Indian J Pediatr
DOI 10.1007/s12098-015-2013-y
ORIGINAL ARTICLE
Is Ultrasound a Useful Tool to Predict Severe Dengue Infection?
Sriram Pothapregada 1 & Poonam Kullu 2 & Banupriya Kamalakannan 1 &
Mahalakshmy Thulasingam 3
Received: 9 July 2015 / Accepted: 23 December 2015
# Dr. K C Chaudhuri Foundation 2016
Abstract
Objectives To study the role of ultrasound in children with
dengue fever and determine its role in predicting the severity
of the disease.
Methods This was a retrospective hospital based study con-
ducted from 1st August 2012 to January 31st 2015 at a tertiary
care hospital in Puducherry.
Results Two hundred and fifty four children were admitted with
dengue fever and among them non-severe dengue and severe
dengue were seen in 62.6 % and 37.4 % respectively. Mean age
of presentation was 7.0 (3.3) years. M: F ratio was 1.2:1
Ultrasound was performed on all children with dengue fever
during the critical period of illness as an early sign of plasma
leakage and at the time of discharge. The diagnosis was con-
firmed by NS1 antigen and dengue serology. Ultrasonography
showed positive findings in 156 cases (61.4 %) during the crit-
ical period of illness. Ultrasound findings were analyzed using
logistic regression among severe and non-severe dengue
and P value of <0.05 was taken as significant. The common
ultrasound findings that were significantly associated with se-
vere dengue infection on univariate analysis were gall bladder
wall thickening, ascites, pleural effusion, pericardial effusion,
pericholecystic fluid, hepatomegaly, splenomegaly and
* Sriram Pothapregada
psriram_ped@yahoo.co.in
1
Department of Pediatrics, Indira Gandhi Medical College and
Research Institute, Puducherry 605009, India
2
Department of Radiodiagnosis, Indira Gandhi Medical College and
Research Institute, Puducherry, India
3
Department of Community Medicine, Indira Gandhi Medical
College and Research Institute, Puducherry, India
mesenteric adenopathy. On multivariate analysis, gall bladder
thickening and hepatomegaly were significantly associated with
severe dengue infection. Gall bladder wall thickening (GBWT)
with honeycombing pattern was the most specific finding in
severe dengue infection in the study and significantly associated
with severe thrombocytopenia (Platelet count <50,000/mm3).
The clinical improvement coincided with resolving of the ultra-
sound findings at the time of discharge.
Conclusions Ultrasound can be used as an early predictor as
well as an important prognostic sign for severe dengue infec-
tion especially during an epidemic.
Keywords Severe dengue . Ultrasound . Gall bladder wall
thickening . Plasma leakage . Ascites . Pleural effusion
Introduction
Dengue fever is the most rapidly spreading mosquito-borne
viral infection with 30-fold increase in last five decades and
has become a major public health problem world-wide. The
revised WHO dengue fever guideline (2011) has defined se-
vere dengue infection as the presence of severe plasma leak-
age, severe bleeding and severe organ failure [1]. Hence, plas-
ma leakage is an essential component of severe dengue infec-
tion. It can initially present as a transient plasma leakage into
serosal cavities in the critical period, and later on progress to
shock, hemorrhage and multiorgan failure which are life
threatening [2]. The most important challenges for clinicians
are to identify the early signs of plasma leakage and triage
those children who will progress to severe dengue infection.
The currently available biomarkers are difficult to implement
in clinical practice. Serial hematocrit values as a sign of plas-
ma leakage are hard to interpret due to individual variations,
absence of baseline hematocrit values, intravenous fluid

administration and bleeding. The use of radiological parame-
ters in assessment of plasma leakage in the form of ascites and
pleural effusion is an alternative. Chest X-rays can only detect
significant pleural effusions. Ultrasonography can be a used a
useful tool in predicting severe dengue infection at an early
stage of illness [3]. The main advantages of ultrasonography
are its high sensitivity to detect even smaller amounts of pleu-
ral effusion and ascites in children with transient plasma leak-
age. Gall bladder wall thickening showing a “honeycomb”
pattern on ultrasonography is the most specific sign that may
help in the early diagnosis, as well as in the prognosis, of
severe dengue infection with very few previous published
reports in the past in children [4–6]. Ultrasound can be poten-
tially used to assess and monitor children at-risk of developing
severe dengue infection. By giving priority to at risk children,
hospital resources could be more efficiently allocated, and
patients who are not at high risk could be discharged earlier.
Secondly, ultrasound could be used as a cheaper, less invasive
means of monitoring for signs of plasma leakage. The goal of
this study is to analyze these two potential uses of ultrasound.
Material and Methods
After approval by the Institute Ethics committee, case records
of all children admitted with dengue fever at a tertiary care
hospital at Puducherry between 1st of August 2012 to January
31st 2015 were reviewed. The case definition, diagnosis and
management of dengue fever in children were as per the 2011
World health Organization (WHO) revised guidelines [1].
Two hundred and fifty four confirmed cases of dengue fever
were included in the study. Seven children, where ultrasound
was not done were excluded from the study. They were cate-
gorized as severe and non-severe dengue infection and the
ultrasound findings during the critical period of illness were
retrospectively analysed. A detailed record of clinical and lab-
oratory profile, and the treatment given was recorded in a
predesigned proforma. The diagnosis was confirmed by NS1
antigen-based ELISA test (J. Mitra kit, India) or dengue serol-
ogy for IgM and IgG antibodies (Kit from National Vector
Born Disease Control Programme, Pondicherry and National
Institute of Virology Pune, India). Severe dengue was classi-
fied as the presence of severe plasma leakage in the form of
shock, severe bleeding and severe organ impairment. The
presence of plasma leakage was confirmed by clinical signs,
hematocrit change >20 %, and ultrasound findings.
Ultrasound machines (Philips HD7-XE model) with 5–
7 MHz curvilinear probes were used. Ultrasound was per-
formed by a single experienced radiologist in the department
of radiology during the critical period of illness, since the
likelihood of finding plasma leakage is the highest at this time
point and ultrasound was repeated at the time of discharge in
children with positive findings. Abdominal scanning was
Indian J Pediatr
done after 6 h fasting to allow better distention of gall bladder
(GB). GB wall thickening (GBWT) and was measured by
callipers between two layers of anterior wall. GBWT >0.3 cm
showing a “honeycomb” pattern (Sachar and Sunder’s sign) or
laminated/onion-peel/multilayered diffuse GBWT pattern or
transient reticular pattern was taken as positive sign for severe
dengue infection [7]. Thoracic scanning was done in either
sitting or supine posture. Both the pleural spaces were evaluat-
ed through an intercostal approach by visualizing bilateral
costophrenic angles. Pericardial space was also evaluated for
effusion subcostally. The standard guidelines for measurement
of liver and spleen in children were used [8]. Timing, localiza-
tion and relation to dengue severity of the ultrasonography
findings were determined, as well as the relation with serial
hematocrit and platelet values.
The SPSS 16.0 statistical software (IL Chicago) was used
for data analysis. Qualitative variables such as the presence of
various ultrasound features were expressed as frequencies and
percentages and the data were expressed as medians with in-
terquartile ranges (IQR). Differences in non-continuous data
of 2 groups were analysed by Pearson’s Chi-square test or by
Fisher’s exact test. Continuous variables between 2 groups
were analysed by unpaired t-test in case of normally distrib-
uted data; and by Mann Whitney U test in case of non-
parametric data. Relationships between continuous data were
examined by Pearson’s correlation for parametric data and
Spearman’s correlation for non-parametric data. Multivariate
analysis was conducted to identify the variables independently
associated with laboratory-positive dengue. Ultrasound find-
ings as early predictors of severe dengue infection were deter-
mined by multivariate analysis. Odds ratio (OR) was calculat-
ed to measure the degree of association and the results were
presented as unadjusted odds ratio (OR), adjusted OR, with
95 % confidence interval (CI). Significance was taken at P
value < 0.05.
Results
Two hundred and fifty four confirmed cases of dengue fever
were enrolled in the study and the ultrasound findings during
the critical period of illness were retrospectively analyzed
(Table 1). Non-severe dengue infection was seen in 159 cases
(62.6 %) and 95 children (37.4 %) had severe dengue infec-
tion. NS1 Ag was positive in 210 (82.7 %) cases and IgM
MAC ELISA was positive in 44 cases and IgG MAC
ELISA was positive in 17 children (6.7 %). The mean age of
presentation was 7.0 (3.3) y. M: F ratio was 1.2:1 Ultrasound
was performed on all children with dengue fever during the
critical period and at the time of discharge.
The common ultrasound findings in children admitted with
dengue fever were hepatomegaly, splenomegaly, gall bladder
wall thickening (GBWT), pericholecystic fluid, hypoechoic
Indian J Pediatr

Table 1 Clinical and demographic profile of dengue fever infection during the critical period of illness was gall bladder
Demographic profile Number (%) wall thickening (GBWT). A thickened gallbladder wall was
detected in 2 cases (1.2 %) in non-severe dengue and 23 cases
Number of cases 254 (24.2 %) in severe dengue infection (P = 0.001). The median
Mean age in years 7.0 (3.3) thickness of the gallbladder wall at enrollment was 0.37 cm
Age > 6 y 148 (58.3) (IQR, 0.27–0.50 cm) in patients with non-severe dengue vs.
Male to Female ratio 1.2:1 0.54 cm (IQR, 0.34–0.75 cm) in those with severe dengue
Non-severe dengue infection 159 (62.6) (P = 0.01). The common associated findings with gall bladder
Severe dengue 95 (37.4) wall thickening (GBWT) were ascites, pericholecystic fluid,
Severe dengue with complications 16 (6.3) pleural effusion and splenomegaly. Gall bladder wall thicken-
Duration of fever at admission (days) 4.8 (1.8) ing was seen in 58.8 % of cases with secondary infection
Duration of hospital stay (days) 6.5 (2.7) (positive dengue IgG antibody) and was significantly associ-
Bleeding 51 (20.1) ated with severe dengue infection (P < 0.001).
Platelet count < 50,000/mm3 43 (16.9) The most common ultrasound findings associated with
Fluid refractory shock 6 (2.4) severe dengue infection with hematocrit >20 % with con-
Mortality 6 (2.4) comitant platelet count <50,000/mm3 were gall bladder
wall thickening, ascites, pericholecystic fluid, pleural effu-
Data represented as Mean (SD) and Number (%) sion, and pericardial effusion. There was an inverse corre-
lation of gallbladder wall thickness with platelets counts
liver parenchyma, ascites, pleural effusion, mesenteric lymph- <50,000/mm3 and was statistically significant (P < 0.001).
adenopathy, pericardial effusion, portal cavernoma and chole- Among the children where ultrasound was normal, 81.6 %
lithiasis (Table 2). of cases had platelet count > 1,00,000/mm3.
The ultrasound findings among non-severe and severe den- Three children with severe dengue infection presented with
gue infection during the critical period of illness is given in hematemesis, melena, shock with splenomegaly and among
Table 3. On univariate analysis, the most common ultrasound them, two children had portal cavernoma on ultrasonography.
findings associated with severe dengue infection were gall The follow-up ultrasound findings 3 mo after treatment were
bladder wall thickening, ascites, pleural effusion, pericardial normal. Among the children who had gall bladder wall thick-
effusion, pericholecystic fluid, hepatomegaly, splenomegaly ening the follow up repeat ultrasound at the time of discharge
and mesenteric lymphadenopathy (Table 2). On multivariate showed resolution in 23 cases (93 %) and coincided with the
analysis, it was seen that gall bladder wall thickening (OR 2.6, clinical improvement. There were six deaths (2.4 %) and com-
95 % CI 1.05–206.29, P < 0.001) and hepatomegaly (OR 1.2, mon factors for poor prognosis were refractory shock, enceph-
95 % CI 1.31–8.98, P < 0.001) were the most common ultra- alopathy and multi-organ dysfunction.
sound findings associated with severe dengue infection.
The most common ultrasound finding that was used as an
early specific sign of plasma leakage in severe dengue Discussion

Table 2 Ultrasound findings in dengue fever The common ultrasound findings as predictors of severe den-
gue infection in the index study included gall bladder wall
Ultrasound findings Number (%)
thickening (GBWT), ascites, pleural effusion, pericholecystic
Normal 98 (38.5) fluid, hepatomegaly, splenomegaly, pericardial effusion, and
Pleural effusion 13 (5.1) mesenteric lymphadenopathy.
Ascites 18 (7) Gall bladder wall thickening (GBWT) was seen 24.2 % of
GB wall thickening 25 (9.8) cases of severe dengue infection and the degree of thickening
Hepatomegaly 156 (61.4) had a direct correlation with dengue severity and was used as an
Splenomegaly 57 (22.4) early warning sign for plasma leakage in the index study.
Portal cavernoma 2 (0.8) Gallbladder wall thickening in severe dengue infection was first
Mesenteric adenopathy 12 (4.7) reported by Pramuljo et al. in 1991 [4]. Venkata Sai et al. in their
Pericholecystic fluid 22 (8.7) study have demonstrated gallbladder wall thickening in 100 %
Pericardial effusion 5 (1.9) of the patients with severe dengue and concluded that, during
Cholelithiasis 2 (0.8)
an epidemic outbreak, gallbladder wall thickening, either with
Hypoechoic liver parenchyma 16 (6.3)
or without signs of polyserositis in a febrile patient, should
suggest the possibility of severe dengue infection [6].
Data represented as Number (%) Setiawan et al. found gallbladder wall thickening > 3.0 mm

Table 3 Ultrasound findings
among severe and non-severe Ultrasound findings Severe dengue (95)
dengue infection
Normal 18 (18.9)
Pleural effusion 13 (13.6)
Ascites 14 (14.7)
GB wall thickening 23 (24.2)
Hepatomegaly 77 (81)
Splenomegaly 35 (36.8)
Portal cavernoma 3 (3.1)
Mesenteric adenopathy 10 (10.5)
Pericholecystic fluid 20 (21)
Pericardial effusion 4 (4.2)
Data are in n(%), OR, (95 % CI) P < 0.05 significant
OR Odds ratio; CI Confidence interval
and >5 mm in 95 % cases and 91.7 % respectively with severe
dengue infection and concluded that thickening of gall bladder
wall could be utilized as a criterion for patient hospitalization,
monitoring and in selection of patients with higher risk for
progressing to shock [9]. There is a considerable association
between GBWT and the severity of dengue infection and its
use as an ancillary factor in the diagnosis and prognosis in chil-
dren has been corroborated by other authors as well [10–12].
Four distinct gallbladder wall thickening patterns were ob-
served in dengue fever: A striated pattern of multiple hypoechoic
layers separated by echogenic zones, asymmetric pattern with
echogenic tissue projecting into the gallbladder lumen, a central
hypoechogenic zone separated by two echogenic layers and a
uniform echogenic pattern. In children with severe dengue infec-
tion, striated pattern is the most common form probably due to
fluid accumulation between the gallbladder wall layers, thereby
producing striations [13]. In the index study, along with gall
bladder wall thickening (GBWT), pleural effusion and ascites
due to plasma leakage were more commonly observed in severe
dengue in comparison to non-severe dengue and the clinical
improvement coincided with resolving of the ultrasound findings
and a very few in the past studies have reported this in children
[6, 7, 14]. The probable pathogenesis of GBWT, ascites, and
pleural effusion in severe dengue infection are increased capil-
lary permeability secondary to release of cytokines and inflam-
matory cells, endothelial damage due to the virus, immune com-
plexes deposition on capillary endothelium and decreased intra-
vascular osmotic pressure [2].
Balasubramanian et al. in a comparative analysis of signs
of plasma leakage which included clinical signs,
hemoconcentration, hypoproteinemia, ultrasonography and
chest radiography, concluded that ultrasonography is the best
method for screening dengue hemorrhagic fever with 91.42 %
sensitivity and negative predictive value of 84.21 %. Ascites,
pleural effusion, gallbladder wall thickening and hepatomeg-
aly were reported by the authors as predominant sonographic
Indian J Pediatr
Non-severe Univariate OR*(95 % CI) p value
dengue (159)
80 (50.3) 0.23 (0.12–0.41) <0.001
5 (3.1) 4.8 (1.68–14.17) 0.003
04 (2.5) 6.6 (2.13–21.01) 0.0006
2 (1.2) 25 (5.75–109.2) <0.001
79 (50) 4.3 (2.37–7.89) <0.001*
22 (13.8) 3.6 (1.96–6.75) <0.001
0 – –
2 (1.2) 9.1 (2.17–62.67) <0.001
2 (1.2) 20.7 (5.4–134.2) <0.001
1 (0.6) 6.8 (0.85–172.8) 0.03
findings and with thrombocytopenia strongly favoured the
diagnosis of severe dengue infection and advocated the role
of ultrasound in estimating the severity of the disease and
identifying the patients with higher risk for progressing to
shock [15]. Chacko and Subramanian, in their study reported
that the presence of ascites and pleural effusion were the most
predictive indicators of shock; on the other hand, gallbladder
wall thickening was not associated with the presence of shock
[2]. A similar study conducted during the epidemic in 1997 by
Joshi et al. showed pleural effusion and ascites as common
findings in severe dengue infection whereas gall bladder wall
thickening was not a prominent finding and opined that gall
bladder wall thickening (GBWT) cannot be taken as a sole
definitive sign of severe dengue infection in children [5].
A diffuse gall bladder wall thickening (GBWT) is not spe-
cific for dengue fever as it occurs in other conditions like
enteric fever, leptospirosis, hypoalbuminemia, portal hyper-
tension, end-stage cirrhosis, hepatitis, pancreatitis, cholecysti-
tis, chronic heart failure, and renal insufficiency [16].
However, the other conditions can be differentiated by the
pattern of Gall bladder wall thickening [17]. In the index
study, two cases of dengue fever presented with right hypo-
chondriac pain and were diagnosed as acute cholecystitis.
However, ultrasound showed features of mild thickening of
the gall bladder wall with visible stratification along with
honeycombing pattern with a rim of fluid around the gall
bladder which was characteristic of severe dengue infection
and hence, surgical intervention was avoided and the cases
improved with symptomatic management.
This study highlights the usefulness of ultrasonography in
picking subclinical plasma leakage among children with den-
gue fever and its utility in predicting the occurrence of severe
dengue infection at an early stage of illness. In comparison to
ultrasonography, hematocrit is a poor indicator of subclinical
plasma leakage and changes in the hematocrit often occur too
late to be of clinical benefit [15, 18]. This study shows that a
Indian J Pediatr
substantial proportion of mildly ill patients showing signs of
plasma leakage had an increased risk for progression to shock
compared to patients without plasma leakage and careful
monitoring of circulatory status is merited in these children.
The limitation of the present study is that ultrasound was
done in the critical period of illness and at the time of discharge,
whereas significant changes in vascular permeability may oc-
cur after the initial ultrasound done during the critical period of
presentation. Serial ultrasonography may, therefore, be needed
to detect the presence of plasma leakage rather than one time
ultrasound during the critical period but there were practical
difficulties in performing it due to lack of portable bedside hand
held devices and its clinical application is still limited in re-
source poor settings. The another limitation is that ultrasonog-
raphy lacks wider applicability as it is not routinely used due to
financial and logistical limitations in resource poor settings.
Conclusions
Ultrasonography is an important investigative tool in
predicting the severity of dengue infection in children. It can
help to identify the cases at risk for shock which require mon-
itoring of the circulatory status during the critical period to
timely recognize and possibly prevent shock.
Acknowledgments Dr. Vijayalakshmi Sivapurapu, intensivist for criti-
cal input in conducting and drafting the manuscript.
Contributions SP: Did the study, data collection and analysis, literature
search, analyzed, drafted the manuscript, critical review and finalized the
manuscript; PK: Did the study, data analysis and drafted the manuscript;
BK: Data collection, analysis, literature search and drafted the manu-
script; MT: Data collection, statistical analysis and drafting the manu-
script. SP will act as the guarantor of the paper.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
References
1. World Health Organization, Regional Office for South-East Asia.
Comprehensive guidelines for prevention and control of dengue
and dengue hemorrhagic fever, revised and expanded edition.
WHO-SEARO 2011. (SEARO Technical Publication Series No 60)
2. Chacko B, Subramanian G. Clinical, laboratory and radio-
logical parameters in children with dengue fever and predic-
tive factors for dengue shock syndrome. J Trop Pediatr.
2008;54:137–40.
3. Shlaer WJ, Leopald JR, Scheible FW. Sonography of thickened gall
bladder wall: a non specific finding. Am J Roentgenol. 1981;136:
337–9.
4. Pramuljo HS, Harun SR. Ultrasound findings in dengue
haemorrhagic fever. Pediatr Radiol. 1991;21:100–2.
5. Joshi P, Rathnam VG, Sharma S, et al. USG findings in dengue
hemorrhagic fever : our experience in the recent epidemic. Indian J
Radiol Imaging. 1997;7:189–92.
6. Venkata Sai V, Dev B, Krishnan R. Role of ultrasound in dengue
fever. Br J Radiol. 2005;78:416–8.
7. Oliveira GA, Machado RC, Horvat JV, et al. Transient reticular
gallbladder wall thickening in severe dengue fever: a reliable sign
of plasma leakage. Pediatr Radiol. 2010;40:720–4.
8. Konuş OL, Ozdemir A, Akkaya A, Erbaş G, Celik H, Işik S.
Normal liver, spleen, and kidney dimensions in neonates, infants,
and children: evaluation with sonography. AJR Am J Roentgenol.
1998;171:1693–8.
9. Setiawan MW, Samsi TK, Wulur H, Sugianto D, Pool TN. Dengue
haemorrhagic fever: ultrasound as an aid to predict the severity of
the disease. Pediatr Radiol. 1998;28:1–4.
10. Wu KL, Changchien CS, Kuo CH, et al. Early abdominal sono-
graphic findings in patients with dengue fever. J Clin Ultrasound.
2004;32:386–8.
11. Colbert JA, Gordon A, Roxelin R, et al. Ultrasound measurement of
gallbladder wall thickening as a diagnostic test and prognostic in-
dicator for severe dengue in pediatric patients. Pediatr Infect Dis J.
2007;26:850–2.
12. Gupta S, Singh SK, Taneja V, Goulatia RK, Bhagat A, Puliyel JM.
Gall bladder wall edema in serology proven pediatric dengue hem-
orrhagic fever: a useful diagnostic finding which may help in prog-
nostication. J Trop Pediatr. 2000;46:179–81.
13. Teefey SA, Baron RL, Bigler SA. Sonography of the gallbladder:
significance of striated (layered) thickening of the gallbladder wall.
AJR Am J Roentgenol. 1991;156:945–7.
14. Srikiatkhachorn A, Krautrachue A, Ratanaprakarn W,
Wongtapradit L, Nithipanya N. Natural history of plasma leakage
in dengue hemorrhagic fever: a serial ultrasonographic study.
Pediatr Infect Dis J. 2007;26:283–90.
15. Balasubramanian S, Janakiraman L, Kumar SS, Muralinath S,
Shivbalan S. A reappraisal of the criteria to diagnose plasma leak-
age in dengue hemorrhagic fever. Indian Pediatr. 2006;43:334–9.
16. Sehgal A, Gupta S, Tyagi V, Bahl S, Singh SK, Puliyel JM. Gall
bladder wall edema is not pathogenic of dengue infection. J Trop
Pediatr. 2002;48:315–6.
17. Van Breda Vriesman AC, Engelbrecht MR, Smithuis RH, Puylaert
JB. Diffuse gallbladder wall thickening: differential diagnosis. Am
J Roentgenol. 2007;188:495–501.
18. Michels M, Sumardi U, de Mast Q, et al. The predictive diagnostic
value of serial daily bedside ultrasonography for severe dengue in
Indonesian adults. PLoS Negl Trop Dis. 2013;7:e2277.