38

Journal of The Association of Physicians of India Vol. 63 May 2015

Original Article

Catching Dengue Early: Clinical Features and

Laboratory Markers of Dengue Virus Infection
Prakash Babaliche1, Darshan Doshi2

Abstract

Editorial Viewpoint

Background and Objectives : Dengue fever is one of the most common

tropical diseases worldwide. Early diagnosis of dengue helps in patient
triage and timely management of dengue virus infection. This study was
undertaken to note the early clinical features supported by detection of
NS1 antigen for diagnosis of dengue virus infection.

T h e s t u d y i s a c r o s s sectional one.

Methodology : In this study a total of 100 adult patients presenting with

clinical features of dengue infection from January 2012 to December 2012
were studied. The diagnosis was confirmed with NS1 rapid diagnostic test
(RDT) whose efficacy was later tested with IgM ELISA.

Results : In this study young males were predominantly affected. NS1

positivity was 68%. The sensitivity of NS1 in predicting dengue infection
compared to IgM was 92.86% and specificity was 90% with strength of
agreement considered to be very good based on Kappa statistics. Clinical
features like retro-orbital pain, myalgia, arthralgia, rashes and bleeding
manifestations were significantly associated with NS1 positivity. Similarly
icterus, oedema, hypotension, altered sensorium, thrombocytopenia
and raised creatinine were significantly more in NS1 positive patients.
Anomalously, SGOT was more than SGPT, which can help in differentiating
dengue virus infection from other viral infections early in the course.
Conclusion : We conclude that dengue infection, which possesses
serious public health problem, can be diagnosed early with the help of
clinical features like retro-orbital pain, myalgia, bleeding manifestations,
thrombocytopenia and anomalously SGOT greater than SGPT that is
supported by detection of NS1 antigen.

Background

engue fever is an important

arthropod-borne viral
infection of humans. Worldwide,
an estimated 2.5 billion people are
at risk of infection. 1 It is estimated
that more than 50 million infections
occur each year, of which 500,000
hospitalisations are of dengue
haemorrhagic fever, mainly among
children, with the case fatality rate
exceeding 5% in some areas. 1-4
Diagnosing dengue early is
challenging because the initial
symptoms of dengue infection are

often non-specific and serological

tests, which are the mainstay
of current laboratory diagnosis,
confirm dengue late in the course
of illness. 5
Before day 5 of illness, during
the febrile period, dengue
infections may be diagnosed by
virus isolation in cell culture, by
detection of viral RNA by nucleic
acid amplification tests (NAAT),
or by detection of viral antigens

As per this study SGOT

can be more elevated than
SGPT in dengue.
The study reiterates the
known facts about dengue.

by ELISA or rapid tests. Virus

isolation in cell culture is usually
performed only in laboratories with
the necessary infrastructure and
technical expertise. The isolation
and identification of dengue
viruses in cell cultures usually
takes several days. Nucleic acid
detection assays with excellent
performance characteristics may
identify dengue viral RNA within
24-48 hours. However, these tests
require expensive equipment and
reagents. 6
Clinical features of dengue virus
infection are usually nonspecific
ranging right from self-limiting
disease like fever, headache,
myalgia, rashes, and arthralgia to
dengue haemorrhagic fever and
dengue shock syndrome.
Hence there is a lacunae in
diagnosing dengue virus infection
early both in relation to clinical
features and laboratory tests.
Hence, this study was undertaken
to address this issue and help
clinicians to diagnose dengue fever
early with help of clinical features
and laboratory investigations.

Professor, 2Post Graduate, Department of General Medicine, JNMC, KLE University, Belgaum, Karnataka
Received: 07.11.2013; Revised: 07.04.2014; Re-revised: 08.07.2014; Accepted: 10.07.2014

Journal of The Association of Physicians of India Vol. 63 May 2015

Material and Methods

The present study was a one year
cross-sectional study comprising
of 100 patients conducted in the
Department of Medicine, KLES
Dr. Prabhakar Kore Hospital and
Medical Research Centre, Belgaum
from January 2012 to December
2012.
Patients with age more than
12 years, history of documented
fever of more than 38 C of less
than seven days plus two or
more signs and symptoms from
the following: headache, retroorbital pain, myalgia, arthralgia,
rash, hypotension and bleeding
manifestations, were included in
the study. Patients with localised
source of infection were excluded
from the study.
Ethical clearance was obtained
prior to the study and written
informed consent was obtained
from the participating patients.
Patients were interviewed for
demographic data such as age,
sex and occupation were noted.
Histories of similar complaints in
past and current treatment were
noted. Patients were subjected to
a thorough physical examination,
vitals (pulse rate, blood pressure
and respiratory rate) and other
clinical signs and symptoms of
dengue fever. Systemic examination
was carried out. Patients underwent
routine laboratory investigations,
electrocardiograms in addition to
NS1 Rapid detection test using
SD Bioline Dengue Duo kit and
establishing the efficacy of this
test against IgM ELISA done
on the 8 th day of fever. Patients
with suspected co-infections like
malaria, leptospirosis, enteric
f e ve r o r o t h e r i n f e c t i o n s we r e
investigated and those who were
found to have a specific cause were
excluded from the study.
The categorical data was
expressed as rates, ratios and
proportions and comparison was
done using chi-square test. The
continuous data was expressed

as mean standard deviation

(SD). The diagnostic accuracy of
NS1 antigen testing, in predicting
dengue infection was determined
by sensitivity, specificity, positive
p r e d i c t i ve va l u e a n d n e g a t i ve
predictive value. Kappa agreement
was used to correlate the
agreements. A p value of less than
or equal to 0.05 was considered as
statistically significant.

Results
A total of 100 patients fitting the
inclusion criteria were selected for
the study. 68% of the patients tested
NS1 positive. Of the 100 patients,
70 patients test ed positive for
IgM ELISA. Out of which 65 were
positive for NS1 antigen test while
five were negative. The sensitivity of
NS1 in predicting dengue infection
compared to IgM ELISA was 92.86%
a n d s p e c i f i c i t y wa s 9 0 % w i t h
95.59% positive predictive value
and 84.38% negative predictive
value (p < 0.001) with kappa value
of 0.813 and strength of agreement
considered very good (Table
1). Majority of them were males
(62%). 60% of the patients aged
less than 30 years, The presenting
complaints are given in Table 2. Of
these, myalgia, rashes, retro-orbital
pain, arthralgia and bleeding
manifestations were significantly
m o r e i n N S 1 p o s i t i ve p a t i e n t s
(Table 3). Bleeding manifestations
included melaena, epistaxis, gum
bleeding, pervaginal bleeding and
haematuria. Of these majority of
them had melaena (8 patients).
The present study revealed,
bradycardia was present in 31%
of the patients and hypotension in
4% of patients all of whom were
NS1 positive. Icterus and oedema
was observed in 16% and 9% of
patients respectively both of which
were significantly associated with
NS1 positivity(p < 0.05). Systemic
examination revealed abdominal
tenderness in 49% of the patients,
reduced air entry in bilateral lung
bases in 16% and bilateral coarse
crepitations in 5% of the patients.
Neurological involvement was

39

present in 5% of the patients, all of

whom were NS1 positive (Table 4).
Laboratory investigations
revealed thrombocytopenia in 87%
of the patients (mean 37120.57
32304.99 /mm 3) with significantly
more in NS1 positive patients (p
0.002). Leucopenia was present
in 16% of the patients (mean
leucocyte count 5500 2489.66 /
mm 3). Haematocrit was raised in
11% of the patients (Table 5). Serum
creatinine was deranged in 17% of
the patients (mean 1.19 1.07 mg/
dl) and was significantly deranged
in NS1 positive patients (p 0.011).
In this study, total bilirubin was
raised in 25% of patients and the
mean total bilirubin was found to
be 1.04 1.17 mg/dl. The SGOT
and SGPT were abnormal in 76%
and 51% of patients with mean
values being 122.04 172.27 and
91.81 123.60 IU/L, respectively.
Interestingly, the study showed,
SGOT more than SGPT. The alkaline
phosphatase was raised in 43% of
patients with mean values being
144.39 91.99 (Table 6). Serum
sodium and serum potassium were
found to be normal in 95% and 97%
of the patients with mean values of
136.16 4.33 and 4.04 0.55 meq/L
respectively. Hyponatraemia and
hyperkalaemia were present in 3%
patients each while hypernatraemia
was noted in 2% of the patients.
ECG revealed sinus bradycardia in
31% of the patients.

Discussion
Dengue is one of the most
underreported tropical diseases and
during epidemics, overreporting
can occur at some hospitals. The
lack of laboratory resources and the
nonspecific clinical presentation of
non-severe cases greatly contribute
to this situation.
In the present study slight male
preponderance was seen that is,
62% of patients were males and
the male to female ratio was 1.63:1.
In this study most of the patients
(60%) were aged less than 30 years
followed by 30 to 40 years (15%),

40

Journal of The Association of Physicians of India Vol. 63 May 2015

Table 1: Diagnostic accuracy of NS1

in comparison to IgM ELISA
after seven days

Table 2: Presenting complaints

IgM
NS1 test
Total
Positive Negative
Positive
65
3
68
Negative
5
27
32
Total
70
30
100
p < 0.001; Kappa = 0.813
SE of kappa = 0.063
95% confidence interval: From 0.689 to 0.937

Fever
Headache
Myalgia
Retro-orbital pain
Pain abdomen
Rash
Arthralgia
Bleeding
manifestation
Vomiting
Diarrhoea

The strength of agreement is considered to

be very good.
Sensitivity: 92.86%; Specificity: 90%
PPV: 95.59%; NPV:84.38%

51 to 60 years (12%) and 41 to 50

years (10%). The mean age of the
study population was 32.48 13.87
years. In the present study all
the patients presented with fever
100% followed by headache in
82%, myalgia in 72%, retro-orbital
pain in 62% and pain abdomen
in 49% of patients. On clinical
examination, icterus and oedema
was observed in 16% and 9% of
patients that were statistically
significant in NS1 positive patients
(p < 0.016 and p <0.031 respectively).
Hypotension was seen in 4% of
patients all of whom were NS1
positive. Abdominal tenderness
was present in 49% of patients,
arthralgia in 31%, rashes in 36%

History

Headache

Present
Absent
Myalgia
Present
Absent
Retro orbital pain Present
Absent
Pain abdomen
Present
Absent
Rash
Present
Absent
Arthralgia
Present
Absent
Bleeding
Present
manifestation
Absent
Vomiting
Present
Absent
Diarrhoea
Present
Absent

22 (22)
20 (20)
2 (2)

and neurological involvement was

present in 5% of patients.
In our study bleeding
manifestations were present in 22%
of the patients of which majority
presented with melaena (8%).
B l e e d i n g m a n i f e s t a t i o n s we r e
significantly more in NS1 positive
patients (p < 0.001).
Several studies have reported
different clinical features and
complications of dengue fever.
However, there is scarcity of data
on the assessment of early clinical
manifestations in dengue infection.
A study from Singapore by Low
JGH et al reported headache in
80%, myalgia in 69.2%, retro-orbital
pain in 26% and pain abdomen in

Table 3: Clinical features associated with dengue diagnosis

using NS1 antigen test in patients evaluated up to 7
days of fever onset
Presenting
complaints

Distribution (n=100)
Number (%)
100 (100)
82 (82)
72 (72)
62 (62)
49 (49)
36 (36)
31 (31)

NS1 positive NS1 negative

No. (%)

No. (%)

53 (64.6)
15 (83.3)
54 (75.0)
14 (50.0)
47 (75.8)
21 (55.3)
40 (81.6)
28 (54.9)
31 (86.1)
37 (57.8)
25 (80.7)
43 (62.3)
22 (100.0)
46 (59.0)
17 (85.0)
51 (63.8)
2 (100.0)
66 (67.4)

29 (35.4)
3 (16.7)
18 (25.0)
14 (50.0)
15 (24.2)
17 (44.7)
9 (18.4)
23 (45.1)
5 (13.9)
27 (42.2)
6 (19.4)
26 (37.7)
0 (0.0)
32 (41.0)
3 (15.0)
29 (36.3)
0 (0.0)
32 (32.7)

p value
0.124
0.016
0.016
0.069
0.004
0.004
<0.001
0.068
0.327

11.6% of patients as early clinical

symptoms in dengue infection. 7
In our study packed cell volume
was increased in 11% of patients.
Thrombocytopenia was seen in
87% of patients and leucopenia
seen in 16% of the patients. Serum
creatinine was raised in 17% of
p a t i e n t s t h a t wa s s t a t i s t i c a l l y
significant (p < 0.011) in NS1
positive patients.
T h e S G O T l e ve l s i n d e n g u e
infection have a tendency to be
greater than SGPT levels. This
pattern is similar to that seen in
alcoholic hepatitis but differs from
the pattern in other viral hepatitis.
The exact cause for this is unknown,
but it is hypothesised that it may be
due to excess release of SGOT from
damaged liver cells during dengue
infection. Another explanation is
involvement of myocytes. 8 In our
study we found elevation of liver
enzymes with SGOT being higher
than SGPT (mean SGOT 122.04 and
mean SGPT 91.81). The SGOT and
SGPT found to be increased in 76%
and 51% of patients respectively.
This abnormal pattern may be used
as an early indicator of dengue
infection.
The ECG findings revealed sinus

Table 4: Association of clinical signs with NS1 antigen test

results
Variables
Pulse rate

< 60 /min
> 60 /min
Hypotension Present
Absent
Icterus
Present
Absent
Oedema
Present
Absent
Normal
RS
Air entry B/L
bases
B/L Coarse
crepitations
PA
Normal
Tenderness
present
CNS
Normal
Altered sensorium

NS1 findings
Positive
Negative
(n=68)
(n=32)
No. (%)
No. (%)
24 (77.4)
7 (22.6)
44 (63.8)
25 (36.2)
4 (100.0)
0 (0.0)
64 (66.7)
32 (33.3)
15 (93.8)
1 (6.3)
53 (63.1)
31 (36.9)
9 (100.0)
0 (0.0)
59 (64.8)
32 (35.2)
51 (63.0)
30 (37.0)
13 (86.7)

2 (13.3)

4 (100.0)

0 (0.0)

28 (54.9)

23 (45.1)

40 (81.6)

9 (18.4)

63 (66.3)
5 (100.0)

32 (33.7)
0 (0.0)

p value

0.175
0.161
0.016
0.031

0.073

0.004
0.116

Journal of The Association of Physicians of India Vol. 63 May 2015

Table 5: Complete blood count

Distribution
(n=100)
PCV
> 50
11
(%)
< 50
89
Total
100
Mean SD
42.4 8.3
87
Platelet count TCP
(/mm3)
Normal
13
Total
100
Mean SD
37121 32305
Normal
78
TLC
(/mm3)
Leucopenia
16
Leucocytosis
6
Total
100
Mean SD
5500 2490
Variables

Findings

PCV: Packed cell volume; TLC: Total

leucocyte count; TCP: Thrombocytopenia

bradycardia in 31% of patients.

The NS1 antigen test for the
diagnosis of acute dengue infection
had demonstrated considerable
variation in sensitivity (49.8%98.7%) but the specificities reported
were more consistent with all being
> 90%. 9 In this study NS1 test was
positive for dengue infection in 68%
of patients and 70% of patients were
positive for dengue infection on
IgM. Of these, 65 were positive for
dengue infection on NS1 while five
were negative. The sensitivity of
NS1 in predicting dengue infection
compared to IgM was 92.86% and
specificity was 90% with 95.59%
p o s i t i ve p r e d i c t i ve va l u e a n d
84.38% negative predictive value (p
< 0.001). The strength of agreement
was considered to be very good
based on Kappa statistics (Kappa
0.813; SE of kappa = 0.063; 95%
confidence interval: From 0.689 to
0.937).
Overall the present study
s h o we d t h e u sefulnes s of N S1
antigen test which is an excellent
tool in addressing potentially
fatal, epidemic-prone dengue
infection based on its easy and
fast application compared to
immunochromatography based
dengue serology tests.
Similarly, clinical features,
like retro-orbital pain,
myalgia, arthralgia, rash,
bleeding manifestations along

Table 6: Liver function test

Variables
Total
bilirubin
(mg/dl)
SGOT
(IU/L)

Findings
Normal
Raised
Total
Mean SD
Normal
Raised
Total

Mean SD
Normal
Raised
Total
Mean SD
Alkaline
Normal
phosphatase Raised
Total
Mean SD
SGPT
(IU/L)

Distribution
(n=100)
75
25
100
1.04 1.17
24
76
100
122 172.3
49
51
100
91.8 123.6
57
43
100
144.4 92

with laboratory findings like

thrombocytopenia, SGOT > SGPT
strongly support the diagnosis of
dengue fever.
The limitations of this study
were, smaller sample size, and
NS1 antigen test was not evaluated
considering PCR, which has higher
sensitivity than NS1 antigen tests
though which was beyond the
scope of this study. Further studies
comprising of large sample size
with polymerase chain reaction
(PCR) would further explore the
role of NS1 antigen testing in the
diagnosis of dengue infection.

Conclusion
Early identification of dengue
infection in acute phase sera using
NS1 antigen rapid detection test
is valuable in terms of disease
progression and mortality. In
our study, NS1 RDT showed
promising results with sensitivity
and specificity of 92.86% and 90%
respectively when compared with
IgM-ELISA done later in the course
o f i l l n e s s . H o we ve r , i n h i g h l y
suspected cases of dengue infection
clinical management should not
rely on negative serological results.
Considering only clinical
features, in our study we found
that presence of retro-orbital pain,
myalgia, bleeding manifestations,
rashes and arthralgia were

41

significantly (p value < 0.05) more

in patients who were NS1 positive.
Patients with dengue fever are
more prone to have liver enzyme
derangement as found in our study
and preferentially high SGOT
may serve as an early indicator of
dengue infection.
Similarly thrombocytopenia was
more significant (p value 0.002)
in NS1 positive patients and it
is a very important indicator of
prognosis in dengue fever.
Thus we conclude that dengue
infection, which possesses serious
public health problem, can be
diagnosed early with the help
of clinical features like retroorbital pain, myalgia, bleeding
manifestations, thrombocytopenia,
SGOT greater than SGPT that is
supported by detection of NS1
antigen.

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WHO. Scientific Working Group Report

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TDR/WHO. Evaluation of commercially

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3.

Guzman MG, Kouri G. Dengue: an update.

Lancet Infect Dis 2002; 2:33-42.

4.

Gubler DJ. The changing epidemiology of

yellow fever and dengue, 1900 to 2003: full
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Ramos MM, Tomashek KM, Arguello DF

et al. Early clinical features of dengue
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WHO. Dengue and dengue haemorrhagic

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7.

Low JG, Ong A, Tan LK, et al. The Early

Clinical Features of Dengue in Adults:
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8.

Chhina RS, Goyal O, Chhina DK, Goyal

P, Kumar R, Puri S. Liver function tests
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