Heart and liver are infected in fatal cases of dengue: three PCR based case studies

Abstract

BackgroundDengue is a global problem mainly in the tropics. Meticulous clinical management of cases has reduced the death rate significantly, but large numbers of people still succumb to severe complications of the infection. Presence of myocarditis is often overlooked leading to a poor outcome. Clinical management guidelines of dengue do not stress the importance of myocarditis as a manifestation in dengue infection. Severe hepatic dysfunction also needs emphasis.Case presentationWe present three patients who had come to hospital on the 3rd day of fever. Two of them (case 1 and 3) were in shock on admission and case 2, who was stable on the3rd day, went into the critical phase and developed shock while in the hospital on the 4thday. All three had tachycardia on admission that got worse with time. The clinical course was unstable with fluctuations in urine output and deterioration of organ function. Despite frequent monitoring and life support they survived only 2–3 days in hospital. All three patients had myocarditis during the critical phase. In the first case, myocarditis was confirmed by troponin estimation and echocardiogram. In the second and third cases, histopathology confirmed myocarditis. Haemorrhagic necrosis of the liver was found in case 2 and 3 with exponential rise of transaminases. In all three cases, viral RNA was detected in both heart and liver tissues by PCR amplification.ConclusionsWe stress that detection of myocarditis and liver involvement in any dengue patient is important from the onset of the illness where treatment should be tailored to prevent development of hypotension. Our findings are novel as PCR and histology are rarely done on tissues of deceased dengue patients in the world. Studies are needed to find therapeutic interventions to reverse cardiac and hepatic dysfunction in dengue infection.

Comparative analysis of liver involvement caused by two DENV-2 lineages using an immunocompetent murine model

“…Elevated levels of these enzymes are an early marker of DEN. Transaminase levels are higher in patients presenting DHF or DSS, and the increase is usually mild or moderate; however, an increase in enzyme levels of more than tenfold has been reported 20 , 22 , 84 . An increase in transaminase levels has also been seen in immunocompetent mice infected with DENV-2 19 , 57 , 59 .…”

“…Liver involvement is commonly seen in DEN, and although more frequently associated with SD, it is also present in nonsevere cases of DEN 18 , 80 . Liver function abnormalities induced by DENV infection range from a mild rise in transaminase and bilirubin levels to acute liver failure, which may lead to death 22 , 81 , 82 . ALT and AST are considered indicators of liver abnormalities, as they are released into the bloodstream following liver cell injury 83 .…”

“…The tissue alterations caused by the infection range from an asymptomatic increase in transaminases to acute liver failure, which has fatal outcomes 21 – 23 . The most commonly reported clinical alteration is the elevation of ALT and AST levels, which are observed in the initial days after onset of fever and peak in the period of convalescence 18 , 22 . Hepatomegaly is common as well; however, it is more frequently observed in patients with DHF 15 , 24 , 25 .…”

A systematic review on phytochemicals for the treatment of dengue

“…When under observation with infection various clinical manifestations prevailed like acute GI bleeding, myocarditis, severe diarrhea, sepsis and occult bleeding. Another case study reported by Kularatne, Rajapakse, et al (2018) and Kularatne, Ralapanawa, et al (2018), revealed cases of involvement of vital organs like myocardium and hepatic system leading to complications, which was further proved as infection was DENV in the organs was evidenced by PCR technique. It has also revealed that dengue infection leads to meningoencephalitis, one of the neurological manifestations resulting in death of the patients (Soni, Das, George, Aggarwal, & Sivasankar, 2017).…”

Dengue Virus and Vaccines: How Can DNA Immunization Contribute to This Challenge?

“…It first infects dendritic cells and then monocytes/macrophages, where it replicates and spreads infective particles that can reach different organs. Studies with patients that succumb to infection revealed that the virus can replicate in several organs, such as the liver, heart, lung, and brain (6)(7)(8). It interacts with different cell receptors through the E protein [reviewed in (9)].…”