes aegypti, the principal vector, in tropical countries because of the hot and humid climatic conditions associated with overpopulation and urbanization,5 and possibly global warming. Classical dengue fever (CDF) is an influenza (flu)like illness, usually self-limiting in nature, and is caused by one of the four serotypes of dengue virus. 1 Associate Professor, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India 2 Professor, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India 3 Resident, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India 4 Professor & Head, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India
Corresponding author: Rubii Malhotra, 804, Dilkash Apartments, River Bank Colony, Lucknow, 226018, Uttar Pradesh, India. Email: [email protected]
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Dengue haemorrhagic fever (DHF), on the other hand, is a more severe form of the disease. DHF is characterised by multisystem haemorrhagic manifestations which occur due to an associated thrombocytopenia. This is the most common haematological manifestation of DHF. According to the WHO definition, CDF is characterised by an abrupt onset of fever after a 2–7day incubation period, with temperatures reaching 41 C. The fever is accompanied by non-life-threatening systemic symptoms like malaise, headache and retroorbital pain. A transient macular rash is often seen on days 1 to 2 of the illness. Associated blood dyscrasias include thrombocytopenia and neutropenia. The illness is usually self-limiting with minimal systemic sequelae, but it may require prolonged convalescence lasting several weeks. DHF is a severe and potentially fatal form of the disease and 25,000 deaths are reported annually globally. WHO defines DHF as CDF associated with thrombocytopenia (20% above baseline). Its most severe form, dengue shock syndrome (DSS), is associated with hypotension, narrowing of pulse pressure (¼ 75,000/mm3
Retinal profile: a clinical indicator of severity in dengue fever in a suburban Indian environment Rubii Malhotra, Luxmi Singh, RK Bundela, Pragati Garg, Diva Kant, Ankit Garg and BB Lal Trop Doct 2014 44: 143 originally published online 10 April 2014 DOI: 10.1177/0049475514529759 The online version of this article can be found at: http://tdo.sagepub.com/content/44/3/143
Published by: http://www.sagepublications.com
On behalf of: THET
Additional services and information for Tropical Doctor can be found at: Email Alerts: http://tdo.sagepub.com/cgi/alerts Subscriptions: http://tdo.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Jun 9, 2014 OnlineFirst Version of Record - Apr 10, 2014 What is This?
Downloaded from tdo.sagepub.com at UNIV WASHINGTON LIBRARIES on December 1, 2014
Original Article
Retinal profile: a clinical indicator of severity in dengue fever in a suburban Indian environment
Tropical Doctor 2014, Vol. 44(3) 143–147 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514529759 tdo.sagepub.com
Rubii Malhotra1, Luxmi Singh2, RK Bundela1, Pragati Garg2, Diva Kant3, Ankit Garg3 and BB Lal4
Abstract Purpose: To study the retinal changes in subjects suffering from dengue fever and check if these changes can be taken as sufficient indicator of severity and progression of the disease. Patients/Methods: A detailed history was recorded of 118 patients on whom ocular examination, including direct ophthalmoscopy, indirect ophthalmoscopy and coloured fundus photography, was performed. Results: Forty-seven percent of patients were found to have posterior segment abnormalities. Retinal vein dilatation or tortuosity was the most common finding followed by changes in the optic disc (8.4% of patients) and background haemorrhage (6.7% of patients). With increasing severity of thrombocytopenia, the proportion of patients with retinal abnormalities increased. In patients with grade I thrombocytopenia, no fundal abnormality was found. In those with grade II thrombocytopenia, fundal abnormality was found in 13.63% patients, whereas in the grade III category it was 27.90%. Conclusions: Severity of thrombocytopenia had a significant association with retinal abnormalities. Occurrence of fundus changes increases with an increase in severity of thrombocytopenia. Fundus changes were found in all patients with grade IV thrombocytopenia.
Keywords Dengue, thrombocytopenia, viral, retinal abnormalities
Introduction Dengue fever, caused by the bite of the vector mosquito Aedes aegypti and resulting flavivirus infection, is the most prevalent mosquito-borne viral disease in humans. The highest incidence is found in tropical zones such as South East Asia, India and its neighbouring countries.1 Each year, more than 100 million people suffer from this disease worldwide. The World Health Organization (WHO) reports that, globally, more than 2.5 billion people are currently at risk of dengue fever.2 Dengue is a disease which has multisystem involvement with associated complications that have also been found to affect the eye. Ocular involvement with dengue fever and dengue haemorrhagic fever has not been commonly reported in the past; however an increasing number of patients of dengue fever with associated ocular complications are now being recorded. This may be the result of an increase in incidence reported from different parts of the world including
India.3,4 This is a result of a rapid upsurgence of Aedes aegypti, the principal vector, in tropical countries because of the hot and humid climatic conditions associated with overpopulation and urbanization,5 and possibly global warming. Classical dengue fever (CDF) is an influenza (flu)like illness, usually self-limiting in nature, and is caused by one of the four serotypes of dengue virus. 1 Associate Professor, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India 2 Professor, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India 3 Resident, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India 4 Professor & Head, Ophthalmology Department, Era’s Lucknow Medical College & Hospital, Lucknow, India
Corresponding author: Rubii Malhotra, 804, Dilkash Apartments, River Bank Colony, Lucknow, 226018, Uttar Pradesh, India. Email: [email protected]
Downloaded from tdo.sagepub.com at UNIV WASHINGTON LIBRARIES on December 1, 2014
144
Tropical Doctor 44(3)
Dengue haemorrhagic fever (DHF), on the other hand, is a more severe form of the disease. DHF is characterised by multisystem haemorrhagic manifestations which occur due to an associated thrombocytopenia. This is the most common haematological manifestation of DHF. According to the WHO definition, CDF is characterised by an abrupt onset of fever after a 2–7day incubation period, with temperatures reaching 41 C. The fever is accompanied by non-life-threatening systemic symptoms like malaise, headache and retroorbital pain. A transient macular rash is often seen on days 1 to 2 of the illness. Associated blood dyscrasias include thrombocytopenia and neutropenia. The illness is usually self-limiting with minimal systemic sequelae, but it may require prolonged convalescence lasting several weeks. DHF is a severe and potentially fatal form of the disease and 25,000 deaths are reported annually globally. WHO defines DHF as CDF associated with thrombocytopenia (20% above baseline). Its most severe form, dengue shock syndrome (DSS), is associated with hypotension, narrowing of pulse pressure (¼ 75,000/mm3
