Dengue: an escalating problem
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7353.1563 (Published 29 June 2002) Cite this as: BMJ 2002;324:1563
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Dear editor: After my first published article, on the effect of
Carica papaya leaf juice on dengue fever patient in Sri Lanka Family
Physician - 2008, 29, 17-19 and details about this research in the
independent medical association news letter of Srilanka , there was a wide
publicity to these findings in the local and international media. This
resulted in many patients using this simple herbal remedy on their own
when they were diagnosed as having dengue fever. Many patients under my care
living in and around my medical clinic (Maharagama - Sri Lanka) took this
treatment on their own accord and I had the opportunity of observing the
effects of Carica Papaya leaf juice on about 60 dengue positive patients
which included Hospitalized patients- including 10 treated in the Medical
ICU.
All these patients have consumed Carica papay leaf juice on their own
accord with the permission of their attending physician. I was able to get
all the information of these patients using an especially design data
collecting form, with the permission of the patient. In this ongoing
observational study which is not published yet, I have observed that
Carica Papaya leaf juice brings speedy recovery to dengue patients with
great beneficial effects.
The first published article in Sri Lanka Family Physician - 2008, 29, 17-
19 is available on the College of General Practitioners of Sri Lanka WEB (
http://www.cgpsl.org/ ) or http://cgpsl.org/downloads/pdf_cgpsl/7.pdf .
The information available in this study will be very useful to the
medical community. I will be happy and have no objection for publishing.
Competing interests: No competing interests
Dear Editor, we report here two cases of proven dengue (positive test
for dengue antigen in serum) who developed very low platelet count (30,000
in a 10 year old male and 29,000 in 14 year old male). The papaya leaves
were ground into paste and spoonful (4 hourly) was given to the patients
and the platelet count rose to 1,00,000 in 10 year old by evening i.e.
within 12 hours of initiating the treatment and 2,50,000 in the 14 year
old in two days. There is one study where a suspension of 15 mg /kg of
powdered Carica papaya leaves in palm oil was given to 5 mice and has been
investigated for its effect on thrombocyte counts in them. Equal numbers
of animals received corresponding volumes of either palm oil alone or
physiological saline solution. Thrombocyte counts before and at 1, 2, 4,
8, 10, 12, 24, 48 and 72 hours after dosing revealed significantly higher
mean counts at 1, 2, 4, 8, 10 and 12 after dosing with the C. papaya leaf
formulation as compared to the mean count at hour 0. There was only a non-
significant rise of thrombocyte counts in the group having received saline
solution1.
Recovery time from low platelet count is reported from 5-7 days after
platelet and blood transfusions2. However, the recovery time in both these
cases was 12-48 hrs that too without any platelet and blood transfusion.
Since I (NK) am a medical doctor and guardian of these children, therefore I
could decide this intervention. The Active principle substances in the
papaya leaves (responsible for the release and/or production of
thrombocytes) should be isolated and identified. And this intervention
should be evaluated in larger studies. This could help in a big way to the
resource poor setting and able to significantly reduce the hospital
expenditures and mortality with better prognosis and early recovery.
1. Sathasivam K, Ramanathan S, Mansor SM, Haris MR, Wernsdorfer WH.,
Thrombocyte counts in mice after the administration of papaya leaf
suspension. Wien Klin Wochenschr. 2009 Oct;121 Suppl 3:19-220
2. Betty Chacko, Gayathri Subramanian. Clinical, Laboratory and
Radiological Parameters in Children with Dengue Fever and Predictive
Factors for Dengue Shock Syndrome. Journal of Tropical Pediatrics Vol. 54,
No. 2.
Competing interests: No competing interests
Dengue, the most important mosquito borne viral infection, causes
large epidemics in many countries. Of many infections that affect man,
dengue (break-bone fever) is particularly known for causing severe muscle
and joint pain, often prompting patients to use substantial amounts of
analgesics for pain relief. Aspirin is specifically avoided because of its
adverse effects on platelet function and the risk of Reyes syndrome in
children. National and International guidelines lists paracetamol as the
analgesic/antipyretic of choice in dengue.
Paracetamol is sold as an over the counter medication in almost all
tropical countries where dengue occurs and patients have ready and easy
access to it. A high proportion of hospitalised dengue patients start
taking paracetamol prior to admission. Some even ingest more than 4 grams
of paracetamol a day to obtain adequate analgesia. A recent report from
Sri Lanka describes paracetamol overuse with therapeutic intent in febrile
children (having acute viral like illnesses) as a risk factor for
developing fulminant hepatic failure1. Therapeutic doses of paracetamol
may cause liver injury in some patients2. Watkins et al, found that 31 –
44% of persons taking therapeutic doses of paracetamol (4g/day), had
alanine transaminase (ALT) levels more than 3 times the upper limit of
normal3. Paracetamol metabolism is altered during acute viral hepatitis.
It has been suggested that the 24 hour intake of paracetamol in patients
with acute liver disease should be restricted to around 2g/day4.
Dengue causes liver involvement in a number of patients5.
Hepatomegaly and elevations in aspartate (AST) and alanine transaminase
levels are common; levels of AST are higher than that of ALT. Fulminant
hepatic failure and hepatic encephalopathy are seen in some. Postulated
mechanisms for liver injury includes direct viral damage or various immune
mediated effects mainly through cytokines, T cells, apoptosis or free
radicals5.
Paracetamol induced liver injury may be an additional mechanism to be
considered for liver involvement in dengue. It may act in synergy with
other factors to cause different hepatic manifestations. Studies in
progress may better define the specific contribution made by paracetamol
and if the recommended safe daily dose of paracetamol in dengue should be
lower than 4 grams/day. We wonder if dengue guidelines should include a
warning statement of the potential ill effects of repeated paracetamol
intake on the liver in dengue when they recommend its use as an
analgesic/antipyretic in such patients.
1. Sri Ranganathan S, Sathiadas MG, Sumanasena S, Fernandopulle M,
Lamabadusuriya SP, Fernandopulle BMR. Fulminant hepatic failure and
paraceamol overuse with therapeutic intent in febrile children. Indian J
Pediatr 2006;73:871-875.
2. Jalan R, Williams R, Bernuau J. Paracetamol: are therapeutic doses
entirely safe. Lancet 2006;368:2195-96.
3. Watkins PB, Kaplowitz N, Slattery JT, et al. Aminotransferase
elevations in healthy adults receiving 4 grams of acetaminophen daily: a
randomized controlled trial. Jama 2006;296(1):87-93.
4. Lee WM. Acetaminophen and the U.S. Acute Liver Failure Study
Group: lowering the risks of hepatic failure. Hepatology 2004;40(1):6-9.
5. Seneviratne SL, Malavige GN, de Silva HJ. Pathogenesis of liver
involvement during dengue viral infections. Trans R Soc Trop Med Hyg
2006;100(7):608-14.
Suranjith L Seneviratne MRCP: Central Manchester and Manchester
Childrens University Hospital,Manchester, UK
Ananda Wijewickrama MRCP: Infectious Diseases Hospital, Sri Lanka
Jennifer Perera MD: University of Colombo, Sri Lanka
Competing interests:
None declared
Competing interests: No competing interests
here in new-delhi{india}we are passing through worst-ever
epidemic of dengue fever,although its effect is decreasing
but daily i am encountering one case of suspected dengue,
almost every physician is going for routine blood tests
in every case of pyrexia,but in some of my patients who
otherwise were not having true blood pictures of dengue
fever and were having hepatomegaly and gastritis,has shown
edema of gall-bladder wall along with ascites or fluid
collection in upper abdomen.these findings were not common
in earlier epidemic of dengue in delhi.i have come across
about 52 cases of suspected dengue and about 3 of them
has shown these findings on ultrasound examinations.
Competing interests:
None declared
Competing interests: No competing interests
I am a physician working in Dhaka, Bangladesh. For last few years we
are experiencing the out breaks of dengue.Yes I am experiencing the post
dengue palmar and plantar pruritus among my patients. I think more than
95% of my patients had complained of the symptoms during the convalescent
period. This pruritus may or may not be associated with erythematous rash
ont he palms or soles. The association is in both dengue classical and
haemorrhagic infections.
Competing interests: No competing interests
This a rather late response have been away and now catching up with
the BMJ.
There is a symptom which I have found in a small number of dengue patients
and which might be considered diagnostic. It is the intense intense itch
(with or without an eruption) which appears after the acute phase has
subsided.
I was reminded of this feature when I myself was at first quite puzzled
by the unexplained itch in my hands and in the soles of my feet (which
lasted for a few hours only),
until I was reminded about it in Manson Bar's Tropical Medicine. I
subsequently asked all my patients with suspected and later proven dengue
to report this symptom if it occurred. The incidence was impressive,
which made me wonder whether many consider it of no consequence and so
fail to report it.
Have any readers seen this symptom in dengue? Perhaps our American friends
would like to call it PPP!
B C Boyd
Competing interests: No competing interests
Sir,
We read clinical review on Dengue :an escalating problem by Drs.Robert
gibbon and D.Vaughan with keen interest.
Dengue is growing problem of developing countries along with other
infectious and Nutritional diseases.This clinical review was well written
covering nearly all the aspect of Dengue but needs extra perspective from
clinician who deals cases of Dengue Haemorrhagic fever without the benefit
of PICU.
we would like to add to this review from our experience in dealing with
Dengue Haemorrhagic fever.
1)Dengue Haemorrhagic fever has immunopathologic basis for its
clinical manifestations.It occurs in paients who have developed some
immunity against it.This is the reason for D.H.F. being common in natives
rather than genetic susceptibility.
2)Infants (<_1year of="of" agemay="agemay" develope="develope" d.h.f.="d.h.f." if="if" they="they" have="have" recieved="recieved" antibodies="antibodies" from="from" immune="immune" mother.="mother." p="p"/>3)Strong clinical suspicion with evidence of pleural effusion on X-ray is
diagnostic of D.H.F.
4)Positive torniquet test(Hess's capillary fragility test)along with
thrombocytopenia and raised haematocrit values are diagnostic of D.H.F.
and is a good indicator for early resuscitation.
5) Use crystalloids in initial resuscitation/rehydration and to use
colloids when harmatocrit is down.
In the end we agree with the authors that cost effective vaccine is needed
for prevention and control of dengue.
Competing interests: No competing interests
dear sir,
very thankful for receiving all the information in your excellent journal.
I was very suprised not to have seen eupatorium mentioned in the -at least
symptomatic- treatment of dengue.
any practitioner with some experience in this field will tell how useful
this herb/homeopathic dilution is in the treatment of the picture
described above.
please ask around and look up the "old books",patients will be most
grateful to you.
if you decide to publish these remarks you may change the english to
"proper" english.
yours sincerely,bueno de mesquita
I do paste hereunder just one description of eupatorium and its
actions.
A DICTIONARY OF PRACTICAL
MATERIA MEDICA
By John Henry CLARKE, M.D.
Presented by Médi-T ®
Eupatorium Perfoliatum.
Eupatorium perfoliatum. Boneset. Thoroughwort. N. O. Compositæ.
Tincture of whole plant.
Clinical.─Anus, herpes of. Back, pain in. Bilious fever. Bones,
pains in. Cough. Dengue. Diarrhœa. Fractures. Gout. Hiccough.
Hoarseness. Indigestion. Influenza. Intermittent fever. Jaundice. Liver,
soreness of. Measles. Mouth, cracks of. Ophthalmia. Relapsing fever.
Remittent fever. Rheumatism. Ringworm. Spotted fever. Syphilitic pains.
Thirst. Wounds.
Characteristics.─Eupat. perfol. is an old-world remedy, having
been recommended by Dioscorides for ill-conditioned ulcers, dysentery,
stings of reptiles, chronic fevers, obstructed liver. The leading
characteristic for its homœopathic use is the distressing bone-
pains it causes, such as are found in connection with malarial fevers and
influenza. Soreness will be found running throughout the proving: headache
with soreness internally, parietal protuberances sore; with pain and
soreness in eyeballs; cough with extreme soreness down trachea, soreness
of chest, aching in limbs throughout the body. A characteristic cough of
Eup. perf. has > by getting on hands and knees. W. P. Defriez reports a
case in point: Every winter for several years the patient had been annoyed
by a dry, hacking cough, with paroxysms lasting some time, only relieved
by getting on hands and knees. Eupat. Perfol. cured. The chills of Eu.
perf. begin in the small of the back, with aching in the limbs as though
every bone in the body were being broken; high fever with increased
aching, followed by sweat scanty or profuse; sweat > all pains except
headache, which is <_. xmlns:periodicity="urn:x-prefix:periodicity" periodicity="periodicity" is="is" marked.="marked." there="there" may="may" be="be" a="a" double="double" periodicity:_="periodicity:_" chill="chill" morning="morning" one="one" day="day" evening="evening" the="the" next.="next." liver="liver" strongly="strongly" affected="affected" by="by" eup.="eup." perfol.="perfol." bilious="bilious" vomiting="vomiting" and="and" diarrh339a="diarrh339a" sick-headaches="sick-headaches" cough="cough" arising="arising" from="from" irritation="irritation" of="of" liver.="liver." catarrhal="catarrhal" symptoms="symptoms" are="are" prominent.="prominent." nocturnal="nocturnal" loose="loose" cough.="cough." hoarseness="hoarseness" with="with" aching="aching" soreness="soreness" trachea.="trachea." hoarse="hoarse" rough="rough" scraping="scraping" in="in" bronchia.="bronchia." compelling="compelling" patient="patient" to="to" hold="hold" his="his" chest="chest" hands.="hands." stiffness="stiffness" general="general" soreness.="soreness." cannot="cannot" twist="twist" body="body" either="either" while="while" standing="standing" sitting="sitting" or="or" lying.="lying." lie="lie" bed="bed" on="on" account="account" feeling="feeling" as="as" if="if" every="every" bone="bone" was="was" bruised="bruised" causing="causing" despair="despair" moaning="moaning" crying="crying" out.="out." p="p"/>Bone-pains of
all descriptions appear under Eupat. perf. Sleepiness and yawning.
Sensation as if falling to left. Pain and extreme tenderness of left
glutei muscles. Hale describes the fever of E. perfol. as follows: "The
chill is nearly always in the morning, and is preceded for several hours
by thirst, soreness and aching of the bones. The thirst continues during
the chill and heat. The chill is attended by nausea, vomiting of bile,
intense aching and soreness in the flesh of the extremities, and often all
over the body. These symptoms continue during the heat, especially the
vomiting, which is often painful and incessant. The heat is apt to be
prolonged until evening or into the night, and may be followed or not by
sweat (with chilliness). If no sweating occurs the apyrexia is short and
attended by chilliness, nausea, thirst, and debility, showing that the
febrile action never altogether subsides, giving a true type of Remittent
fever─a fever in which Boneset is often our best remedy,
especially if occurring in summer and autumn, and is attended by very
severe bilious symptoms." Lying on back <cough. Kneeling with face
towards pillow > cough. Rising up > headache. Eating = violent
distressing pains which are only relieved by vomiting. There is intense
thirst, but drinking cold water = shuddering and vomiting of bile.
Chilliness predominates, wants to be covered; > in house, <in open
air; <after being in ice-house. I have found Eup. perf. most useful in
influenza.
Relations.─Bryonia is the closest analogue; but Bryonia has free
sweat, and the pains make the patient keep still. Eup.
perfol.─has scanty sweat, and its pains cause restlessness.
Compare also: Arn., Caps., Chel., Symph., Podoph., and Lycop.; nausea from
smell of food, Colch. Compatible: Nat. mur. and Sepia, which also follow
well.
SYMPTOMS.
1. Mind.─Feels at night as if going out of his
mind.─Moaning; anxiety; despondency.─Very restless;
cannot keep still, though wishes to.
2. Head.─Early in morning whirling around in brain as if he had
been whirled in cool screen: repeated after a short
cessation.─Headache with a sensation of soreness internally;
> in the house; <when first going into the open air; > by
conversation.─Headache and nausea every other morning, when
awaking.─Pain in occiput after lying, with sense of weight; must
aid with hand in lifting head.─Beating pain in forehead and
occiput, after rising.─Soreness and pulsation on the back part
of the head.─Heat on the top of the head.─Violent
headache, comes on before the chill rid lasts through all the stages, and
is worst during the sweat.
3. Eyes.─Painful soreness of eyeballs.─Great aversion
to light.─Painful soreness of lids.
5. Nose.─Coryza, with sneezing; aching in every bone.
8. Mouth.─Paleness of the mucous membrane of the
mouth.─Tongue covered with white fur.─Soreness of the
corners of the mouth.
11. Stomach.─Nausea from smell of food or
cooking.─Indigestion from alcohol, of old
people.─Thirst for cold water.─Thirst for large
draughts of cold water before and during chill.─Vomiting
immediately after drinking, and preceded by thirst.─Nausea and
vomiting of food.─Vomiting after every
draught.─Vomiting of bile, with trembling and great nausea,
causing great prostration.─Tight clothing is oppressive.
12. Abdomen.─Soreness in region of liver; on moving or
coughing.─Colicky pains in upper abdomen, with headache and
other pains.─Abdomen full and tympanitic.
13. Stool and Anus.─Constipation, with
catarrh.─Morning diarrhœa.─Purging stools,
with smarting and heat in anus.
14. Urinary Organs.─Dark-coloured, clear urine.─Dark-
brown, scanty urine, depositing a whitish, clay-like
sediment.─Itching of the mons veneris.
17. Respiratory Organs.─Hoarseness.─Hoarseness <
mornings; soreness in trachea and bronchia.─Cough with soreness
and heat in bronchia; flushed face, and tearful eyes.─Hacking
cough in the evening.─Cough from a cold, <2 to 4 am.;
excited by tickling in chest, causing tightness of chest; cough <lying
on back, > kneeling with face towards pillow; scanty expectoration;
painful fulness in head on coughing or blowing nose; lowness of
spirits.─Hectic cough, from suppressed intermittent
fever.─Difficulty of breathing, attended with perspiration,
anxious countenance, sleeplessness.─Soreness in chest; <from
inspiration.─Inability to lie on the l. side.─Sharp
pain through r. chest on deep inspiration; feels at night as if going out
of his mind; disturbed breathing frightens him.
19. Heart.─Pressure as if heart was in too small a
space.─Pain, soreness, and heaviness behind sternum and in
cardiac region; <by least motion or turning body around.
20. Neck and Back.─Beating pain in nape and occiput; better
after rising.─Aching pain in the back, as from a
bruise.─Weakness in small of back.─Trembling in back
during fever.
21. Limbs.─Aching in bones with soreness of the
flesh.─Intense soreness and aching in limbs, as if bruised or
beaten.─Wrists pain as if broken or dislocated.─Heat
in the hands, sometimes with perspiration.─Dropsical swelling of
both feet and ankles.─Heat in the soles of the feet, in the
morning.
25. Skin.─Jaundice.
26. Sleep.─Stretching and yawning; yawning before chill;
sleepiness with difficult breathing.─Has to lie with head
high.─Headache on awaking.
27. Fever.─Thirst a long time before the chill, which continues
during the chill and heat.─At the conclusion of the chill,
vomiting of bile, or after every draught.─Pain in the bones (as
if broken) all over, before the commencement of the
chill.─Headache, backache, and thirst during the
chill.─During the chill and heat, throbbing
headache.─The chill is induced or hastened by taking a drink of
cold water.─Distressing pain in the scrobiculus cordis,
throughout the chill and heat.─Aching pains, with moaning during
the cold stage.─Coldness during nocturnal
perspiration.─Chilliness throughout the night and morning;
trembling and nausea from least motion; intense aching and soreness in
back and limbs; more shivering than the degree of coldness
warrants.─The intermittent fever paroxysm generally commences in
the morning.─Fever commences in morning; attended with
painfulness, trembling, weakness, and soreness; but little or no
perspiration.─Great weakness and prostration during the
fever.─Headache and trembling during the
heat.─Vomiting of bile at the close of the hot
stage.─Vomiting of bile after the chill.─The fever
goes off by perspiration and sleep. During the apyrexia, loose
cough.─When there is perspiration it relieves all the symptoms
except the headache.
Copyright © Médi-T ® 2000
Main
Competing interests: No competing interests
Re: Dengue: an escalating problem
A competing interest (often called a conflict of interest) exists when professional judgment concerning a primary interest (such as the validity of research) may be influenced by a secondary interest (such as financial gain). We believe that readers should know about any such competing interests.
Competing interests: No competing interests