THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
38
https://www.theamericanjournals.com/index.php/tajmspr
PUBLISHED DATE: - 29-07-2024
https://doi.org/10.37547/TAJMSPR/Volume06Issue07-06
PAGE NO.: - 38-48
CORRELATION BETWEEN ABDOMINAL
ULTRASOUND FINDINGS AND PLATELET
COUNT IN DENGUE FEVER PATIENTS:
IMPLICATIONS FOR EARLY DIAGNOSIS AND
MANAGEMENT
Laiba Razaq
Akhtar Saeed Trust Hospital, Pakistan
Abdullah Khan
Akhtar Saeed Medical and Dental College, Pakistan
Muhammad Nouman Tariq
Akhtar Saeed Medical and Dental College, Pakistan
Syed Shayan Gilani
Akhtar Saeed Medical and Dental College, Pakistan
Saima Khan
Akhtar Saeed Trust Hospital, Pakistan
Muhammad Raza
Akhtar Saeed Medical and Dental College, Pakistan
Muhammad Faizan Ali
Akhtar Saeed Medical and Dental College, Pakistan
Tehreem Asghar
Akhtar Saeed Medical and Dental College, Pakistan
Syed Muhammad Ali Akbar
Akhtar Saeed Medical and Dental College, Pakistan
Seneen Noor
The International Center of Medical Sciences Research (ICMSR), 5900 Balconies Drive#12581,
Austin TX, 78731 USA
The International Center of Medical Sciences Research (ICMSR), Islamabad Pakistan
RESEARCH ARTICLE
Open Access
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
39
https://www.theamericanjournals.com/index.php/tajmspr
Elyeen Noor
The International Center of Medical Sciences Research (ICMSR), Islamabad Pakistan
The International Center of Medical Sciences Research (ICMSR), Office 5479 321-323 High
Road Chadwell Heath Essex United Kingdom Rm6 6ax, USA
INTRODUCTION
Dengue fever (DF) is a significant global health
threat, primarily transmitted by the Aedes aegypti
mosquito. This viral infection presents a myriad of
symptoms, including sudden onset high-grade
fever, anorexia, lethargy, headache, retro-orbital
discomfort, myalgia, arthralgia, weakness, sore
throat, and a macular skin rash. Severe cases of DF
necessitate hospitalization, with an estimated
500,000 hospital admissions occurring annually
worldwide (1-
2). The transmission of DF is facilitated by various
factors, one of which is the structural similarity
between the fatty acid synthase 1 (FAS1) of Aedes
aegypti mosquitoes and that of humans. This
similarity potentially plays a crucial role in the viral
replication process, contributing to the spread of
the infection (3).
In Asian populations, DF exhibits a case-fatality
rate ranging from 0.5% to 3.5% (4). Complications
of DF extend beyond the typical flu-like symptoms
and can affect multiple organ systems, including
the hepatobiliary and vascular systems. Common
hematological manifestations include bleeding
diathesis
and
thrombocytopenia,
which
significantly impact disease severity (3, 5-6).
One severe complication of DF is Dengue Vascular
Permeability Syndrome (DVPS), characterized by
an increase in microvascular permeability. This
Abstract
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
40
https://www.theamericanjournals.com/index.php/tajmspr
syndrome leads to plasma leakage, resulting in
various clinical manifestations, including pleural
effusion, ascites, gallbladder wall thickening
(GBWT), hepatomegaly, and splenomegaly (3, 5, 7-
8). Abdominal ultrasound has emerged as a
valuable diagnostic tool in the assessment of DVPS-
related changes. It offers a non-invasive method for
detecting gallbladder wall thickening, ascites, and
other signs of fluid accumulation, aiding in the
early identification of patients at risk of
progressing to the critical phase of the disease (7-
9).
In comparison to traditional imaging modalities
like
chest
X-rays,
abdominal
ultrasound
demonstrates superior sensitivity in detecting
pleural effusion, with the ability to detect smaller
volumes of fluid. This heightened sensitivity
enables early diagnosis and timely intervention,
ultimately improving patient outcomes (10-11).
The primary objective of ongoing research in this
field is to establish correlations between
abdominal ultrasound findings, platelet counts,
and disease severity in DF patients. By elucidating
these relationships, clinicians aim to develop more
effective strategies for early intervention and
management, thereby reducing morbidity and
mortality associated with severe DF cases.
METHODS
Data Collection
Following the Strobe guidelines, this prospective
study was conducted at the Radiology department
of Akhtar Saeed Trust Hospital. Over a one-month
period from October 1st to October 30th, 2022, 100
patients diagnosed with dengue fever (confirmed
via positive non-structural protein 1 (NS-1)
antigen or elevated dengue immunoglobulin IgM)
were included. Patients were referred from
outpatient, inpatient, and emergency departments
for abdominal ultrasonography. A 3.5 MHz
curvilinear probe and water-soluble gel were
utilized with a Toshiba Ultrasound machine for
imaging. Scans were performed with patients in a
supine position, employing the intercostal
approach over the right hypochondrium region.
Gallbladder wall thickness was measured using
calipers, with a normal upper limit set at 3 mm,
measured on the anterior wall. Splenomegaly was
defined as a spleen measuring more than 12 cm.
Patients provided informed written consent via a
questionnaire. The study protocol was approved by
the institution's ethics committee.
Inclusion and Exclusion Criteria
Inclusion Criteria
1. Patients diagnosed with dengue fever based on
serological tests, including positive results for non-
structural protein 1 (NS-1) antigen or elevated
dengue immunoglobulin IgM.
2. Patients who provided informed written consent
to participate in the study.
3. Patients aged 18 years and above.
4. Dengue patients with a history of fever lasting
fewer than 5 days.
Exclusion Criteria
1. Patients with pre-existing gallbladder disease
were excluded from the study.
2. Individuals who declined to provide consent for
participation.
3. Dengue patients with a history of fever lasting
more than 5 days.
Search Strategy
To identify relevant literature on the diagnostic,
prognostic, follow-up, and complication detection
role of ultrasonography in dengue fever,
comprehensive searches were conducted in
standard medical electronic databases such as
PUBMED and Google Scholar. The search terms
'dengue fever,' 'dengue hemorrhagic fever,' and
'dengue vascular permeability syndrome' were
combined with terms such as 'ultrasound,'
'abdominal ultrasonography,' 'gall bladder
thickening,' 'pericholecystic edema,' 'ascites,' and
'chest ultrasonography.' All types of studies
including abstracts, case reports, case series,
randomized controlled trials, non-randomized
controlled trials, and comparative studies were
retrieved and thoroughly reviewed. There were no
restrictions imposed based on age, gender,
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
41
https://www.theamericanjournals.com/index.php/tajmspr
geographical location, or sample size."
Data Compilation and Statistical Analysis
The collected data were organized into tables using
Microsoft Excel spreadsheet and analyzed utilizing
SPSS 25.0 software. Statistical analysis was
performed w
ith a significance level set at P ≤ 0.05.
RESULTS
Demographic Characteristics
In this cross-sectional study, 100 suspected cases
of Dengue Fever (DF) underwent abdominal
ultrasound examinations at the radiology
department. Among them, 60 patients (60%) were
male and 40 patients (40%) were female, all testing
positive for dengue serology. Out of the 100
seropositive cases, patients were classified as 38
with DF without warning signs, 33 with DF
exhibiting warning signs, and 29 with severe DF.
Correlation Analysis
Correlation
analysis
revealed
significant
associations between platelet count and both
splenomegaly (r = -0.371, p < 0.01) (table 1), and
ascites (r = -0.643, p < 0.01) (table 2), indicating
that lower platelet counts were associated with a
higher likelihood of these ultrasound findings.
Table 1: Correlation between Platelet Count
and Splenomegaly
. This table displays the
Pearson correlation coefficients between platelet
count and splenomegaly, along with their
respective significance levels. The correlation
coefficient of -0.371 indicates a significant negative
correlation between platelet count and the
presence of splenomegaly in patients with dengue
fever. ** Correlation is significant at the 0.01 level
(2-tailed).
Platelet count
Splenomegaly
Platelet count
Pearson
Correlation
1
-.371
**
Sig. (2-tailed)
.000
N
100
99
Splenomegaly
Pearson
Correlation
-.371
**
1
Sig. (2-tailed)
.000
N
99
99
Table 2: Correlation between Platelet Count and
Ascites. This table presents the Pearson correlation
coefficients between platelet count and ascites,
along with their significance levels. The correlation
coefficient of -0.643 suggests a significant negative
correlation between platelet count and the
occurrence of ascites in patients diagnosed with
dengue fever. **. Correlation is significant at the
0.01 level (2-tailed).
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
42
https://www.theamericanjournals.com/index.php/tajmspr
Platelet count
Ascites
Platelet count
Pearson
correlation
1
-.643
**
Sig. (2-tailed)
.000
N
100
100
Ascites
Pearson
correlation
-.643
**
1
Sig. (2-tailed)
.000
N
100
100
Age Distribution
The age distribution analysis revealed that the
most commonly affected age group among the
studied cases was between 21 to 30 years,
comprising 26% of the cases, followed by the age
groups of 31 to 40 years (20%) and 41 to 50 years
(13%). The mean age was 43.1 years with a
standard deviation of 21.02 (Fig 1)
Figure 1: Age Distribution of Dengue Fever Cases.
This figure illustrates the distribution of age groups
among patients diagnosed with dengue fever. The
most commonly affected age group was 21 to 30
years, representing 26% of the cases.
Subsequently, the age groups of 31 to 40 years and
41 to 50 years accounted for 20% and 13% of the
cases, respectively.
Presenting Complaints
High-grade fever was the predominant presenting
complaint among all patients (100%). Additional
complaints included nausea, vomiting, fatigue, sore
throat, dry cough, epigastric pain, myalgia,
arthralgia, severe headache, and retro-orbital pain.
Sonographic Findings
On the day of presentation, Gallbladder Wall
Thickness (GBWT) and Pericholecystic edema,
indicated by an increase in gallbladder wall
thickness, was observed in 76 out of 100 patients
(76%). The mean thickness of pericholecystic
edema was 6.25 mm, ranging from 3.7 to 11.3 mm.
Mild to moderate ascites was detected in 31 out of
100 patients (31%). Splenomegaly, defined as a
9
26
20
13
11
7
6
5
3
4
9
7
6
4
4
2
3
1
5
17
13
7
7
3
4
2
2
0
5
10
15
20
25
30
Total patients included in the study
total
female
male
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
43
https://www.theamericanjournals.com/index.php/tajmspr
spleen measuring more than 12 cm, was observed
in 32 out of 100 patients (32%).
The mean thickness of pericholecystic edema in the
study was 6.25 mm (range: 3.7
–
11.3 mm), higher
than reported in another study by Nainggolan L et
al (12). Abdominopelvic ascites was the least
common finding, whereas in another study pleural
effusion was reported as the least common finding
(12).
A relationship between pericholecystic edema and
platelet count was illustrated by a negative
correlation in the scatter diagram (Fig 2)
Fig 2: Scatter plot illustrating the relationship between pericholecystic edema (y-axis) and
platelet count (x-axis) in patients with dengue fever.
Each data point represents an individual patient,
with the negative correlation indicated by the
downward trend of the dots.
The following figure shows the sonographic
findings in different age groups. The X-axis shows
the age and the y-axis shows the number of
patients (Fig 3)
Figure 3: Sonographic Findings in Different Age Groups.
0
5
10
15
20
10 to 20
21 to 30 31 to 40 41 to 50 51 to 60
61 to 70 71 to 80 81 to 90 91 to 100
pericholecystic edema
ascites
splenomegaly
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
44
https://www.theamericanjournals.com/index.php/tajmspr
This figure displays the distribution of sonographic
findings across different age groups of patients.
The X-axis represents age groups, while the Y-axis
indicates the number of patients.
Pericholecystic edema and ascites were more
prevalent in patients with non-severe dengue with
warning signs and severe dengue, with statistically
significant differences noted (13). However,
organomegaly incidence was comparable across
different severity levels of dengue. Gall bladder
wall thickness could not be measured in 8 patients
due to contracted gall bladders.
Sonographic findings depicted in different patients
illustrated various abnormalities, such as
pericholecystic edema and pelvic free-fluid,
indicative of plasma leakage into div cavities (Fig
4 and 5).
Fig. 4. A 31year old man presented to emergency with high-grade fever with chills, nausea,
vomiting, arthralgias, and myalgias for 3 days.
CBC shows a platelet count of 75,000 and NS-1
came positive. The patient was sent for abdominal
USG and pericholecystic edema of 9.8mm and mild
pelvic ascites was seen. Just like ascites, pleural
effusion is part of polyserositis which results in
plasma leakage into the pleural cavity.
Fig. 5. Pelvic free-fluid seen in a 56-year-old woman with a history of 5-day fever and a platelet
count of 43,000.
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
45
https://www.theamericanjournals.com/index.php/tajmspr
In a study by Kamrun Nahar, median platelet
counts below specific thresholds were associated
with various ultrasound findings, including gall
bladder edema, ascites, pleural effusion, and
hepatomegaly (14). The following table shows the
relationship of platelet count with different
ultrasonographic findings (table 3).
Table 3: Platelet count Relationship with pericholecystic edema, abdominopelvic ascites and
splenomegaly
Platelet count
Pericholecystic
edema
Abdominopelvic
ascites
Splenomegaly
20,000-40,000
13
11
6
40,001-80,000
17
11
10
80,001-120,000
30
9
10
120,001-160,000
16
0
6
There was no mortality reported in our patients.
We found a difference in the length of hospital stay,
but this difference was not statistically significant.
So therefore, when consolidated with clinical
presentations of dengue patients, this finding may
assist clinicians in further management of severe
dengue
DISCUSSION
Infectious diseases continue to pose a significant
global health challenge, with dengue fever standing
out as one of the most prevalent and clinically
diverse conditions (15-20). This cross-sectional
study provides valuable insights into the clinical
and sonographic characteristics of dengue fever
(DF) patients undergoing abdominal ultrasound
examinations. The predominance of males in our
study population aligns with previous literature
suggesting a higher susceptibility of males to
dengue infection. The classification of patients into
categories of DF severity
—
without warning signs,
with warning signs, and severe DF
—
facilitates a
comprehensive understanding of the disease
spectrum (3-5, 21).
Gall bladder wall thickness (GBWT) or
pericholecystic edema emerged as the most
common sonographic finding in our study cohort,
consistent with existing literature highlighting the
utility of abdominal ultrasound in identifying
plasma leakage manifestations characteristic of
severe dengue (13). Interestingly, our study
expands upon previous findings by Parmar JP et al.,
who identified four distinct GBWT patterns during
their investigation into DF severity prediction.
These patterns include a striated pattern of
multiple hypoechoic layers separated by echogenic
zones, an asymmetric pattern with echogenic
tissue projecting into the gall bladder lumen, a
central hypoechogenic zone separated by two
echogenic layers, and a uniform echogenic pattern.
Such detailed characterization of GBWT patterns
enhances
our
understanding
of
the
pathophysiological mechanisms underlying DF
progression and may hold promise for refining
prognostic algorithms (22).
The prevalence of mild to moderate ascites and
organomegaly further underscores the systemic
involvement of multiple organs during the course
of dengue infection. Notably, the incidence of these
sonographic findings demonstrated a negative
correlation with platelet count, suggesting a
potential association between disease severity and
hematological parameters.
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
46
https://www.theamericanjournals.com/index.php/tajmspr
The age distribution analysis revealed a higher
prevalence of DF among younger adults,
particularly between the ages of 21 to 30 years,
which may reflect increased exposure to mosquito
vectors in this demographic group. The diverse
array of presenting complaints underscores the
multisystemic nature of DF, with high-grade fever
being the hallmark symptom, consistent with the
disease's acute febrile phase.
Comparisons with previous literature highlight
variations in sonographic findings and their
prevalence across different studies. While our
study observed a higher mean thickness of
pericholecystic edema compared to previous
reports, the incidence of abdominopelvic ascites
was relatively lower. Such differences underscore
the heterogeneity of clinical presentations and
sonographic manifestations in dengue patients,
influenced
by
factors
such
as
patient
demographics, disease severity, and study
methodologies (23-25).
Furthermore, the association between platelet
count and ultrasonographic findings corroborates
findings from previous studies, emphasizing the
prognostic
significance
of
hematological
parameters in predicting disease progression and
severity. The observed relationships between
platelet count and sonographic abnormalities
underscore the potential utility of ultrasound as a
non-invasive tool for prognostication and risk
stratification in dengue patients (26-27).
The clinical significance of our findings is
underscored by their potential implications for
patient management. While no mortality was
reported in our study cohort, differences in
hospital stay length were observed, albeit not
statistically significant. Integrating sonographic
findings with clinical presentations may aid
clinicians in the timely identification of severe
dengue cases, enabling prompt intervention and
improved patient outcomes (28-29).
Overall, this study contributes to the existing div
of literature on the clinical and sonographic
characterization of dengue fever, emphasizing the
importance of multimodal approaches for accurate
diagnosis, prognostication, and management of
this significant public health concern. Further
longitudinal studies are warranted to validate the
prognostic value of ultrasound findings and
optimize their integration into clinical practice
guidelines for dengue management.
LIMITATIONS
Follow-up ultrasound scans were not conducted
after patients were discharged from the hospital.
CONCLUSION
Ultrasound serves as a valuable adjunctive tool for
detecting fluid leakage and plays a crucial role in
cost-effective prediction of disease severity. The
observed findings, such as gallbladder wall
thickening, pleural effusion (bilateral or
unilateral), ascites, and splenomegaly, strongly
support the diagnosis of dengue fever and aid in
achieving an early diagnosis. These abdominal
findings, combined with the gradual decrease in
platelet count, indicate the severity of the illness
and influence disease prognosis.
Availability of data and materials
All data and materials are retained by the first and
corresponding authors.
Funding
This study received no external funding.
Conflict of interest
The authors declare no conflicts of interest.
REFERENCES
1.
Guzman MG, Gubler DJ, Izquierdo A, Martinez E,
Halstead SB. Dengue infection. Nat Rev Dis
Primers.
2016
Jul
21;2:16055.
doi:
10.1038/nrdp.2016.55
2.
World Health Organization. Dengue and severe
dengue.
Available
at:
https://www.who.int/news-room/fact-
sheets/detail/dengue-and-severe-dengue.
Accessed January 2022.
3.
Moras E, Achappa B, Murlimanju BV, Raj GN,
Holla R, Madi D, D’Souza NV, Mahalingam S.
Early diagnostic markers in predicting the
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
47
https://www.theamericanjournals.com/index.php/tajmspr
severity of dengue disease. 3 Biotech. 2022
Oct;12(10):268. doi: 10.1007/s13205-022-
03365-3.
4.
Nguyen TT, Le NT, Nguyen NM, Do VC, Trinh
TH, Vo LT. Clinical features and management of
children with dengue-associated obstructive
shock syndrome: A case report. Medicine
(Baltimore). 2022 Oct 28;101(43):e31322. doi:
10.1097/MD.0000000000031322.
PMID:
36316901; PMCID: PMC9622697.
5.
Manzoor N, Farooq SM, tul Sughra SK, Siddiqi
MI, Arooj S, Ishfaq A, Gilani SA, ul Abidin SZ.
Role of ultrasonography in the diagnosis of
dengue fever: Ultrasonography in The
Diagnosis of Dengue Fever. Pakistan
BioMedical Journal. 2022 Jan 31:375-9.
6.
Santhosh VR, Patil PG, Srinath MG, Kumar A,
Jain A, Archana M. Sonography in the diagnosis
and assessment of dengue Fever. J Clin Imaging
Sci. 2014 Mar 21;4:14. doi: 10.4103/2156-
7514.129260. PMID: 24744971; PMCID:
PMC3988603.
7.
Thomas L, et al. Dengue Vascular Leakage Is
Augmented by Mast Cell Degranulation
Mediated by Immunoglobulin Fcγ Receptors.
eLife.
2016;5:e05291.
doi:
10.7554/eLife.05291.
8.
Ibrahim MA, Hamzah SS, Md Noor J, et al. The
association of ultrasound assessment of
gallbladder wall thickness with dengue fever
severity. Ultrasound J. 2022;14:13. doi:
10.1186/s13089-022-00262-w.
9.
Leite LA, Macedo FC. Abdominal ultrasound
findings in patients with dengue fever. J Diagn
Med Sonogr. 2019;35(4):291-296.
10.
Dewan N, Zuluaga D, Osorio L, Krienke ME,
Bakker C, Kirsch J. Ultrasound in Dengue: A
Scoping Review. Am J Trop Med Hyg. 2021 Jan
18;104(3):826-835. doi: 10.4269/ajtmh.20-
0103. PMID: 33534759; PMCID: PMC7941833.
11.
Moro L, et al. Comparison between chest X-ray
and ultrasound diagnosis of pulmonary
complications in patients with severe dengue.
Rev Soc Bras Med Trop. 2017;50(3):353-356.
12.
Nainggolan L, Wiguna C, Hasan I, Dewiasty E.
Gallbladder Wall Thickening for Early
Detection of Plasma Leakage in Dengue
Infected Adult Patients. Acta Med Indones.
2018 Jul;50(3):193-199. PMID: 30333268
13.
Martínez-Sellés M, et al. Cardiac findings in
patients with dengue fever epidemic. Rev Esp
Cardiol (Engl Ed). 2015;68(11):991-992.
14.
Nahar K, Akhter S, Barua S, Begum D, Hasan
MK. Ultrasonographic assessment of dengue
fever and its correlation with platelet count:
Correlating USG and platelet count in dengue
fever. Bangladesh Med Res Counc Bull.
2021;47(1):23-8.
15.
Azhar A, Saeed U, Piracha ZZ, Amjad A, Ahmed
A, Batool SI, et al. SARS-CoV-2 related HIV, HBV,
RSV, VZV, Enteric viruses, Influenza, DENV, S.
aureus and TB co-infections. Arch Pathol Clin
Res. 2021;5(1):026-033.
16.
Piracha ZZ, Saeed U, Ahmed RAI, Khan FNA,
Nasir MI. Global emergence of Langya virus: A
serious public health concern. J Global Health.
2023;13.
17.
Piracha ZZ, Saeed U, Tariq MN, Gilani SS, Rauf
M, Ghyas H, et al. Emerging One Health
Preparedness to Combat National Burden of
Diseases in Pakistan: A Comprehensive Insight.
J
Community
Med
Health
Solutions.
2023;4(2):080-088.
18.
Piracha ZZ, Tariq MN, Rasool M, Gilani SS, Saeed
U, Rana MSF, Arif M, et al. Catalyzing Global
Action: Addressing SARS-CoV-2 Vaccine
Hesitancy,
Knowledge
Disparities,
and
Epidemic Preparedness Challenges in Pakistan.
Biomed J Sci & Tech Res. 2022;52(3):43702-
43707.
19.
Uppal SR, Uppal R, Khan AA, Saeed U, Piracha
ZZ, Ali Z. Estimating the Prevalence of Fungal
Nail Infections and Potential Concerns for
Central Disease Surveillance Hub in Pakistan.
Arch Clin Biomed Res. 2022;6(3):462-465.
20.
Uppal SR, Khan AA, Uppal R, Saeed U, Piracha
ZZ, Uppal R. Rising Surge of Antimicrobial
Resistance and Urinary Tract Infections in
THE USA JOURNALS
THE AMERICAN JOURNAL OF MEDICAL SCIENCES AND PHARMACEUTICAL RESEARCH
(ISSN
–
2689-1026)
VOLUME 06 ISSUE07
48
https://www.theamericanjournals.com/index.php/tajmspr
Pakistani
Children:
A
Potential
Life-
Threatening Scenario. Fortune J Health Sci.
2022;5(2):281-283.
21.
Araújo FMM, et al. Sonographic findings in
patients with dengue fever. J Ultrasound Med.
2019;38(2):491-497.
22.
Parmar JP, Mohan C, Vora M. Patterns of Gall
Bladder Wall Thickening in Dengue Fever: A
Mirror of the Severity of Disease. Ultrasound
Int Open. 2017 Apr;3(2):E76-E81. doi:
10.1055/s-0043-105262. Epub 2017 Jun 7.
PMID: 28603785; PMCID: PMC5464115.
23.
Tandon R, Yadav D. Ultrasonographic findings
in dengue hemorrhagic fever: a retrospective
analysis. J Clin Diagn Res. 2016;10(6):TC10
–
TC13. doi: 10.7860/JCDR/2016/18114.7990.
24.
Guzmán MG, Harris E. Dengue. Lancet.
2015;385(9966):453-465.
doi:
10.1016/S0140-6736(15)00126-8.
25.
Huy NT, et al. Factors associated with dengue
shock syndrome: a systematic review and
meta-analysis.
PLoS
Negl
Trop
Dis.
2015;9(6):e0003972.
doi:
10.1371/journal.pntd.0003972.
26.
Tan J, Liu J, Zhang Q. The relationship between
platelet count and ultrasonographic findings in
patients with dengue fever: A retrospective
analysis.
Medicine
(Baltimore).
2018;97(51):e13727.
doi:
10.1097/MD.0000000000013727.
27.
Kalayanarooj S, et al. Platelet-associated
dengue illness (PADI): a novel risk factor for
dengue hemorrhagic fever. Pathog Glob Health.
2017;111(7):332-341.
doi:
10.1080/20477724.2017.1392423.
28.
Lye DC, et al. The first dengue epidemic in
Singapore: a cost analysis. Trans R Soc Trop
Med
Hyg.
2014;108(5):305-312.
doi:
10.1093/trstmh/tru059.
29.
Thomas L, et al. Evaluation of a commercial
dengue NS1 antigen-capture ELISA for
laboratory diagnosis of acute dengue virus
infection. J Virol Methods. 2009;15(2):151-
154. doi: 10.1016/j.jviromet.2009.03.024
