S U D A N E S E J O U R N A L O F PA E D I AT R I C S
ORIGINAL ARTICLE
Clinical, biochemical and outcome profile
of dengue fever in hospitalised children in
Eastern Uttar Pradesh, India
Ankur Singh(1) , Abhishek Abhinay (1), Rajniti Prasad (1), Om Prakash Mishra (1)
(1) D
 epartment of Paediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi,
India
ABSTRACT
Dengue fever is an important cause of acute
febrile illness in the postmonsoon season in India.
This study was done to record the incidence of
dengue in admitted patients with acute febrile
illness in a hospital setting. The study also intends
to record the clinical, biochemical and outcome
profile of paediatric dengue cases admitted in
tertiary centres in Eastern Uttar Pradesh, India.
It was a prospective case record analysis at a
tertiary care research hospital in Eastern Uttar
Pradesh. The study recruited fifty-53 children
(<18 years) with serology-proven diagnosis of
dengue disease. Disease was confirmed by doing
Ns1Ag, IgM antibody test by ELISA method.
Six hundred children were screened and 53 met
the inclusion criteria. The incidence of dengue
disease in hospitalised acute febrile illness was
8.8%. There were thirty-one males. The mean
age of presentation of the study population
was 9.32 ± 5 years with a range of 0.25 – 17
years. Fever (94%), nausea and vomiting (59
%), abdominal pain (55%), persistent vomiting
(49%), thrombocytopenia (<100,000 [66%]),
and petechiae and purpura (43%) were the
important clinical manifestations. Six required
intensive care monitoring. There was only one
Correspondence to:
Professor Ankur Singh
Department of Paediatrics, Institute of Medical
Sciences, Banaras Hindu University, Varanasi, India.
Email: ankur@bhu.ac.in
Received: 24 December 2020 | Accepted: 17 November 2023 https://doi.org/10.24911/SJP.106-1608787494
2023; Vol 23, Issue No.
death. Dengue fever is an important cause of
acute febrile illness in children. Case fatality
rate can be minimised with proper World Health
Organisation classification and protocol-based
management of cases.
KEYWORDS
Dengue fever; Children; Outcome; Eastern Uttar
Pradesh; India.
INTRODUCTION
Dengue is the most prevalent Flavivirus infection
in tropical and subtropical countries. It is caused
by mosquito vectors: Aedes aegypti and Aedes
albopictus [1,2]. Dengue has become endemic to
every region in India due to unplanned urbanisation
and poor water sanitation services. There have
been published reports of dengue infection from
all over India, mainly from metropolitan cities
[3–7]. Dengue has become an important cause
of acute febrile illness in postmonsoon season in
small cities too. There has been a lack of studies
on the dengue profile of paediatric patients in
this eastern part of Uttar Pradesh. To address this
knowledge gap, we undertook this study to know
How to cite this article:
Singh A, AbhinayA, Prasad R, Mishra OP. Clinical,
biochemical and outcome profile of dengue fever in
hospitalised children in Eastern Uttar Pradesh, India.
Sudan. Sudan J Paediatr.2023;23(2):171–176.
http://www.sudanjp.org 171
https://www/sudanjp.com
S U D A N E S E J O U R N A L O F PA E D I AT R I C S
the incidence of dengue disease in acute (fever <5
days) febrile illness in the paediatric age group in
hospitalised children. A secondary objective was
to enlist the age profile, clinical, biochemical and
outcome profiles in the paediatric age group.
MATERIALS AND METHODS
The present study was conducted at the
Department of Paediatrics between periods from
September to December 2018. It was a prospective
observational study of all dengue cases, admitted
to the paediatric ward of less than 18 years of
age. The primary objective was to study the
incidence of dengue disease in acute febrile
illness in hospitalised paediatric patients. All
relevant demographic, clinical and biochemical
information was recorded in predesigned
performa. The case of dengue was defined by the
presence of compatible clinical symptoms with
positive serology test by ELISA method (either of
Ns1Ag, IgM). Cases were further classified based
on the World Health Organisation (WHO) criteria
[8]. Cases were managed according to the latest
WHO protocol [8]. Laboratory parameters were
recorded at admission and discharge. Parameters
were compared among cases based on their
severity. Frequencies for qualitative variables
were recorded. Quantitative variables were
summarised with mean and SD. Comparison
among quantitative variables was made using
the student t test, analysis of variance-one-way.
A nonparametric test of Wilcoxon was used for
a paired data set where the SD was too high. The
chi-square test was used for comparison among
groups. The nonparametric test Kruskal – Wallis
was used to compare means among groups where
data was NonGaussian. Significance was taken as
p < 0.05.
RESULTS
A total of 600 children less than 18 years of age
were screened for dengue serology and disease.
There were 8.8% confirmed cases of dengue. We
recruited 53 dengue disease cases with 31 males
and 22 females (Table 1). The majority of cases
(49/53) belonged to Varanasi urban and semi-
urban areas. The mean age of presentation of
the study population was 9.32 ± 5 years with a
172 http://www.sudanjp.org
https://www/sudanjp.com
2023; Vol 23, Issue No. 2
range of 0.25 – 17 years. There were 43 cases of
nonsevere dengue (probable dengue = 4, dengue
with warning signs = 39) and 10 cases of severe
dengue. The prominent clinical manifestations
were: fever (94%), nausea and vomiting (59%),
abdominal pain (55%), persistent vomiting
(49%), lethargy and headache (40%), body pain
and anorexia (36%), rash (28%), and eye pain
(23%).
Other less common manifestations were: cough,
diarrhoea, convulsion, nasal bleeding, blood in
stool, vaginal bleed, mucosal bleed, bleeding
gums, and blood in the urine. -66% of cases
had low platelet count (<100,000) at the time
of presentation. Petechiae and purpura were
present in 43% of cases. The mean duration of
hospital stay was 4.58 ± 2.85 days in the study
population. There was a significant difference in
haemoglobin, platelet and haematocrit parameters
at admission and discharge in the dengue with
warning signs group (Table 2). On the contrary,
severe dengue cases had significant differences
in total leucocyte count and platelet at admission
and discharge (Table 2).
There was a significant difference among the three
groups based on hospital stay. This difference was
more significant between probable dengue versus
dengue with warning signs and probable dengue
versus severe dengue (Table 3). There was no
significant difference in mean age at presentation
in all three groups. There were only six cases
that required paediatric intensive care admission.
The successful discharge rate was 93%. The case
fatality rate was (1.8%). There were two cases
that were left against doctors’ advice (LAMA).
DISCUSSION
Dengue fever is one of the most common causes
of acute febrile illness in postmonsoon season in
India. The present study recruited 53 cases with 32
males and 22 females. Slight male preponderance
has been found in various Indian studies too [3–
7]. The mean age of presentation was 9.32 ± 5.0
years, slightly higher than previously reported
studies [3–7]. This might be due to early reporting
of symptoms by elderly children, increased
awareness among the general public about the
disease, and better availability of diagnostic
S U D A N E S E J O U R N A L O F PA E D I AT R I C S 2023; Vol 23, Issue No. 2

Table 1. Demographic, clinical and outcome characteristics of study group

(n = 53).

Parameter N
Gender Male 31 (58.49%)
Female 22 (41.50%)
Locality Varanasi 49 (92.45%)
Jaunpur 1 (1.88%)
Bhabhua 1 (1.88%)
Bhadohi 1 (1.88%)
Rohtas 1 (1.88%)
Discharge 49 (92.45%)
Outcome Death 1 (1.88%)
LAMA 2 (3.77 %)
Requiring PICU Yes 6 (11.32%)
Admission
Fever lasting for 2–7 days 50 (94.33%)
Fever at the time of presentation 12 (22.64%)
Persistent vomiting 26 (49.05%)
Nausea and vomiting 31 (58.49%)
Abdominal pain 29 (54.71%)
Lethargy/restlessness 21 (39.62%)
Rash 15 (28.30&)
Headache 21 (39.62%)
Eye pain 12 (22.64%)
Body pain 19 (35.84%)
Anorexia 19 (35.84%)
Liver enlargement (>2 cm ) 21 (39.62%)
Vomit with blood 1 (1.88%)
Blood in stool 3/51 (5.88%)
Nasal bleed 5/52 (9.61%)
Bleeding gums 2/52 (3.84%)
Blood in urine 1 (1.88%)
Vaginal bleed 3 (5.66 % )
Haematuria 1/34 (2.94%)
Diarrhoea 7 (13.20%)
Cough 9 (16.98%)
Convulsion or coma 6 (11.32%)
Mucosal bleeding 3 (5.66 % )
Platelet count 35 (66.03%)
<100,000 at time of presentation
Petechiae 10/52 (19.23%)
Purpura 13 (24.52%)

(Continued)

http://www.sudanjp.org 173
https://www/sudanjp.com
S U D A N E S E J O U R N A L O F PA E D I AT R I C S 2023; Vol 23, Issue No. 2

Parameter N
Capillary leak (pleural effusion/ascites) 6 (11.32%)
Probable dengue 4 (7.54%)
Dengue with warning signs 39 (7.35%)
Severe dengue 10 (18.86%)
LAMA, Left against medical advice; PICU, Paediatric Intensive Care Unit.

Table 2. Summary characteristics of quantitative variables (n = 53).

Parameter Mean ± SD or median (IQR)

Age (years ) 9.32 ± 5.0
Parameter Mean ± SD or median (IQR)
---------------------------------------------- -------------------------------------
Hospital stay (days) 4.58 ± 2.85
Hb at admission (gm/dl) 11.63 ± 2.15
Hb lowest (gm/dl) 10.55 ± 1.92
Hb highest (gm/dl) 12.23 ± 2.04
Hb at discharge (gm/dl) 11.00 ± 1.58
TLC at admission (cells/µl) 6,430 (5,995)
TLC lowest (cells/µl) 4,185 (3,715)
TLC highest (cells/µl) 7,195 (5,060)
TLC at discharge (cells/µl) 6,230 (3,780)
Platelet at admission (cells/µl) 47,000 (119,000)
Platelet lowest (cells/µl) 36,500 (84,000)
Platelet highest (cells/µl) 130,000 (70,000)
Platelet at discharge (cells/µl) 119,000 (80,000)
Hct at admission (%) 35 ± 5.74
Hct lowest (%) 31.39 ± 4.51
Hct highest (%) 36.61 ± 5.40
Hct at discharge (%) 32.56 ± 4.18
Urea (mg/dl) 27.35 (15.9)
Creatinine (mg/dl) 0.7 ± 0.25
Sodium meq/l) 136.28 ±6.08
Potassium (meq/l) 4.55 ± 0.71
SGOT (IU/l) 116 (136.5)
SGPT (IU/l) 60.9 (71.1)
Total bilrubin (mg/dl) 0.54 ± 0.62
Direct bilirubin (mg/dl) 0.34 ± 0.60
Indirect bilirubin (mg/dl) 0.20 ± 0.13
Total protein (gm/dl) 6.0 ± 0.84
Albumin (gm/dl) 3.4 ± 0.48
Alkaline phosphatase (IU/l) 214.85 (201.5)
Hb, Haemoglobin; Hct, Haematocrit; IQR, Interquartile range; SD, Standard deviation; SGOT,
Serum glutamic oxaloacetic transaminase; SGPT, Serum glutamic pyruvic transaminase;
TLC,Total leucocyte count.

174 http://www.sudanjp.org
https://www/sudanjp.com
S U D A N E S E J O U R N A L O F PA E D I AT R I C S
Table 3. Number of hospital days based on dengue severity.
Hospital stay (days)
Dengue severity
Median (IQR)
Probable dengue
Dengue with
warning signs
Severe dengue
IQR, Interquartile range.
and therapeutic services in the region. Common
symptoms of fever, cough and coryza may be
attributable to other common upper respiratory
symptoms in younger children by treating
clinicians; thereby leading to underdiagnosis
of dengue in the younger population. Fever,
vomiting and abdominal pain were the consistent
features of the disease (Table 1). This finding is in
congruence with previous published Indian studies
[3–7]. The presence of thrombocytopenia was not
associated with bleeding manifestation. Children
showed bleeding manifestations even at >50,000
platelet counts. There were children who did not
bleed even at <10,000 platelet count. This finding
shows that there are other mechanisms that are
responsible for bleeding in dengue disease [9–12].
These are suppression of haematopoiesis directly
by the dengue virus, indirect immune injury,
consumptive coagulopathy, platelet function
defect, and damage of vascular endothelial cells.
Newer WHO classification of dengue fever has
facilitated in early diagnosis and protocol-based
treatment of dengue fever. Children with warning
signs are admitted and hydrated well so they do not
enter the phase of critical illness or complication
(severe dengue). In this study, our maximum
number of patients were from the category of
nonsevere dengue (probable dengue −4; dengue
with warning signs −39). Advantages of the new
WHO classification are: the children are picked
up early in disease progression, get protocol-based
treatment and platelet infusions are discouraged,
leading to less morbidity and mortality. All previous
studies had shown mortality of 1% – 2%; similar
findings in our study population [3–7]. Few studies
have compared the previous WHO Classification
(1997) with the present WHO classification (2009)
[13]. They have found better sensitivity and
specificity of the present WHO classification over
2023; Vol 23, Issue No. 2
p-value
2 (1,3)
4 (3,5) 0.004
6 (5,8)
the previous one in the Indian population too. The
better outcome in the present study is supported
by our biochemical parameters. There has been
a significant change in monitoring parameters of
disease at the time of admission and at discharge.
Nonsevere dengue disease has shorter hospital
stays as compared to severe dengue disease. This is
due to developing complications in severe disease;
leading to longer hospital stays. Only a few patients
required paediatric intensive care management.
This suggests that patients can be managed in a
normal ward if proper classification of disease is
done at the time of diagnosis. This will also reduce
the financial burden on patients and hospitals. It
will further reduce the demand for intensive care.
The present study has a limitation of small sample
size. We studied only hospitalised children. Out-
patient nonsevere dengue cases were not taken.
This important limitation underestimates the
actual burden of the problem in this region.
Serotyping and genotyping of prevalent dengue
strain was not done. Therefore, there is a need to
study the prevalent dengue strain in this region.
This will help to develop vaccine design and
deployment strategies for the disease.
This study has brought up important points.
It constitutes the first study in this Varanasi
region focussing on an estimate of the burden of
problems faced by children of this region. Public
health policymakers should improve preventive
and therapeutic services in the region to combat
vector-borne diseases during postmonsoon
season.
CONFLICT OF INTEREST
The authors declare that they have no competing
interests.
http://www.sudanjp.org 175
https://www/sudanjp.com
S U D A N E S E J O U R N A L O F PA E D I AT R I C S
FUNDING
None.
ETHICAL APPROVAL
Institute ethical clearance was taken from
the Institute Ethical Committee (Dean/2019/
EC/1017) (dated: 18/01/2019). Written informed
consent was obtained from parents of children
included in the study.
REFERENCES
1. Halstead SB. The XXth century dengue pandemic:
need for surveillance and research. World Health
Stat Q. 1992;45(2–3):292–8.
2. Xu G, Dong H, Shi N, Liu S, Zhou A, Cheng Z, et al.
An outbreak of dengue virus serotype 1 infection
in Cixi, Ningbo, People’s Republic of China, 2004,
associated with a traveler from Thailand and
high density of Aedes albopictus. Am J Trop Med
Hyg. 2007;76:1182–8. https://doi.org/10.4269/
ajtmh.2007.76.1182
3. Sahana KS, Sujatha R. Clinical profile of dengue
among children according to revised WHO
classification: analysis of a 2012 outbreak from
Southern India. Indian J Pediatr. 2015;82:109–13.
https://doi.org/10.1007/s12098-014-1523-3
4. Pothapregada S, Kamalakannan B, Thulasingham
M, Sampath S. Clinically profiling pediatric patients
with dengue. J Glob Infect Dis. 2016;8:115–20.
https://doi.org/10.4103/0974-777X.188596
5. Mishra S, Ramanathan R, Agarwalla SK.
Clinical profile of dengue fever in children: a
study from Southern Odisha, India. Scientifica
(Cairo). 2016;2016:6391594. https://doi.
org/10.1155/2016/6391594
176 http://www.sudanjp.org
https://www/sudanjp.com
2023; Vol 23, Issue No. 2
6. Joshi R, Baid V. Profile of dengue patients
admitted to a tertiary care hospital in Mumbai.
Turk J Pediatr. 2011;53:626–31.
7. Mittal H, Faridi MM, Arora SK, Patil R.
Clinicohematological profile and platelet trends
in children with dengue during 2010 epidemic
in north India. Indian J Pediatr. 2012;79:467–71.
https://doi.org/10.1007/s12098-011-0586-7
8. World Health Organization. Dengue guidelines
for diagnosis, treatment, prevention and
control: new edition. Geneva, Switzerland:
World Health Organization; 2009 [cited 2019 Oct
09]. Available from: https://apps.who.int/iris/
handle/10665/44188
9. Narayanan M, Aravind MA, Thilothammal N, Prema
R, Sargunam CS, Ramamurty N. Dengue fever
epidemic in Chennai – a study of clinical profile and
outcome. Indian Pediatr. 2002;39:1027–33.
10. Méndez A, González G. Dengue hemorrágico en
niños: diez años de experiencia clínica [Dengue
haemorrhagic fever in children: ten years of
clinical experience]. Biomedica. 2003;23:180–93.
https://doi.org/10.7705/biomedica.v23i2.1210
11. Funahara Y, Ogawa K, Fujita N, Okuno Y. Three
possible triggers to induce thrombocytopenia in
dengue virus infection. Southeast Asian J Trop
Med Public Health. 1987;18:351–5.
12. Dewi BE, Takasaki T, Kurane I. In vitro assessment
of human endothelial cell permeability: effects
of inflammatory cytokines and dengue virus
infection. J Virol Methods. 2004;121:171–80.
https://doi.org/10.1016/j.jviromet.2004.06.013
13. Sabeena S, Chandrabharani K, Ravishankar N,
Arunkumar G. Classification of dengue cases in
Southwest India based on the WHO systems-a
retrospective analysis. Trans R Soc Trop Med
Hyg. 2018;112:479–85. https://doi.org/10.1093/
trstmh/try080