INTRODUCTIONDengue ranks among the most important mosquito-borne viral disease in the world. Dengue fever is an acute infectious disease caused by an arbovirus in the Flavivirus genus. It has four serotypes, and the mosquito Aedes aegypti is the vector. While dengue is a global concern, currently close to 75% of the global population exposed to dengue are in the Asia-Pacific region.Dengue virus was isolated in India for the first time in 1945. Over the last few years, atypical manifestations of ABSTRACT Background: Although dengue virus is a non hepatotropic virus, liver injury due to dengue infection is not uncommon. Atypical manifestations with liver involvement have frequently been reported, ranging from mild elevations of aminotransferase levels to fulminant hepatitis. The aim of the present study is to study the serum transaminases level in various forms of dengue infection and correlate with severity. Methods: An analysis of 151 serologically confirmed cases (0-14 yrs) of dengue from June 2017 to July 2017 at a tertiary care hospital, Dharwad was made to assess the frequency and degree of hepatic dysfunction in children with dengue infection by analyzing serum transaminase levels. Patients were classified according to WHO as dengue without warning signs, with warning signs and severe dengue. Patients were divided into primary and secondary dengue based on serology and serum transaminases levels were assessed in each of the above groups. Patients with normal aminotransferase levels were categorized into Grade A, those with atleast one of the enzymes raised to less than 3 times the reference range as Grade B, those with atleast one of the enzymes elevated more than 3 times but less than 10 times as Grade C and those with elevations more than 10 times as Grade D. χ2 test was applied to check statistical significance. Results: During the study period, the total number of serologically confirmed cases of dengue were 151 among which dengue fever without warning signs were 38, with warning signs were 91 and severe dengue were 22. Serum transaminase levels were significantly raised in severe dengue (χ2=14.228, df=6, p=0.027).It was also found that transaminases were significantly higher in secondary dengue infection than primary dengue ( χ2=10.155, df=3, p=0.017). Transaminases were significantly elevated in non-survivors (χ2=16.958, df=3, p<0.001). Conclusions: Hepatic dysfunction was common in all forms of dengue infection, with AST rising significantly more than ALT. Transaminases were significantly elevated in severe dengue and secondary dengue infections. Patients with significantly high transaminases had a poor outcome.
Neonatal liver failure (NLF) is rare and carries a high mortality. Common aetiologies include neonatal haemochromatosis (NH), haematological malignancies, viral infections and liver-based metabolic defects. Early diagnosis and referral to a paediatric liver centre is recommended as liver transplantation is the only definitive treatment when supportive or a disease-specific treatment fails. A baby girl was born by Emergency LSCS for pathological cardiotocography at 33+2 weeks of gestation. Her mother had been previously well and had normal pregnancy. She was birth in poor condition requiring cardiopulmonary resuscitation. She was transferred to a level 2 neonatal unit for ventilator management. At birth she had coagulopathy which remained refractory to medical treatment. She required multiple ionotropes, multiple blood products and high dextrose load. She was transferred to a tertiary neonatal unit for the management of acute renal failure. With persistent evidence of only marginally raised liver enzymes and significantly reduced synthetic and excretory function of liver it was unlikely to be explained by solely bacterial or viral illness. Extensive infection screen were negative. Metabolic screening tests were done. She was referred to liver unit. Lip biopsy confirmed the diagnosis of NH. She had a liver transplant on day 36 of life. Histology showed nodular cirrhosis secondary to neonatal haemochromatosis. At age 4 months, she is continuing to thrive well with normal liver function tests. NH is the single most common cause of NLF (40%) and usually presents with severe neonatal liver disease associated with hepatic and extrahepatic iron deposition but sparing the reticulo-endothelial system. NH is hypothesised to be an alloimmune process where maternal antibodies are directed towards fetal liver antigen. Rate of recurrence in subsequent pregnancy is up to 80% and could be effectively prevented by antenatal intravenous immunoglobulin. Early and aggressive medical treatment is essential for improving the outcome. Treatment conundrum of NH continues with some case series showing a success rate of 10 to 20% following a ‘cocktail’ of antioxidants and chelating agents which have not been evaluated systematically and liver transplantation remains the only definitive treatment.
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