Is dengue emerging as important cause of acute liver failure in endemic regions?

Table 1 Baseline investigation of the infant with acute liver failure caused by Dengue infection

Investigation	Result	Reference range
Hb	8.4 g/dL (haematocrit 25.9%)	10.0-13.2 g/dL
Total leukocyte count	14000/mm3	6-17.2 × 103/uL
Differential count	Neutrophil (N) 68, Lymphocyte (L) 25	N 15-45, L-47-77
Platelet	98 × 103 cells/mm3	1.5-4.5
Peripheral smear	No malarial parasite, no atypical cell, microcytic hypochromic picture
ALT	3853 IU	13-45 IU/L
AST	20861 IU	9-80 IU/L
Total bilirubin	8.28 mg/dL	< 1.2 mg/dL
Direct bilirubin	4.59 mg/dL	< 0.2 mg/dL
Total protein	4.02 g/dL
Alkaline phosphatase	171 IU	80-280 IU
Prothrombin time	56.4 s	11.5-15.3
Control	12.4 s
CRP	90 mg/L	0-5 mg/L
Renal function test	Urea 121.6 mg/dL	7-20 mg/dL
	Creatinine -0.3	0.2-0.4 mg/dL
Infective etiology work up	LDH antigen for malarial parasite - negative Chikungunya PCR - negative Hepatitis A IgM, anti hepatitis E IgM - negative Hepatitis B surface antigen - negative Hepatitis C IgM - negative Dengue NS-1 antigen and IgM antibody - positive (serum capture enzyme linked immunosorbent assay) Leptospira IgM - negative

ALT: Alanine transaminase; AST: Aspartate transaminase.

Table 2 Differential diagnosis in cases presenting with fever and acute hepatic failure[12]

	Acute viral hepatitis	Complicated malaria	Leptospirosis	Dengue associated ALF
High grade fever	Absent	Present	Present	Present
Haematocrit	Normal	Normal	Falls	Raised
Platelet	Normal	Decreased	Normal	Decreased
SGOT	Raised	Normal	Normal	Raised
SGPT	Raised	Normal	Normal	Raised
SGOT/SGPT	Raised	Normal	Normal	Markedly raised
Hypoalbuminemia	Not seen in acute viral hepatitis may be seen in acute on chronic cases	Absent	Absent	Present especially in DHF due to plasma leakage[11]
Renal function test	Deranged	Normal	Normal	Deranged in DHF and DSS due to hypotension
Plasma leak	Absent	Rare	absent	Present
Peripheral smear	-	Malaria Parasite	-	-