Management of Transaminitis in Dengue Fever
Regular monitoring of liver function tests is necessary in patients with dengue fever regardless of baseline liver function test results, with increased vigilance for those with elevated transaminases.
Understanding Liver Involvement in Dengue
- Liver dysfunction in dengue is common, with elevated transaminases (AST and ALT) observed in up to 93.3% and 82.2% of patients respectively 1
- Transaminitis in dengue typically peaks around days 6-7 of illness, with AST levels often higher than ALT 2
- The prevalence of hepatic dysfunction increases with disease severity - SGOT (AST) is elevated in 66.7%, 78.6%, and 91.7% of patients with dengue without warning signs, with warning signs, and severe dengue respectively 3
Assessment and Monitoring
Grade transaminitis based on elevation of AST/ALT levels 4:
- Grade 1: AST/ALT > ULN to 3.0× ULN
- Grade 2: AST/ALT > 3.0 to 5.0× ULN
- Grade 3: AST/ALT > 5.0 to 20× ULN
- Grade 4: AST/ALT > 20× ULN
Initial workup should include 4:
- Review of medications and supplements with hepatotoxic potential
- Evaluation for viral hepatitis (HBV, HCV)
- Alcohol consumption history
- Assessment for other causes of liver injury
Monitor liver function tests regularly throughout the illness 5:
- For mild transaminitis: Every 1-2 weeks
- For moderate to severe transaminitis: More frequent monitoring (every 2-3 days)
- Continue monitoring until normalization of liver enzymes
Management Based on Severity
Mild Transaminitis (Grade 1)
- Close monitoring without specific treatment 4
- Monitor labs 1-2 times weekly 4
- Avoid hepatotoxic medications if possible 5
Moderate Transaminitis (Grade 2)
- Discontinue potential hepatotoxic medications if medically feasible 4
- Increase monitoring frequency to every 3 days 4
- Limit acetaminophen to <3000 mg/day (1000 mg every 8 hours) 6
Severe Transaminitis (Grade 3-4)
- Consider hepatology consultation 4
- Discontinue all hepatotoxic medications 4
- Monitor for signs of acute liver failure (encephalopathy, coagulopathy) 7
- Supportive care is the mainstay of treatment 5
Special Considerations
Acetaminophen Use
- Male gender and acetaminophen >8g are associated with increased serum transaminases in dengue patients 6
- Limit acetaminophen to 1000 mg every 8 hours or <3000 mg/day for dengue cases to prevent worsening of transaminitis 6
Monitoring for Disease Progression
- Elevated transaminases negatively correlate with platelet count - as transaminases increase, platelet counts decrease 3
- Patients with elevated AST (93.8%) and ALT (81.2%) have a higher incidence of bleeding manifestations 3
- Hypoalbuminemia and A:G ratio reversal are significantly more common in severe dengue and should be monitored 3
Timing of Liver Involvement
- Peak AST levels and lowest serum albumin levels typically occur 24 hours before maximum fluid leakage and 24 hours after peak viremia 2
- Liver function tests done too early might not reflect the extent of liver involvement in acute infection 2
- Severe liver involvement can occur in the absence of fluid leakage, even after the peak viremia 2
Pitfalls and Caveats
- Liver function tests done early in the disease course (before day 5-6) may underestimate the extent of liver damage 2
- Severe liver involvement can occur without other warning signs of severe dengue 2
- While most cases have mild-to-moderate transaminitis, approximately 7-11% of patients may develop severe transaminitis (>10× ULN) 1
- Dengue should be considered in the differential diagnosis of acute hepatitis in endemic areas 1
- Avoid aspirin due to the risk for hemorrhagic complications in dengue 5