Thesis

A DISSERTATION ON
“AN ASSOCIATION BETWEEN SERUM CALCIUM LEVEL AND

SEVERITY OF DENGUE VIRUS INFECTION IN GOVT. MOHAN
KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM.”
Submitted to
THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY
CHENNAI – 600 032, TAMILNADU
In partial fulfillment of the regulations

for the awards of the degree of
M.D GENERAL MEDICINE
BRANCH – I
GOVERNMENT MOHAN KUMARAMANGALAM

MEDICAL COLLEGE, SALEM
MAY– 2020
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation titled “AN ASSOCIATION
BETWEEN SERUM CALCIUM LEVEL AND SEVERITY OF
DENGUE VIRUS INFECTION IN GOVT. MOHAN
is a bonafide and genuine research work carried out by me under the guidance
Dr. D.VIJAYARAJU MD, Professor of the Department, Department of
general medicine, Government Mohan Kumaramangalam Medical College
Hospital, Salem, Tamil Nadu, India.
Date: Signature of the Candidate
Place: Salem DR.S.KESAVAN

CERTIFICATE FROM THE GUIDE
This is to certify that the dissertation entitled “AN ASSOCIATION
DENGUE VIRUS INFECTION IN GOVERNMENT MOHAN
is the bonafide work of Dr. KESAVAN.S in partial fulfillment of the
university regulations of the Tamil Nadu Dr. M.G.R. Medical University,
Chennai, for M.D General Medicine Branch I examination to be held in
MAY 2020.
Date : Prof. Dr. D.VIJAYARAJU M.D.,

Professor,
Place : Salem
Department of General Medicine,
Govt. Mohan Kumaramangalam
Medical college and hospital, Salem
CERTIFICATE FROM THE HOD
MAY 2020.
Date : DR. S.SURESH KANNA M.D.,

Professor and HOD,
Place : Salem Department of General Medicine,
Govt. Mohan Kumaramangalam
Medical college and hospital,
Salem.
CERTIFICATE FROM THE DEAN
MAY 2020.
Date : DR.K.THIRUMAL BABU,M.D., D.M.,

THE DEAN,
Place : Salem Govt. Mohan Kumaramangalam Medical
College and hospital,
Salem.
GOVERNMENT MOHAN KUMARAMANGALAM
MEDICAL COLLEGE
COPYRIGHT
I hereby declare that the Government Mohan
Kumaramangalam Medical College Hospital, Salem, Tamil Nadu,
India, shall have the rights to preserve, use and disseminate this
dissertation / thesis in print or electronic format for academic /
research purpose.
Date: SIGNATURE OF THE CANDIDATE

Dr. KESAVAN.S
Place: Salem
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ASSOCIATION BETWEEN SERUM CALCIUM LEVEL AND
SEVERITY OF DENGUE VIRUS INFECTION” IN
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL
COLLEGE HOSPITAL, SALEM of the candidate Dr.KESAVAN.S
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ACKNOWLEDGEMENT
I owe my thanks to The Dean, Government Mohan Kumaramangalam
Medical College and Hospital Prof. Dr. K.THIRUMAL BABU M.D.,D.M,
for allowing me to avail the facilities needed for my dissertation work.
I am grateful to Prof. Dr. S.SURESH KANNA M.D., Professor and
Head of the Department of Medicine, Government Mohan Kumaramangalam
Medical College and Hospital for permitting me to do the study and for his
encouragement. I have great pleasure in expressing my deep sense of gratitude
and respect to Prof. Dr. D.VIJAYARAJU M.D., Professor Department of
Medicine, Government Mohan Kumaramangalam Medical College and
Hospital and Prof. Dr. MANJULA M.D., Professor, Department of medicine
and chief of medical unit III, Government Mohan Kumaramangalam Medical
College and Hospital, for approving this study and giving suggestions and
guidance in preparing this dissertation.
I am extremely thankful to my unit assistant professors, Dr. P.ARUL
M.D., Dr. P.SADHASIVAM M.D., and Dr. S.PALANIVELRAJAN M.D.,
Registrar, Department of medicine for their valuable guidance and constant
encouragement.
I wish to acknowledge all those, including my other postgraduate
colleagues and my wife who have directly or indirectly helped me to complete
this work with great success.

Finally, I thank the patients who participated in the study with their
extreme patience and co-operation without whom this project would have been
impossible.
Above all, I thank the Lord Almighty for this kindness and benevolence.
CONTENTS
S.NO TITLE PAGE NO.
1. INTRODUCTION 1
2. AIMS AND OBJECTIVES 3
3. REVIEW OF LITERATURE 4
4. MATERIALS AND METHODS 49
5. OBSERVATION AND RESULTS 55
6. DISCUSSION 74
7. LIMITATIONS OF THE STUDY 78
8. CONCLUSION 79
9. ANNEXURES
BIBILIOGRAPHY 81
PROFORMA 88
ABBREVIATIONS 90
ETHICAL COMMITTEE APPROVAL LETTER 92
ANTI PLAGIARISM CERTIFICATE 93
MASTER CHART 94
1. INTRODUCTION
Dengue is a disease of major concern throught the world due to its
ability to cause huge burden on public health system since it is rapidly
transmitted by mosquito. Based on (WHO) World Health Organization reports,
about 50 to 100 million new dengue infections are estimated to occur annually,
with a steady increase in the number of countries reporting the disease. [1]
Dengue infection presented with variety of clinical manifestations
ranging from asymptomatic infection or simple viral illness to dengue shock
syndrome. Dengue causes severe bleeding, circulatory shock and even death.
So early diagnosis and recognition of severe form of dengue infections like
dengue hemorrhagic fever, dengue shock syndrome is cornerstone in
management. Though dengue infections are common in paediatric age group,
adult admissions has been increased in recent years especially in India.
However, the data of adult dengue infections are limited; this study is to get
additional data on dengue infections among adults.
In India, particularly in Tamilnadu state in recent years dengue has been
a major health issue contributing to significant mortality and morbidity. The
major factors contributing to this mortality is severe form of dengue infection
and its complications like shock syndrome, hemorrhagic manifestations and
severe thrombocytopenia. So we need to identify the patients who are all going
to these complications.
1
In patients with severe dengue infection numerous serum bio chemical
parameter changes occur with the onset of plasma leakage, these derangements
are not apparent in non severe dengue patients. The various biochemical
markers has been measured to identify the severe form of dengue infection like
AST, ALT, platelet count, PCV and electrolytes especially calcium levels.
This study is done in Government Mohan Kumaramangalam medical
college, Salem and deals with serum calcium levels in association with severity of
dengue infection.
2
2. AIMS AND OBJECTIVES
 To find out the correlation between serum calcium levels and severity of
dengue infection.
 To estimate the serum calcium levels in patients with suspected dengue
fever and with warning signs of dengue fever.
 To suggest further studies in the following areas
(a) Role of calcium supplementation in dengue fever for reduction of
severity,
(b) To use serum calcium levels as a potential biomarker to predict
severe dengue infection.
3
3. REVIEW OF LITERATURE
HISTORICAL REVIEW:
Dengue was also known as “Dandy fever” .The first probable case of
Dengue fever was recorded in a Chinese medical encyclopedia. The term
“Break bone fever” was coined during the Philadelphia epidemic in 1780, by
Benjamin Rush because of the symptoms of myalgia & arthralgia.
Severe dengue was first recognized during dengue epidemics in the
Philippines and Thailand during 1950’s. Nowadays, severe dengue affects most
Asian and Latin American countries .Severe dengue complicated by
hemorrhages; shock and death were reported in outbreaks in Australia (1897),
Greece (1928) and in Formosa (1931). Mosquito borne transmission by Aedes
aegypti was demonstrated in 1903. Its viral etiology was demonstrated in 1906.
In Japan, Sabin isolated the virus in 1944 and demonstrated the existence of
dengue viral serotypes, but the one isolated in Calcutta in 1944 from the blood
of US soldiers was considered as a first report for a longtime.
After World War II, pandemics with intensified transmission of multiple
viral serotypes started in Southeast Asia, leading to outbreaks of dengue
hemorrhagic fever.
4
In India, first major epidemic illness compatible clinically with dengue
occurred in Madras in 1780 followed by spread throught the country.
FIGURE 1: Areas based on suitability of dengue transmission [2]
FIGURE 2: Average annual number of DF/DHF cases (WHO 1955-2007)[9]
5
EPIDEMIOLOGY:
DENGUE GLOBAL BURDEN
Around 2.5 billion people – two fifths of the world's population in
tropical and subtropical countries are at risk. Around 50 million dengue
infections occur worldwide every year .Almost 5, 00,000 people with DHF
require hospitalization each year. Majority (approximately 90%) of them are
children aged less than five years, with about
2.5% mortality. [9]
FIGURE 3: Dengue cases notified and incidence in WHO regions in 2013-2017
6
Epidemics of dengue are increasing in frequency. During epidemics,
infection occurs in those who have not been previously exposed to the virus at
rate of 40% to 50% but can also reach about 80% to 90%. In 2016 major
outbreaks occurred throught the world. After which, a drop in the number of
cases in 2017-18 occurred, followed by sharp increase in cases is being
observed in 2019.
DENGUE BURDEN IN INDIA
FIGURE 4: No. of cases and no. of deaths due to dengue in 2010-2017 in
India
7
Major outbreaks in India occurred in 1996, 2006 and 2010 with reduction in
case fatality rates with each epidemic due to better management techniques
followed after launch of national dengue treatment guidelines. The disease has a
seasonal pattern with peak incidence after the monsoons. However, the southern
and western states of the country show a perennial transmission.
FIGURE 5: Seasonal trend of dengue cases in India in 2010-2013
The epidemics from India are those from Calcutta (1963),
Vishakapattanam (1964), West Bengal (1968), Ajmer (1969), Kanpur (1969),
Delhi (1970), Rajasthan (1985) and Delhi (1996).
8
Major DF outbreak in India occurred between September and October
2006 involving more than 12 thousand cases and 184 deaths, of which
approximately 3366 cases and 65 deaths were from Delhi alone. In 2006 the
number of cases reported as compared to 2005 showed some reduction whereas
the case fatality rate remained above 1%. In 2009, in India 15,535 cases were
reported with 96 deaths while in 2010 28,292 cases with 110 deaths were
reported. In 2013, till August, 22092 cases were reported with 74 deaths.
FIGURE 6: Dengue cases notified and deaths notified in India in 2013-2017
9
DISEASE BURDEN IN TAMIL NADU
In Tamil Nadu, there has been a rise in the number of dengue cases
reporting units. In 1998, dengue cases were reported from only 4 units which
increased to 33 units in 2006 due to the availability of serodiagnostic facilities
at different centres. Out of 30 districts in Tamil Nadu, dengue cases have been
reported from 29 districts during 1998-2005 which include DF/DHF outbreaks
in Chennai in 2001, Nagercoil and Trichirapalli (2003) and DF outbreaks in
Krishnagiri and Dharmapuri (2001).
FIGURE 7: State-wise comparision of no. Of cases 2013 vs 2017
A total of 128 cases and 5 deaths occurred in 1998 which increased to
1600 cases and 12 deaths in 2003. Around 1150 cases, 8 deaths occurred
during 2005. After that major outbreaks in Tamilnadu occurred in 2007, 2009,
2012 and 2013.
10
THE VIRUS:
The Dengue virus belongs to genus Flavivirus. There exist 4 types
called as DEN1, DEN 2, DEN 3, and DEN 4. Recently a new serotype of
dengue virus called DEN 5 has been identified from a 37 yrs old foreigner in
Malaysia (Sarawak state). Researchers demonstrated that this serotype DEN 5
is genetically similar to other four serotypes. Non structural protein called as
NS antigen is of 5 types and is surrounded by a lipoprotein envelope.
FIGURE 8: Electron microscopic picture of Dengue virus.
The function of envelope protein is to bind to host cells and
haemagglutination of RBC [3, 4] NS-1 has direct relation to viral titres, it is
higher in patients with DHF compared with patients with dengue fever. The
elevated levels of serum NS-1 signify the patients at risk of dengue
hemorrhagic fever. There are about 3 sub-types for DENV-1, six for DENV-2
(one of which is found in non-human primates), four for DENV-3 and four for
DENV-4.
11
THE VECTOR AND THE LIFE CYCLE OF DENGUE VIRUS:
Dengue viruses are transmitted from an infected person to other person
by the bite of the female Aedes mosquito. In India, in most urban areas, Aedes
aegypti is the main vector; Also Aedes albopictus is incriminated in many
states. Also other species like Aedes polynesiensis and Aedes niveus have also
been incriminated as secondary vectors in some countries. [9]. The average
survival of Aedes aegypti is about 30 days and Aedes albopictus is about 8
weeks. Aedes is a daytime biter.
FIGURE 9: Aedes aegypti mosquito.
Aedes aegypti lives and multiplies in water storage containers, water
reservoirs, overhead tanks, unused tyres, coconut shells, disposable cups,
unused grinding stones etc… Aedes albopictus prefers natural habitats such as
tree holes, latex collecting cups in rubber trees, bamboo stumps, coconut shells,
etc. Aedes albopictus breeding has been reported recently in domestic habitats
as well.
12
FIGURE 10: Life cycle of Aedes aegypti
Aedes mosquito is a tropical and subtropical variety and is widely
distributed. Also, due to lower temperatures, Aedes aegypti is relatively
uncommon above 1000 metres. Aedes aegypti is highly domesticated and
strongly anthropophilic and a nervous feeder and is a discordant species. Aedes
albopictus feeds on both humans and animals and an aggressive feeder and also
does not require a second blood meal for the completion of the gonotropic
cycle. After an adult female mosquito bites a human with dengue fever it enters
and multiplies in the mosquito. Viral multiplies over a period of 8-12 days
(extrinsic incubation period) . There after virus can spread through bite of the
mosquito. Transmission of dengue virus within mosquitoes can occur by
transovarial spread.
13
THE HOST:
Humans are the main amplifying host of the virus .The viraemia in
humans reaches high titres two days before the onset of the fever (non-febrile)
and lasts 5–7 days after the onset of the fever (febrile). It is only during these
periods that the vector species gets infected on biting the viremic human.
Transmission primarily occurs via the bite of a vector. There are also reports of
congenital dengue infections in neonates born to mothers infected very late in
the pregnancy.
The dengue virus enters via the skin while an infected mosquito is
taking a blood meal. Intrinsic incubation period is about four to ten days,
followed by a wide spectrum of clinical illness, although most infections are
asymptomatic or subclinical. During the acute phase of illness the virus is
present in the blood and its clearance from generally coincides with
defervescence. After infection, serotype specific and cross-reactive antibodies
and CD4+ and CD8+ T cells remain measurable for years in the human host.
Initial infection by one serotype provides permanent immunity to that
serotype. Secondary infection with another serotype or multiple infections with
different serotypes leads to severe form of dengue (DHF/DSS).
14
Infection with Serotype 1 followed by Serotype 2 is more dangerous on
comparing of infection with Serotype 4 followed by Serotype 2. Antibody-
dependent enhancement (ADE) of infection has been proposed as a mechanism
to explain severe dengue in the course of a secondary infection and in infants
with primary infections. Here non-neutralizing, cross-reactive antibodies
produced during a primary infection, or acquired passively at birth, bind to
epitopes on the surface of a heterologous infecting virus and facilitate virus
entry into Fc -receptor-bearing host cells. During a secondary infection, cross-
reactive memory T cells are also rapidly activated which proliferate and
express cytokines.
TRANSMISSION CYCLE: [9]
Enzootic cycle: This cycle exists between monkeys and Aedes. Viruses do not
cause disease in monkeys and the viraemia lasts for about 2–3 days. All the
four dengue serotypes (DEN 1 to 4) have been isolated from monkey.
Epizootic cycle: This occurs from an adjoining human epidemic cycles by
bridge vectors. The epizootic cycle was observed in Sri Lanka among touqe
macaques (Macaca sinica) during 1986–1987 in a study area. Within 3kms of
the study area 94% macaques were found affected on a serological basis.
15
Epidemic cycle: Maintained by human- Aedes aegypti - human cycle with
periodic/cyclical epidemics. All serotypes circulate and give rise to
hyperendemicity. Strong anthrophilicity with multiple feeding behaviour and
highly domesticated habitats of Aedes aegypti makes it an efficient vector. The
persistence of dengue virus, therefore, depends on the development of high
viral titres in the human host to maintain transmission in mosquitoes. In arid
zones where rainfall is scanty during the dry season, high vector population
builds up in man-made storage containers.
A number of factors that contribute to initiation and maintenance of an
epidemic which includes:
THE VIRUS
The strain of the virus influences the magnitude and duration of the
viraemia in humans.
THE VECTOR
The density, behaviour and vectorial capacity of the vector population.
THE HOST
The susceptibility of the human population (decided by both genetic
factors and pre-existing immune profile).
16
PATHOGENESIS:
Host immune responses play a major role in the pathogenesis of Dengue
Fever. The most favoured mechanism is cytokine storm. These circulating
cytokines plays a main role in development of haemorrhage and shock.
Coagulopathy
Mechanism of Coagulopathy associated with dengue Fever still remains
unclear. Thrombocytopenia associated with coagulopathy increases the severity
of hemorrhage. Release of heparin sulphate or chondroitin sulphate from the
glycocalyx may also contribute to the coagulopathy.
In shock, blood levels of tumor necrosis factor receptor, IFN-γ, and IL-
2 are rised. C1q, C3, C4, C5–C8, and C3 proactivators are reduced, and C3
catabolic rates are rised. These factors may interact to increased vascular
permeability through the nitric oxide final pathway. Levels of factor XII are
depressed. A mild degree of disseminated intravascular coagulation, liver
damage, and thrombocytopenia operates synergistically.
Capillary leakage and shock
Hypotension is caused by plasma leakage due to temporary alteration in
the characteristics of the endothelial fibre matrix. Here, Anti-NS1 antibody acts
as auto-antibodies that cross-react with platelets and non-infected endothelial
cells, leading to disturbances in capillary permeability. Plasma leakage may
17
manifest as any combination of haemoconcentration, pleural effusion, Ascites.
It usually becomes evident on 3 to 7 days of illness [5].
FIGURE 11: Pathogenesis in dengue infection. [7]
Microscopically, there is perivascular edema in the soft tissues and
widespread diapedesis of red cells on to the vessel wall.
18
FIGURE 12: Pathogenesis in dengue infection [6]
CLINICAL FEATURES:
Dengue virus infected person may be asymptomatic or symptomatic and
clinical manifestations vary from mild undifferentiated fever to severe
haemorrhage and shock. The clinical presentations depend on various factors
such as age, virus strain, immune status of the host, and primary or secondary
infection. After an average intrinsic incubation period of 4–6 days (range 3–14
days), various non-specific, constitutional symptoms like fever and headache,
19
backache and generalized malaise may develop. Thereafter, there may be retro-
orbital pain on eye pressure or eye movement, photophobia, pain in the muscles
and joints and, backache. These symptoms may persist from several days to a
few weeks. It is noteworthy that these symptoms and signs are marked in
frequency and severity of DF.
Fever: The body temperature is usually between 39 °C and 40 °C, and may be
biphasic, lasting 5–7 days in the majority of cases.
Rash Transient widespread rash is seen on head, limbs, back and chest regions
during the first two to three days. These rashes disappear at the end of febrile
period. Some patients may have itching.
FIGURE 13: Impression mark on skin of a dengue patient. [6]
Haemorrhagic manifestations:
Skin haemorrhage may be demonstrated as a positive tourniquet test
and/or petechiae. Other bleeding manifestations such as massive epistaxis,
20
hyper menorrhea and gastrointestinal bleeding also occur in severe DF,
complicated with thrombocytopenia.
Tourniquet test: [9]
A blood pressure cuff is applied and inflated to midpoint between
systolic and diastolic blood pressure. The test is positive if there are more than
10 petechiae per square inch. In DHF it is more than 20. The test may be only
mildly positive or negative during the phase of profound shock (DSS).
FIGURE 14: Hemorrhagic manifestations of dengue infections. [7]
21
CLINICAL CRITERIA FOR DF / DHF/DSS:
Dengue Fever (DF):
An acute febrile illness of 2-7 days duration with ≥2 of the symptoms
mentioned below
Headache, pain behind the eyeball, body ache, joint pain, skin rash, bleeding
tendencies.
Dengue Haemorrhagic Fever (DHF):
A). A case with clinical criteria of dengue Fever
Plus
B). Haemorrhagic tendencies evidenced by one or more of these features
mentioned below
1. More than 20 petechial spots on tourniquet test
2. GI and mucosal bleeding
3. Petechial rashes
Plus
C) Low platelet count (<100 000 cells per cu. mm)
Plus
D). Third space fluid collection manifested by one or more of the
following:
1. A rise in average hematocrit for age and sex > 20%
22
2. More than 20% fall in hematocrit after fluid therapy
3. Clinical/radiological evidence of third space fluid collection
Dengue Shock Syndrome:
Features of DHF mentioned in their criteria with clinical evidence
circulatory shock (tachycardia with narrow of pulse pressure <20mm of hg)
EXPANDED DENGUE SYNDROME (EDS):
Mild or Severe organ involvement may be occur in DF/DHF. Unusual
manifestations of DF/DHF are commonly associated with co-morbidities and
with other co-infections.
Clinical manifestations observed in EDS are as follows:
1. NEUROLOGICAL:
Encephalopathy, Encephalitis, Febrile seizures, Intra cranial bleed.
2. GASTRO INTESTINAL OR HEPATIC:
Acute pancreatitis, acute hepatitis, Fulminant hepatic failure,
Cholecystitis, Cholangitis
3. RENAL INVOLVEMENT:
Acute renal failure, Hemolytic uremic syndrome, acute tubular necrosis
23
4. CARDIAC INVOLVEMENT:
Cardiac arrhythmia, Cardiomyopathy, Myocarditis, Pericardial effusion
5. RESPIRATORY:
Pulmonary edema, ARDS, Pulmonary haemorrhage, Pleural effusion
6. EYE INVOLVEMENT:
Conjunctival bleed, Macular haemorrhage, Visual impairment, Optic neuritis
Natural course of dengue Infection:[6]
The clinical course of illness passes through the following three phases:
• 1.Febrile phase
• 2.Critical phase
• 3.Convalescent phase
1. Febrile phase
 Patients develop high grade fever suddenly and usually last 2-7 days.
 Facial flushing, rash, generalised body ache, vomiting and headache.
 Sore throat, injected pharynx and conjunctival injection.
 The initial laboratory evidence is reduction of leucocytes followed by
platelet count reduction.
24
FIGURE 15: Natural course of dengue illness
2. Critical phase (Leakage phase)
 The critical phase often occurs after 3rd day of fever (may occur earlier)
or around defervescence indicated by a rapid drop in temperature.
 In other viral infections, the patient’s condition improves as the
temperature subsides, but the contrary happens in severe dengue infection
wherein the patient may deteriorate and manifest third space plasma
leakage or organ dysfunction.
 The period of plasma leakage usually persists for 36-48 hrs.
25
3. Convalescent phase (recovery phase)
 Plasma leakage stops followed by redistribution of fluids collected in
third spaces such as peritoneum and pleural cavity with generalised
pruritus.
 The recovery of platelet count is typically preceded by recovery of white
cell count. This phase usually occurs after 6-7 days of fever and last for
2-3 days.
 Patient may develop pulmonary edema because of fluid overload if the
fluid replacement is not optimized carefully.
CASE DEFINITION: [6]
Probable DF/DHF:
A case compatible with clinical description (Clinical Criteria) of dengue
fever during outbreak.
(OR)
Non-ELISA based NS1 antigen/ IgM positive.
(A positive test by RDT will be considered as probable due to poor sensitivity
and Specificity)
26
Confirmed dengue Fever:
A case compatible with the clinical criteria of dengue fever with at least
one of the following
 Isolation of the dengue virus (culture +VE) from serum, plasma,
leucocytes.
 Demonstration of IgM antibody titre by ELISA positive in single serum
sample.
 Positive Serum NS1-ELISA.
 IgG sero conversion in paired sera after 2 weeks of illness with four
fold increase titre of IgG.
 Detection of viral nucleic acid by PCR (polymerase chain reaction).
FIGURE 16: Criteria for dengue infections.

27
GRADING OF DF/DHF:
Dengue Fever (DF):
 Fever of 2-7 days with ≥2 of these clinical features Headache, pain
behind eyeball, body ache, joint pain.
 With or without laboratory evidence of leucopenia, thrombocytopenia
and no evidence of plasma leakage.
Dengue Haemorrhagic Fever (DHF I):
 Above dengue fever criteria plus positive tourniquet test with evidence
of plasma leakage.
 Thrombocytopenia with platelet count < 1, 00,000/ cu.mm and
hematocrit rise more than 20% over baseline.
Dengue Haemorrhagic Fever II (DHFII):
 Above DHF I criteria plus some evidence of spontaneous bleeding in
skin or other organs (epistaxis, gum bleeds, black tarry stool) and
abdominal pain.
 Thrombocytopenia (platelet count less than 100000/ cu.mm) and Hct
rise more than 20% over baseline
28
FIGURE 17: Clinical spectrum of dengue infection [8,9]
Dengue Haemorrhagic Fever III (DHFIII / DSS):
 Above DHF II criteria plus clinical evidence of circulatory
failure(tachycardia, narrowing of pulse pressure, cold peripheries)
 Thrombocytopenia with platelet count less than 100000/ cu.mm and Hct
rise more than 20% over baseline.
Dengue Haemorrhagic Fever IV (DHFIV / DSS):
 Profound shock with undetectable blood pressure or pulse.
 Thrombocytopenia with platelet count less than 100000/ cu.mm and Hct
rise more than 20% over baseline.
29
LABORATORY INVESTIGATIONS: [6]
In endemic areas, early symptoms of dengue fever similar to other
prevalent diseases such as chikun gunya, malaria, viral infection, leptospirosis,
urinary tract infection and typhoid etc... For proper management of dengue
fever exclusion of these above conditions is hence very crucial.
ELISA-based NS1 antigen tests:
Dengue NS1 antigen is a highly conserved glycoprotein which is
produced in both membrane-associated and secretion forms, is abundant in the
serum of patients with dengue infection in the early stage. It has been found to
be useful for the diagnosis of acute dengue infections. It is a simple test that is
more specific and high sensitivity. NS1 antigen enables detection of the cases
very early, i.e. in the viremic stage, which has epidemiological significance for
containing the disease transmission. The NS1 ELISA-based antigen assay is
commercially available for DENV nowadays and many investigators have
evaluated this assay for its sensitivity and specificity. This NS1 assay may also
useful for differential diagnosis between flavi viruses because of its high
specificity. This test is usually positive for initial 5 days of illness.
IgM Antibody Capture Enzyme-Linked Immuno Sorbent Assay (MAC-
ELISA):
MAC-ELISA has been used widely in the past few years. It is a simple
test that requires a very little sophisticated equipment. MAC-ELISA is based
30
on detection of the dengue specific antibodies in the test serum by capturing
them using anti-human IgM which was already bounded to the solid phase. An
enzyme substrate is added to give a specific colour reaction for easy detection.
FIGURE 18: Serology in dengue infection.[10]
The anti-dengue IgM antibody develops a little faster than IgG and it is
usually detectable from 5th day of illness. However, the rapidity varies
considerably among patients. Some patients have detectable IgM antibodies on
days 2 to 4 after the onset of illness, while others may not develop IgM even
after seven to eight days after the onset. In some primary infections, detectable
IgM antibodies may persist for ≥ 90 days, but in most patients it is undetectable
31
level by 60 days. Hence MAC-ELISA has become an invaluable tool for of
DF/DHF surveillance. In dengue non endemic areas, it can be used for clinical
surveillance for viral illness and population-based sero surveys, with the
certainty that any positives denote an evidence of recent infections. It is
especially useful for hospitalized patients, those who are generally admitted in
the late phase of clinical illness after detectable IgM is already present in the
blood.
Polymerase chain reaction (PCR):
Molecular diagnosis based on RT-PCR (reverse transcription
polymerase chain reaction), such as one-step or nested RT-PCR, real-time RT-
PCR or nucleic acid sequence-based amplification (NASBA) has gradually
replaced the older virus isolation methods as the new standard for the detection
of dengue virus.
IgG-ELISA:
An IgG-ELISA has been developed that compares well to the
haemagglutination inhibition (HI) test. This test can be used to differentiate
primary and secondary dengue
infections. The test is simple and easy to perform and it indicates past
infections only. Hence this test is not considered as a diagnostic test.
32
Serological tests:
Apart from MAC-ELISA and IgG-ELISA, there are a few serological
tests are available for the diagnosis of dengue virus infection such as
complement fixation (CF), hemagglutination-inhibition (HI) and neutralization
test(NT). These are not routinely used due to various technical problems.
RDTs:
These tests would give a false negative result. Reliability on such tests to
guide clinical management of DF results in an increase in the case fatality ratio.
Hence, use of RDT kit is not recommended under the national programme.
Collection of samples:
Laboratory diagnosis of dengue depends on proper collection, storage,
processing and shipment of the specimens. While collecting blood samples for
33
serological studies from suspected dengue (DF/DHF) cases, all universal
precautions should be taken. While sending the samples for lab confirmation,
the following data includes, the day of onset of fever and day of sample
collection should be mentioned to guide the laboratory for the type of test (NS1
for samples collected from day 1 to day 5 and IgM after day 5) to be
performed.
NVBDCP recommended tests for laboratory diagnosis:
For confirmation of dengue virus infection, Government of India (GoI)
recommended use of NS1 ELISA for initial five days of illness and IgM
capture ELISA after five day of illness.Directorate of National Vector Borne
Disease Control Programme (NVBDCP) has formed a network of laboratories
for surveillance of dengue fever cases (sentinel surveillance hospitals and apex
referral laboratories) across the country since 2007. These laboratories are also
having diagnostic facilities in all endemic areas. They are linked with Apex
Referral Laboratories (ARLs) for backup support and serotyping of dengue
samples with advanced diagnostic facilities. For details about the laboratories,
please refer to NVBDCP website www.nvbdcp.gov.in.
These laboratories receive the samples from a particular area, diagnose
and send the reports (line list) regularly to districts/municipal health authorities
for implementation of preventive measures at primary health care level to
interrupt the transmission.
34
Supply of kits:
IgM ELISA test kits (1 kit = 96 tests) are being provided by the National
Institute of Virology (NIV) to the identified laboratories.
The laboratory findings of acute DF:
 Leucopenia with decreasing neutrophils is seen during the febrile period.
 Platelet counts are usually within normal limits
 Mild reduction in platelet count (1 to 1.5 lakh cells/mm³) is common. About
half of all DF patients have platelet count <1 lakh cells/mm³, but severe
thrombocytopenia with platelet count of <0.5 lakh cells/mm³ is rare.
 Mild rise in Hct of around 10 %.
The laboratory findings of DHF:
 The WBC count may be normal, but sometimes with predominant
neutrophils in the early febrile phase. Thereafter, there is a drop in WBC’s
and neutrophils towards the end of the febrile phase. The change in total
WBC count (≤5000 cells/mm³) and ratio of neutrophils to lymphocytes
35
(neutrophils<lymphocytes) is useful to predict plasma leakage in the critical
period of dengue.
 A sudden drop in platelet count to <100 000 occurs by the end of the febrile
phase before the onset of shock or end of afebrile phase. The level of platelet
count is correlated with severity of DHF.
 A sudden rise in hematocrit is observed shortly after the drop in platelet
count. Haemo concentration or rising hematocrit by 20% from the baseline
value
 Thrombocytopenia (<1 lakh cells/mm3) .A rise in hematocrit occurs in
almost all DHF cases, particularly in cases with shock. Sometimes the
hematocrit level may be affected by early volume replacement and bleeding
manifestations. Increased AST/ALT ratio (more than 2) may be seen in some
cases.
 Electrolyte abnormalities : Reduction of serum sodium and calcium levels
36
COMPLICATIONS OF SEVERE DENGUE:
Liver failure
In liver hepatocytes and Kupffer cells support viral replication. Levels of
(AST&ALT) aspartate transaminase and alanine transaminase are significantly
higher, and plasma proteins particularly albumin level is significantly lower
among patients with severe grades of DHF.
Fulminant liver failure can occur due to hepatitis and progressive liver
failure leading to hepatic encephalopathy. Jaundice may or may not be present.
In cases with CNS involvement (hepatic encephalopathy) neurological
examination may show hyper-reflexes and extensor plantar response.
Encephalopathy
Factors contributing to the development of encephalopathy includes,
hepatic dysfunction, electrolyte imbalances, hypoperfusion (due to shock),
cerebral edema (due to vascular changes leading to fluid extravasation), in
patients having features of encephalitis the dengue virus has been isolated from
the (CSF) cerebrospinal fluid.
Cardiac complications
Varies from asymptomatic bradycardia to serious conditions like
pericardial effusion and Myocarditis. Most of these cardiac manifestations are
reversible with other features of dengue fever.
37
MANAGEMENT:
Management of dengue Fever (DF):
Management of simple dengue fever is symptomatic and supportive,
i). Bed rest is advised during the acute phase.
ii). Use cold/tepid sponging to reduce the temperature below 38.5°C.
iii). Antipyretics (paracetamol) may be used to lower the body temperature.
Aspirin and NSAIDS like Ibuprofen should be avoided because it may
cause vomiting, gastritis, acidosis, platelet dysfunction and severe bleeding.
Paracetamol dose can be repeated every 6th hourly depending upon fever
and body ache.
iv). Oral fluids and electrolyte therapy is recommended for patients who
having excessive sweating or vomiting.
v). Patients should be closely monitored for 24 to 48 hours after the end of
febrile phase for development of warning signs and complications.
Management during Febrile Phase:
Paracetamol is recommended to reduce the temperature below 39°C.
Adequate oral fluids should be advised to the extent the patient tolerates. Fruit
juices or Oral rehydration solution (ORS) used for the treatment of diarrheal
diseases are preferable to plain water. Intravenous fluid should be given if the
patient is having diarrhea persistent vomiting or refusing to take feed. Patients
38
should be closely monitored for warning signs and signs of shock. The
transition from the febrile to the afebrile stage is critical period and usually
occurs after the 3rd day of illness. Serial hematocrit may be essential to guide
treatment plan, as they reflect the degree of plasma leak and need for
intravenous fluids. Hematocrit should be determined daily especially from the
3rd day until the temperature remains normal for one or two days.
Management of DHF Grade I and II: [6]

Hospitalization is advised in patients who have reduced platelet count
and rised Hct and warning signs of dengue fever. All these candidates should
be monitored closely to prevent further complications. In critical phase of
illness patient may develop of shock is during transition from febrile to abferile
phase, which usually occurs after third day. In spite of fluid therapy if the
patient has fall in BP, reduction in urine output or other features of shock, the
management for Grade III/IV DHF/DSS should be instituted. Oral rehydration
along with antipyretics like Paracetamol, sponging, etc. as described should be
given.
Management of Shock in DHF Grade III / IV: [6]

Immediately after hospital admission, the hematocrit, platelet count and
vital signs should be done periodically.
Treatment algorithm for DHF Grades III and IV is given.
39
FIGURE 19: Volume replacement algorithm for patients with DHF I and II
40
FIGURE 20: Volume replacement algorithm for patients with DHF III
41
FIGURE 21: Volume replacement algorithm for patients with DHF IV
42
CHOICE OF INTRAVENOUS FLUIDS FOR RESUSCITATION:
Colloids may be the preferred choice if the blood pressure has to be
restored quickly in patients with narrow range of pulse pressure (<10mm of hg)
0.9% saline NS- Normal plasma chloride ranges from 95 to 105 mmol/L and
thus 0.9% Saline is a preferred for initial fluid therapy, however repeated
administration of 0.9% saline may produce hyperchloraemic acidosis. In this
situation may be a suitable alternative. Ringer’s Lactate should better be
avoided in liver failure and in patients taking metformin where lactate
metabolism may be abnormal.
Colloids
Colloids are gelatin-based, dextran-based or starch-based solutions. One
of the concerns regarding their use is their impact on coagulation. Dextran bind
to von Willebrand factor/Factor VIII complex and impair coagulation the
most..
Indications for Platelet transfusion: [6]
1. Platelet count less than 10,000cells/cu.mm in the absence of bleeding
manifestations (Prophylactic platelet transfusion).
2. Haemorrhage with or without thrombocytopenia. Packed cell transfusion and
FFP along with platelets may be required in patients presenting with severe
hemorrhage.
43
Criteria for admission of a patient:
 Constant fever (high grade) despite anti-pyretic therapy
 Severe thrombocytopenia, Rising hematocrit
 Patients with significant bleeding from any site
 Signs of hypotension ,shock and organ involvement
 Evidence of plasma leakage (clinical or radiological)
Criteria for discharge of patients:
 Afebrile for at least 24 hours without antipyretics
 No respiratory discomfort
 Platelet count > 0.5 lakh cells/cu.mm
 Return of appetite and Good urine output
 Minimum 2 - 3 days after recovery from shock
Detection of fluid overload in patients:
Fluid overload is the most common complication in dengue fever
treatment.The signs and symptoms include facial puffiness, abdominal
distension, breathlessness and wheezing.
Treatment of fluid overload:
The following points should be noted:
 Urinary bladder catheterization done to monitor hourly urine
output.
44
 Furosemide should be administered during dextran infusion
because the hyperoncotic nature of dextran will maintain the intravascular
volume while furosemide depletes in the intravascular compartment. After
furosemide, the vital signs should be monitored every 15 minutes for one hour
to look for its effects.
 If there is no urine output in response to furosemide, the
intravascular volume status (CVP or lactate) is to be checked. If it is adequate,
pre-renal failure is excluded, thus implying that the patient is in an acute renal
failure status. These patients may require ventilatory support any time. If the
intravascular volume is inadequate /the blood pressure is unstable, check the
ABCS and other electrolyte imbalances.
 Pleural and abdominal tapping can be life-saving in cases with
severe respiratory distress and in case of failure of the above management.
Traumatic bleeding is the most serious complication of the procedure and leads
to death. Hence caution needed
Vaccine for dengue infection [6]
As of now there is no licensed vaccine available for dengue. A
tetravalent dengue vaccine is under trial. A live attenuated recombinant,
tetravalent vaccine called CYD-TDV (Chimeric Yellow fever virus -Dengue
virus Tetravalent Dengue Vaccine) may be useful in near future in preventing
dengue infection.
45
DENGUE AND CALCIUM:
In dengue fever various biochemical parameters altered with the onset of
plasma leakage, particularly in hematocrit, platelet count, elevation of liver
enzymes, hyponatremia, and hypocalcemia Etc. These changes are not apparent
in non severe dengue cases.
The relationship between serum calcium levels and dengue fever was
analyzed by various studies across the world and observed that calcium level is
reduced in severe form of dengue infection.
The calcium ion plays an important role in normal cellular function and
myocardial contractility. [11].
Hypocalcemia may also be commonly seen in other illness like severe
sepsis, traumatic injury. So, it has a relationship to mortality in severely ill
patients. The exact cause for this relation is not defined. The following possible
mechanisms may be the cause for hypocalcemia, parathyroid insufficiency,
defective vitamin D3 synthesis, reduced dietary intake during illness [17, 28].
The measurement of serum calcium is routinely not done in clinical
practice for dengue infection. [20-22].
Hypocalcemia in dengue:
Reduced calcium levels are commonly observed in dengue infections.
Sometimes it may present with feature of hypocalcemic tetany. [30]. The
prevalence of hypocalcemia in dengue infection is around 80%. [27].
46
Calcium in the dengue pathogenesis:
In in-vitro studies, the presence of calcium ion is obligatory for the
cytotoxic activity of the dengue virus and the cell death is associated with
increased concentration of intracellular calcium ion [23]. Therefore, it’s
postulated that hypocalcaemia in dengue fever could be due to the influx of
calcium ions and calcium replacement could enhance the dengue virus activity by
increasing the concentration of intracellular calcium ions. This can be supported
by in vitro studies showing that calcium channel blockers inhibiting the activity of
the influx of calcium ions in to T cells and macrophages and reducing the disease
activity of dengue [24]. However, there is only very limited supportive evidence
on calcium supplementation in the management of dengue fever [25].
Another study demonstrated that when the medium was calcium depleted
production of cytokines by cultured spleen cells was inhibited. On adding
calcium back, it was restored. CCB inhibited the transmission of the
suppressor signal and production of suppressor cytokines in a dose-dependent
manner [31]Some studies also propose that, in dengue virus infection the
production of nitrite is dependent on calcium and can be inhibited by
CCB.[32,33] Thus, in dengue fever calcium plays a major role in the
immunity.
Role of calcium on myocardium:
Calcium is essential for myocardial functioning. Cardiac involvement in
dengue fever has been registered in many studies [34,35] Myocarditis due to
47
dengue may present as ECG changes like sinus bradycardia, sinus tachycardia,
diastolic dysfunction , inverted T-wave and pericardial effusion, rised levels of
creatine phosphokinase CPK-MB levels. Suggested mechanism is that Calcium
storage abnormality in the infected myocardial cells is responsible for
occurrence of myocarditis.
Salgado et al., [36] tried to prove that alteration in calcium level in
dengue is targeting myocardial cells resulting in myocarditis. They exposed
human skeletal myocytes to dengue virus and studied the intracellular Calcium
changes. The viral replication in myocytes was proved by confocal
fluorescence microscopy. It was proposed to be resulting in contractile
dysfunction and arrhythmias.
The potential role of calcium in treatment of dengue:
Oral calcium carbonate and vitamin D3 in patients with dengue fever
results in better clinical recover and lesser duration of illness. This inference
was observed in a study done in Mexico, with less number of dengue fever
patients [18]. In another study it was shown that oral calcium carbonate may
improve the platelet count in dengue fever patients but currently no RCT’s is
available to demonstrate the effectiveness of calcium in preventing dengue
fever complications. Hence, oral or IV calcium therapy in the treatment of
dengue infection is not routinely included in published guidelines
48
4. MATERIALS AND METHODS:
STUDY POPULATION:
This study was conducted among 100 patients who are admitted
with fever in Government Mohan Kumaramangalam Medical College,
Salem, in department of General Medicine, between January 2018 and
December 2018.
INCLUSION CRITERIA:
• AGE: 15-50 yrs.
• Either sex.
• Patients with hypotension.
• Patients with third space fluid collection like ascites pleural

effusion, gallbladder edema evidenced by USG.
• Patients with severe thrombocytopenia.
• Patients with bleeding manifestations.
EXCLUSION CRITERIA:
• Patient refusal.
• Patient with co morbid conditions like diabetes, liver
diseases, cardiac failure.
• Patients with fever associated with other illness like URI,
LRI, and UTI.
• Patient with co-morbidities like diabetes, chronic liver
disease, chronic kidney disease etc…
49
ANTICIPATED OUTCOME:
In severe form of dengue infection there is reduction of serum calcium
levels compared with those who are dengue negative or having mild form of
dengue infection. It might be helpful in predicting the disease severity in
dengue.
DATA COLLECTION:
Demographic and clinical details of the patient are collected using a pre
designed profoma. The serum calcium level is measured at 2 days interval after
admission.
STUDY PROTOCOL:
The serum calcium values are compared with disease severity . The
disease severity is classified based on WHO guidelines. Severe dengue
infection is identified by one of the following features including shock, plasma
leakage, bleeding manifestations, severe thrombocytopenia.
LABORATORY INVESTIGATIONS:
1. BLOOD: HB, TC, DC, ESR, Hct, platelet count
2. Blood Urea
3. Serum Creatinine
50
4. LFT (SGOT, SGPT)
5. Serum electrolytes.
6. Serum calcium.
7. IgM ELISA
8. NS-1 Antigen
7. Other relevant indications, if required.
SPECIMEN COLLECTION:
An unhemolysed serum or plasma is used.
RADIOLOGICAL INVESTIGATIONS:
1. USG-Abdomen : to find out third space fluid collection
(Such as ascites, pleural effusion, Gall bladder wall edema)
2. CHEST X RAY: to find out pleural effusion.
ESTIMATION OF CALCIUM:
Method: Arsenazo
Mode: Endpoint
51
Principle:
Arsenazo combines with calcium ions at PH 6.5 to form a coloured
chromophore .The color produced is directly proportional to the concentration
of calcium in the sample which is measured at 650nm.
Reagent composition
• Calcium standard:10mg/dl
• Arsenazo III
• Buffer
Procedure
The assay was performed after calibration.
10µl of serum was mixed with 1ml of reagent, mixed and incubated for 10
minute at room temperature and absorbance of standard and sample read
against reagent blank at 650 nm.
Calculation
Serum Calcium (mg/dL) = (Abs.T) - (Abs.B) × 10

(Abs.S) - (Abs.B)
Reference Range
Serum calcium 8.5 - 10.5 mg/dl
52
Linearity
The kit is linear up to 16 mg/dl
DIAGNOSIS OF DENGUE:
1. IgM-capture MAC-ELISA testing.
2. ELISA based NS-1 antigen testing.
CLASSIFICATION OF SEVERE DENGUE INFECTION:
(WHO CLINICAL CRITERIA, 2009):
Severe dengue infection (SDI) is defined by one or more of the
following:
(i) Plasma leakage that may lead to shock (dengue shock) and/or fluid
accumulation, with or without respiratory distress, and/or
(ii) Severe bleeding, and/or
(iii) Severe organ impairment, of which most occur during the critical
phase .
ETHICAL CLEARANCE : Obtained
DESIGN OF STUDY : Hospital based observational, prospective

study.
53
FINANCIAL SUPPORT : Nil
PERIOD OF STUDY : January 2018 to December 2018.
CONSENT : Individual written and informed consent
DEPARTMENTS ASSOCIATED : Department of microbiology and bio-

chemistry
CONFLICT OF INTEREST : Nil
STATISTICAL ANALYSIS:
The collected data were analysed with IBM.SPSS statistics software
23.0 Version. To describe about the data descriptive statistics frequency
analysis, percentage analysis were used for categorical variables and the mean
& S.D were used for continuous variables. To find the significant difference in
the multivariate analysis the one way ANOVA with Tukey's Post-Hoc test was
used. To find the significance in categorical data Chi-Square test was used. In
all the above statistical tools the probability value .05 is considered as
significant level.
54
5. OBSERVATIONS AND RESULTS:
STUDY DESIGN:
Total population under study

100
Dengue positive Dengue negative
(NS-1/ IgM positive/ both) (NS-1/IgM negative/both)
62 38
This population is only

for study included
(62)
Diagnosis
NS-1 – 53
GROUPS
IgM - 09
DF without warning signs Dengue with warning Severe dengue

signs only infection *
21
24 17
*SDI includes warning signs also
55
1. AGE DISTRIBUTION
TABLE 1: Age distribution among all fever cases
AGE Frequency Percent

15- 20 yrs 36 36.0
20 - 29 yrs 38 38.0
30 - 39 yrs 18 18.0
>= 40 yrs 8 8.0
Total 100 100.0
Age
40.0
35.0
30.0
25.0
Percentage
20.0
15.0
10.0
5.0
0.0
< 20 yrs 20 - 29 yrs 30 - 39 yrs >= 40 yrs
FIGURE 1: Bar diagram depicting age distribution among all fever cases
56
2. GENDER DISTRIBUTION
TABLE 2: Gender distribution among all fever cases
GENDER Frequency Percent

Female 42 42.0
Male 58 58.0
Total 100 100.0
Gender
42.0%
58.0%
Female Male
FIGURE 2: Pie diagram depicting gender distribution among all fever cases
57
3. COMPARISON BETWEEN AGE WITH GROUPS
TABLE 3: Comparison between age with groups
Comparison between Age with Groups

Groups
Dengue Dengue
No
without with
Severe
Total x2 - P-
Dengu
warnin warnin
Dengu value value
e e
g g
< 20 Count 12 8 9 7 36
yrs % 31.6% 38.1% 37.5% 41.2% 36.0%
20 - Count 14 8 11 5 38
29
% 36.8% 38.1% 45.8% 29.4% 38.0%
yrs
Age 30 - Count 9 3 3 3 18
39 0.958
% 23.7% 14.3% 12.5% 17.6% 18.0% 3.155
yrs #
>= Count 3 2 1 2 8
40
% 7.9% 9.5% 4.2% 11.8% 8.0%
yrs
Count 38 21 24 17100
Total 100.0
% 100.0% 100.0% 100.0% 100.0%
%
# No Statistical Significance at P>0.05 level
Age with Groups

100%
90%
80%
70%
Percentage
60%
50%
40%
30%
20%
10%
0%
No Dengue Dengue without Dengue with Severe Dengue
warning warning
Groups
< 20 yrs 20 - 29 yrs 30 - 39 yrs >= 40 yrs
FIGURE 3: Bar diagram depicting comparison between age with Groups
INFERENCE: There is no statistical significance between age and fever
groups under study with p-value of 0.958.

58
4. COMPARISON BETWEEN GENDER WITH GROUPS
TABLE 4: Comparison between gender with groups
Comparison between Gender with Groups

Groups
No Dengue Dengue Total x2 - P-
Severe value
Dengu without with value
Dengue
e warning warning
Count 18 8 9 7 42
Female
% 47.4% 38.1% 37.5% 41.2% 42.0%
Sex
Count 20 13 15 10 58
Male 0.853
% 52.6% 61.9% 62.5% 58.8% 58.0% 0.785
#
Count 38 21 24 17 100
Total 100.0
% 100.0% 100.0% 100.0% 100.0%
%
# No Statistical Significance at P>0.05 level
Gender with Groups

100%
90%
80%
70%
Percentage
60%
50%
40%
30%
20%
10%
0%
warning warning
Groups
Female Male
FIGURE 4: Bar diagram depicting comparison between gender with Groups
INFERENCE: There is no statistical significance between gender and fever
groups under study with p value of 0.853
59
5. COMPARISON OF PLATELET COUNT WITH DENGUE STATUS
TABLE 5: Comparison of platelet count with dengue status
Comparison of PC with Dengue status by One way ANOVA

Minimu Maxim P-
N Mean S.D F-value
m um value
No Dengue 38 1.47 0.34 .15 2.03
Dengue without
21 1.40 0.31 .99 2.03
warning 0.0005
PC 24.136
Dengue with **
24 1.06 0.48 .35 1.93
warning
Severe Dengue 17 0.54 0.49 .10 1.70
** Highly Significant at P < 0.01 level
Tukey's Post-hoc test for Multiple comparison

95% C.I
Dependent Variable Mean Std. P- Lower Upper
Difference Error value Bound Bound
Dengue
0.912
without .07163 .10884 -.2130 .3562
#
warning
Dengue
No Dengue 0.001
with .41252* .10437 .1396 .6854
**
warning
Severe 0.0005
.93505* .11680 .6297 1.2404
PC Dengue **
Dengue
0.027
Dengue with .34089* .11961 .0282 .6536
*
without warning
warning Severe 0.0005
.86342* .13060 .5220 1.2049
Dengue **
Dengue with Severe 0.0005
.52252* .12689 .1907 .8543
warning Dengue **
** Highly Significant at P < 0.01 level * Significant and # No Statistical Significance
at P >0.05 level
60
Platelet count with Dengue status
1.60
1.40
1.20
1.00
Mean
0.80
0.60
0.40
0.20
0.00
warning warning
Groups
FIGURE 5: Bar diagram depicting Comparison of platelet count with dengue
status
INFERENCE:
There is no statistical difference in platelet counts between dengue
negative and dengue positive cases without warning signs (p=0.912)
There is high statistical significance in platelet count between dengue
negative and dengue with warning signs (p=0.001)/severe dengue infection
(p=0.0005)
There is high statistical significance in in platelet count between dengue
with warning signs and severe dengue infection (p=0.0005)
61
6. COMPARISON OF HCT WITH DENGUE STATUS
TABLE 6: Comparison of Hct with dengue status
Comparison of Hct with Dengue status by Oneway ANOVA

Mini Maxi F- P-
N Mean S.D mum mum value value
Hct No Dengue 38 32.22 3.72 24.50 41.00
Dengue without
21 36.83 4.97 29.50 45.50
warning 0.0005
9.230
Dengue with **
24 35.40 3.11 28.50 42.00
warning
Severe Dengue 17 38.76 7.41 25.00 50.00

95% C.I
Dependent Variable Mean Std. Lower Upper
Difference Error P-value Bound Bound
Hct No Dengue Dengue without
warning -4.60965* 1.27388 0.003 ** -7.9403 -1.2790
Dengue with
-3.17215 1.22152 0.052# -6.3660 .0217
warning
Severe Dengue 0.0005 -
-6.54102* 1.36700 -2.9669
** 10.1152
Dengue Dengue with
1.43750 1.39989 0.734 # -2.2227 5.0977
without warning
warning Severe Dengue -1.93137 1.52848 0.588 # -5.9278 2.0650
Dengue with Severe Dengue
-3.36887 1.48513 0.113 # -7.2519 .5142
warning
** Highly Significant at P < 0.01 level and # No Statistical Significance at P >0.05 level
62
Hematocrit with Dengue status
45.00
40.00
35.00
30.00
25.00
Mean
20.00
15.00
10.00
5.00
0.00
warning warning
Groups
FIGURE 6: Bar diagram depicting comparison of hct with dengue status
INFERENCE:
There is high statistical significance in hematocrit between dengue
negative and severe dengue infection (p=0.0005)
There is no statistical significance in hematocrit between dengue with
warning signs and severe dengue infection (p=0.113)
63
7. COMPARISON OF SR.CAL WITHIN STUDY GROUPS
TABLE 7: Comparison of Sr.Cal within study groups
Comparison of Sr.Cal with Dengue status by One way ANOVA

Mea S. Mini Maxi P-
N n D mum mum F-value value
No Dengue 0.7
38 8.98 7.30 10.35
0
Dengue
0.5
without 21 9.27 8.45 10.20
1 0.000
Sr.Cal warning 20.843
5 **
Dengue with 0.9
24 7.95 6.55 10.05
warning 6
Severe 1.1
17 7.60 6.00 9.55
Dengue 2

95% C.I
Mean Std.
Dependent Variable P-value Lower Upper
Difference Error
Bound Bound
Dengue
-
without -.28484 .22299 0.580 # .2982
.8679
warning
No Dengue
0.0005
Dengue with 1.03629* .21383 .4772 1.5954
**
warning
Severe 0.0005
1.38421* .23929 .7586 2.0099
Dengue **
Sr.Cal
Dengue
0.0005
Dengue with 1.32113* .24505 .6804 1.9618
**
without warning
1.66905* .26756 .9695 2.3686
Dengue **
Dengue Severe
-
with Dengue .34792 .25997 0.541 # 1.0276
.3318
warning
** Highly Significant at P < 0.01 level and # No Statistical Significance at P
>0.05 level
64
Sr.Cal within study groups
10.00
9.00
8.00
7.00
6.00
Mean
5.00
4.00
3.00
2.00
1.00
0.00
warning warning
Groups
FIGURE 7: Bar chart depicting comparison of Sr.Cal within study groups
INFERENCE:
There is no statistical significance in serum calcium levels between
dengue negative with dengue positive without warning signs (p=0.580)
dengue with warning signs and severe dengue infection (p=0.541)
There is high statistical significance in serum calcium levels between
dengue negative and dengue positive with warning signs (p=0.0005)
dengue positive without warning signs and severe dengue infection
(p=0.0005)
dengue positive without warning signs and dengue with warning signs
(p=0.0005)
65
8. FREQUENCY OF WARNING SIGNS AMONG DENGUE PATIENTS
Frequency of warning signs
dengue with warning signs

dengue without warning signs
FIGURE 8: Pie chart depicting frequency of warning sign among dengue cases
TABLE 8: Frequency of warning signs among dengue patients
Comparison between WS with Groups

Groups
Dengue Dengue X2 -
value
P-value
without with Severe
warning warning Dengue Total
21 0 0 21
Negativ Count
e
100.0% 0.0% 0.0% 33.9%
WS %
0 24 17 41
Positive Count 62.0 0.0005
00 **
0.0% 100.0% 100.0% 66.1%
%
21 24 17 62
Count
Total
100.0% 100.0% 100.0% 100.0%
%
66
9. COMPARISON OF PLASMA LEAKAGE WITHIN DENGUE
POSITIVE GROUPS
TABLE 9: Comparison of Plasma leakage within dengue positive groups
Comparison of Plasma leakage within dengue positive groups

Groups
Dengue Dengue X2 - P-
without with Severe value value
Count 20 17 7 44
%
Negative 95.2% 70.8% 41.2% 71.0%
PL Count1 7 10 18 13.327 0.001
%
4.8% 29.2% 58.8% 29.0% **
Positive
Count 21 24 17 62
Total % 100.0% 100.0% 100.0% 100.0%
.
Plasma leakage within dengue positive
groups
100%
80%
Percentage
60%
40%
20%
0%
Dengue without warning Dengue with warning Severe Dengue
Groups
Negative Positive
FIGURE 9: Bar chart depicting comparison of Plasma leakage within dengue

positive groups
10. COMPARISON OF PLATELET COUNT WITHIN DENGUE
POSITIVE GROUPS
67
TABLE 10: Comparision of Platelet count within Dengue positive groups
Comparison of Platelet count within Dengue positive groups

Maxi
N Mean S.D Minimum mum F-value P-value
Dengue
without 1.40 .31 .99 2.03
21
warning
Dengue 0.0005
PC 18.882
with 24 1.06 .48 .35 1.93 **
warning
Severe
17 0.54 .49 .10 1.70
Dengue
Multiple Comparisons
Mean Std. P- 95% C.i
Dependent Variable
Difference Error Value LB UB
Dengue
0.028
Dengue with .34089* .12896 .0308 .6509
**
without warning
PC .86342* .14081 .5249 1.2020
Dengue 5 **
Dengue
Severe 0.001
with .52252* .13681 .1936 .8515
Dengue **
warning
68
PC with Dengue status
1.60
1.40
1.20
1.00
Mean
0.80
0.60
0.40
0.20
0.00
Groups
FIGURE 10: Bar chart depicting Platelet count within Dengue positive groups
INFERENCE:
The mean value of platelet count among patients with dengue without
warning signs in 1.40lakhs/cu.mm, in patients with dengue with warning signs
is 1.06 lakh/cu.mm, in patients with severe dengue infection is 0.54
lakh/cu.mm.
There is high statistical significance between platelet count and severity
of dengue (p<0.01).
69
11. COMPARISION OF SERUM CALCIUM WITHIN DENGUE POSITIVE
GROUPS:
TABLE 11: Comparision of serum calcium within dengue positive groups
Comparison of Sr.Calcium within Dengue positive groups by Oneway

ANOVA
Minim Maxim F- P-
N Mean S.D um um value value
Sr.Cal Dengue
without 21 9.27 .51 8.45 10.20
warning
Dengue 0.0005
19.766
with 24 7.95 .96 6.55 10.05 **
warning
Severe
17 7.60 1.12 6.00 9.55
Dengue
Multiple Comparisons
Mean 95% C.i
Std.
Dependent Variable Differenc P-Value
Error LB UB
e
Sr.Cal Dengue Dengue
0.0005
without with 1.32113* .26471 .6847 1.9576
**
warning warning
Severe 0.0005
1.66905* .28903 .9741 2.3639
Dengue **
Dengue Severe
with Dengue .34792 .28083 0.435 # -.3273 1.0231
warning
** Highly Significant at P < 0.01 level and # No Significant at P > 0.05 level
70
Sr.Cal within Dengue positive groups
10.00
9.00
8.00
7.00
6.00
Mean
5.00
4.00
3.00
2.00
1.00
0.00
Dengue without Dengue with warning Severe Dengue
warning
Groups
FIGURE 11: Bar chart showing comparison of Sr.Ca within Dengue positive
groups
INFERENCE:
The mean serum calcium levels in dengue patient without warning signs
is 9.27meq/l, in dengue patients with warning signs is 7.95 meq/l, in patients
with severe dengue infection 7.60 meq/l.
DF without warning signs and severe dengue / DF with warning
signs(p=0.0005)
dengue with warning signs and severe dengue infection(p=0.0005)
Hence, reduced serum calcium levels occurs both in dengue patient
with warning signs and severe dengue infection

71
12. VARIOUS MANIFESTATIONS OF SEVERE DENGUE
26% 26% PLASMA LEAKAGE
BLEEDING MANIFESTATIONS
SHOCK
SEVERE
THROMBOCYTOPENIA
22%
26%
FIGURE 12: Various manifestations of severe dengue
13. COMPARISON BETWEEN TRANFUSION WITHIN DENGUE

POSITIVE GROUPS
TABLE 13: Comparison between transfusion within dengue positive groups
Comparison between Transfusion with Groups

Groups
Dengue Dengue X2-
P-value
without with Severe value
Tranfu Negative Count 21 24 6 51
sion % 82.3
100.0% 100.0% 35.3%
%
Positive Count 0 0 11 11
35.39 0.0005
% 17.7
0.0% 0.0% 64.7% 8 **
%
Total Count 21 24 17 62
% 100.0
100.0% 100.0% 100.0%
%
72
Transfusion with Groups
100%
90%
80%
70%
Percentage
60%
50%
40%
30%
20%
10%
0%
Groups
Negative Positive
FIGURE 13: Bar chart depicting comparison between transfusion within

dengue positive groups
INFERENCE:
There is 64.7 % of severe dengue patients requiring transfusions (packed
cells, platelets, FFP)
There is high statistical significance between transfusions in dengue
with/without warning signs and severe dengue infection (p=0.0005)
73
6. DISCUSSION:
Dengue is a major arboviral infection spread by mosquitoes. In
Southeast Asia, the Pacific, and the Americas every year, there are around 50
million dengue infections and around 500,000 individuals hospitalized with DHF.
Dengue is a rapidly emerging disease in India and it has been prevalent for about
230 years here. India recorded 99913 cases and 220 deaths during a major
outbreak in 2015 according to the NVBDCP.
In severe dengue infection various serum biochemical parameter
changes occur due to plasma leakage. Thus analyzing the relation between serum
free calcium and its association with severe dengue infection may prove helpful in
improving treatment outcomes. Hypocalcaemia is known to be associated with
plasma leakage during severe dengue and this insists the need for studies on this
area so as to improve the treatment outcomes.
In view of the above said we did a study titled “an association between
serum calcium level and severity of dengue virus infection in Government Mohan
Kumaramangalam medical college hospital, salem.” to assess the correlation
between serum ionized calcium as a biochemical marker of severity of dengue
infection.
74
Padmini Prakash Habbu et al ., at Ashwini Rural Medical College,
Hospital and Research Centre, Sholapur over the period of 6 month with
sampling of 70 individuals studied Hb, SGOT and SGPT, creatinine and calcium
estimations of Healthy control and Dengue patients and found that in dengue
patients Calcium level decreased in DF range from 5.5-10 mg/dl and 8-11 mg/dl
among the controls the Hb values are low as compared to Healthy controls it’s
ranging from 6.0 - 11gm/dl in dengue patients and 10.0-15.0gm/dl in Healthy
controls. SGOT and SGPT values are raised in dengue as compared to healthy
controls it’s ranging between 56 - 532 IU/L among dengue patients and 19-60
IU/L among healthy control groups. The creatinine values are almost same in
control and patients ranging between 0.5- 2.8 mg/dl. Calcium level decreased in
DF range from 5.5-10 mg/dl and 8-11 mg/dl among the controls [37]
Jayachandra et al., of Department of Medicine, BMC, Bangalore
conducted a study using 145 patients and concluded that hypocalcemia is
associated with severe dengue infection compared with dengue fever patients
without warning signs. [38]
Mitrakrishnan C Shivanthan et al., of University of Colombo,
Department of Medicine, Sri Lanka studied the relation between dengue infection
and serum calcium levels and found that dengue related Myocarditis has a
relationship with alteration in intracellular calcium level. They also observed that
there is increased mortality in severe dengue with hypocalcemia. [39]
75
N J Dahanayaka et al., studied the significance of detecting
hypocalcaemia to predict severity of dengue infection .Using 36 probable cases
of dengue conducted a cross sectional study at University Medical Unit
(UMU), Teaching Hospital Anuradhapura and found that Positive and negative
predictive values of hypocalcaemia predicting TSFA was 29% and 100%
respectively with a positive likelihood ratio of 2.17 (95% CI 1.84-2.551). Mean
SIC (lowest) among patients with TSFA (Third space fluid accumulation) was
0.97 (SD 0.1) mmol/l compared to 1.12 (SD 0.14) mmol/l among those without
TSFA (p=0.035). Patients with hypocalcaemia had significantly lower platelet
count and serum albumin levels (Table 3). All five patients with platelet count
<20 000 × 109/L had hypocalcemia. [40]
Constantine GR et al., Studied the association of Hypocalcemia with
disease severity using 135 patients in Sri Lanka and found that there is
significant correlation between dengue severity and Serum Ca2+ levels. [41]
Madura Adikari et al ., of Colombo North Teaching Hospital, Ragama,
Sri Lanka conducted a prospective follow up study in a tertiary care centre in
Sri Lanka throughout a one year period in 61 patients with severe dengue
infection and found that 52(85%) showed hypocalcemia during the first 24
hours of onset of severe dengue infection. Mean ionized calcium level of the
population was 0.96 mmol/L and the range being 0.53-1.48 mmol/L. There was
76
major reduction in serum calcium level within the first 24 hours of the onset of
severe dengue clinical criteria. [42]
Dr. Aditya Mahajan et al ., of Department Of General Medicine, A J
Institute Of Medical Sciences / Rajeev Gandhi University Of Health Sciences,
India conducted a study over 2 years on Correlation between Serum Ionized
Calcium and Severity of Dengue Infection using a cross-sectional study done at
A.J Institute of Medical Sciences in Mangalore, Karnataka with 50 probable
cases and found that a statistically significant association was found between
serum ionized calcium and dengue severity(p value- <0.000001) . It was also
observed that there was a statistically significant association (p value-
<0.000001) between serum ionized calcium and hematocrit (p value-
<0.000001) Also a statistically significant association was found between
serum ionized calcium and ALT levels (p value- <0.000001). [43]
Alagarasu K et al., done a study in Maharashtra comparing the Vitamin
D levels in dengue infection with those that of healthy population and concluded
that it was significantly high in dengue patients. [44]
77
7. LIMITATIONS:
1. The time of measurement in serum calcium level is not constant in
all patients because, it was measured at different times of illness in
various patients. Hence, we cannot conclude that at which stage of
disease calcium level started to decline.
2. Study population includes age group of only 15-50 yrs. Beyond this
range of age the pattern of correlation between calcium and dengue
could not be concluded.
3. The duration of hypocalcemia in dengue is not constant in all
patients and hence onset, duration and recovery from hypocalcemia
could not be defined.
4. Some patients may have low calcium levels due to other causes but
this proportion is very minimal. So we did not evaluate for other
causes of hypocalcemia.
78
8. CONCLUSION:
A total of 100 cases were studied.
Dengue diagnosis was made by detection of NS-1 antigen and IgM
antibody.
NS-1 antigen was tested during first 5 days from the onset of illness. IgM
antibody was tested after 5 days of onset of illness
62 cases were seropositive for dengue (62%).
Dengue cases were classified according to WHO guidelines.
Dengue positive cases (NS-1/IgM) was split into 3 category
1. Dengue fever (DF - 21 cases (33.9%)
2. Dengue fever with warning signs - 24 cases (38.7%)
3. Severe dengue infection - 17 cases (27.4%)
In severe dengue infection (total of 17 cases), 2(11.76%) cases presented
with shock, 4(23.52%) cases were positive for third space fluid collection
(plasma leak evidenced by pleural effusion, ascites and gall bladder wall
edema), 7(41.17%) cases presented with various bleeding manifestations,
rest 4(23.52%) cases manifested with both plasma leakage and profound
shock. Platelet count and rise of hematocrit in dengue fever was significantly
correlated with disease severity.
79
There is no statistical significance (p=0.580) between dengue negative
patients (Mean serum calcium level =8.98 meq/l) and dengue without warning
signs (Mean serum calcium level =9.27 meq/l).
There is high statistical significance (p=0.0005) in serum calcium level
between dengue without warning signs (Mean serum calcium level =9.27
meq/l) and dengue with warning signs (Mean serum calcium level =7.95 meq/l)
/severe dengue (Mean serum calcium level =7.60 meq/l).
Hence, incidence of hypocalcemia occurs more frequently in dengue cases
with warning signs and severe dengue infection.
Hence, it was observed that serum calcium levels shows significant
correlation with dengue fever severity. The Mean serum calcium levels was
significantly lower in cases with severe dengue infection and dengue fever
with warning signs than in patients with dengue fever without warning
signs.
Furthermore, the serum calcium levels can be used as a potential bio-
marker to predict the severity of dengue infection and can be used a
prognostic marker as well. But further studies are needed to support this.
We suggest further studies in the following areas i) Role of calcium
therapy as a part of dengue infection treatment ii) effects of hypocalcemia on
cardiac and skeletal muscles in dengue fever .
80
BIBILIOGRAPHY:
1. World Health Organization and Tropical Diseases Research. Dengue:
Guidelines for diagnosis, treatment, prevention and control. Geneva:
World Health Organization; 2009: new edition.
2. Dengue: Guidelines for treatment, prevention and control. Geneva:
World Health Organization, 2009.
3. Baruah K, Biswas A, Suneesh K, Dhariwal AC. Dengue fever:
Epidemiology and clinical pathogenesis.Chapter 13, Major tropical
diseases: Public health perspective.Goa: Broadway publishing
House;2014: 255–71.
4. Dash AP, Bhatia R, Kalra NL. Dengue in South East Asia: An appraisal
of case management and vector control. Dengue Bulletin. 2012;36:1–12.
5. Kalayanarooj S. Clinical manifestations and management of
dengue/DHF/DSS. Tropical Medicine and Health. 2011; 39 (4 suppl)
83–9.
6. National Guidelines for Clinical Management of dengue FeverProf (Dr)
JagdishPrasad, Director General of Health Services, Government of
India released the new Guidelines with Special Focus on Case
Management
7. Simmons, C., Farrar, J., van Vinh Chau, N. and Wills, B. (2012).
Dengue. New England Journal of Medicine, 366(15), pp.1423-1432.
81
8. Wali J P, Biswas A, Aggarwal P, Wig N, Handa R. Validity of
tourniquet test in dengue hemorrhagicfever, J Assoc Physicians India.
1999;47(2):203–204.
9. Comprehensive guidelines for prevention and control of dengue and
dengue haemorrhagic fever. Revised and expanded edition. (SEARO
Technical Publication Series No. 60 ISBN 978-92-9022-387-0
10. Peeling RW, Artsob H, Pelegrino JL, etal. Evaluation of diagnostic tests:
dengue.Nat Rev Microbiol 2010;8:Suppl:S30-S38.
11. Zaloga GP. Hypocalcemia in critically ill patients. Crit Care Med.
1992;20:251 62.
12. Zivin JR, Gooley T, Zager RA, Ryan MJ. Hypocalcemia: a pervasive
metabolic abnormality in the critically ill. Am J Kidney Dis.
2001;37:689-98.
13. Vivien B, Langeron O, Morell E, Devilliers C, Carli PA, Coriat P, Riou
B. Early hypocalcemia in severe trauma. Crit Care Med. 2005;33:1946-
52.
14. Carlstedt F, Lind L, Rastad J, Stjernström H, Wide L, Ljunghall S.
Parathyroid hormone and ionized calcium levels are related to the
severity of illness and survival in critically ill patients. Eur J Clin Invest.
1998;28:898-903.
15. Burchard KW, Gann DS, Colliton J, Forster J. Ionized calcium,
parathormone, and mortality in critically ill surgical patients. Ann Surg.
1990;212:543-50.
82
16. Forman DT, Lorenzo L. Ionized calcium: its significance and clinical
usefulness. Ann Clin Lab Sci. 1991;21:297-304.
17. Zaloga GP. Hypocalcemia in critically ill patients. Crit Care Med.
1992;20:251-62.
18. Sanchez-Valdez E, Delgado-Aradillas M, Torres-Martinez JA, Torres-
Benitez JM (2009) Clinical response in patients with dengue fever to
oral calcium plus vitamin D administration: study of 5 cases. P W
Pharmacol Soc 52: 14-17.
19. Cabrera-Cortina JI, Sanchez-Valdez E, Cedas-DeLezama D, Ramirez-
Gonzalez MD (2008) Oral calcium administration attenuates
thrombocytopenia in patients with dengue fever.Report of a pilot study.
P W Pharmacol Soc 51: 38-41.
20. Singh PS, Singh N (2012) Tetany with Plasmodium falciparum
infection. J Assoc Physicians India 60: 57-58.
21. Desai TK, Carlson RW, Geheb MA (1988) Prevalence and clinical
implications of hypocalcemia in acutely ill patients in a medical
intensive care setting. Am J Med 84: 209-214.
22. Baines PB, Thomson AP, Fraser WD, Hart CA (2000) Hypocalcaemia
in severe meningococcal infections. Arch Dis Child 83: 510-513.
23. Khanna M, Chaturvedi UC, Dhawan R, Tekwani BL, Pandey VC.
Presence of Ca2+ is obligatory for the cytotoxic activity of dengue
virus-induced cytotoxic factor. Immunology 1991;72: 73-8.
83
24. Dhawan R, Chaturvedi UC, Khanna M, Mathur A, TekwaniBL, Pandey
VC, Rai R N. Obligatory role of Ca2+ in the cytotoxic activity of
dengue virus-induced cytotoxin. Int JExp Pathol 1991; 72: 31-9.
25. Cabrera-Cortina JI, Sánchez-Valdéz E, Cedas-DeLezama D,Ramírez-
González MD. Oral calcium administration attenuates thrombocytopenia
in patients with dengue fever. Report of a pilot study. Proc West
Pharmacol Soc 2008; 51: 38-41.
26. Sitprija V. Altered fluid, electrolyte and mineral status in tropical
disease, with an emphasis on malaria and leptospirosis. Nat Clin Pract
Nephrol. 2008;4:91–101. [PubMed]
27. Bunnag T, Kalayanarooj S. J Med Assoc Thai. Vol. 94. Bangkok,
Thailand: 2011. Dengue shock syndrome at the emergency room of
Queen Sirikit National Institute of Child Health; pp. S57–63. [PubMed]
28. Zaloga GP, Chernow B. The multifactorial basis for hypocalcemia
during sepsis. Studies of the parathyroid hormone-vitamin D axis. Ann
Intern Med. 1987;107:3641. [PubMed]
29. Uddin KN, Musa AKM, Haque WMM, Sarker RSC, Ahmed AKMS. A
follow up on biochemical parameters in dengue patients attending
BIRDEM hospital. Ibrahim Med Coll J. 2008;2:25–7.
30. Wiwanitkit S, Wiwanitkit V. Hypocalcemia, tetany and dengue. Indian J
Pediatr. 2012;80:618. [PubMed]
84
31. Khare M, Chaturvedi UC. Transmission of dengue virus-specific
suppressor signal depends on the presence of calcium. Indian J Med Res.
1995;102:1–8. [PubMed]
32. Misra A, Mukerjee R, Chaturvedi UC. Production of nitrite by dengue
virus-induced cytotoxic factor. Clin Exp Immunol. 1996;104:406–11.
[PMC free article] [PubMed]
33. Mukerjee R, Misra A, Chaturvedi UC. Dengue virus-induced cytotoxin
releases nitrite by spleen cells. Int J Exp Pathol. 1996;77:45–51. [PMC
free article] [PubMed]
34. Wichmann D, Kularatne S, Ehrhardt S, Wijesinghe S, Brattig NW, Abel
W, et al. Cardiac involvement in dengue virus infections during the
2004/2005 dengue fever season in Sri Lanka. Southeast Asian J Trop
Med Public Health. 2009;40:727–30. [PubMed]
35. Kularatne SA, Pathirage MM, Kumarasiri PV, Gunasena S,
Mahindawanse SI. Cardiac complications of a dengue fever outbreak in
Sri Lanka, 2005. Trans R Soc Trop Med Hyg. 2007;101:804–8.
[PubMed]
36. Salgado DM, Eltit JM, Mansfield K, Panqueba C, Castro D, Vega MR,
et al. Heart and skeletal muscle are targets of dengue virus infection.
Pediatr Infect Dis J. 2010;29:238–42. [PMC free article] [PubMed]
37. Habbu PP, Shaikh AK. Dengue fever: an observational study in area of
Solapur, Maharashtra. Int J Health Sci Res. 2015; 5(3):169-172.
85
38. Jayachandra1, Kavya S T1, Sphoorti P Pai1, Balakrishna A. Utility of
serum free calcium as a predictor of severity in dengue fever. Bangalore
Medical College and Research Institute, Department of Medicine,
Bangalore Cukurova Medical Journal 2017;42(4):609-616
39. Shivanthan, Mitrakrishnan C, and SenakaRajapakse. “Dengue and
calcium.” International journal of critical illness and injury science vol.
4,4 (2014): 314-6. doi:10.4103/2229-5151.147538
40. Dahanayaka, N.J., Agampodi, S.B., KodithuwakkuArachchi, U.P.K.A.,
Vithange, S.P., Rajapakse, R., Ranathunga, K. and Siribaddana, S.,
2017. Dengue fever and ionized calcium levels: significance of detecting
hypocalcaemia to predict severity of dengue. Ceylon Medical Journal,
62(1), pp.67–69. DOI: http://doi.org/10.4038/cmj.v62i1.8438
41. Constantine GR, Rajapakse S, Ranasinghe P, Parththipan B,
Wijewickrama A, Jayawardana P (2014) Hypocalcemia is associated
with disease severity in patients with dengue. J Infect Dev Ctries
8:1205-1209. doi: 10.3855/jidc.4974
42. Adikari M, Perera C, Fernando M, Loeb M Premawansa S, et al. (2015)
Prevalence of Hypocalcemia and Its Potential Value as a Biochemical
Marker in Patients with Severe Dengue Infection. J Trop Dis 4: 188.
doi:10.4172/2329- 891X.1000188
43. Dr.Aditya Mahajan. “A Study on Correlation between Serum Ionized
Calcium and Severity of Dengue Infection.” IOSR Journal of Dental and
Medical Sciences (IOSR-JDMS), vol. 18, no. 3, 2019, pp 44-52.
86
44. Alagarasu K, Bachal RV, Bhagat AB, Shah PS, Dayaraj C. Elevated
levels of vitamin D and deficiency of mannose binding lectin in dengue
hemorrhagic fever. Virol J. 2012;9:86.
87
PROFORMA:
NAME: AGE: SEX: IP NO.: DATE:

PRESENTING COMPLAINTS :
Fever- ____days
H/O PRESENT ILLNESS :
FEVER - ………days
Continuous/intermittent
Low/ high grad
Chills and rigors +/-
VOMITING - if yes , ……….. Episodes / day
Projectile /non projectile
ABDOMINAL PAIN
ABDOMINAL DISTENSION
RASHES - petechial spots/purpura / subconjuctival bleed / ecchymosis

/epistaxis / gum bleed / malena / hemetemesis.
OTHER SYMPTOMS:
Nausea, Headache, Retro orbital pain, Arthralgia, Giddiness, Chest pain,
Cough, Sore throat, Dysuria , loose stools ,Seizure , Altered sensorium.
88
PAST H/O :
HTN/ DM / BA/ PTB / COPD / CAD / CVA / CLD / CKD / seizure disorder /
surgical H/O / trauma H/O / drug allergies / atopy H/O / RHD / RVD
Recent H/O fever, if yes – details
PERSONAL H/O : smoker/ alcoholic
ON EXAMINATION
Patient conscious / drowsy / unconscious
Afebrile / febrile
Hydration status
Pallor / cyanosis / clubbing / jaundice / pedal edema / lymphadenopathy
Scars / sinuses / eschar / rashes / petechiae, purpuric spots
VITALS: BP (mm hg), Pulse pressure (mm hg)
PR (min), Spo2 (%),CRT (secs)
CVS – S1S2 +, murmur +/-
RS – NVBS +, added sounds +/-, B/L air entry-equal/ diminished
Abdomen - soft /distended, Organomegaly +/-, Free fluid +/-,

Bowel sounds +/-
CNS – conscious / drowsy / unconscious
Oriented / confused / irritable
Neck stiffness / kernig’s / brudzinsky’s
89
ABBREVIATIONS:
DF - Dengue Fever
DHF - Dengue Hemorrhagic Fever
DSS - Dengue Shock Syndrome
EDS - Expanded Dengue Syndrome
SDI - Severe Dengue Infection
Hct - Hematocrit
NS-1 - Non Structural protein antigen
RDT - Rapid Diagnostic Tests
ABCS - Acidosis Bleeding Calcium Sugar
NVBDCP - National Vector Borne Disease Control Programme
MAC-ELISA - IgM Antibody Capture Enzyme-Linked Immuno Sorbent
Assay
CYD-TDV - Chimeric Yellow fever virus -Dengue virus Tetravalent
Dengue Vaccine
90
MASTER CHART ABBREVIATIONS:
DOA - Date Of Admission
WS - Warning Signs
DOF - Day Of Fever (on admission)
BM - Bleeding Manifestations
PL - Plasma Leakage
PE - Pleural Effusion
A - Ascites
GBE - Gall Bladder wall Edema
PC - Packed Cells
FFP - Fresh Frozen Plasma
Plt - Platelet
91
92
93
MASTERCHART
W B
S.No Age Sex IP no DOA DOF shock Platelet count Hb Hct PL/USG Sr. Ca²⁺ NS1/ IgM SDI Transfusions
S M
PC1 PC2 % PE A GBE Mg/dl NS1 IgM PC FFP Plt
1 17 M 21935 06.01.18 4 - - - 0.88 1.22 9.8 30 33 - - - 9.9 9.4 NT + No 0 0 0
2 23 F 22477 10.01.18 4 + + - 1.30 1.57 10.5 33 38 - - + 8.5 9.2 NT + Yes 0 0 0
3 22 M 22615 11.01.18 3 - - - 1.18 2.45 13.2 40 42 - - - 8.8 9.2 - NT No 0 0 0
4 17 M 22849 13.01.18 4 + - + 0.20 0.33 9.3 29 33 - - - 9.0 8.8 NT + Yes 2 4 4
5 14 M 23371 18.01.18 5 + - - 1.65 2.20 12.1 37 39 - - + 8.9 9.3 NT + No 0 0 0
6 31 F 23499 19.01.18 2 - - - 1.41 1.50 14.5 45 43 - - - 8.6 9.1 + NT No 0 0 0
7 35 M 22314 09.01.18 5 - - - 1.01 1.78 9.8 29 33 - - - 9.0 9.8 NT - No 0 0 0
8 18 F 22918 14.01.18 2 - - - 1.22 1.68 10.6 32 35 - - - 10.2 10 - NT No 0 0 0
9 13 M 23216 16.01.18 4 + - - 0.81 1.26 11.2 35 34 - + - 7.4 7.9 NT + No 0 0 0
10 29 F 23297 16.01.18 5 + - - 1.50 2.40 9.8 30 32 - - - 9.4 9.7 NT - No 0 0 0
11 44 M 23488 19.01.18 6 + + - 0.27 0.17 17.5 48 45 + + - 5.9 6.1 NT + Yes 0 2 2
12 31 M 23513 20.01.18 8 - - - 1.44 2.16 10.2 31 34 - - - 8.5 8.7 NT - No 0 0 0
13 13 F 23758 22.01.18 4 - - - 1.25 1.78 11.2 34 32 - - - 8.6 8.8 - NT No 0 0 0
14 34 M 23799 23.01.18 2 + - - 1.96 1.17 14.1 44 40 - - - 7.4 7.0 NT + No 0 0 0
15 28 F 24006 25.01.18 6 + - - 0.37 0.62 11.0 33 35 - - - 8.1 8.3 NT + No 0 0 0
16 19 M 24441 29.01.18 5 - - - 1.68 1.25 14.0 42 45 - - - 10.0 9.7 NT + No 0 0 0
17 26 F 24658 31.01.18 2 - - - 1.48 1.60 9.2 28 30 - - - 10.0 10.2 - NT No 0 0 0
18 17 M 24719 01.02.18 4 - - - 0.92 1.55 8.5 27 27 - - - 9.7 10.1 NT - No 0 0 0
19 40 M 24833 02.02.18 2 - - - 1.26 1.12 12.3 37 37 - - - 8.7 9.0 - NT No 0 0 0
20 14 F 25112 05.02.18 1 + - - 1.54 0.70 9.9 30 34 - - - 8.1 8.0 NT + No 0 0 0
21 27 M 25244 06.02.18 4 + - - 0.42 0.38 10.3 30 40 + - + 7.0 6.3 NT + No 0 0 0
22 15 M 25919 10.02.18 5 - - - 1.38 1.44 11.5 35 37 - - - 8.4 8.2 NT - No 0 0 0
23 38 F 26554 14.02.18 7 + - - 0.94 1.14 9.2 28 34 - - - 8.8 8.5 NT - No 0 0 0
24 19 F 27110 20.02.18 3 - - - 1.02 0.96 10.8 32 35 - - - 10.1 9.6 + NT No 0 0 0
25 23 M 27936 27.02.18 6 - - - 1.41 0.98 14.0 42 45 - - - 9.3 9.4 NT + No 0 0 0
94
S.No Age Sex IP no DOA DOF WS shock BM Platelet count Hb Hct PL/USG Sr. Ca²⁺ NS1/ IgM SDI Transfusions

26 22 M 28059 02.03.18 3 - - - 1.29 1.88 13.1 40 38 - - - 8.4 8.2 - NT No 0 0 0
27 13 M 8511 19.03.18 6 - - - 1.48 2.20 14.5 46 45 - - - 9.0 9.3 NT + No 0 0 0
28 27 M 28114 28.03.18 4 + - - 1.53 1.77 11.2 34 40 - - - 9.1 8.8 NT + No 0 0 0
29 16 F 28319 11.04.18 5 - - - 0.88 1.10 9.8 30 34 - - - 8.6 8.7 - - No 0 0 0
30 19 M 8647 27.04.18 5 + - - 0.61 1.32 11.1 35 37 - - + 8.0 7.3 NT + No 0 0 0
31 37 F 28553 16.05.18 2 - - - 1.40 1.66 9.2 27 30 - - - 10.2 9.9 - NT No 0 0 0
32 25 M 28776 18.05.19 3 + - - 1.72 1.00 11.7 35 37 - - - 6.3 6.8 NT + No 0 0 0
33 29 F 28941 09.06.18 9 - - - 1.60 2.46 13.6 41 40 + - - 9.1 8.8 NT - No 0 0 0
34 14 M 29102 17.06.18 4 - - - 1.00 0.92 9.5 29 30 - - - 8.6 8.7 - - No 0 0 0
35 21 M 8640 09.07.18 3 - - - 1.49 2.33 10.0 30 30 - - - 10.4 10.1 - NT No 0 0 0
36 29 F 29119 20.07.18 5 + - - 1.00 1.48 10.7 32 35 - - - 9.0 8.8 NT + No 0 0 0
37 35 M 29240 27.07.18 3 + - - 1.56 1.10 11.2 31 33 - - + 10.1 10.6 - NT No 0 0 0
38 16 F 8965 29.07.18 2 - - - 1.62 1.28 12.5 37 35 - - - 10.3 9.9 + NT No 0 0 0
39 22 M 29580 02.08.18 5 + - - 0.42 0.28 10.2 32 40 + - - 7.0 6.6 NT + No 0 0 0
40 46 M 30082 07.08.18 5 - - - 1.66 1.25 9.1 27 30 - - - 8.9 8.7 - - No 0 0 0
41 15 M 30419 11.08.18 3 + + - 0.27 0.17 13.6 38 41 + + + 7.9 6.5 NT + Yes 0 2 2
42 17 F 30465 11.08.18 5 - - - 1.39 1.46 11.5 35 35 - - - 9.7 10.2 - - No 0 0 0
43 14 F 31695 16.08.18 6 + - - 0.80 0.51 9.5 30 35 - - + 6.8 7.1 NT + No 0 0 0
44 19 M 31884 17.08.18 4 - - - 1.21 1.44 12.3 37 37 - - - 8.7 9.0 - NT No 0 0 0
45 33 M 32115 23.08.18 7 - - - 1.33 2.17 10.2 31 34 - - - 7.6 7.8 NT - No 0 0 0
46 27 M 32198 23.08.18 5 - - - 1.06 0.92 11.5 35 37 - - - 8.8 9.0 NT + No 0 0 0
47 18 F 32677 27.08.18 3 - - - 1.18 1.92 8.9 27 30 - - - 9.0 8.8 - NT No 0 0 0
48 47 M 32914 30.08.18 3 + - - 1.02 1.86 12.8 38 35 - - - 8.1 8.4 NT + No 0 0 0
49 22 M 33090 31.0818 6 - - - 1.06 2.40 9.8 30 30 - - - 8.6 8.5 NT - No 0 0 0
50 28 F 33114 31.08.18 2 - - - 1.44 1.40 9.2 28 30 - - - 8.4 8.7 - NT No 0 0 0
95
51 41 M 34225 02.09.18 2 - - - 2.5 1.12 12.3 37 35 - - - 8.3 8.6 + NT No 0 0 0
52 34 M 34372 03.09.18 3 - - - 1.29 1.72 11.5 35 34 - - - 9.2 8.9 NT - No 0 0 0
53 28 F 9246 07.09.18 5 - - - 1.62 2.10 9.8 30 34 - - + 9.4 9.1 NT + No 0 0 0
54 14 F 9311 07.09.18 6 + - - 1.10 0.85 10.0 30 33 - - - 8.1 7.6 NT + No 0 0 0
55 35 M 35119 13.09.18 3 + - + 0.90 0.24 10.4 32 37 - - - 9.4 9.7 NT + Yes 1 2 4
56 19 M 35448 15.09.18 2 + + - 1.09 1.74 9.8 30 32 - - - 9.2 9.1 - NT No 0 0 0
57 27 F 35620 16.09.18 4 + - - 1.55 1.40 11.0 33 34 - - + 8.6 8.7 - - No 0 0 0
58 15 M 36002 19.09.18 6 - - - 1.20 1.04 10.2 30 30 - - - 8.5 8.9 NT + No 0 0 0
59 21 F 36105 20.09.18 5 - - - 1.45 2.60 12.1 37 35 - - - 9.3 9.0 NT + No 0 0 0
60 17 M 36112 20.09.18 2 + - - 0.38 0.22 15.8 45 55 + + + 7.5 7.4 NT + Yes 0 0 0
61 24 M 36667 24.09.18 4 + - - 1.08 1.20 13.6 41 40 - - - 7.9 7.6 NT + No 0 0 0
62 16 F 36814 25.09.18 4 - - - 1.50 1.47 10.0 30 32 - - - 8.7 8.6 - - No 0 0 0
63 18 M 36978 29.09.18 5 + - - 1.60 1.28 12.5 38 40 - - - 10.2 9.9 NT + No 0 0 0
64 20 M 37225 01.10.18 3 - - - 1.90 1.48 13.1 36 35 - - - 9.0 9.2 + NT No 0 0 0
65 34 F 37549 03.10.18 7 - - - 1.49 1.30 9.6 29 30 - - - 8.7 8.7 NT + No 0 0 0
66 21 M 37700 05.10.18 4 + - - 0.88 1.27 9.8 30 40 - + - 9.9 8.5 - - No 0 0 0
67 38 F 10521 08.10.18 6 + + - 0.25 0.37 13.9 41 37 + + + 7.5 7.1 NT + Yes 0 0 0
68 24 M 10857 10.10.18 8 + - - 0.34 0.56 10.4 32 37 - - + 7.1 6.8 NT + No 0 0 0
69 20 F 38866 11.10.18 5 + - - 0.17 0.10 15.3 44 51 + + - 8.0 7.6 NT + Yes 0 2 4
70 13 F 39324 14.10.18 2 - - - 1.10 2.00 9.8 30 32 - - - 9.2 9.5 - NT No 0 0 0
71 30 F 39952 19.10.18 5 + - - 0.21 0.09 7.8 24 25 - - - 8.8 8.7 NT - No 2 6 16
72 45 F 40233 22.10.18 4 + - + 0.68 0.56 11.6 35 34 - - - 6.8 7.1 NT + Yes 1 0 0
73 32 M 40719 26.10.18 7 + - - 1.30 0.95 10.5 32 35 - - - 9.5 9.2 NT + No 0 0 0
74 13 F 40950 28.10.18 4 + - - 0.51 0.92 9.3 30 27 - - - 7.3 6.9 NT + No 0 0 0
75 25 M 40981 28.10.18 4 + - - 1.48 1.33 10.2 30 40 - - + 8.4 8.7 - - No 0 0 0
96

76 20 M 41116 02.11.18 4 - - - 1.86 1.12 13.0 40 42 - - - 9.1 8.8 + NT No 0 0 0
77 36 M 41258 03.11.18 12 + - - 1.52 1.76 11.2 34 33 + - - 7.6 7.9 NT - No 0 0 0
78 15 F 41723 07.11.18 2 + - - 0.81 0.90 12.1 37 35 - - - 8.5 8.7 + NT No 0 0 0
79 27 M 42051 10.11.18 6 + - - 1.78 1.45 11.2 34 37 - - - 9.2 9.5 NT + No 0 0 0
80 43 F 42087 10.11.18 5 + - + 1.62 1.88 7.7 24 27 - + + 7.1 7.5 NT - NO 1 4 4
81 19 M 42419 13.11.18 3 - - - 1.50 1.42 11.4 35 37 - - - 8.6 8.6 NT + No 0 0 0
82 26 M 9652 15.11.18 6 - - - 0.92 1.20 12.2 37 34 - - - 10.1 9.7 NT + No 0 0 0
83 18 M 42555 16.11.18 7 + - + 2.32 1.08 13.5 37 37 - - - 7.9 8.2 NT + Yes 1 0 0
84 32 F 42602 16.11.18 5 + - - 0.34 0.21 16.4 45 53 + - + 7.0 6.7 NT + Yes 0 0 0
85 13 F 42887 18.11.18 2 - - - 1.42 1.29 11.9 36 35 - - - 8.8 9.1 + NT No 0 0 0
86 22 M 43431 23.11.18 5 + - - 1.72 1.95 9.8 30 38 - - - 7.5 7.1 NT + No 0 0 0
87 35 F 43867 26.11.18 3 + - - 0.80 0.56 10.2 31 35 - - - 8.0 7.4 NT + No 0 0 0
88 16 M 44003 28.11.18 2 + - + 1.63 1.02 11.5 32 34 - - - 7.2 7.7 NT + Yes 1 0 0
89 19 F 44361 30.11.18 4 + + - 0.18 0.19 18.0 51 48 + + + 6.3 7.0 NT + Yes 0 4 4
90 22 F 44452 01.12.18 3 + + - 1.90 1.61 9.8 30 30 - - - 9.2 9.5 - NT No 0 0 0
91 29 M 44592 02.12.18 1 - - - 1.10 0.93 13.6 42 45 - - - 9.5 9.7 + NT No 0 0 0
92 23 M 45119 06.12.18 3 + - - 0.67 0.57 12.1 36 44 + + - 6.1 5.9 NT + Yes 0 0 0
93 31 F 45242 07.12.18 7 - - - 1.48 1.30 10.3 31 30 - - - 10.4 10.0 NT + No 0 0 0
94 26 M 45673 10.12.18 4 + - + 0.10 0.10 6.6 22 28 - - + 6.2 6.4 NT + Yes 4 4 6
95 17 F 46195 13.12.18 5 + - + 0.31 0.14 9.3 29 34 - - - 8.7 9.2 NT + Yes 1 2 2
96 28 M 46310 14.12.18 4 - - - 1.52 1.29 11.0 33 34 - - - 8.8 8.7 - - No 0 0 0
97 44 M 46807 18.12.18 3 - - - 0.99 1.62 12.6 38 40 - - - 9.3 9.5 + NT No 0 0 0
98 21 F 46994 19.12.18 7 + - - 1.80 2.20 10.5 32 33 + - - 9.3 9.2 NT - No 0 0 0
99 25 F 47115 24.12.18 5 + - - 0.30 0.50 15.9 42 39 - - - 8.0 7.7 NT + No 0 0 0
100 20 M 47276 25.12.18 4 + + - 0.74 0.51 10.3 32 40 - - - 9.1 8.8 NT + Yes 0 0 0
97

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A DISSERTATION ON

“AN ASSOCIATION BETWEEN SERUM CALCIUM LEVEL AND

THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY

CHENNAI – 600 032, TAMILNADU

In partial fulfillment of the regulations

M.D GENERAL MEDICINE

GOVERNMENT MOHAN KUMARAMANGALAM

I hereby declare that this dissertation titled “AN ASSOCIATION

BETWEEN SERUM CALCIUM LEVEL AND SEVERITY OF

DENGUE VIRUS INFECTION IN GOVT. MOHAN

KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM.”

Dr. D.VIJAYARAJU MD, Professor of the Department, Department of

general medicine, Government Mohan Kumaramangalam Medical College

Hospital, Salem, Tamil Nadu, India.

Date: Signature of the Candidate

Place: Salem DR.S.KESAVAN

This is to certify that the dissertation entitled “AN ASSOCIATION

BETWEEN SERUM CALCIUM LEVEL AND SEVERITY OF

DENGUE VIRUS INFECTION IN GOVERNMENT MOHAN

KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM.”

is the bonafide work of Dr. KESAVAN.S in partial fulfillment of the

university regulations of the Tamil Nadu Dr. M.G.R. Medical University,

Chennai, for M.D General Medicine Branch I examination to be held in

Date : Prof. Dr. D.VIJAYARAJU M.D.,

This is to certify that the dissertation entitled “AN ASSOCIATION

BETWEEN SERUM CALCIUM LEVEL AND SEVERITY OF

DENGUE VIRUS INFECTION IN GOVERNMENT MOHAN

KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM.”

is the bonafide work of Dr. KESAVAN.S in partial fulfillment of the

university regulations of the Tamil Nadu Dr. M.G.R. Medical University,

Chennai, for M.D General Medicine Branch I examination to be held in

Date : DR. S.SURESH KANNA M.D.,

This is to certify that the dissertation entitled “AN ASSOCIATION

BETWEEN SERUM CALCIUM LEVEL AND SEVERITY OF

DENGUE VIRUS INFECTION IN GOVERNMENT MOHAN

KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM.”

is the bonafide work of Dr. KESAVAN.S in partial fulfillment of the

university regulations of the Tamil Nadu Dr. M.G.R. Medical University,

Chennai, for M.D General Medicine Branch I examination to be held in

Date : DR.K.THIRUMAL BABU,M.D., D.M.,

I hereby declare that the Government Mohan

Kumaramangalam Medical College Hospital, Salem, Tamil Nadu,

dissertation / thesis in print or electronic format for academic /

Date: SIGNATURE OF THE CANDIDATE

This is to certify that this dissertation work titled “AN

ASSOCIATION BETWEEN SERUM CALCIUM LEVEL AND

SEVERITY OF DENGUE VIRUS INFECTION” IN

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL

COLLEGE HOSPITAL, SALEM of the candidate Dr.KESAVAN.S

with registration Number 201711404 for the award of M.D DEGREE in

the branch of GENERAL MEDICINE - I personally verified the

uploaded thesis file contains from introduction to conclusion pages and

result shows 10% percentage of plagiarism in the dissertation.

Guide & Supervisor sign with Seal.

I owe my thanks to The Dean, Government Mohan Kumaramangalam

Medical College and Hospital Prof. Dr. K.THIRUMAL BABU M.D.,D.M,

for allowing me to avail the facilities needed for my dissertation work.

I am grateful to Prof. Dr. S.SURESH KANNA M.D., Professor and

Head of the Department of Medicine, Government Mohan Kumaramangalam

encouragement. I have great pleasure in expressing my deep sense of gratitude

and respect to Prof. Dr. D.VIJAYARAJU M.D., Professor Department of

Medicine, Government Mohan Kumaramangalam Medical College and

Hospital and Prof. Dr. MANJULA M.D., Professor, Department of medicine

and chief of medical unit III, Government Mohan Kumaramangalam Medical