临床严重程度与实验室参数与登革热病毒中各种血清型的相关性：基于医院的研究

抽象

Objectives。Dengue fever, being hyperendemic with analogous presentations as in many other acute febrile illnesses, poses a challenge in diagnosis during the acute stage. Additionally, the coexistence of multiple serotypes further complicates the disease prognosis. The study was undertaken to determine the dengue virus serotypes, clinical, and laboratory markers as predictors in the severity of infection.方法。在患有急性发热疾病的106名患者中进行了预期研究，具有阳性NS1抗原/ IgM ELISA。从医疗记录中提取临床数据，包括人口统计学，临床介绍，实验室调查以及包括住院时间和结果的临床介绍，实验室调查以及课程。通过多重逆转录酶聚合酶链反应（RT_PCR）来检测登革热血清型。结果。在106例RT-PCR确认的情况下，Denv-3是56名（52.8％）患者中最常见的血清型，其次是27例（25.4％）患者的Denv-3和Denv-4繁殖。在我们的研究中见证了多种血清型的繁殖。升高的肝酶和含量增加的铁蛋白是良好的生物标志物，以利用AST（134 U / L），ALT（88 U / L）和铁蛋白（3670ng / ml）的截止水平来区分登革热。肌肉骨骼，其次是胃肠道，表现均比呼吸和皮肤表现相对较高。结论。This study provides more information on the dengue serotypes. The clinical spectrum along with laboratory parameters such as ferritin, liver enzymes, platelet can be used as potential biomarkers in prediction of dengue severity. The data demonstrated will be useful in early detection and monitoring of the disease.

1.介绍

登革热（DF）是一个主要的公共卫生问题。这是一个常见的蚊子疾病，在印度南部沿海地区流行。全球负担估计表明每年3.9亿感染。其中，在亚洲看到了70％的实际负担[1]。这是载体传播疾病中死亡率和发病率的重要原因。

Four antigenically different dengue virus serotypes (DENV-1, DENV-2, DENV-3, and DENV-4) are known to cause infections in humans. Chances for developing dengue hemorrhagic fever-dengue shock syndrome (DHF-DSS) increases significantly with a history of the previous infection with one of the four serotypes. Early diagnosis, serotyping, and providing timely warning of dengue fever epidemics to the concerned authorities become very important for better patient outcomes and to curb the rapid spread of the virulent serotypes within the community [2]。The hyperendemicity with coinfection of two or more serotypes during the same period has been widely suspected as one of the major causes of disease severity in dengue patients in India [3]。当多个血清型在一个人中普遍存在时，登革热监视变得重要[4]。

在目前的研究中，我们针对（1）鉴定登革热病例的登革热病毒血清型，因为其在该地区的分布未记录（2），以确定不同的血清型临床表现及其与疾病的关联严重程度和（3）研究铁蛋白，血小板计数和差异白细胞计数等标志物的关联，因为评估登革热的严重程度时的风险预测因子。

2.方法

在印度麦加尔大教育中心的患者中进行了一项前瞻性研究，在卡纳塔克卡达喀岛坎达区的登革唱爆发期间，登革热期间登革热的临床可疑迹象和症状。该地区是登革热的流行，在每个雨季都会看到案件的陡峭上升。在研究中纳入18岁以上的患者。在本研究中排除了门诊基础或减少18岁的人的病例。

Out of 3,801 suspected patients with fever during the period of July to October 2019, 991 were tested positive by NS1/IgM ELISA. Serotype analysis was performed for 106 patients. Patients were categorized based on WHO classification as stage 1—dengue without warning signs, stage 2—dengue with warning signs, and stage 3—severe dengue. A sample size of 106 was calculated considering a power of 80%, confidence level of 95%, proportion of DENV-1 to be 68.8%, and absolute precision of 5%.

使用的公式是 whereN = sample size,P = proportion of interest (68.8%),Q = 1 − P，和D = absolute precision (5%) [3]。

2.1。采样技术：方便采样

2.1.1。血清学诊断

一种cute phase serum samples within 7 days of onset of symptoms which were positive for dengue NS1 rapid immunochromatographic test/IgM positive by ELISA (Panbio) were analyzed from 106 patients. The samples were stored at −20°C.

2.1.2。分子诊断

根据试剂盒协议，使用QIAAMP病毒RNA迷你提取试剂盒（QIAGEN，德国）提取病毒RNA。将提取的RNA储存在-80℃直至使用。对Dengue血清型确认进行多重二步逆转录酶PCR。CDC登革热引物和探针和主混合一步的PRIME脚本™RT-PCR套件（Takara Bio，Japan）在本研究中被使用。进行多重测定，用于检测4血清型Denv-1，DenV-2，DenV-3和Denv-4。根据CDC登革热套件方案，使用热循环条件进行PCR扩增：在50℃下保持在30分钟，保持循环2：2.​​0分钟，在95°C;在60.0°C下在95°C和1分钟的荧光获得15秒，可在60.0°C下获得45个循环。扩增产物被算用于特定通道中的荧光检测增加。在试剂盒中提供了阳性对照。

该研究在制度伦理委员会批准后进行了批准，并从患者的知情同意下进行。

2.2。统计分析

分类数据以频率和比例的形式分析。以平均值，中位数和比例的形式分析定量数据。在SPSS版本17中输入并分析完整数据。对于定量数据，绘制受体操作曲线（ROC）以建立截止浓度。对于铁蛋白，Kruskal-Wallis测试用于研究登革热的严重程度。一种值<0.05被认为是显着的。

3. Results

在106例确诊的积极案件中，登革热在男性（68）中主要见于女性（38）（图1）。根据年龄组 - 明智的分布，在21-30岁（36）年龄组中看到了更积极的病例，然后在31-40岁（29），51-60岁（14），18-20岁，41-50年（11），61岁以上（5）。平均年龄为35.27。

该区域中不同登革热血清型的发病率如图所示2。

The various comorbidities associated with dengue were diabetes mellitus (10.4%), diabetes with hypertension (0.9%), and malignancy (0.9%). According to WHO dengue classification, 70.8%, 24.5%, and 4.7% belonged to stages 1, 2, and 3, respectively.

所有病例都出现发烧了ging from 99°C to 104.5°C followed by symptoms such as headache, malaise, chills, and rigors. Musculoskeletal manifestations such as myalgia and backache followed by gastrointestinal manifestations including vomiting, abdominal pain, and ascites were the next common clinical presentation, with the least number presenting with respiratory manifestations such as cough and cold and cutaneous manifestations such as rash and erythema. DENV-3 followed by mixed serotypes DENV-3 and DENV-4 presented with the above symptoms. Rash and cough was not a manifestation seen in the serotypes commonly found in the present study (Figure1和Table1）。

3.1。实验室参数

3.1.1。铁丁

In our study, the association of ferritin levels in patients categorized according to WHO classification of dengue was significant with avalue of 0.009 and interquartile range from 925 ng/ml–13,829 ng/ml. The maximum ferritin level rise being 87,945 ng/ml was noticed in a severe dengue case. The mean ferritin levels in dengue without warning signs, dengue with warning signs, and severe dengue were 2,304.48, 12,431.00, and 54655.25 ng/ml, and the cutoff values were 640, 2458, and 35,930 ng/ml, respectively. The cutoff for ferritin to differentiate between dengue and severe dengue was 3670 ng/ml. The area under the curve (AUC) for ferritin obtained in predicting dengue versus severe dengue is 0.849 with 95% CI (0.712, 0.985).

3.1。2. Platelet Levels

在第1阶段入院期间观察到的最低血小板水平为3000，第2阶段为46,076，第3阶段为每毫米58,400个细胞³。The median platelet count in stage 1 was 85,000, stage 2 was 31,500, and stage 3 was 33,000. The价值与<0.05显着。在预测登革热与严重登革热中获得的最大血小板降的AUC为0.635，95％CI（0.454,0.817）。IQR在第1阶段为53,000-85,000，第2阶段为16,250-31,500，第3阶段为22,000-33,000级。在医院住宿期间的最大血小板下降并没有表现为登革热严重程度的预测因素。共有9名患者的血小板计数超过1,50,000个细胞/ mm³。

3.1.3。肝酶

Serum ALT and AST observed were in the higher range with a maximum value of ALT and AST being 502 (IQR, 28–153 U/L) and 1737 (IQR, 40–240 U/L), respectively. On plotting the receiver operating characteristics (ROC), the cutoff for AST was 134 U/L and ALT was 88 U/L. The AUC for AST and ALT obtained in predicting dengue versus severe dengue is 0.757, 0.731 with 95% CI (0.586, 0.928) and (0.551, 0.911) (Figure3）。

一个与登革热严重程度的USG胆囊是显着的（值0.001）。脂肪肝的变化是我们研究中观察到的常见特征。在8.5％的感染个体中观察到血杂细胞淋巴淋巴梗细胞症（HLH）综合征（表2）。

3.2. Serotype Analysis

The most common monotypic serotype in this region was DENV-3 seen in 56 (52.8%) patients, followed by multiple serotypes DENV-3 and 4 in 27 (25.4%) patients; all 4 serotypes in 8 (7.5%) patients; and DENV-2, 3, and 4 in 7 (6.6%) of patients (Table3）。具有多种类型的多种血清型是一个特征，Denv-3在这些情况下是常见的血清型。血清型分布模式是Denv-3血清型，并在93名患者中发现，39名患者Denv-4，21例患者中的Denv-2，其次在12名患者中进行Denv-1（表3）。

No association was found between the severity of disease and serotype, as the percentage of severe dengue was less in number. DENV-3 was found in 8 out of 9 cases of HLH syndrome. The least common serotype was DENV-1. No fatalities were observed in the patients included in this study.

4。讨论

Dengue fever has a dynamic pattern ranging from mild febrile illness to a spectrum of manifestations including hemorrhage, multiorgan dysfunction, HLH, and death. In the present study, the pattern of the clinical and laboratory parameter in patients during the monsoon season 2019 dengue outbreak in Dakshina Kannada was studied. With 991 dengue IgM confirmed cases during four months, dengue continues to be an endemic disease. The male population has dengue predominately in the ratio of 2 : 1. In other studies, a similar male preponderance was seen [4]。概率是因为该地区是为了登革热和雄性曝光的流行一种edes在他们的工作场所或旅行时蚊子。在我们的人口中，登革热在20至40岁之间观看了20至40岁，这可能归因于成年人的流动，以获得其生计，易于使用卫生保健设施，以及对该地区蚊帐高患病率的认识。

On clinical evaluation, WHO stage 1-type DF was found in a higher number of cases than severe dengue of stage 2 and stage 3, which was comparable with studies conducted in Bali [5]。一种ll four serotypes existed during the study period. The data show the most common serotype prevalent in this geographical region is DENV-3 which was seen in a study in Indonesia and in different parts of India such as Kerala and Uttar Pradesh [4,6]。In Delhi, the DENV-2 serotype was predominant [7]。没有血清型与疾病的严重程度合作。感染血清型的毒力有相当大的变异，这是动态的。由于我们是该地区登革热血清型的第一次研究，不能制定对分子血清型的比较分析。研究表明，在这些病例中，单个患者中的多种血清型的共存作为贡献因素在这些情况下，登革扬的严重程度增加[8,9]。

在马来西亚和印度在丹佛-3中观察到胃肠道和肌肉骨骼症状的高患病率，与我们的研究类似，在Denv-4中观察到皮肤和呼吸系统症状，因为Denv-4在丹佛4中不普遍存在目前的研究[8,10]。在台湾人口进行的一项研究中，与Denv-2相比，Denv-3患者用皮疹呈现[11]。一种nother study by Kumaria showed DENV-4 presenting with hemorrhagic manifestations, but with low positivity DENV-4 rate [6]。一种steady rise in the ferritin levels along with levels of 2,304 ng/ml in stage 1 DF and the highest level up to 87,945 ng/ml seen among severe dengue with HLH syndrome correlated well with studies conducted by Roy Chaudhuri et al. and Soundaravally et al. [12,13]。因此，铁蛋白可以是DF诊断和预后的重要血清生物标志物。DF中的总细胞计数减少，但没有与严重程度指数平行。肝脏酶如血清ALT和AST显着增加，这些参数也可以用作急性发热病例中登革热的标志物。如Ho等人的研究所述，高温胰血症以及升高的ALT和AST水平。[14]。Alt和AST水平的增加被视为标记，以区分与其他原因如肝脏脓肿和急性肝炎的其他原因分化[15]。血小板减少症was a feature in most of the cases with DENV-3 in our study which was similar to a study by Tsai et al. [11]。

结论

Denv-3血清型和Denv-3和Denv-4血清型繁殖在印度卡纳塔克邦的Dakshina Kannada地区普遍存在。本研究得出结论，具有多种血清型的繁殖与登革热感染的疾病严重程度无关。该研究还表明，诸如铁蛋白和血清AST和ALT等生物标志物可以更好地预测因素来评估疾病严重程度，并应考虑这些标记的串行估计。这些结果提供了临床和血清型特征的新数据，以便更好地管理人口中的登革热。

数据可用性

用于支持本研究结果的数据集可根据要求从相应的作者获得。

利益冲突

作者声明他们没有利益冲突。

致谢

该研究部分由Kasturba Medical College，Mangalore，Mahe提供资金。作者感谢Kasturba Medical College，Mangalore，Mahe，为这项研究提供资金。作者真诚地感谢CDC，亚特兰大，为进行这项研究提供登革热社和探讨。

参考资料

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