ORIGINAL ARTICLE OPEN ACCESS

Risk Factors and Secondary Infections in

Dengue Hemorrhagic Fever Patients
Humera Nasim1, Madiha Ehtesham1, Saima Ambreen1, Muhammad Arif1, Muhammad Kamran Khan1, Aqsa Naseer2, Faizan
Fazal 3, Tayyaba Saleem 3, Mohammad Ebad Ur Rehman3
1
Department of Medicine, Holy Family Hospital, Rawalpindi, 2Department of Gastroenterology, Holy Family Hospital,
Rawalpindi,3Rawalpindi Medical University, Rawalpindi, Pakistan.

ABSTRACT

Background: Dengue hemorrhagic fever (DHF) is a fatal manifestation of dengue disease. DHF’s risk
factors profile holds significance importance in the clinical practice and efficient care plan are
required during dengue disease flare-up. The aim of this study was to investigate the risk factors for
pathogenesis of dengue disease and dengue hemorrhagic fever.

Methods: In this descriptive cross-sectional study, data was obtained from 256 patients with
diagnoses of Dengue hemorrhagic fever (DHF). Comprehensive history, physical assessment and
biochemical estimations were recorded. Patients were followed to identify and assess the risk factors
for DHF. The Statistical Package of Social Sciences for analysis of data. Stratification of residence and
socioeconomic status to see effect of these on result variable by applying chi square test. p value of
<0.05 was taken as significant.

Results: Among the 256 patients, the mean age of the age (Mean±SD) of study population was
28.4±12.1 years, 162 (63.28%) were less than 40 years of age and 94 (36.72%) were >40 years. The
males were 181 (70.70%) and females were 75 (29.30%). The frequency of risk factors was observed
to be 26 (10.8%) patients had Diabetes Mellitus, 55(21.5%) hypertension, 25(9.8%) hyperlipidemia.
Secondary infection occurred in 192 (75%) but results were insignificant (p>0.05). All diseases were
common in participants who belonged to the urban area.

Conclusion: Secondary infection was most common risk factor in patients with DHF and found mostly
in less than 40 age than older patients. Whereas, males were predominately affected more than the
females (p<0.05).

Keywords: Severe Dengue, Dengue Hemorrhagic Fever, Risk Factor.

Corresponding author:
Dr. Faizan Fazal
Rawalpindi Medical University,
Rawalpindi, Pakistan.
Email: [email protected]
ORCID iD: 0000-0002-2091-2088
Doi: https://doi.org/10.36283/PJMD12-2/008

How to cite: Nasim H, Ehtesham M, Ambreen S, Arif M, Khan MK, Naseer A, et al. Risk Factors and
Secondary Infections in Dengue Hemorrhagic Fever Patients. Pak J Med Dent. 2022;12(2): 43-49. doi:
10.36283/PJMD12-2/008

This is an open-access article distributed under the terms of the CreativeCommons Attribution License (CC BY) 4.0
https://creativecommons.org/licenses/by/4.0/

PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2023, VOL. 12 (02) DOI: https://doi.org/10.36283/PJMD12-2/008 43
Nasim et al.

INTRODUCTION care assets for the executives. Therefore, this study

Dengue is a mosquito spreader disease mostly found aimed to investigate the risk factor for the
in tropical and sub-tropical locales of more than 100 pathogenesis of dengue disease and dengue
nations1. Two-fifths of the total population or 2500 hemorrhagic fever.
million individuals are presently in danger of dengue,
and roughly 50 million new cases happen overall2. The METHODS
worldwide commonness of dengue disease has This Descriptive Cross-Sectional Study was held at the
expanded drastically in late decades, especially in Department of irresistible illnesses, Holy Family
America, Western Pacific, and Southeast Asia3. emergency clinic, Rawalpindi between June 2016 to
November 2016. Inclusion criteria were patients of
Dengue hemorrhagic fever (DHF), a conceivably both sexes diagnosed with Dengue hemorrhagic
deadly appearance of dengue contamination, was first fever (DHF) over 14 years old and ≤ 70 years. The
perceived during the 1950s during dengue disease in the exclusion criteria for this study were patients
Thailand and Philippines. Today, DHF in South Asia causes diagnosed with dengue fever, not meeting the criteria
a critical number of deaths. The identification of danger of DHF and patients with known co-morbids like a renal
variables of DHF has its suggestions for clinical practice4. It disappointment (serum Cr> 3mg/dl), cardiovascular
enables the doctors to organize care during a flare-up of breakdown (EF < 30% on echocardiography) known
dengue contamination. Furthermore, it offers a sign to danger (affirmed on biopsy report), cirrhosis of liver
the investigation of the pathogenesis of dengue and hypoalbuminemia. The study was conducted
contamination. after Ethical approval was obtained from the ethical
reviewal board of the hospital. This examination was
Epidemiological danger variables of dengue led after the endorsement from the Holy family clinic
hemorrhagic fever, for example, age and gender moral survey advisory group. The patients satisfying the
were distinguished in some studies. Co-morbidities inclusion criteria were chosen by successive inspecting
has reported as being a risk for DHF in several studies techniques from the division of irresistible sicknesses of
from dengue-affected areas and countries. The Holy family emergency clinic, Rawalpindi. Composed
effect of age on dengue hemorrhagic fever consent was taken from the infected. For the
infection studied by analysis showed that infants conclusion of various risk variables of DHF, a detailed
and children had higher chances of developing pertinent history was obtained and a careful physical
DHF. One study showed about 60% of patients were assessment was performed.
below 30 years5.
After history and examination, investigations were
The male gender is also associated with a relatively performed for each patient including hematocrit,
greater risk of dengue hemorrhagic fever. One study total leukocyte count, platelets count, serum IgM, IgG
showed that about 67.8% of the patients were males6. for dengue, and ultrasound abdomen and chest.
The secondary disease has been all around perceived
as the more forceful type of dengue contamination. The information regarding the patient’s presentation
Wichmann et al. in their examination indicated that was collected on a structured self-made question-
auxiliary dengue contamination was essentially naire to combine data for all the patients. All the
connected with the improvement of DHF in information was entered and examined through the
grown-ups. Practically 87% of patients had auxiliary Statistical Package of Social Sciences (SPSS v 22). For
contamination7. age Mean and SD were determined. Recurrence and
rates were determined for absolute factors like sexual
Co-morbidities, for example, hypertension, diabetes orientation, age gathering, and presence or nonat-
mellitus and hyperlipidemia are among the couple tendance of risk factors I-e optional contamination
of driving reasons for mortality and dismalness in DM, HTN, and hyperlipidemia. Effect modifiers were
Asia. Notwithstanding, the pathophysiology behind controlled through stratification of residence and
diabetes prompting DHF results is not surely known at socioeconomic status to see the effect of these on the
this point, even though various examinations have result variable by applying the chi-square test. A p-val-
proposed that diabetes mellitus can bring about ue of <0.05 was taken as noteworthy.
invulnerable and endothelial brokenness. One study
has shown the prevalence of hypertension, RESULTS
diabetes and hyperlipidemia as 11.2%, 6.4% and A total of 256 patients were investigated and the
8.5% much more than their normal counterparts6. mean ± standard deviation of the age study
population was 28.48+12.1 years. On analysis of the
Dengue hemorrhagic fever is a serious type of demographics profile, it was observed that 181
dengue. Different DHF peril factors had been (70.70%) were males and 75 (29.30%) were females.
proposed. Be that as it may, these dangerous According to the pattern of age distribution in this
elements may not be summed up to all populations. study, 162 (63.28%) were below 40 years of age and 94
Distinguishing hazard factors for DHF can (36.72%) were of age 40 years and above (Figure 1).
encourage early clinical, preventive and medical

44 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2023, VOL. 12 (02) DOI: https://doi.org/10.36283/PJMD12-2/008
Risk Factors and Secondary Infections in Dengue Hemorrhagic Fever Patients

Figure 1: Distribution of age of participants.

On analyzing the frequency of risk factors, it was infection. Secondary infection was the most
observed that 26 (10.8%) patients had diabetes common and significant risk factor observed in this
mellitus, 55 (21.5%) had hypertension, 25 (9.8%) had study. This is shown in Figure 2.
hyperlipidemia and 192 (75%) had a secondary

Figure 2: Frequency of secondary infections and risk factors.

Analysis of residence with age, gender, diabetes Table 1. According to this data, diabetes,
mellitus (DM), hypertension, hyperlipaemia, and hypertension, hyperlipidemia and secondary
secondary infection as a danger factor for infection were more common in participants who
distinguishing hazard factors have been given in belonged to the urban area.

PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2023, VOL. 12 (02) DOI: https://doi.org/10.36283/PJMD12-2/008 45
Nasim et al.

Table 1: Analysis of residence with age, gender, diabetes mellitus, hypertension, hyperlipaemia,
and secondary infection as a danger factors for distinguishing hazard factors.
Residence
Risk Factors p-Value
Urban Rural
Less than 40 years 93 6
Age 0.355
40 years and above 37 57

Male 105 76
Gender 0.44
Female 45 30

Present 16 10
DM 0.46
Not Present 134 96

Present 33 22
Hypertension 0.468
Not Present 117 84

Present 16 9
Hyperlipidemia 0.362
Not Present 134 97

Secondary Present 114 78

0.383
Infection
Not Present 36 28

Analysis of socioeconomic status with age, gender, hyperlipidemia and secondary infection were more
DM, hypertension, and hyperlipidemia as a danger common in participants who belonged to the lower
factor for distinguishing hazard factors has been given socioeconomic status.
in Table 2. Diabetes mellitus (DM), hypertension,

Table 2: Analysis of socioeconomic status with age, gender, DM, hypertension, and hyperlipidemia as
a danger factor for distinguishing hazard factors.

Socioeconomic Status
Distinguishing Hazard Factor p-Value
Lower Class Middle Class Upper Class
Less than 40 years old 74 68 20
0.532
Age Over 40 years old 41 38 15
Male 82 72 27
0.572
Gender Female 33 34 8
Yes 12 10 4
0.936
DM No 103 96 31
Yes 26 22 7
0.694
Hypertension No 98 84 28
Yes 11 10 4
0.809
Hyperlipidemia No 104 96 31
Yes 11 10 4
0.938
Secondary Infection No 104 96 31

DISCUSSION the old matured 50 years and more established had

The effect of age on DHF studied by previous higher case casualty and hospitalization rates10.
workers showed that babies and kids were in higher Dung and Cam announced in 2003 that over 90% of
danger of creating DHF8,9. Our study too showed dengue dreariness was in people who matured
that most of the patients were young. Guzman et al somewhere in the range of 15 and 25 years11. This
had shown a bipolar example of expanded could be identified with contrasts in way of life, time
mortality, whereby youthful newborn children and spent outside close to vectors, resting without

46 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2023, VOL. 12 (02) DOI: https://doi.org/10.36283/PJMD12-2/008
Risk Factors and Secondary Infections in Dengue Hemorrhagic Fever Patients

mosquito nets, or different parts of lacking infection information relating the seriousness of sickness with the
counteraction among the youthful. Another optional disease is in concurrence with past work
clarification could be that the illness can make Wichmann et al. 25 in their examination indicated that
long-lasting insusceptibility for the individual, so optional dengue contamination was altogether
more seasoned people who have been uncovered connected with the advancement of DHF in
all the more regularly may have more opposition, youngsters, yet not in grown-ups. Likewise, our
diminishing the bleakness rate. This study found information recognized a huge relationship between
same results as previous studies in Cuba10 and in age and kinds of contamination concerning the
Singapore12 where children, 14 years old had a development of DHF.
higher danger of creating DHF contrasted with
youthful grown-ups matured 15 years or more The presence of co-morbidities, for example, diabetes
noteworthy. The reason behind this distinction could has been proposed as a danger variable of the
be because of brought down group invulnerability infection26. Our study showed about 10% of the
and change in transmission design10,12. patients had DM. A case-control study directed in
Singapore discovered patients having hypertension
The distinguishing proof of dangerous components and diabetes are in more danger of DHF27.
of DHF/DSS has its suggestions for clinical practice. It
enables the doctors to organize care during a The results of this study are quite comparable to
flare-up of dengue disease. Additionally, it offers a similar studies conducted in other countries. Similar
hint to the investigation of the pathogenesis of to the results found in this study, A study in Taiwan
dengue disease. This investigation demonstrated a concluded that poor socioeconomic status is an
noteworthy factual relationship between sex and independent risk factor for developing dengue
seropositivity to dengue. The seroprevalence of hemorrhagic fever (DHF) 28. Another study in Taiwan
dengue fever was discovered to be equivalent found that the incidence of Dengue hemorrhagic
among guys and females as indicated by fever is more in patients who are diabetic. This
Duncombe et al.13 However according to a study by conclusion also coincides with the results of this
Montenegro et al.14 there was a prevalence of male study. Thus, it can be said with much confidence
sexual orientation among the 14 patients being that risk factors associated with the development of
considered who passed on of dengue fever. This dengue hemorrhagic fever are quite similar in
could be credited to little sample size. different countries. Attention must be given to
avoiding these risk factors so that dengue
Comorbidities were demonstrated to be related to hemorrhagic fever can be prevented to happen
extreme clinical appearances of a few irresistible especially in high-risk areas and regions.
ailments, for example, SARS15,16, pandemic flu
H1N117, tuberculosis 18,19 and hepatitis C 20. Numerous Strategy creators can organize populace bunches
investigations discovered a relationship between at high danger of creating DHF, for example,
different co-morbidities and DHF results 21 however youthful males, patients in age bunch under 20
just one examination was completed with a years, furthermore, patients having diabetes with
multivariate investigation to change for potential hypertension for immunization when dengue
confounders22. antibodies are accessible, especially in
asset-restricted nations. Segment and comorbidity
Distinguishing hazard factors for DHF can control hazard components may help general well-being
clinicians to emergency dengue patients for the clinicians bring issues to light among high-hazard
correct site of care for nearer observing and early people to take steps and measures against dengue
intercession with liquid revival. In a plague where contaminations.
medical services assets might be extended, hazard
characteristics for DHF can be utilized to organize CONCLUSION
hospital admissions of dengue patients. In our Secondary infection was the most common risk
research, we saw that secondary infection was the factor in patients with DHF. Patients younger than 40
most common danger factor in DHF. In this study were more common than older patients. Males
frequency of risk factors was observed, 26 (10.8%) were predominately affected than females.
patients had Diabetes Mellitus, 55 (21.5%) had
hypertension, 25 (9.8%) had hyperlipidemia and 192 ACKNOWLEDGEMENTS
(75%) had secondary infection with insignificant The authors would like to acknowledge the
results (p<0.05). All diseases were common in cooperation of their fellow doctors and nurses
participants who belonged to the urban area. working in the medical ward along with them.

The secondary disease has been all around perceived CONFLICT OF INTEREST
as the more forceful type of dengue contamination in The authors declare no conflict of interest.
the past22,23, especially with DEN 2 infection24. Our

PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2023, VOL. 12 (02) DOI: https://doi.org/10.36283/PJMD12-2/008 47
Nasim et al.

ETHICS APPROVAL dengue shock syndrome. J Trop Pediatr. 2004;

Ethical approval for conducting this study was 50:301-305. doi: 10.1093/tropej/50.5.301
obtained from the ethics review board of our 10. Guzmán MG, Kouri G, Bravo J, Valdes L, Susana
hospital. V, Halstead SB. Effect of age on outcome of
secondary dengue 2 infections. Int J Infect Dis. 2002;
PATIENT CONSENT 6: 118-124. doi: 10.1016/S1201-9712(02)90072-X
Informed consent was taken from all patients before 11. Dung NT, Cam NN. Dengue fever/dengue hem-
obtaining the data. orrhagic fever in Hanoi – 2003. J Vietnam Prev Med.
2005; 1: 73-77.
AUTHORS’ CONTRIBUTION 12. Ooi EE, Goh KT, Wang DN. Effect of increasing age
HN and ME were involved in the study conception, on the trend of dengue and dengue hemorrhagic
write-up, critical review and approval of the final fever in Singapore. Int J Infect Dis. 2003 7: 231-232.
version. SA, MA, MKH and AN contributed to the 13. Duncombe J, Lau C, Weinstein P, Aaskov J,
research write-up and critical review. FF, TS and MER Rourke M, Grant R, et al. Seroprevalence of dengue
critically review the write-up and approved the final in American Samoa, 2010 [letter]. Emerg Infect Dis.
version of the manuscript to be published. 2013;19:324-326. doi: 10.3201/eid1902.120464
14. Montenegro D, Lacerda HR, Lira TM, Oliveira DS,
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