Platelet Myths in Dengue Hemorrhagic Fever

If you have dengue fever, don't just focus on asking about the platelet count, also be aware of the increase in hematocrit.

Dengue hemorrhagic fever (DHF), as the name suggests, is caused by infection with the dengue virus. Originally, dengue fever was a tropical disease that had spread throughout the world. Its spread is widespread due to very rapid population mobilization, such as tourism, urbanization and migration between countries.

One example of the spread through tourism is a tourist from Queensland, Australia, reported to have contracted dengue fever while on vacation in Bali. Australia is not an endemic country for dengue fever. Cases of dengue fever in Australia are imported from other countries and then lead to local transmission.

Indonesia, which is crossed by the equator, is the most comfortable area for breedingAedes aegypti mosquitoes,the mosquito that spreads the dengue virus that causes dengue fever. An area can be designated as having DHF extraordinary event (KLB) status if the area meets the standard parameters of Minister of Health Regulation Number 1501 of 2010 concerning Certain Types of Diseases that Can Cause Outbreaks and Efforts to Control Them.

Article 4 states that DBD is included in infectious diseases. Article 6 and 7 mention the criteria for declaring an outbreak, including a doubling or more of new cases within a one-month period compared to the average monthly number in the previous year.

Also read: Nervousness of Dengue Fever

Dengue comes from the Swahili language, a tribe in Africa, which means 'to stagger'. This word describes the condition of a patient infected with dengue, staggering around due to fever, headache and muscle aches. So far, it is known that the dengue virus has four serotypes, Denv-1, 2, 3, and 4. It has now been proven that there are 5 serotypes, Denv-5, which was isolated in October 2013 in India.

In Jakarta, Denv-2, is the most dominant dengue virus serotype that infects, followed by Denv-3, Denv-1, and Denv-4. A person can be infected two or more times by the same (homologous) or different (heterologous) dengue virus serotypes, where heterologous infection can potentially cause dengue shock syndrome (DSS).

The condition of DSS can be fatal when adequate care is not available. Deaths from dengue infections occur due to delayed detection and also delayed proper treatment, causing patients to fall critically ill.

In cases of dengue infection, hematocrit increase, known as hemoconcentration, and decreased platelet count, known as thrombocytopenia, are the major concerns.

In Indonesia, there were 131,265 cases of dengue fever in 2022, with 1,183 deaths. Based on data from the Ministry of Health (Kemenkes), 73 percent of the fatalities were children. In 2023, there were 114,435 cases of dengue fever, with 894 deaths. Compared to 2022, the number of cases and deaths due to dengue fever has decreased.

However, this year, up to the 14th week or mid-April 2024, according to records from the Ministry of Health, there has been an outbreak with a total of 60,296 infection cases and 455 deaths due to dengue infection. Compared to 2023, based on data from the Ministry of Health, during the same period there were 20,502 cases, indicating an increase in the number of cases and deaths up to three times the number of dengue infection cases.

2024 is still a long way to go. All stakeholders must work together to overcome this dengue problem. Don't let the victims continue to fall.

KOMPAS/FAKHRI FADLURROHMAN

A nurse checks the condition of a patient with dengue hemorrhagic fever who is being treated at Taman Sari Regional Hospital, Jakarta, Tuesday (16/4/2024).

Blood examination

When a patient is infected with dengue fever, the standard examination carried out is blood examination, including hematology and immunology examinations. The hematological examination used for monitoring dengue infection is mainly the hematocrit and platelet count, while the immunological examination that needs to be carried out to confirm the diagnosis is the examination of dengue NS1 and/or dengue IgG/IgM.

In cases of dengue infection, the increase in hematocrit, known as hemoconcentration, and the decrease in platelet count, known as thrombocytopenia, are the main concerns. Generally, the laboratory results that patients and their families pay attention to and remember are the decreased platelet count.

Platelets have become a standard measurement for the general public to gauge the severity of dengue fever. Platelets have become a myth, especially for those who associate the death of dengue-infected patients with a decrease in platelet count.

The spread of information by word of mouth makes platelets the suspect main cause of death of patients infected with dengue fever so that patients and families will try hard to increase platelets as soon as possible. They will give milk, foods containing iron, eat nuts, or eat bone marrow.

Also read: Dengue Fever in Adults

Traditional Chinese medicine is also widely used, such as consuming angkak, a kind of red yeast. It is not wrong, but it is necessary to inform the treating doctor to get good supervision.

In fact, based on research, the main problem with dengue infection is plasma leakage which can cause shock and death. Plasma leakage is a condition of increased permeability of the blood vessel walls due to spacing of the interendothelial junction and focal adhesions which are the host's response to infectious pathogens. Plasma leakage and the extent of the leakage can only be identified by its secondary effects on plasma volume and body fluid distribution, such as hemoconcentration, pleural effusion, and ascites.

Currently, the common method to monitor plasma leakage in patients with dengue fever (DBD) and dengue shock syndrome (DSS) is through serial hematocrit and albumin measurements that can identify plasma leakage. However, this method is still considered inadequate as basic data on patients' hematocrit or albumin levels are usually unknown.

Another method used for this purpose is ultrasonography (USG). Serial USG examinations can identify plasma leakage during the defervescence phase.

What laboratory tests need to be carried out in cases of suspected or confirmed dengue infection? There are primarily two tests, namely hematocrit and platelet count.

KOMPAS/ADRYAN YOGA PARAMADWYA

A nurse takes a sample of a dengue fever patient's blood at Tamansari Regional General Hospital in West Jakarta on Wednesday (6/3/2024). Cases of dengue fever in Jakarta have been on the rise since early February 2024.

Hematocrit

Hematocrit is the percentage of the volume of all red blood cells in the blood and its value is expressed in percentage, with reference values for adult men being 39.9-51.1 percent and for adult women being 34-45.1 percent. Hematocrit testing is carried out using an automatic hematology tool.

For patients with dengue fever, hematocrit values increase due to plasma leakage or the release of body fluids from intravascular to extravascular spaces. Blood vessels can be likened to water pipes, if the walls of the pipes have holes, then plasma leakage can be described as the flow of water from those holes.

The release of bodily fluids or plasma "floods" the surrounding tissues causing the patient to appear swollen (edema) and can also "flood" into body cavities, such as the pleura (the lining of the lungs) which is called pleural effusion, or into the abdominal cavity which is known as ascites. One of the diagnostic criteria for dengue fever is an increase in hematocrit levels by more than 20 percent.

Plasma leakage is a fatal event for patients. If plasma leakage is not addressed, just like a leaking pipe, the amount of water in the pipe will decrease, and the bucket will only be filled with a small amount of water.

In fact, based on research, the main problem with dengue infection is plasma leakage which can cause shock and death.

Likewise, plasma leaks that are not handled properly will result in "dryness" in our body's organs, such as the kidneys, which can result in acute kidney failure, and patients can fall into a state of shock. The lost fluid must be replaced.

If there is no indication or doctor's recommendation for hospitalization, increase intake of isotonic electrolyte fluids. Compared to plain water, isotonic fluids have a rehydration effect similar to administering through an intravenous infusion. When plasma fluid exits the blood vessels, it carries not only water but also electrolytes commonly referred to in layman's terms as body salts.

An important thing to do during home care is to undergo a blood examination (hematology) at the laboratory every day. After obtaining the results, do not hesitate to consult with the treating doctor to ensure the patient's condition is monitored.

If there is an indication or recommendation for hospitalization, you should immediately comply with the doctor's recommendations, to prevent falling into a state of shock. During treatment, we need to participate in monitoring the amount and speed of intravenous fluid administration, so that it is in accordance with the therapy targets given by the doctor.

The administration of infusion fluids in cases of plasma leakage is like a double-edged sword. On one hand, it should not be too little to achieve the rehydration target. On the other hand, it should not be too much because excessive fluid can "drown" the body's organs.

KOMPAS/ADRYAN YOGA PARAMADWYA

Nurses prepare IV fluids for dengue hemorrhagic fever patients at Tamansari Regional Hospital, West Jakarta, Wednesday (6/3/2024).

Platelets

Let's explore platelets which have become a myth in society when talking about dengue fever. The job of platelets in the body is to slow or stop bleeding, help heal wounds, and "patch" leaks that occur due to stretched interendothelial junctions in vascular walls.

The decreased number of platelets or thrombocytopenia is influenced by three factors, namely decreased production, increased consumption, and increased destruction factors.

If a patient experiences a decrease in the number of platelets, don't panic. With the current advances in blood transfusion techniques, if needed, the patient can be given a platelet component transfusion to increase the number of platelets in the body.

It is important to note in cases of thrombocytopenia that patients should be prevented from falling, such as when they need to get out of bed to use the bathroom. Usually, patients experience dizziness and unsteady walking (remember the meaning of dengue in the beginning of the article) so they need to be guided. If the patient is injured, it will be difficult to stop bleeding. Additionally, the patient needs to eat soft food to prevent bleeding in the digestive tract, which is indicated by melena (black stools due to bleeding in the digestive tract).

Also read: Living with DHF

As discussed above, there are some people who provide supplementation using various ingredients or herbal remedies to increase platelet counts. This occurs because in cases of dengue fever, laypeople tend to only focus on platelet counts.

Be wise in taking supplements or potions to increase platelets because there is a risk called a masking effect. A momentary increase in platelets occurs due to the "squeezing" of reserve platelets into the circulation, but 1-2 days later the platelets decrease again because actually the three factors that cause platelets to decrease have not been resolved.

Important message

Don't ignore it if you have a high fever, immediately consult a doctor. Don't be sarcastic if the doctor orders you to be hospitalized. If your family, neighbors, friends or colleagues are sick with dengue fever, don't just focus on asking about their platelet count. It is also important to ask what the hematocrit value is.

Stephanie Settrin Ch, Clinical Laboratory Practitioner, Researcher in Community Based Dengue Study, Faculty of Medicine, University of Indonesia