386 Journal of Rawalpindi Medical College (JRMC); 2021; 25(3): 386-389 Original Article Alanine Transaminase levels in Patients of Dengue Fever in the Suburbs of Islamabad Hassan Mumtaz1, Irfan Afzal Mughal2, Amna Faruqi3, Noor-ul-Ain Irfan4, Shamim Mumtaz5, Asma Irfan6 1 House Officer, Holy Family Hospital, Rawalpindi. 2 Associate Professor, Department of Medicine, HBS Medical & Dental College, Islamabad. 3 Associate Professor, Department of Medicine, Islamabad Medical & Dental College, Islamabad. 4 Final Year MBBS Student, Islamabad Medical & Dental College, Islamabad. 5 Professor, Department of Medicine, Islamabad Medical & Dental College, Islamabad. 6 Associate Professor, Department of Physiology, Islamabad Medical & Dental College, Islamabad. Author’s Contribution 1,3,6 Conception of study 2 Experimentation/Study conduction 2,4 Analysis/Interpretation/Discussion 3,6 Manuscript Writing 4,5 Critical Review 1,5 Facilitation and Material analysis Corresponding Author Dr. Asma Irfan Professor of Physiology, Islamabad Medical and Dental College, Islamabad Email: asma.irfan@imdcollege.edu.pk Article Processing Received: 01/04/2021 Accepted: 23/09/2021 Cite this Article: Mumtaz, H., Mughal, I.A., Faruqi, A., Irfan, N., Mumtaz, I., Irfan, A. Alanine Transaminase levels in Patients of Dengue Fever in the Suburbs of Islamabad. Journal of Rawalpindi Medical College. 30 Sep. 2021; 25(3): 386-389. DOI: https://doi.org/10.37939/jrmc.v25i3.1619 Conflict of Interest: Nil Funding Source: Nil Access Online: Abstract Objective: This study was carried out to observe hepatic damage in patients with dengue fever (DF) by measuring alanine transaminase levels. Materials and Methods: A cross-sectional study of three months duration was carried out in the Department of Medicine, Dr. Akbar Niazi Teaching Hospital affiliated with Islamabad Medical & Dental College, Pakistan. The sampling technique was Non-Random consecutive sampling and 118 patients were included in our study. Serum Alanine Transaminase (ALT) (normal = 7-56 IU/L), serum Aspartate Transaminase (AST) (normal = 10-40 IU/L) were determined and ultra-sound abdomen was performed. Statistical analysis was done using SPSS Version 24. The Chi-square test was used to observe the relationship between categorical variables. Phi, Cramer’s V, Pearson’s, and Spearman’s Correlation tests were used to study the association of age and gender with ALT levels. Results: There were 72% males (n=85) and 28% females (n=33). Patients were grouped according to age and mean ALT (95+86 IU/L) and AST (134.7+ 98 IU/L) levels were calculated in the different age groups. These levels were found to be significantly raised (P=0.00) in the age groups of 9-18 years and 19-25 years as compared to the other age groups. Moreover, males had high ALT levels as compared to females, however, a significant difference was not observed. There was also no association seen of gender with raised ALT levels (P=0.564), Phi & Cramer’s V=0.56, and Spearman’s correlation coefficient=0.320. Conclusions: ALT and AST levels were elevated above the normal in our sample indicating hepatic involvement. Keywords: Dengue, Serum Alanine Transaminase, Serum Aspartate Transaminase, Hepatic Dysfunction. 387 Journal of Rawalpindi Medical College (JRMC); 2021; 25(3): 386-389 Introduction Dengue is a widespread infectious illness seen in countries located in the tropics and is fast spreading in all zones of WHO worldwide.1 This disease is viral in nature and is mosquito-borne. Dengue virus spreads by the bite of female mosquitoes, mainly of the Aedes aegypti species, which also transmits chikungunya, yellow fever, and Zika infections and, to some extent, by another species of mosquito, the Aedes albopictus. Dengue infection is prevalent in the tropics, with local disparities in risk depending on temperature, rain, and unexpected fast migration of people to urban areas.2 In the 1950s, documentation of severe dengue was done, during a dengue epidemic in the Philippines and Thailand. Presently, most Asian and Latin American countries are affected by it and have become a major reason for hospitalization and death, particularly among children. It has been assessed, that every year approximately 0.39 billion cases of dengue are observed and out of these, about 25% of patients present with clinical manifestations of this disease.2 In South-East Asia, the fatality rate is about 1%, but in India, Indonesia and Myanmar higher rates (3%-5%) have been recorded.3 In Pakistan, the initial documented outbreak of dengue fever occurred in 1994. Thereafter, an explosive occurrence of dengue cases, at the end of the year 2005 in Karachi, led to it being recognized as a yearly epidemic trend.4,5 An epidemic of dengue fever has afflicted Pakistan since the year 2010. The city of Lahore recorded 257 fatalities and 16,580 patients were confirmed positive. Moreover, from the remaining parts of the country, the number of reported cases was 5000, while some sixty people died due to dengue complications. In Pakistan, the epidemic has affected mainly the provinces of Punjab, Sindh, and Khyber Pakhtunkhwa.4,5 Clinically, the illness of Dengue fever (DF) ranges from an asymptomatic form to a wide range of syndromes with serious clinical manifestations. Symptomatic infection may present as a mild but incapacitating DF to a highly fatal Dengue haemorrhagic fever (DHF), as well as a Dengue Shock Syndrome(DSS) condition due to plasma escape in DHF patients.1 In some cases, hepatic and central nervous system damage has also been seen.6 Observed hepatic dysfunction ranges from minor damage reflected by raised transaminases to extensive injury and failure of the hepatic cells, with patients exhibiting jaundice.6 Deranged functioning of the liver has been observed more commonly in patients of DSS and DHF.7,8 Thus, in order to reduce associated morbidity and mortality, this ailment should be diagnosed at the earliest possible so that appropriate therapy may be instituted. There is a minimal data record of altered liver activity in such patients in Pakistan. The purpose of our study was to assess the spectrum of hepatic disorder in patients suffering from Dengue Fever. Materials and Methods This cross-sectional study, with a duration of three months, was carried out in the Department of Medicine, Dr. Akbar Niazi Teaching Hospital affiliated with Islamabad Medical & Dental College, Bharakahu Islamabad, Pakistan. WHO calculator was used to calculate the sample size. The estimated minimal sample size required for this study was 111 cases of Dengue infection with absolute precision required to be 0.07. Non-Random consecutive sampling was performed. As per WHO guidelines, all clinically suspected patients between 9 and 70 years of age presenting at the OPD, from July 2019 to Oct 2019 were screened. Serologically confirmed cases by Dengue NS1 Antigen, Dengue Virus IgG, and IgM were included in our study. All cases were subjected to detailed history taking, followed by a thorough clinical examination. In addition to routine investigations, Serum Alanine Transaminase (ALT) (normal = 7-56 IU/L), serum Aspartate Transaminase (AST) (normal = 10-40 IU/L), and ultra-sound abdomen were performed for detection of liver pathology. Patients suffering from other liver diseases e.g. Hepatitis, Alcoholic Hepatitis, Drug-Induced Hepatitis, etc. were excluded from our study. Statistical analysis was performed using SPSS Version 24. The Chi-square test was used to observe the relationship between categorical variables. Phi, Cramer’s V, Pearson’s, and Spearman’s Correlation tests were used to study the association of age and gender with ALT levels. Results A total of 118 patients were enrolled in our study, with 72% males (n=85) and 28% females (n=33) (Figure 1). Patients were grouped according to age (Figure 2) and mean ALT (95+86 IU/L) and AST (134.7+ 98 IU/L) levels were calculated in the different age groups (Table 1). These levels were found to be significantly raised (P=0.00) in the age groups of 9-18years and 19- 388 Journal of Rawalpindi Medical College (JRMC); 2021; 25(3): 386-389 25 years as compared to the other age groups (Table 2). Thus, younger age was found to be positively associated with raised ALT levels (Table 3). In addition, more males had high ALT levels as compared to females; however, there was no significant difference. There was also no association or relationship seen of gender with raised ALT levels (P=0.564), Phi & Cramer’s V = 0.56, and Spearman’s correlation coefficient =0.320. Figure 1: Distribution of Dengue patients according to sex Figure 2: Distribution of Dengue patients according to age Table 1: ALT and AST levels in different age groups Age groups(yrs) Number of patients=n ALT IU/L (mean + SD) AST IU/L (mean + SD) 9-18 15 117.9+108 186.1+120 19-25 32 101.2+112 133.7+124 26-35 36 84.5+59 118.1+65 36-45 19 89.2+73 127.6+83 46-55 10 70.2+135 96.1+41 56-65 2 212.5+152 276.5+173 66-75 4 85.50+77 158.0+98 Table 2: Relationship between age groups and ALT levels Chi-Square Tests Value df Asymptomatic Significance (2-sided) Pearson Chi-Square 132.132 72 0.001 Likelihood Ratio 71.966 72 .479 Linear-by-Linear Association 1.426 1 .232 N of Valid Cases 118 *** Highly significant Table 3: Association and relationship of age and ALT levels Value Significance Nominal by Nominal Phi 1.058 0.001 Cramer' s V .432 0.0001 Interval by Interval Pearson's R .110 .234 Ordinal by Ordinal Spearman Correlation .096 .300 N of Valid Cases 118 Discussion We witnessed in our study that in Pakistan, the spread of dengue infection mainly occurred in August and September and we found our results to conform to a national report published previously. The probable reason for this being that this is soon after the rainy season, when the environment is extremely humid and thus, favourable for the breeding of mosquitoes.9 In our present study, we observed that mostly the younger age groups were affected as compared to the older ones, which might be due to their greater exposure to the outdoor environment. It was observed that most of our patients were in the 15-35 year age bracket. Another interesting finding was that twice as many males were affected as females, owing probably to females being confined indoors, as compared to males who take on most outdoor work and responsibilities. Similar results have been observed in previous studies.10 Hepatic dysfunction is a common occurrence in Dengue infection, as it is believed to attack the reticuloendothelial system of the patient.9,11,12 Hepatic damage could be a result of either the virus directly attacking the cells or, because of an excessive immune reaction of the host to the viral antigens.9 Some studies conducted in other countries, like Thailand and India 389 Journal of Rawalpindi Medical College (JRMC); 2021; 25(3): 386-389 have shown that the foremost reason for sudden liver failure in the younger age group, was dengue infection in about 34% and 18% of the cases, respectively.13 Another previous study observed that complications and deaths due to acute Dengue fever were significantly associated with abnormal liver function and high levels of aminotransferases. Patients with Dengue Hemorrhagic Fever, Dengue Septic Shock, hepatic and respiratory failure, as well as patients with encephalopathy, all had significant elevation of AST. Moreover, AST levels were found to be raised twice as much as ALT, in contrast to other viral infections. Similarly in another study carried out in Alexandria Hospital.10 from November 2003 till December 2004, showed that 90.6% of patients had raised AST and 71.7% had raised ALT levels. Raised aminotransferases were also reported by Souza et al.14, Wong15, Chinh, and colleagues.16 It was found that AST level was raised more than ALT.14,16,17 In a similar study conducted by Trung and colleagues in South Vietnam, 650 DF patients were recruited and raised transaminases were found in all patients. This was also associated with the severity of illness in terms of vascular leakage and bleeding.15 Conclusion Thus, we can conclude that raised ALT level can be considered an important parameter in determining morbidity and mortality in young patients suffering from Dengue, and as such can be employed as an early marker for assessment of disease severity. The limitation of our study was that our data was limited to just a suburb of Islamabad and our sampling was not done at a national level. References 1. Khetarpal N, Khanna I. Dengue fever: causes, complications, and vaccine strategies. Journal of immunology research. 2016;2016. 2. Dengue and severe dengue WHO.https://www.who.int/news-room/fact- sheets/detail/dengue-and-severe-dengue 3. Kalenahalli Jagadishkumar, MBBS, MD,* Puja Jain, MBBS, Vaddambal G. Manjunath, MBBS, DCH, DNB, and Lingappa Umesh, Hepatic Involvement in Dengue Fever in Children - NCBI Iran J Pediatr. 2012 Jun; 22(2): 231–236 4. Dengue Fever/ Programmes/ Pakistan- WHO EMRO http://www.emro.who.int/pak/programmes/dengue-fever.html 5. Khan J, Khan I, Ghaffar A, Khalid B. Epidemiological trends and risk factors associated with dengue disease in Pakistan (1980–2014): a systematic literature search and analysis. BMC public health. 2018 Dec 1;18(1):745. 6. Kalenahalli Jagadishkumar, MBBS, MD,* Puja Jain, MBBS, Vaddambal G. Manjunath, MBBS, DCH, DNB, and Lingappa Umesh, Hepatic Involvement in Dengue Fever in Children Iran J Pediatr. 2012 Jun; 22(2): 231–236. 7. Petdachai W. Hepatic dysfunction in children with dengue shock syndrome. Dengue Bulletin. 2005;29: 112–7. 8. Itha S, Kashyap R, Krishnani N, Saraswat VA, Choudhuri G, Aggarwal R Profile of liver involvement in dengue virus infection. Natl Med J India. 2005 May-Jun; 18(3):127-30 9. Khan E, Kisat M, Khan N, Nasir A, Ayub S, Hasan R. Demographic and clinical features of dengue fever in Pakistan from 2003–2007: a retrospective cross-sectional study. 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