The British Journal of Radiology, 78 (2005), 416418

DOI: 10.1259/bjr/54704044

2005 The British Institute of Radiology

Role of ultrasound in dengue fever

P M VENKATA SAI, MBBS, DMRD, DNB, FICR, B DEV, MBBS, MD, DNB and R KRISHNAN, R S MBSS, MD
Department of Radiology and Imaging Sciences, Sri Ramachandra Medical College & Research Institute (DU), Porur,
Chennai 600 116, Tamil Nadu, India

Abstract. This study was performed to find out whether ultrasound is an important adjunct to clinical and
laboratory profile in diagnosing dengue fever or dengue haemorrhagic fever and to further determine whether
ultrasound is useful in predicting the severity of the disease. Ultrasound was performed on 128 patients (29
years) with clinical suspicion of dengue fever. Serological tests were performed to confirm the diagnosis. 40
patients were serologically negative for dengue fever and later excluded from the study. Of the remaining 88
serologically positive cases, 32 patients underwent ultrasound on second to third day, repeated on fifth to
seventh day of fever and in 56 patients ultrasound was done only on fifth to seventh day of fever. Of the 32
patients who underwent the study on second to third day of fever, all showed gall bladder wall thickening and
pericholecystic fluid, 21% had hepatomegaly, 6.25% had splenomegaly and right minimal pleural effusion.
Follow-up ultrasound on fifth to seventh day revealed ascites in 53% left pleural effusion in 22% and pericardial
effusion in 28%. Of the 56 patients who underwent the study on fifth to seventh day of fever for the first time all
had gall bladder wall thickening, 21% had hepatomegaly, 7% had splenomegaly, 96% had ascites, 87.5% had
right pleural effusion, 66% had left pleural effusion and 28.5% had pericardial fluid. To conclude, in an
epidemic of dengue, ultrasound features of thickened gall bladder wall, pleural effusion and ascites should
strongly favour the diagnosis of dengue fever.

Dengue is a mosquito-borne infection that in recent

years has become a major international public health
problem [1]. Dengue fever (DF) has been known for
more than a century in the tropical areas of South East
Asia and the Western Pacific regions [2]. Clinically
dengue manifests with acute onset of fever, severe
headache, retro-ocular pain and pain involving the muscles
and joints. Haemorrhagic diasthesis and thrombocytopenia with concurrent haemoconcentration is a constant
finding.
In early July 2002, there was an outbreak of dengue in
Chennai, a coastal city in Southern India. Since there is no
single test that can be used to diagnose the condition with
a reasonable degree of accuracy and reliability, the
diagnosis is based on clinical appearance in combination
with serology. Serology takes approximately 7 to 10 days
to give a positive result. The purpose of our study was to
analyse retrospectively the ultrasound features in patients
with DF, to find out whether ultrasound is an adjunct to
clinical and lab profile in the diagnosis of DF and to
further determine whether ultrasound is useful in predicting the severity of the disease

Materials and methods

Our institutional review board approved this retrospective study; informed consent was not required.
Between June and July 2002, 128 subjects (80 male, 48
female; mean age, 5 years; age range 29 years) who were
clinically suspected of having DF were referred for
ultrasound scanning of both abdomen and thorax.
Common clinical manifestations included fever (n5128),
severe headache (n5104), retro-ocular pain (n584), pain in
Received 24 May 2004 and in final form 4 November 2004, accepted
6 December 2004.

416

the muscles and joints (n580), and purpuric spots on

the body (n522). Blood laboratory investigation in 88
patients revealed thrombocytopenia (average platelet
count 40 000 cells mm23) with concurrent haemoconcentration. Based on the clinical and laboratory findings
65 patients were diagnosed as classical dengue fever
(CDF), 19 patients had dengue haemorrhagic fever
(DHF) and 4 patients were diagnosed as dengue shock
syndrome (DSS).
All ultrasound examinations were performed with a
portable machine (L&T symphony model) using 3.5 MHz
and 5 MHz probes. Abdominal scanning was done after
6 h of fasting to allow better distension of gall bladder
(GB) [3]. GB wall thickening, which was the consistent
finding in all the serologically positive cases, was measured by placing the calipers between the two layers
of anterior wall [4]. Thoracic scanning was done in
either sitting or supine posture. Both the pleural spaces
were evaluated through an intercostal approach.
Pericardial space was also evaluated for effusion subcostally. In all the patients ultrasound was performed prior to
serology.
Serological tests using paired sera was performed to
confirm the diagnosis in all the 128 patients which revealed
88 patients to be serologically positive for DF [5, 6]. The
remaining 40 patients were serologically negative. The 88
serologically positive patients were then sorted into two
groups based on the days of study. Group I (n532)
included patients who had symptoms and signs consistent
with DF and in whom ultrasound was performed on the
second to third day after onset of fever. These patients also
had a follow up scan on fifth to seventh day. Group II
(n556) included patients who underwent ultrasound only
on fifth to seventh day after onset of fever. For the 40
serologically negative patients ultrasound was performed
on an average of 3.9 days (range, same day to 7 days) after
admission.
The British Journal of Radiology, May 2005

Ultrasound in dengue fever

Results (Tables 14)

Ultrasound findings in Group I
Of the 32 patients who underwent the study on second
to third day of fever, 7 had hepatomegaly (21.8%), 32 had
GB wall thickening and pericholecystic fluid (100%), 2 had
splenomegaly (6.25%) and 2 had right-sided pleural
effusion (6.25%). None had ascites, left sided pleural
effusion or pericardial effusion. On follow-up scan (days
57), hepatomegaly was noted in four more patients
Table 1. Profile of 88 serologically positive cases
Day of examination

Number of cases

2nd3rd day
5th7th day

32
56+32 (follow up cases)

(12.5%), splenomegaly in three more patients (9.37%) and

right sided pleural effusion in 21 more patients (65.6%).
GB pathology persisted in all the patients. New findings
including ascites were noted in 17 patients (53.12%), left
sided pleural effusion in 7 patients (21.8%) and pericardial
effusion in 9 patients (28.12%).

Ultrasound findings in Group II

Of the 56 patients who underwent the study on fifth to
seventh day of fever, GB pathology was noted in all the 56
patients (100%), 34 patients had hepatomegaly (60.9%), 17
had splenomegaly (30.35%), 4 had ascites (7.14%), 55 had
right sided pleural effusion (96.46%), 37 had left sided
pleural effusion (66.07%) and 16 had pericardial effusion
(28.57%).

Table 2. Summary of ultrasound findings in Group I

Days of examination

Gall bladder wall thickening

with pericholecystic fluid
Hepatomegaly
Splenomegaly
Right pleural effusion
Left pleural effusion
Ascites
Pericardial effusion

No. of patients (n532)

2nd3rd day

5th7th day

32 (100)

32 (100)

7
2
2
0
0
0

(21.8)
(6.25)
(6.25)
(0)
(0)
(0)

4
3
21
7
17
9

(12.5)
(9.37)
(65.6)
(21.8)
(53.12)
(28.12)

Number in parentheses are percentages.

Table 3. Summary of ultrasound findings in Group II

Features

40 serologically negative patients

Of the 40 patients who were serologically negative for
DF, GB pathology was present in 14 patients initially but
disappeared later on follow-up scan. A clinical review of
17 other patients revealed that their symptoms were not
classical of DF. Nine patients could not be followed up as
they discharged themselves against medical advice.
Our study demonstrated thickened GB wall and
pericholecystic fluid (Figure 1) as the most common initial
ultrasound finding in all the 88 serologically positive cases
(100%) followed by right sided pleural effusion (71.87%),
ascites (53.2%), left sided pleural effusion (21.87%) and
pericardial effusion (28.5%). Hepatomegaly and splenomegaly were noted in 34.3% and 15.6% of patients,
respectively.

No. of patients (n556)

5th7th day

Gall bladder Wall thickening

with pericholecystic fluid
Hepatomegaly
Splenomegaly
Right pleural effusion
Left pleural effusion
Ascites
Pericardial effusion

56 (100)
34
17
55
37
4
16

(60.9)
(30.35)
(96.46)
(66.07)
(7.14)
(28.57)

Number in parentheses are percentages.

Table 4. Summary of ultrasound findings in Group I and

Group II
Features

No. of patients (n588)

5th7th day

Gall bladder Wall thickening

with pericholecystic fluid
Hepatomegaly
Splenomegaly
Right pleural effusion
Left pleural effusion
Ascites
Pericardial effusion

100%
34.3%
15.6%
71.87%
21.87%
53.2%
28.5%

The British Journal of Radiology, May 2005

Figure 1. Ultrasound subcostal view to show gall bladder wall

thickening and pericholecystic fluid.
417

P M Venkata Sai, B Dev and R Krishnan

Discussion
Dengue is an acute febrile viral disease caused by
flavivirus. It occurs in two forms: DF, a milder form of the
disease and DHF, the most severe form. Dengue has
become a major international public health concern in
recent years [2]. It is now endemic in more than 100
countries and threatens the health of 40% of the worlds
population. It is estimated that 50 million dengue
infections occur each year with 5 000 000 cases of DHF
and at least 12 000 deaths annually mainly among children
[1]. The increase of DF is due to uncontrolled population
growth and urbanization in the absence of appropriate
water management, global spread of dengue strains via
travel and trade and due to erosion of vector control
programmes [7]. In India the problem is even more acute
because since 1963, more than 50 outbreaks have been
reported by the National Institute of Communicable
diseases, New Delhi [8].
Dengue viruses are transmitted to humans through the
bites of infective female Aedes mosquito. The incubation period of the disease is 314 days. The onset of the
disease is recognized by the sudden onset of high fever,
retro-orbital pain, thrombocytopenia and haemorrhagic
manifestations. Common laboratory findings include
pancytopenia, neutropenia, increased haemoconcentration,
thrombocytopenia and prolonged bleeding time. These
findings are consistent with increased vascular permeability, plasma leakage, abnormalities of haemostasis and
protein losing shock syndrome, which commonly occur in
DF pathogenesis.
Serology is the mainstay in the diagnosis of DF.
Haemagglutination inhibition antibodies usually appear
at detectable level by day 5 to 6 of febrile illness. The
diagnosis of DF is often delayed owing to time taken for
availability of results. The aim of our study was to
evaluate the ultrasound findings in DF, to find whether
ultrasound of the abdomen is an important adjunct to
clinical and laboratory profile in diagnosing DF and
further if ultrasound is useful in predicting the severity of
the disease.
The ultrasound findings in early milder form of DF
include GB wall thickening, pericholecystic fluid, minimal
ascites, pleural effusion, pericardial effusion and hepatosplenomegaly. Severe forms of the disease are characterized by fluid collection in the perirenal and pararenal
region, hepatic and splenic subcapsular fluid, pericardial
effusion, pancreatic enlargement and hepatosplenomegaly.
These findings have been demonstrated in studies carried
out by the Department of Child Health in Indonesia [9]
and by Joshi et al [10] in Army Hospital, Delhi Cantt.
They had also found abnormal liver parenchyma, which
has been attributed to intraparenchymal and subcapsular
haemorrhages. In our study however we could not
appreciate any significant change in the echotexture of
the liver. None of these studies suggested GB wall
thickening as the initial finding in DF (100%) as observed
in our study, followed and pleural effusion. GB wall
thickening in DF may be due to decrease in intravascular
osmotic pressure. These findings may also occur in other

418

viral infections, enteric fever and leptospirosis, but in other

viral infections the historical profile, symptom complex
evolution and physical findings do not mimic those of DF.
Ultrasound features of enteric fever include splenomegaly,
intra-abdominal lymphadenopathy, bowel abnormalities in
the form of intramural thickening of the terminal ileum
and caecum, renal abnormalities like arteriectasis and
perinephric fluid collection in addition to GB wall
thickening and polyserositis. Leptospirosis also shows
gross abnormalities involving hepatic and renal parenchyma. GB wall thickening also occurs in association with
other conditions such as ascites, hypoalbuminaemia,
congestive cholecystopathy and in patients with cirrhosis
of liver and portal hypertension. It is a very non-specific
finding when considered in isolation and is therefore a
major limitation of this study.
To conclude ultrasound of the abdomen is an important
adjunct to clinical profile in diagnosing DF and may help
to direct further confirmatory investigations. Further
diagnosis can be made early in the course of disease
compared with other modes of diagnosis. During an
epidemic the ultrasound findings of GB wall thickening
with or without polyserositis in a febrile patient should
suggest the possibility of DF/DHF.

Acknowledgments
We thank Dr Uday Charan Murmu, Assistant Professor
of Paediatric Medicine, Mr S Porchelvan, Department of
Biostatistics and Mr S Santhosh, Department of
Radiology & Imaging Sciences Sri Ramachandra
Medical College & Research Institute (Deemed
University), Chennai for his invaluable help in evaluation
for the study.

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The British Journal of Radiology, May 2005