Received: 9 October 2018 Revised: 2 August 2019
DOI: 10.1111/tme.12658
ORIGINAL ARTICLE
Coagulation abnormalities in dengue and dengue haemorrhagic
fever patients
Jawad Hassan | Munira Borhany
Naveena Fatima | Tahir Shamsi
Department of Hematology, Hemostasis &
Thrombosis, National Institute of Blood
Disease & Bone Marrow Transplantation,
Karachi, Pakistan
Correspondence
Munira Borhany, Department of Hematology,
Hemostasis & Thrombosis, National Institute
of Blood Disease & Bone Marrow
Transplantation, ST 2/A Block 17 Gulshan-e-
Iqbal, KDA Scheme 24, Karachi, Pakistan.
Email: muniraborhany@gmail.com
1 | I N T RO DU CT I O N
Dengue is a serious viral infection among humans. Almost 2.5 billion
people are at risk of infection worldwide, out of which approximately
Transfusion Medicine. 2019;1–5.
Accepted: 30 November 2019
| Madiha Abid | Uzma Zaidi |
Summary
Objective: The aim of this study was to assess abnormality of coagulation and anti-
coagulation parameters in dengue fever patients and the impact of these tests on the
management of patients.
Background: Dengue fever is endemic in Pakistan with seasonal rise in cases. Mor-
bidities and mortalities are proportionately reported to be increasing and associated
with disseminated intravascular coagulation resulting in haemorrhagic or thrombotic
manifestations in patients having deranged coagulation profiles.
Methods/Materials: This observational and descriptive study was conducted on con-
firmed Dengue patients at the National Institute of Blood Diseases during the years
2013 to 2016. Patients of all age groups were included in this study. Results were
analysed by SPSS version 23.
Results: A total of 200 patients were selected with the mean age being 28.68 years
(±13.28) and male predominance (147/200). The mean platelet count, haemoglobin
and haematocrit at base line for bleeders and non-bleeders showed significant
results, where platelet count at baseline for bleeders was 24 000, whereas for non-
bleeders it was 29 000 and it showed significant correlation with bleeding (P-value
.027). Platelets were transfused to 76 (38%) patients. However, none of the spe-
cialised haemostasis parameters beside the platelet count correlated with bleeding,
requiring platelet transfusions.
Conclusion: Our study showed a significant association of platelet counts,
haemoglobin and haematocrit with bleeding. It can be concluded that coagulation
and anticoagulation profiles will not benefit the management of dengue patients
and in countries like Pakistan, it will only add to the economic burden on the
patients.
KEYWORDS
anticoagulation, coagulation, dengue, dengue fever, platelet count
975 million live in regions of South East Asia, America and the
Pacific.1 Suspected dengue outbreaks were recorded in Pakistan,
Saudi Arabia, Yemen, Sudan and Madagascar in 2005 to 2006.2-5
Morbidity and mortality rates in the tropical and subtropical region
wileyonlinelibrary.com/journal/tme © 2019 British Blood Transfusion Society 1
2 HASSAN ET AL.

are related to serious inflammatory effects. Every year, approximately TABLE 1 Biochemistry parameters of bleeders and non-bleeders
100 million cases of dengue are reported worldwide. There are four Bleeders Non-bleeders
dengue serotypes (DENV1-DENV4).6 As per clinical manifestations, Parameters (n = 44) (n = 156) P-value
dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) Urea (mg dL ) −1
23.84 ± 14.71 20.26 ± 10.13 .136
are the most aggravated cases.6 The clinical picture of dengue fever Creatinine (mg dL−1) 0.934 ± 1.428 0.74 ± 0.251 .375
(DF) shows abnormal haemostatic activities, which is demonstrated by −1
Total Bilirubin (mg dL ) 3.623 ± 20.11 1.58 ± 10.86 .522
thrombocytopenia (platelet counts less than 150 000 L), raised
Direct Bilirubin (mg dL−1) 11.81 ± 75.77 0.34 ± 0.293 .321
haemoglobin and haematocrit and decreased total leucocyte counts.7 −1
SGPT (μL ) 180.7 ± 304.3 123.4 ± 110.2 .226
Virus may also cause deranged liver function tests by damaging the
Alkaline phosphatase 259.6 ± 179.2 262.6 ± 181.4 .921
hepatocytes.8 Moreover, platelet function is abnormal in dengue
PO4 (μL−1)
infections.9 Coagulation and anticoagulation mechanisms are reported
LDH (μL−1) 1163.1 ± 887.7 969.6 ± 708.0 .188
to be affected and evidenced by prolonged partial thromboplastin
time (APTT), prothrombin time (PT), hyperfibrinogenemia and decreased
fibrin monomers (FMs).8-11
Furthermore, the acute febrile phase is manifested by headache,
body aches, weakness, joint pains, gastric discomfort and lasts up to 3 | RE SU LT S
three to 5 days. Reductions in the levels of specific coagulation fac-
tors, such as II, V, VII, VIII, IX, X, antithrombin, and alpha-2 anti- Out of the 200 patients, 147 were males; mean age of the patients
8-11
plasmin, have been reported in small numbers of DHF patients. was 28.7 ± 13.28 years. Fever, vomiting and bodyaches were the
No published data are available regarding this aspect of dengue virus three most common complaints in descending order of frequency,
infection in Pakistan. Pakistan is a source poor country and majority respectively. A major haematological manifestation, that is, mild to
of patients face considerable financial constraints. Performing labo- moderate type of bleeding was found in 22% of patients. Dengue was
ratory investigations are a major burden for these patients. The confirmed by the antigen test (NS-1) in 126 (63%) and serology (IgA,
National Institute of Blood Disease (NIBD) is a specialised referral IgM, IgG) in 37 (18.5%) patients. Combined antigen and serology was
centre for blood diseases with the capacity to perform specialised present in 37 (18.5%). Biochemistry parameters showed insignificant
coagulation testing. We receive 100 to 200 cases of DF per year. results between bleeders and non-bleeders as shown in (Table 1).
This is why the aim of our study was to assess whether special coag- Furthermore, biochemistry parameters were deranged and showed
ulation laboratory tests have an impact on the management of raised serum glutamic pyruvic transaminase (SGPT), lactate
patients with DF. dehydrogenase (LDH), bilirubin and creatinine. Mean platelet count at
baseline for bleeders was 24 000, whereas for non-bleeders it was
29 000; haemoglobin was 16.85 vs 14.47 g/dL and haematocrit was
2 | MATERIALS AND METHODS 46.48% vs 42.64% for bleeders and non-bleeders respectively, and
showed significant correlation with bleeding (Table 2) but not with
A total of 200 patients were enrolled at NIBD during the peak other parameters. Platelets were transfused to 76 (38%) patients.
months (August-November) of dengue in Pakistan. In this observa- However, none of the specialised haemostasis parameters beside the
tion, land descriptive study data were collected from the patients platelet count correlated with bleeding, requiring platelet transfusions
admitted with dengue, having complete test results from 2013 to (Table 3).
2016 through convenience sampling after obtaining informed con-
sent. Patients of all age groups were included in the study. As per
hospital policy and study protocol, platelet transfusion can be given 4 | DI SCU SSION
at <30 platelet count to the bleeders and non-bleeders depending
on the condition and wish of the patient and their family. The Dengue infection may result in a self-limiting febrile infection
patients were tested for dengue by NS-1 antigen and IgA, IgM, known as DF or DHF characterised by increased vascular perme-
IgG serology by solid-phase immunochromatographic assay (MP ability and abnormal haemostasis.7 DF is endemic in Pakistan with
Diagnostics MULTISURE dengue Ab/Ag Rapid Test kit) during seasonal rise in cases. However, recently the transmission of DF
febrile and toxic phases. A complete blood count was obtained at has intensified in the country with increased incidence due to poor
least once a day on SysmexXN1000 analyser. Biochemistry was per- health as well as the lack of vaccine and sanitation problems. Mor-
formed on COBAS c111 by the spectrophotometeric method. Coag- bidities and mortalities are proportionately reported to be increas-
ulation and anticoagulation parameters were performed on STAGO ing in number.12 Increased morbidity and mortality in dengue virus
and SysmexCA-1500 through the immune turbidimetric method. All infection is associated with disseminated intravascular coagulation
clinical and laboratory parameters were measured on baseline as resulting in haemorrhagic or thrombotic manifestations in patients
well as during follow up visits. Data were analysed using SPSS ver- having deranged coagulation profiles.13 Therefore, this study was
sion 23. conducted to determine whether specialised coagulation
HASSAN ET AL. 3

TABLE 2 Laboratory parameters of bleeders and non-bleeders

Pre treatment Post treatment

Variables Bleeders (n = 44) Non bleeders (n = 156) P-value Bleeders (n = 44) Non bleeders (n = 156) P-value
Haemoglobin (g dL−1) 16.85 ± 1.36 14.47 ± 2.23 .000a 13.23 ± 1.79 13.56 ± 1.822 .282
−1
Total leukocyte counts (1 × 10 L )
9
4.90 ± 2.46 4.80 ± 2.80 .834 6.56 ± 2.524 6.72 ± 8.79 .845
Platelets (1 × 109 L−1) 24.4 ± 14.13 29.6 ± 11.63 .027a 84.70 ± 70.55 90.05 ± 69.08 .657
Neutrophils (%) 43.05 ± 17.73 40.19 ± 20.12 .362 36.38 ± 13.2 35.56 ± 16.99 .737
Lymphocytes (%) 44.53 ± 17.66 39.76 ± 19.07 .124 46.88 ± 15.05 42.90 ± 18.25 .144
Haematocrit (%) 46.48 ± 4.91 42.64 ± 6.12 .000* 40.16 ± 3.43 39.99 ± 3.46 .280
a
Among all parameters, association between bleeders and non-bleeders showed significant results with platelet counts and transfusion.
*Significance.

T A B L E 3 Laboratory and clinical

Laboratory parameters Bleeders, % Non-bleeders, % P-value
characteristics of bleeders and non-
bleeders PT <12 s 66.7 33.3 .545
>16 s 86.4 13.6
APTT <25 s 100 0 .519
>36 s 78.4 21.6
FIB <2 g L−1 77.6 22.4 .630
>4 g L−1 37.5 87.5
D. Dimer <0.10 μg mL−1 100 0 .675
>0.50 μg mL−1 78.1 21.9
AT-III <87% 20.9 79.1 .508
>117% 68.2 38.8
Pro C <83% 25.5 74.5 .15
>113% 0 100
Pro S <68% 21 79 .461
>106% 0 100
FM <11 μg mL−1 20.4 79.6 .221
>24 μg mL−1 25.8 77.4
VIII <50% 78.3 21.7 .165
>150% 0 100
IX <50% 75.3 24.7 .679
>150% 100 0
Platelet count ≤30 μL−1 18 47.5 .008*
>30 μL−1 4 31
Platelet transfusion Yes 12.5 25.5 .004*
No 9.5 52.5

Note: Association of bleeders and non-bleeders with platelet count and transfusion requirement were
highly significant. Partial thromboplastin time (PT) control: 12 to 16 seconds, activated partial
thromboplastin time (APTT) control: 25 to 36 seconds, fibrinogen (FIB): 2 to 4 g L−1, dimer (D): 0.10 to
0.50 μg mL−1, fibrin monomer (FM): 11 to 24 μg mL−1, protein C (Pro C): 83% to 113%, anti-thrombin
(AT): 87% to 117%, protein S (Pro S): 68% to 106%.
*Chi-square testing P < .008 and P < .004.

parameters are associated with the bleeding risk and can be used
to guide management.
Fever, body aches and vomiting were among the main symptoms
and mild to moderate bleeding was the main sign in our patients, com-
parable to the findings in studies conducted by14 in Faisalabad
Pakistan and a study carried out in Jeddah,15 which showed fever,
vomiting and abdominal pain as the most common symptoms among
others. Bleeding was present in 44 (22%) patients; however, platelets
were transfused to 76 patients (38%) due to low platelet counts and
family concerns. Mild to moderate type of bleeding such as gum
4 HASSAN ET AL.
bleed, epistaxis, bruises and hematuria was documented in these
patients.
Coagulation and anticoagulation parameters were evaluated in
our study such as PT, APTT, fibrinogen, D-Dimers, FMs, FVIII, FIX,
Antithrombin III and proteins C and S. Almost all the parameters were
deranged to an extent; however, they did not show any statistical sig-
nificant association with the risk of bleeding manifestations (Table 3).
A Brazilian study showed that during dengue infection, coagulation
and fibrinolysis parameters are altered due to their activation.4,8,16,17
D-dimer, activated partial thromboplastin time18,19 and PT,8,18 are
increased in the acute phase; however, natural anticoagulants such as
protein C, protein S, and antithrombin are significantly reduced during
the early disease stages. Despite limited clinically significant bleeding
and only mild alterations in the results of coagulation screening tests,
children with DSS had significant abnormalities in all of the major
pathways of the coagulation cascade.20 Also, other studies found
changes in coagulation parameters like mild prolongation of the PT,
APTT and reduced fibrinogen levels and reductions in the levels of
several factors such as II, V, VII, VIII, IX, X, antithrombin and
α-2-antiplasmin during the acute phase of DHF.8,9,11 In contrast to
the present study, one study found that PT and APTT can be used as
a tool in predicting bleeding in DHF, with tendency increased in pro-
longation of more than 30 seconds. Another observation is that mor-
tality increased with platelet count of less than 50 000 μL than those
whose platelet count was more than 50 000 μL.21 Another study
described an association of higher Plasminogen activator inhibitor-1
(PAI-1) levels and lower protein S levels with an increased severity of
bleeding.20 A study on Vietnamese children found that despite
derangements in all the major pathways of the coagulation cascade, it
is surprising to see absence of thrombotic complications and in fre-
quent findings of severe bleeding manifestations.8 Another study con-
cluded that APTT and tissue plasminogen activator (tPA)/PAI-1ratio
can serve as early indicators of disease severity.22 Sanjaya Kulasing
found significant association of raised APTT and PT INR with leaking
and bleeding in patients with DF along with liver enzymes such as
alanine aminotransferase and aspartate aminotransferase.23 None of
the above studies have comprehensively evaluated and compared all
the coagulation parameters with respect to bleeding manifestations
and neither have they recommended or concluded whether these
parameters need to be incorporated in diagnosing and evaluating the
dengue virus infected patients. Lastly, our study has certain limita-
tions: (a) No DSS patient was included in our study (b) Certain param-
eters such as tPA, PAI, factor v Leiden, Thrombomodulin were not
evaluated. Hence, further studies on a larger scale prospectively
planned are warranted to confirm the findings mentioned in our
study.
5 | C O N CL U S I O N
The platelet count at <50 and >50 × 109 L−1 was the only parameter
identified as a risk factor for bleeding. Specialised haemostasis testing
will not add benefit to the management of these patients and in
countries like Pakistan, it will only add further economic pressure
on them.
ACKNOWLEDG MENTS
Authors acknowledge patients and hospital staff for their valued
cooperation to collect valuable data for completion of this study.
CONFLIC T OF INT ER E ST
The authors declare no conflicts of interest.
AUTHOR CONTRIBU TIONS
M.B. and J.H. conceived main idea & wrote the manuscript. M.A.,
N.F. did data collection and analysis. U.Z. and T.S. critically evaluated
the paper.
OR CID
Munira Borhany https://orcid.org/0000-0001-7867-1275
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How to cite this article: Hassan J, Borhany M, Abid M,
Zaidi U, Fatima N, Shamsi T. Coagulation abnormalities in
dengue and dengue haemorrhagic fever patients. Transfusion
Med. 2019;1–5. https://doi.org/10.1111/tme.12658