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Comparison of Clinical and Laboratory Parameters between Chickungunya and Dengue: Are Liver Enzymes Reliable Indicators in These Infections?

INTRODUCTION Dengue and chikungunya are vector borne diseases sharing not only the season of epidemic but also the clinical features. At times diagnosis is at stake owing to unavailability of specific test and targeted treatment is different for the two diseases as long duration is required in definitive testing. It is important to differentiate between them during their first presentation with routinely available diagnostic tests with shorter turnaround time. The need becomes more in case of dengue in view of possible complications such as dengue hemorrhagic fever and dengue shock syndrome.


INTRODUCTION
Dengue and chikungunya are vector borne diseases sharing not only the season of epidemic but also the clinical features. At times diagnosis is at stake owing to unavailability of specific test and targeted treatment is different for the two diseases as long duration is required in definitive testing. It is important to differentiate between them during their first presentation with routinely available diagnostic tests with shorter turnaround time. The need becomes more in case of dengue in view of possible complications such as dengue hemorrhagic fever and dengue shock syndrome.

AIMS AND OBJECTIVES
The aim of the study is to compare various clinical and laboratory findings between subjects with dengue fever (DF) and Chickungunya fever (CF) and to search for a routinely done investigation which can help to differentiate between the both. The objective of this review is to provide physicians in general practice with a guide to interpreting liver enzyme alterations in chikungunya. While the two groups were found to be sex matched (p=0.82), mean age was found to be significantly lower in DF. Further myalgia and arthalgia was found to be significantly higher in CF while frequency of fever, abdominal pain, nausea, vomiting, respiratory distress was found to be higher in DF.

Laboratory investigations in study subjects
Further when investigations were assessed in both groups, Platelet count were found to be significantly lower while Serum AST, ALT, AST at first and second follow up and ALT at first follow up were found to be significantly higher in dengue fever compared to Chikungunya fever. While platelet counts were found to be significantly lower in DF (p=0.02), liver enzymes were found to be consistently higher in DF at presentation (AST p= 0.001, ALT p=0.06) at 1 week (AST p= 0.002, ALT p=0.06) and at 2 weeks (AST p= 0.001, ALT p=0.003).
Clinical features and investigations in study subjects:-Also fever, bradycardia were found to be significantly frequent in Dengue Fever, and Raised ESR and CRP were common in Chikungunya fever. Both ESR (p=0.006) and CRP (p<0.0001) showed increased frequency of raised levels in Chikungunya Fever. ECG showed significantly higher frequency of bradycardia in Dengue Fever.
Investigations in study subjects:-NO significant difference were observed in HB, TLC, T BIL, Albumin, S. Creatinine, RBS and ALT after 1 week Investigations in study subjects: Also frequency of findings in ECHO, PT/INR , bradycardia on clinical examination and intake of tab Heptral were found to be matched amongst the groups and found to be DF>CGF Diagnostic significance of various investigations in diagnosis of Dengue fever against Chickungunya fever in study subjects: ROC curve was ploted for assessing diagnostic significance of various parameters to detect dengue fever amongst all subjects. AST showed maximum diagnostic significance with area under curve of 83.6% (p<0.0001) .

Figure shows ROC curve analysis of various investigations. (Maximum for AST)
Beneficial effect of Tab Heptral in reducing liver enzymes in Dengue fever : Beneficial effect of Tab Heptral in reducing liver enzymes in dengue fever were also assessed by compairing change in liver enzymes in dengue subjects at first follow up and at second follow up. No significant difference was noted in Both liver enzymes at first follow up but significantly higher reduction in enzyme activity was found in both liver enzymes at second follow up in subjects who were given Tablet Heptral.

DISCUSSION
In Tropical countries like India where vector borne diseases like dengue and chikungunya are rampant, there is great necessity of early diagnosis and treatment to decrease mortality from dengue complications like dengue hemorrhagic fever and dengue shock syndrome. Many a times there is diagnostic dilemma in differentiating dengue from chikungunya which are caused by same vector and in the same season (September to November in India).Also there is lack of diagnostic facilities in ruraland tribal areas of India where costly investigations like dengue serology and chikungunya PCR are not available. In such situations serum transaminases which are available in all basic laboratories and are cheaper offer an diagnostic direction to differentiate dengue from chikungunya as dengue patients show more elevation of serum transaminases and early treatment can be initiated on that basis. However even serum transaminases don't show a upward trend in the first week of infection, its always better to consider each patient as dengue patient when diagnostic dilemma raises in order to avoid deadly complications of dengue. In patients of dengue, basic blood tests like platelet count, packed cell volume, liver enzymes (ALT, AST) are done repeatedly on timely basis to guide the treatment and to know the prognosis. Also these are low cost tests and are available everywhere. 2D ECHO was done in our study in dengue patients with bradycardia or myocarditis as we have seen mortality in a single patient, but any literature for recommendation of routine 2D ECHO was not available for dengue patients. We have used tab heptral (ademetionine) 400mg once or twice daily basis for dengue patients with severe transaminitis and its beneficial effect was found in the second week of follow up and many doctors contraindicate the routine use of heptral in dengue patients and the supporting evidence from literature is lacking.