hemostatic derangement in dengue infection...p < 0.001 : dengue fever (df) vs dengue hemorrhagic...
TRANSCRIPT
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Hemostatic derangement in Dengue infection
By Assoc. Prof. Darintr Sosothikul, MD
Pediatric Hematology-Oncology division, King Chulalongkorn Memorial Hospital,
Faculty of Medicine, Chulalongkorn University
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Outline
• Overview of Severe Dengue • Hematologic and Hemostatic Changes in Severe
Dengue: Thrombocytopenia and platelet dysfunction Vasculopathy and endothelial dysfunction Changes in vWF parameters, ADAMTS13 and multimer Activation of coagulation and fibrinolysis • Management of significant bleeding in severe degue
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1997 WHO dengue classification
Classical Dengue Fever (DF)
Fever,headache,retro-orbital pain,myalgia,arthralgias,+/- Haemorrhagic manifestrations
DHF Grade I Thrombocytopenia Haemoconcentration
DHF Grade II Spontaneous bleeding
DHF Grade III Pulse pressure 20 mmHg, Hypotension, cold clammy skin, restless
DHF Grade IV Profound shock, Undetectable BP and pulse
DSS
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Fever of 2–7 days plus: ▫ Severe plasma leakage ▫ Significant bleeding ▫ Impaired consciousness ▫ Severe organ impairment
(AST or ALT > 1,000) ▫ Severe involvement of the
heart or others organs
Severe Dengue
Dengue: guidelines for diagnosis, treatment WHO 2009
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Pathophysiology in severe dengue
Viremia
Risk factor for severe dengue;
Young age Female
High body mass index Virus strain
Genetic varients Secondary infection by
different serotypes Severe dengue
Transient and reversible imbalance of inflammatory mediators,cytokines and chemokines
Endothelial cell dysfunction
Derangement of coagulation system
Plasma leakage Shock Bleeding
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Hematologic and Hemostatic Changes in Severe Dengue
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Correlation between WBC and PMN in DHF
0
1000
2000
3000
4000
5000
6000
7000
1 2 3 4 5 6 7 8 9 10
Days of illness
WB
C c
ount
0
10
20
30
40
50
60
70
801 2 3 4 5 6 7 8 9 10
Phases of the diseases
PM
N c
ount
WBC countPMN count
Febrile Toxic Convalescent
Correlation between WBC count and ATL count in DHF
0
1000
2000
3000
4000
5000
6000
7000
1 2 3 4 5 6 7 8 9 10
Days of illness
WB
C c
ou
nt
0
5
10
15
20
25
301 2 3 4 5 6 7 8 9
Phases of the diseases
Aty
pic
al l
ymp
ho
cyte
co
un
t
WBC countAtypical lymphocyte count
Febrile Toxic Convalescent
Correlation between WBC and PMN Correlation between WBC and ATL
Peripheral blood changes in DHF
PresenterPresentation NotesLeucopenia is thought to represent a direct effect of dengue virus on the bone marrow.Bone marrow biopsies of children with DHF revealed suppression of hematopoiesis early in the illness, with marrow recovery and hypercellularity in the late stage.In vitro studies have shown that dengue virus infects human bone marrow stromal cells and hematopoietic progenitor cells and inhibits progenitor cell growth
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Correlation between Hct and platelet in DHF
37
38
39
40
41
42
43
44
1 2 3 4 5 6 7 8 9 10
Day of the illness
Hct (
%)
0
20000
40000
60000
80000
100000
120000
140000
1600001 2 3 4 5 6 7 8 9 10
Phases of the disease
Plat
elet
cou
nt
HctPlatelet
Febrile Toxic Toxic Convalescent
Correlation between Hematocrit &platelets in DHF
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Thrombocytopenia I. Peripheral destruction or increased utilization • Dengue 2 virus can bind to human platelet, and
result in immune-mediated platelet destruction • Consumption of platelet during the process of
consumptive coagulopathy II. Decreased production ; dengue-virus-induced
BM suppression depressed platelet synthesis
Mitrakul C, etal Am J Trop Hyg 1977;26:975 La Russa VF. Baillieres Clin Haematol 1995; 8(1): 249-70 Krishnamurti C. Am J Trop Med Hyg 2002; 66(4): 435-41
Thrombocytopenia
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• Decrease Platelet aggregation after stimulation with 5 µm M ADP in DHF patients during febrile or early convalescent period
• 9 in 10 children (90%) with DF and all of children with DHF have decrease platelet aggregation with ADP (DF 60%, DHF 100%), ristocetin (DF 40%, DHF 100%), collagen (DF 70%, DHF 100%) and arachidonic acid (DF 90%, DHF 66.7%)
• Plasma levels of platelet factor 4 and beta thromboglobulin were increased during the acute phase of DHF
Mitrakul C. Am J Trop Med Hyg 1977; 26: 975-84 Srichaikul T. Southeast Asian J Trop Med Public Health 1989; 20 (1): 19-25 Tanyong B, Sosothikul D. Abnormal Platelet Aggregation of Dengue fever in Thai Children 2011
Platelet dysfunction
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Mechanism of platelet activation
Microparticles
Granule secretion
- Adhesive molecules - Chemokines/cytokines - Growth factors - Coagulation factors
In vitro study of dengue infection showed that platelet –derived IL-1B was chiefly released in microparticles and
correlated with sign of increased vascular permeability
Hottz ED,et al. Blood 2013; 122: 3405-14
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Platelet derived microparticles in Dengue infection
P = 0.007
Sosothikul D, et al Poster presentation at European Hematology Association 2014 , Milan ,Italy
(Dengue : N=20)
(N=40)
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Interleukin-1 beta in Dengue infection
P < 0.001
Sosothikul D, et al Poster presentation at European Hematology Association 2014 , Milan ,Italy
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Platelet Activation in Dengue Infection
• The levels of PDMP, and IL-1β were significantly increased in patients with dengue infection compared to the unaffected controls
• Platelet activation can be one of the
mechanism that leads to platelet dysfunction and increased vascular permeability in patients with dengue infection
Sosothikul D, et al Poster presentation at European Hematology Association 2014 , Milan ,Italy
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Vasculopathy • Plasma leakage, due to an increase in
capillary permeability, is a cardinal feature of DHF but is absent in dengue fever.
• Appear to be due to endothelial cell dysfunction rather than injury, as electron microscopy demonstrated a widening of the endothelial tight junctions.
• Dengue virus-infected monocytic cells produce TNF-alpha and activate endothelial cells in vitro.
Anderson R. et al. J Virol 1997;71(6): 4226-32 Bunyaratvej A, et al. southeast Asian J Trop Med Public Health 1997;28 Suppl 3:32-7
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Activation of endothelial cells in dengue infection
controlConvalescentToxicFebrile
Stages of the illness
8.00
6.00
4.00
2.00
sTM
(ng/
ml)
27
ControlDHFDF
GROUP DIAG(DF,DHF)P=0.04
controlConvalescentToxicFebrile
Stages of the illness
400
300
200
100vW
F: A
g (%
)
ControlDHFDF
GROUP DIAG(DF,DHF)
P=0.01
Soluble thrombomodulin Von Willebrand Factor antigen
Sosothikul D, et al. Thromb Haemost 2007; 97: 627-634
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Changes in ADAMTS 13 and VWF parameters in dengue infection
Febrile Toxic Convalescent control
Phase of the illness
0
50
100
150A
DA
MT
S 1
3 (%
)
DFDHFcontrolP=0.039
P=0.002
P=0.003 ADAMTS 13
Sosothikul D, et al. Thromb Haemost 2007; 97: 627-634
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Normal
Abnormal Multimers
Abnormal Multimers
Normal pool plasma
Normal
Abnormal Multimers
Larger than normal
Normal pool plasma
VWF Multimers in DHF
Febrile
Toxic
Convales.
Febrile
Toxic
Convales.
Sosothikul D., et al. Thromb Haemost 2007;97: 627-634
High MW Low MW
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TM
Dengue/Cytokines
Activated endothelial cells
t-PA vWF Platelets seqestration
TF/FVIIa FXa+FV
FIXa+FVIII
Prothrombin Thrombin
FXIa
AT
TAT
Fibrinogen Fibrin D-Dimer
Plasmin Plasminogen + t-PA
- PAI-1
TAFIa
TM
- Fibrinolysis
Coagulopathy in DHF
Sosothikul D, et al. Thromb Haemost 2007; 97: 627-634
TM: thrombomodulin vWF: von Wellibrand factor t-PA: tissue plasminogen PAI: plasminogen activator inhibitor
TF: tissue factor TAT: thrombin anti-thrombin complex AT: anti-thrombin III TAFI: thrombin activatable fibrinolysis inhibitor
PresenterPresentation NotesFrom our previous study in 2007, we have shown that the endothelial cells are activated by Dengue virus and/or cytokines. They can lose protective properties by expressing TF, TM and vWF. The release of plasma VWF might be the mechanism for platelet sequestration causing thrombocytopenia. Furthermore, TF/FVIIa complex activate the clotting system, leading to thrombin generation. The fibrinolysis is initially activated by t-PA. TAFI might be a secondary inhibitor of fibrinolysis in dengue patients.
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Thromboelastometry
CT = clotting time, CFT = clot formation time , MCF = maximum clot firmness
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Coagulation tests in dengue patients during febrile phase
Tests Controls Dengue fever Dengue hemorrhagic fever (n = 30) (n = 22) (n = 19) Hematocrit (%) mean + SD 41.1 + 3.3 37 + 4.4** 44.1 + 3.4 Range (34 - 46.4) (28.2 - 45.8) (37.3 - 50.9) Platelets (x109) mean + SD 289.4 + 832 99.6 + 48.3* 40.8 + 31.4 Range (152 - 485) (0 - 196.2) (0 - 103.6)
Prothrombin time (sec) mean + SD 12.5 + 1.3 14 + 1.8* 16.3 + 4.6 Range (10.6 - 14.7) (10.4 - 17.6) (7.1 - 25.5) APTT (sec) mean + SD 35.9 + 3.1 42 + 6.5* 48.4 + 9.6 Range (29.7 - 40.3) (29 - 55) (29.2 - 67.6) Fibrinogen (mg/dL) mean + SD 429.4 + 110.3 307 + 70.9 306.3 + 94 Range (220 - 678) (165.2 - 448.8) (118.3 - 494.3)
*p
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Results from thromboelastometry
EXTEM
INTEM
CT = clotting time, CFT = clot formation time , MCF = maximum clot firmness
Sosothikul D, et al. Oral Poster presentation at ISTH meeting 2013
PresenterPresentation NotesRotem parameters in our dengue patients showed that DHF patients had a significant longer time in CT ,CFT in EXTEM and INTEM than DF patients. In addition,, DHF patients had significant lesser clot firmness (Lower MCF) and lower amplitude (A10,a20) than DF patients.
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FIBTEM
CT = clotting time, CFT = clot formation time , MCF = maximum clot firmness
Results from thromboelastometry
Sosothikul D, et al. Oral Poster presentation at ISTH meeting 2013
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Thromboelastometry in Dengue
• ROTEM® showed significant changes in hemostasis in both groups of dengue patients, and it was correlated well with standard coagulation studies and severity of the disease • ROTEM® can early detect abnormal fibrinogen function in DHF patients • It may become a useful bedside tool for an early detection and a quick guide to choose appropriate blood products in treatment of DHF patients with bleeding
Sosothikul D, et al.Oral Poster presentation at ISTH meeting 2013
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Management of significant bleeding in DHF
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Risk factors for Hemorrhage in DHF
• A study of risk factors for hemorrhage in 114 patients with DHF/DSS showed no correlation between bleeding and platelet count
• The strongest risk factor for hemorrhage were prolonged duration of shock and a low level of hematocrit at the time of shock
Lum LC, et al. Journal of Pediatrics 2002: 140; 625-31
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Management of significant bleeding
• Significant internal bleeding should be suspected in patients with signs of intravascular hypovolemic without elevation of hematocrit
PRC 5 ml/kg and clinical response/post transfusion hematocrit should be monitored • Do not wait for the hematocrit to drop too low
before deciding on blood transfusion
Thomas L, et al Transfusion 2009; 49:1400 Dengue: guidelines for diagnosis,treatment WHO, Geneva 2009 Comprehensive guidelines for prevention/control DHF WHO Regional Office for Southeast Asia 2011
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FFP and/or platelet –no different in bleeding Increase pulmonary edema, longer hospitalization
Platelet • Benefit in DIC with
platelet < 50,000 or undergoing procedure
• Platelet 0.1 unit/kg/dose • Not indicate for prevent
spontaneous bleeding
FFP • PT or aPTT ratio >1.5 +
DIC or severe bleeding • FFP 10-15 ml/kg
Update on pediatric infectious diseases 2016
Transfusion in dengue with hemorrhage
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NG tube/ foley catheter: • Great care should be taken when inserting a NG tube
or bladder catheters • A lubricated orogastric tube may minimize the trauma
during insertion
Central line • should be done with USG guidance or by an
experienced person
WHO; clinical management of dengue 20121ex
Transfusion in dengue with hemorrhage
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• rFVIIa may have role in case of massive bleeding unresponsive to conventional blood component therapy.
• rFVIIa enhances thrombin generation and also enhances the activity and function of both patients and transfused platelets.
Chuansumrit A, et al Blood Coagul Fibrinolysis 2005; 16(8):545-55
Role of rFVIIa in control of dengue bleeding
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Dengue and prophylactic transfusions
• 106 DSS children with thrombocytopenia and coagulopathy, there was no difference in hemorrhage between patients who received preventive transfusions compared with those who did not
• Patients who received transfusion had higher frequency of development of pulmonary edema and increased length of hospitalization
• Preventive transfusions did not produce sustained improvements in the coagulation status in DSS
Lum LC, et al. Journal of Pediatrics 2003: 143; 682-4
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Conclusions • Bleeding in DHF patient is caused by vasculopathy,
thrombocytopenia, platelet dysfunction, abnormal VWF multimers and coagulopathy (DIC)
• ROTEM® may become a useful bedside tool for an early detection and a quick guide to choose appropriate blood products in treatment of DHF patients with bleeding
• Prophylactic platelet transfusions have not been shown to be effective at preventing or controlling hemorrhage
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Conclusions
• Platelet transfusion should be reserved for dengue patients with major bleeding
• Early recognition of severe dengue, with prompt
correction of hemodynamic status, remains the mainstay for good clinical outcome
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THANK YOU FOR YOUR ATTENTION
Hemostatic derangement in Dengue infection�Outline 1997 WHO dengue classificationSlide Number 4 Pathophysiology in severe dengueSlide Number 7Slide Number 8Slide Number 9ThrombocytopeniaSlide Number 11Slide Number 12Platelet derived microparticles�in Dengue infectionInterleukin-1 beta in �Dengue infection�Platelet Activation in �Dengue Infection VasculopathyActivation of endothelial cells in �dengue infection Changes in ADAMTS 13 and VWF parameters in dengue infectionSlide Number 20 Coagulopathy in DHFSlide Number 22 Coagulation tests in dengue patients �during febrile phaseSlide Number 26Slide Number 27Thromboelastometry in Dengue �Management of significant bleeding in DHF Risk factors for Hemorrhage in DHFManagement of significant bleedingSlide Number 32Slide Number 33Slide Number 34Dengue and prophylactic transfusionsConclusionsConclusionsSlide Number 38