Therapeutic Plasma Exchange as a rescue therapy in three patients of severe Dengue with Hyperferritinemia and acute hepatic failure: A Case Series -

Abstract

Severe Dengue Infection unresponsive to standard therapy carries a very high mortality with limited therapeutic options. Ferritin levels have been evaluated recently for its role as a diagnostic tool in dengue fever. It has also been shown to correlate with severity of dengue. Hyperferritinemia is an important marker for diagnosis of macrophage activation syndrome which is commonly seen in severe dengue. Immunomodulation has been attempted using steroids and IVIG therapy. Both are not recommended therapy for dengue patients of any severity. Treatment guidelines have been developed by World Health Organization(WHO) but there are variations between these guidelines. There are no robust trials and studies about use of plasmapheresis in Severe Dengue. High Volume Plasma Exchange(HVP) in acute hepatic failure have been well studied in recent randomized controlled trial by Larsen et al with improvement in outcome by increasing liver transplant-free survival further suggesting that the effect is mediated by dampening of innate immune response with Therapeutic plasma exchange(TPE). TPE has been attempted in patients of dengue with Hyperferritinemia associated multiorgan failure with variable success.WHO SEARO (World Health Organization in South-East Asia) guidelines recommends considering plasma exchange as a therapeutic option for management of severe dengue patients with hepatic encephalopathy who are clinically deteriorating with standard treatment. Based on the data by Larsen and WHO SEARO guidelines we instituted Plasmapheresis in severe dengue patients who were clinically unresponsive to standard therapies and were deteriorating.