Leonard Nainggolan

Prophylactic Platelets in Dengue: Survey Responses Highlight Lack of an Evidence Base

Dengue is the most important arboviral infection of humans. Thrombocytopenia is frequently observed in the course of infection and haemorrhage may occur in severe disease. The degree of thrombocytopenia correlates with the severity of infection, and may contribute to the risk of haemorrhage. As a result of this prophylactic platelet transfusions are sometimes advocated for the prevention of haemorrhage. There is currently no evidence to support this practice, and platelet transfusions are costly and sometimes harmful. We conducted a global survey to assess the different approaches to the use of platelets in dengue. Respondents were all physicians involved with the treatment of patients with dengue. Respondents were asked that their answers reflected what they would do if they were the treating physician. We received responses from 306 physicians from 20 different countries. The heterogeneity of the responses highlights the variation in clinical practice and lack of an evidence base in this area and underscores the importance of prospective clinical trials to address this key question in the clinical management of patients with dengue.

Time since Onset of Disease and Individual Clinical Markers Associate with Transcriptional Changes in Uncomplicated Dengue

Background Dengue virus (DENV) infection causes viral haemorrhagic fever that is characterized by extensive activation of the immune system. The aim of this study is to investigate the kinetics of the transcriptome signature changes during the course of disease and the association of genes in these signatures with clinical parameters. Methodology/Principle Findings Sequential whole blood samples from DENV infected patients in Jakarta were profiled using affymetrix microarrays, which were analysed using principal component analysis, limma, gene set analysis, and weighted gene co-expression network analysis. We show that time since onset of disease, but not diagnosis, has a large impact on the blood transcriptome of patients with non-severe dengue. Clinical diagnosis (according to the WHO classification) does not associate with differential gene expression. Network analysis however, indicated that the clinical markers platelet count, fibrinogen, albumin, IV fluid distributed per day and liver enzymes SGOT and SGPT strongly correlate with gene modules that are enriched for genes involved in the immune response. Overall, we see a shift in the transcriptome from immunity and inflammation to repair and recovery during the course of a DENV infection. Conclusions/Significance Time since onset of disease associates with the shift in transcriptome signatures from immunity and inflammation to cell cycle and repair mechanisms in patients with non-severe dengue. The strong association of time with blood transcriptome changes hampers both the discovery as well as the potential application of biomarkers in dengue. However, we identified gene expression modules that associate with key clinical parameters of dengue that reflect the systemic activity of disease during the course of infection. The expression level of these gene modules may support earlier detection of disease progression as well as clinical management of dengue.

Concurrent infections of dengue viruses serotype 2 and 3 in patient with severe dengue from Jakarta, Indonesia.

OBJECTIVE To describe the clinical manifestation of patient with severe dengue, to identify the serotypes and genotypes of dengue viruses (DENV) which concurrently infecting the patient, and to explore the possible relationship of severe dengue with the concurrent infection of DENV. METHODS Dengue diagnosis was performed using NS1 antigen detection and IgG/IgM ELISA. Standard clinical and laboratory examinations were performed to obtain the clinical and hematological data. DENV concurrent infections were detected and confirmed using RT-PCR and DENV Envelope gene sequencing. Phylogenetic analyses were performed to determine the genotypes of the viruses. RESULTS The patient was classified as having severe dengue characterized by severe plasma leakage, hemorrhage, and organ damage involving lung, liver, and kidney. Concurrent infection of DENV serotype 2 and 3 was observed. The infecting DENV-2 virus was grouped into Cosmopolitan genotype while DENV-3 virus was classified into Genotype I. Both viruses were closely related to isolates that were endemic in Jakarta. Viremia measurement was conducted and revealed a significantly higher virus titer of DENV-3 compared to DENV-2. CONCLUSIONS The occurrence of multi-serotype DENV infections was presented in a patient with severe clinical manifestation in Indonesia. The hyperendemicity of dengue in Indonesia may contribute to the DENV concurrent infections cases and may underlie the severity of the disease.

Laboratory parameters for predicting Salmonella bacteraemia: a prospective cohort study

Blood cultures for a definitive diagnosis of typhoid fever takes time and are not routinely available. We thus investigated laboratory parameters to predict Salmonella bacteraemia. We conducted a prospective cohort study in Jakarta, Indonesia. Patients with suspected typhoid fever admitted to hospital from October 2014 to December 2016 were included. Out of 187 individuals, 27 had Salmonella typhi and 12 had S. paratyphi in blood cultures. Absolute eosinopenia, elevated aspartate aminotransferase and elevated C-reactive protein > 40 mg/L were positive predictors.

The Association of Lipoprotein Changes and the Development of Plasma Leakage in Dengue Infection

There’s interrelationship between infection and lipoprotein. This is a cohort prospective study which conducted November 2010 – February 2011. This study aimed to assess the changes of HDL-C, LDL-C, total cholesterol (TC), triglyceride (TG), in acute and critical phase of dengue infection and its association with plasma leakage. Subjects who had fever 48 hours or less and Dengue NS1 antigen test positive were admitted to Cipto Mangunkusumo Hospital Jakarta. We examined clinical and CBC daily; level of albumin, HDL-C, LDL-C, TC, TG; ultrasound to find ascites and pleural effusion. Among 51 subjects, 21 subjects (41%) had plasma leakage. There were significant lower of HDL-C, LDL-C, and higher TG in critical phase than acute phase. In critical phase, subjects with plasma leakage had a significant lower HDL-C level [26.3 (8.2) vs 33.1 (12.1) mg/dL, p=0.029] but not for LDL-C, TC, and TG. They also had a significantly higher reduction in HDL-C [19.6 (9.1) vs 11.5 (5.8) mg/dL, p<0.0001] and TC [25.1 (20.0) vs 15.2 (14.5) mg/dL, 0.045] over the course of acute to critical phase. Lipoprotein changes during dengue infection were more pronounced among subjects who developed plasma leakage. The higher reduction in HDL-C is associated with the development of plasma leakage. Normal 0 false false false IN X-NONE X-NONE

Imaging Modalities Role inRecurrent Acute Pancreatitis Diagnosis

Recurrent acute pancreatitis (RAP) is a potentially life-threatening pancreatic disorder. Itrequires a combination of medical and interventional skills to diagnose, determine the etiology, and treat the condition. Recurrencesoccur in 25-30% of all acute pancreatitis cases. The most common cause of RAP is gallstone (microlithiasis). Imaging modalities become an important aspect to evaluate multiple microlithiasis. In this case, we report a 52 years oldoverweight female with RAP and fatty liver ofunknown etiology.We suspected gallstone as the cause of RAP. Physical examination considered normal. Ultrasound and abdominal CT scan wasperformed in whichfatty liver were founded. Since the gallstone is not clearly found with radiologic imaging, we decide to undergoEndoscopic Retrograde Cholangiopancreatography(ERCP)procedure to evaluatea possibility of microlithiasis. ERCPresult showed a multiple microlithiasis, thus we evacuate the stones. Clinical outcome post ERCP and evacuationprocedure was good. We concluded that the best imaging modalities to evaluate microlithiasis in RAP with normal ultrasound and abdominal CT scan is ERCP. Keyword s : recurrent acute pancreatitis (RAP), microlithiasis, endoscopic retrograde cholangiopancreatography (ERCP).

Diagnosis of Acute Pancreatitis as a Compilation of Weil's Disease

ABSTRACT Weil’s disease is a severe form of leptospirosis and caused by pathogenic strain of Leptospira. Weil’s disease affects many organs including pancreas. Acute pancreatitis in leptospirosis is quite rare. Diagnosis of acute pancreatitis in Weil’s disease is based on clinical features, biochemical, and radiologic examination. Sometimes histopathological examination is urged to confirm diagnosis. Management of acute pancreatitis in severe leptospirosis comprise of antibiotic for leptospirosis and supportive treatment for the acute pancreatitis. Early and appropriate treatment is mandated as it was studied to significantly decrease mortality risk We reported a case of 42 year old man suffering Weil’s disease with multi organ complications. Patient complained diffuse abdominal pain. Although the abdominal ultrasonography did not show any abnormalities of the pancreas, the amylase and lipase showed striking results. He recovered uneventfully. This case report demonstrated acute pancreatitis as one of severe leptospirosis complications. Keywords: acute pancreatitis, Weil’s disease, severe leptospirosis