|Year : 2016 | Volume
| Issue : 1 | Page : 152-153
Deciphering the dengue liver disease
(This invited commentary is in response to the case report, "Alam S, Singh AK, Singh B, Agarwal A.Dengue: A rare differential of acute hepatic failure. Med J DY Patil Univ 2015;8:830-2." published in the previous issue of this journal.)
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||22-Dec-2015|
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma V. Deciphering the dengue liver disease
(This invited commentary is in response to the case report, "Alam S, Singh AK, Singh B, Agarwal A.Dengue: A rare differential of acute hepatic failure. Med J DY Patil Univ 2015;8:830-2." published in the previous issue of this journal.). Med J DY Patil Univ 2016;9:152-3
|How to cite this URL:|
Sharma V. Deciphering the dengue liver disease
(This invited commentary is in response to the case report, "Alam S, Singh AK, Singh B, Agarwal A.Dengue: A rare differential of acute hepatic failure. Med J DY Patil Univ 2015;8:830-2." published in the previous issue of this journal.). Med J DY Patil Univ [serial online] 2016 [cited 2020 Aug 10];9:152-3. Available from: http://www.mjdrdypu.org/text.asp?2016/9/1/152/167979
The yellow fever virus and dengue virus are like the two twins who never met. Both are members of Flaviviridae, and both wreak havoc riding on their mosquito vector Aedes. Strangely though the twins have somehow come to affect different group of populations in the globe.  Interestingly, the yellow fever virus got its name because of the affliction of the liver which results in jaundice, although like dengue the yellow fever virus can also cause hemorrhagic fever. The dengue virus on the contrary is more notorious for the associated hemorrhagic fever and shock syndrome. These dominant manifestations have somehow shrouded the hepatic involvement into a virtual oblivion.
Many recent reports have, however, thrown light on the vast spectrum of hepatic manifestations caused by the dengue virus.  These include asymptomatic (and usually inconsequential) liver enzyme elevations, hypoalbuminemia, coagulopathy, precipitation of acute on chronic liver failure and as the authors report, acute hepatic failure. , Acute liver failure (ALF) has been reported on multiple occasions previously and seems to have a good prognosis in most reports. ,, There are some features which may be distinctive for dengue related liver injury: Presence of associated high grade fever, thrombocytopenia, elevated haematocrit, higher elevation in serum glutamic oxaloacetic transaminase than serum glutamic pyruvic transaminase (due to associated myocyte injury) and evidence of plasma leak as evidenced by pleural effusion, and ascites. In endemic areas, these features may allow distinction of dengue related ALF from other entities like viral hepatitis related ALF, malarial hepatopathy, enteric hepatitis, etc.  The clinical spectrum is now also recognized to include the possibility of worsening of underlying chronic liver disease and manifesting as acute on chronic liver failure which is a newly described clinical entity usually manifesting as jaundice and ascites in previously diagnosed or undiagnosed liver disease. In these situations, dengue may act as the acute precipitant. 
Pathologically dengue affects both the hepatocytes and the Kupffer cells, and histological changes may include fatty change, hepatocyte necrosis, Kupffer cell hyperplasia or destruction and variable inflammatory infiltrate without any significant fibrosis.  These changes emphasize that the changes are primarily those of acute hepatitis as is the clinical picture. Numerous therapeutic modalities have been reported to be successful (including use of N-acetyl-cysteine, recombinant factor VII and molecular adsorbent recirculating system) but other reports have indicated equally good outcomes sans this armamentarium. ,, Randomized or comparative studies are unlikely as acute hepatic failure is an uncommon manifestation, and, therefore, the treatment as outlined for acute hepatic failure due to other viral hepatitis should form the bedrock of management.  Briefly, this includes management in Intensive Care Unit, factoring in the likelihood of other possible etiologies, use of N-acetyl-cysteine, administration of oral/rectal lactulose, elective endotracheal intubation for higher grades of encephalopathy, management of intracranial hypertension (using mannitol, hypertonic saline, and possibly barbiturates and hypothermia), surveillance, early recognition and treatment of infection, management of bleeding with platelets and plasma, maintenance of organ support and listing for liver transplantation.  Though the literature about dengue related ALF is primarily in the form of case reports, some of the papers have implicated dengue as a common cause of ALF in pediatric age group in certain regions including Thailand and India. , Therefore, the entity deserves recognition and awareness as clinicians in the endemic regions may encounter dengue related liver injury and the disease may present not just to the general practitioners but to specialists including gastroenterologists. Before a diagnosis of dengue related ALF is established it would be prudent to consider related or additional factors like heavy intake of paracetamol, dengue related encephalopathy and concomitant infection with malaria which may mimic or predispose to ALF. Also, suspicion of dengue must not preclude workup for more common factors like viral markers for hepatitis and other tropical infections. While the authors must be complimented for the successful management of the patient and the good clinical outcome, the transfusion of fresh frozen plasma in absence of bleeding merely for correction of coagulopathy cannot be recommended. 
Recent successful trial of dengue vaccine use in countries of the Asia-Pacific region has raised the hope that the scourge of dengue will soon be put to rest.  But until the time the vision of the vaccine becomes a reality, dengue infection and the resulting phenomenon will keep exercising the evaluative and managerial skills of clinicians in the tropical world.
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