Clinical Profile of dengue patients presenting with epistaxis at a tertiary hospital in Nepal

Clinical Profile of dengue patients presenting with epistaxis at a tertiary hospital in Nepal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Profile of dengue patients presenting with epistaxis at a tertiary hospital in Nepal Sabin Thapaliya, Bishal Budha, Sunil Gyawali, Dijesh Maskey, Saket Jha This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7003641/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Dengue fever can present with hemorrhagic manifestations such as epistaxis. Despite its clinical significance, the specific profile and outcome of dengue patients presenting with epistaxis remains unexplored in Nepal. We conducted record-based retrospective study to analyze demographic and clinical profile of dengue cases with epistaxis admitted to Tribhuvan University, Teaching Hospital, Kathmandu, Nepal, between 1st September 2022 to 30th November 2024. Methods A record-based retrospective study was conducted among patients with dengue fever (NS1 positive with symptoms) and concurrent epistaxis, admitted to our tertiary care center. The collected data encompassed patient demographics, underlying comorbidities, prior medication history, duration of hospital stay, additional bleeding manifestations, platelet count, WBC count, PT/INR, and AST/ALT. The requirement for blood or platelet transfusion was also assessed. Result A total of 27 patients with dengue fever and epistaxis were evaluated. The mean age was 42 years and majority (70.37%) were male. Epistaxis was the initial presentation among 59.26% patients while 40.74% developed it during hospitalization. Epistaxis typically occurred around day 4–7 of illness. At the time of epistaxis, the mean WBC count was 5462.96/µL (range 1,600 − 14,700/µL) and mean platelets count was around 30,000 /µL. Decreasing trend of WBC counts and increasing trend of platelet counts was seen in majority of patients. AST and ALT were elevated (mean AST 424 U/L, ALT: 166 U/L). One third patients experienced additional bleeding, most commonly from oral mucosal followed by GI bleeding. Overall, 62.96% required transfusion and the mean platelet transfusion was about 4 pints. Among those with bleeding from other sites, 89% required transfusion, highlighting the increased severity in this subgroup. Conclusion Epistaxis in dengue patients most commonly occurred between days 3–7 of illness, coinciding with thrombocytopenia, rising WBCs, and elevated liver enzymes. Vigilant clinical monitoring is crucial, as not all case required transfusion, but may signal risk of multisite bleeding. Dengue Fever Epistaxis Warning signs Nepal Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Dengue virus (DENV) belongs to a group of enveloped viruses, Flaviruses which also includes West Nile virus and yellow fever virus, and involves arthropods as their vectors. ( 1 ) Dengue disease can be caused by 1 of 4 distinct but closely related dengue viruses and specifically are transmitted by mosquito of the genus Aedes ( Aedes aegypti, Aedes albopticus ). ( 2 , 3 )The disease is now consistently present over 100 countries in the tropical and subtropical regions of Africa, South East Asia, the Eastern Mediterranean and Western Pacific and has more than 100 million symptomatic cases each year. ( 2 , 3 ) Nepal reported first Dengue case in 2004 in a traveler. ( 4 ) Originally limited to lowland areas if Terai region, it has expanded in recent years. Dengue has spread to higher altitudes and previously unaffected areas in Nepal, influenced by climate change and mosquito breeding patterns. ( 5 , 6 ) Currently clinical dengue is classified as dengue with or without warning signs and severe dengue ( 7 ). Warning signs as mentioned in WHO classification (2009) includes abdominal pain and tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleed, lethargy, restlessness, liver enlargement > 2cm and increase in hematocrit concurrent with rapid decrease in platelet count ( 7 ). Common hemorrhagic manifestations in Dengue include petechiae, epistaxis, gum bleeding, gastrointestinal bleeding and hematuria ( 8 ). Objective In this study, we report laboratory and clinical profiles of adult dengue patients with epistaxis from a tertiary health care facility in Kathmandu, Nepal. Study design We evaluated 27 patients who presented with dengue fever between September 2022 and November 2024, all of whom tested positive for dengue NS1 and simultaneously exhibited epistaxis. These patients were admitted and treated at our tertiary center. We analyzed gender predominance, prior comorbidities, previous medications, total hospital stay, other bleeding manifestations, platelet count and PT/INR on the day of epistaxis, AST/ALT levels and whether transfusion was required or not among these patients with epistaxis. Results The average age of the patients was 42 ± 18.14 (range 14–90) years. Most of the patients (70.37%, 19/27) were male. Around half (48.15%) had some comorbidity. The most common comorbidity was HTN which was seen in 25.93% (n = 7) patients and 11.11% (n = 3) patients had DM. About 40% (n = 11) patients were on some drug prior to dengue infection for their comorbidity. The most common presenting complaint was fever seen in 85.19% patients (n = 23). In this study, 59.26% patients had epistaxis at presentation while 40.74% developed epistaxis during hospital stay. (Fig. 1 ) The mean duration of illness at the time of epistaxis was 5.59 ± 2.56 days (range 2–14 days). The most common time of epistaxis was around 3–7 days (Fig. 2 ). Two thirds of the patients had no bleeding from other site except epistaxis. Of the one third who had bleeding from other sites, oral mucosal bleed was the most common present in 22.22% (n = 6) and GI bleeding was seen in 4 patients (14.82%). Among those who had bleeding from other sites, most were males (88.89%). ( Figs. 1 and 2 ) The mean platelet count on the day of epistaxis was about 30000 (range 6000–110000). One patient had platelet more than 100,000 and on review the patient was a 14-year old child with lupus nephritis. She was not on antiplatelet agents or blood thinners. The mean hemoglobin (Hb) on the day of bleed was 13.77 ± 2.66 (range 9 -18.8 ) . The mean WBC count on the day of bleed was around 5000. ( Figs. 3 and 4 ) At the time of epistaxis, most patients had increasing trend in WBC counts (55.56%). The trend could not be ascertained in 8 patients. Of those whose trend of WBC counts could be ascertained, 15/19 (78.95%) had increasing WBC counts. At the time of epistaxis, most patients had decreasing trend of platelets (51.85% of total, 73.68% of those whose trend could be ascertained). ( Fig. 5 ) AST and ALT levels on the day of epistaxis were elevated with a mean AST of 424 ± 615 and mean ALT of 166 ± 160 U/L. Among 27 patients, 62.96% (n = 17) required transfusion. 2 patients required PRBC transfusion (1 patient required only PRBC while the other patient required Platelets and PRBC transfusion. The latter patient had esophageal ulcer and had presented with esophageal ulcer and melena. Among the 16 patients who needed platelet transfusion, the mean was 4.31 pints of PRP (range 2–8 pints). ( Table 1 ) Table 2 Based on transfusion required or not. Factor Level No Yes p-value Number 10 17 Age, mean (SD) 34.70 (16.63) 46.29 (18.06) 0.11 Sex F 5 (50%) 3 (18%) 0.075 M 5 (50%) 14 (82%) Duration of hospital stay, mean (SD) 6 (4.47) 5.18 (2.83) 0.56 Day of illness at time of epistaxis, mean (SD) 5.10 (1.91) 5.88 (2.89) 0.45 Platelet count on day of epistaxis, mean (SD) 45,800 (30,268.429) 22,176.47(13,163.56) 0.009 Hemoglobin on day of bleed, mean (SD) 12.3 (2.49) 14.63 (2.43) 0.025 WBC count on day of bleed, mean (SD) 4870 (2352.90) 5811.76 (2761.99) 0.38 Among the 9 patients who had bleeding from other sites, 89% required transfusion and only 11% did not require transfusion. Among those who did not require transfusion were patients who had bleeding from gastrointestinal tract (melena, n = 1) and urinary tract (hematuria, n = 1). The majority of individuals who experienced bleeding from other sites were male, accounting for 88.89%. ( Table 1 ) ( Table 2 ) Table 1 Gender predominance on bleeding from other sites Other bleed Sex Total F M None 7 11 18 Yes 1 8 9 Total 8 19 27 Mean duration of hospital stay was 5.48 ± 3.47 days (range 2–14 days). There was no mortality in these patients. Discussion This is a hospital-based case series study. We evaluated 27 patients presenting with dengue fever disease from Sept 2022 to Nov 2024, in whom NS1 was positive and simultaneously had epistaxis. These patients were admitted and treated at our tertiary center. The age distribution of the study sample (N = 27) ranges from 14 to 90 years (mean = 42.0), indicating a wide age diversity among participants. These findings highlight that the sample is primarily composed of adults, though the presence of both younger (minimum = 14) and older individuals (maximum = 90) suggests diversity in age. Out of 27 patients 70.4% (n = 19) were male and 29.6% (n = 8) were female. In our study epistaxis occurred from 2nd to 14th day of illness with a mean of 5.6 days (SD = 2.56). Half of the patients experienced epistaxis by day 5, and 75% by day 7, suggesting a tendency for epistaxis to occur within the first week of illness. Dengue fever passes through 3 stages: the febrile stage lasting 2 to 7 days, the critical or leakage stage which spans 24 to 48 hours and the recovery phase that takes 2 to 7 days.( 9 ) A study in India indicated that the hemorrhagic diathesis was a common complication of dengue fever and usually occurred toward the end of the febrile period, when the symptoms of classic dengue fever resolve. The study also found that bleeding was usually mild and manifests itself as epistaxis, gum bleeding, hematuria, and menorrhagia.( 10 ) Out of 27 participants, 9 (33.3%) reported other types of bleeding in addition to epistaxis which included mucosal bleed, gingival bleed, melena, hematemesis, hemoptysis and hematuria. Prior studies done in India have reported bleeding in the form of purpura, petechiae, ecchymoses, gastrointestinal and retroperitoneal hemorrhage, rectus sheath hematoma, and mild to moderate bleeding from the skin, gums, nose, urinary tract, gastrointestinal tract, lungs, and uterus in dengue patients. ( 10 – 14 ) On the day of epistaxis, platelet count ranged from 6,000 to 110,000/µL, with a mean of about 30,000/µL indicating substantial variability. The median platelet count was 25,000/µL while two-third of the patients had platelets below 39,000 /µL indicating the predominance of moderate to severe thrombocytopenia. These findings highlight that most patients experienced epistaxis at relatively low platelet levels, supporting the role of thrombocytopenia in bleeding risk during illness. Despite platelet count of 110,000, one of our patient had epistaxis, which may be attributed to underlying vascular fragility or immune mediated coagulopathy associated with her history of systemic lupus nephritis. Platelet count ranged from 12,000 to 150,000 with mean of 30,760/µL in a clinical study conducted in India which is quite similar to our findings.( 10 ) The dengue virus has been isolated from various types of white blood cells, including polymorphonuclear leukocytes, monocyte/macrophages, and dendritic cells. It has also been detected in megakaryocyte progenitors cells and circulating platelets that are present in the bloodstream. This reflects that dengue virus may cause a decrease in platelet count by directly interacting with megakaryocytes and platelets. Therefore, it is likely that two processes contribute to the development of thrombocytopenia in dengue patients: Impaired production of platelets and destruction of platelets in the peripheral regions.( 15 , 16 ) Possible mechanism of low platelets counts in dengue are: disruption of platelet production in the bone marrow by the virus and acceleration of their destruction through activation and apoptosis. This delicate imbalance between reduced production and increased clearance reflects the body’s struggle against the infection.( 17 ) Among the 27 patients 51.85% (14 patients) had a decreasing platelet trend, suggesting a possible link between falling platelet levels and the occurrence of epistaxis. 18.52% (5 patients) showed an increasing trend, possibly indicating early phase of recovery or a late-stage response. For 29.63% (8 patients), data on platelet trend was not available, limiting complete analysis. Our study found that most patients experienced a moderate level of thrombocytopenia, consistent with results from earlier research. Among the 17 patients involved in a study, all (100%) presented with epistaxis. Additionally, the study noted that a large number of patients showed signs of cutaneous bleeding, primarily in the form of rashes or petechiae. ( 10 ) Hemoglobin levels on the day of bleeding ranged from 9.0 to 18.8 g/dL, with a mean of 13.77 g/dL. A retrospective descriptive study conducted in Brazil showed anemia in 45.0% of the cases, with lowest mean hemoglobin level of all patients who received any type of transfusion during hospitalization was 9.0 g/dL. ( 18 ) The WBC count on the day of epistaxis ranged from 1,600 to 14,700 cells/µL. The median was 4,900 cells/µL indicating that half of the patients had either low normal or low WBC counts. Out of 27 patients 55.56% (15 patients) showed an increasing WBC trend. The observed trend of rising WBC counts accompanied by a declining platelet count may point towards the nadir of platelet levels. This pattern aligns with the finding of Ananda Rao et al. , who noted that platelets recovery typically follows the resurgence of WBCs. ( 19 ) This inverse trend could signify the critical turning point – where platelets are at their lowest and poised to rebound. In 29.63% (8 patients), the trend data was not available which limits full interpretation. On the day of epistaxis, the mean AST level was 424.4 IU/L (22–2170) IU/L and the mean ALT level was 166.7 IU/L (23–714) IU/L. Similar levels of ALT and AST were reported among dengue patients who presented with epistaxis or bleeding manifestations in Brazil, where more than 80% showed transaminase alterations, with AST ranging from 140.7–478.7 IU/L and ALT from 105.6–229.7 IU/L. Evidence suggests a link between elevated levels of these parameters and increased mortality. Association of these laboratory findings with liver dysfunction and acquired coagulopathy reflects the importance of closely monitoring coagulation status and considering the use of fresh frozen plasma (FFP) transfusions when necessary.( 18 ) Among 17 patients, who needed transfusion, the amount of PRP transfused ranged from 2 units (minimum) to 8 units (maximum) with an average of 4.31 units and median of 4 units. Most patients (75%) received 5 units or less and 25% received 3 units or less. On average 3–5 units of PRP were required per patients depending upon clinical severity and institutional protocols. ( 20 – 22 ) A study reported that 10.6% of patients with dengue hemorrhagic fever required some form of transfusion. Among these, 6.9% received platelet concentrates, 5% were given fresh frozen plasma (FFP), and 3.1% received packed red blood cells. ( 9 ) Conclusion Our study observed that epistaxis most frequently occurred between the third and seventh day of illness, a period marked by declining platelets counts, rising white blood cells, and elevated ALT and AST levels. Strikingly, several patients exhibited bleeding from multiple sites in addition to epistaxis. These observations underscore the critical need for vigilant monitoring of dengue patients for hemorrhagic complications, particularly as the illness progress towards the end of the first week. When bleeding is detected at one site, heightened attention should be given to the possibility of hemorrhage at other locations, ensuring timely intervention and comprehensive patient care. Also, not all patients with epistaxis need platelet transfusion hence clinical monitoring is paramount. Abbreviations WBC Whole Blood Count AST Aspartate Transaminase ALT Alanine Transaminase WHO World Health Organization PT Prothrombin Time INR International Normalized ratio PRBC Packed Red Blood Cells DM Diabetes Mellitus GI Gastro-intestinal Declarations Ethical Approval and Consent to Participate: Ethical approval was obtained from Institutional Review Committee, Tribhuvan University, Teaching Hospital and conducted in accordance with the Declaration of Helsinki. Clinical Trail : Not Applicable Consent for Publication : Written informed consent was obtained from the patient for publication of this research. A copy of the written consent is available for review by the Editor of this journal. Availability of Data and Material: The datasets used during the study are available from corresponding author on reasonable request. Competing Interest: The author declares no competing interests. Funding : Not Applicable Authors Contributions: S.T.: Conception, Design of Work, Analysis, Revison B.B. and D.M.: Writing and Editing of Original Draft S.G. and S.J.: Supervision and Monitoring References Pierson TC, Kielian M. Flaviviruses: braking the entering. Curr Opin Virol. 2013;3(1):3–12. Wong JM, Adams LE, Durbin AP, Muñoz-Jordán JL, Poehling KA, Sánchez-González LM, et al. Dengue: A Growing Problem With New Interventions. Pediatrics. 2022;149(6):e2021055522. Witte P, Venturini S, Meyer H, Zeller A, Christ M. Dengue Fever—Diagnosis, Risk Stratification, and Treatment. Dtsch Arzteblatt Int. 2024;121(23):773–8. Bhandari S, Blackburn JK, Ryan SJ. Spatial Patterns of Dengue Incidence in Nepal During Record Outbreaks in 2022 and 2023: Implications for Public Health Interventions [Internet]. Public and Global Health; 2024 [cited 2025 Apr 12]. Available from: http://medrxiv.org/lookup/doi/ 10.1101/2024.11.06.24316870 Tuladhar R, Singh A, Varma A, Choudhary DK. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7003641","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":493977973,"identity":"3e7176e3-5e68-435c-9bfd-577b3b4c0e42","order_by":0,"name":"Sabin Thapaliya","email":"","orcid":"","institution":"Tribhuvan University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sabin","middleName":"","lastName":"Thapaliya","suffix":""},{"id":493977975,"identity":"b4f0ba72-9f89-4d6e-b108-ba20163ba016","order_by":1,"name":"Bishal 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15:10:25","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":359215,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eHistogram of platelet count on the day of epistaxis\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7003641/v1/a84f6925c645174a24ec9f15.jpg"},{"id":88193323,"identity":"240a4304-0708-4fc6-bd4d-214dcdc9c606","added_by":"auto","created_at":"2025-08-03 15:10:25","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":68517,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTrend of platelets and WBC at the time of epistaxis (n=19 each)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7003641/v1/a8ead4aa39c2dd65dd4fce3b.jpg"},{"id":88193542,"identity":"3090cde7-7b46-4491-ad5a-8f4954285cc6","added_by":"auto","created_at":"2025-08-03 15:18:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1791761,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7003641/v1/9245b9de-31ea-4418-957f-002431b22faf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Profile of dengue patients presenting with epistaxis at a tertiary hospital in Nepal","fulltext":[{"header":"Background","content":"\u003cp\u003eDengue virus (DENV) belongs to a group of enveloped viruses, Flaviruses which also includes West Nile virus and yellow fever virus, and involves arthropods as their vectors. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Dengue disease can be caused by 1 of 4 distinct but closely related dengue viruses and specifically are transmitted by mosquito of the genus Aedes (\u003cem\u003eAedes aegypti, Aedes albopticus\u003c/em\u003e). (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)The disease is now consistently present over 100 countries in the tropical and subtropical regions of Africa, South East Asia, the Eastern Mediterranean and Western Pacific and has more than 100\u0026nbsp;million symptomatic cases each year. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eNepal reported first Dengue case in 2004 in a traveler. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Originally limited to lowland areas if Terai region, it has expanded in recent years. Dengue has spread to higher altitudes and previously unaffected areas in Nepal, influenced by climate change and mosquito breeding patterns. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eCurrently clinical dengue is classified as dengue with or without warning signs and severe dengue (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Warning signs as mentioned in WHO classification (2009) includes abdominal pain and tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleed, lethargy, restlessness, liver enlargement\u0026thinsp;\u0026gt;\u0026thinsp;2cm and increase in hematocrit concurrent with rapid decrease in platelet count (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Common hemorrhagic manifestations in Dengue include petechiae, epistaxis, gum bleeding, gastrointestinal bleeding and hematuria (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e"},{"header":"Objective","content":"\u003cp\u003eIn this study, we report laboratory and clinical profiles of adult dengue patients with epistaxis from a tertiary health care facility in Kathmandu, Nepal.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe evaluated 27 patients who presented with dengue fever between September 2022 and November 2024, all of whom tested positive for dengue NS1 and simultaneously exhibited epistaxis. These patients were admitted and treated at our tertiary center.\u003c/p\u003e\u003cp\u003eWe analyzed gender predominance, prior comorbidities, previous medications, total hospital stay, other bleeding manifestations, platelet count and PT/INR on the day of epistaxis, AST/ALT levels and whether transfusion was required or not among these patients with epistaxis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe average age of the patients was 42\u0026thinsp;\u0026plusmn;\u0026thinsp;18.14 (range 14\u0026ndash;90) years. Most of the patients (70.37%, 19/27) were male. Around half (48.15%) had some comorbidity. The most common comorbidity was HTN which was seen in 25.93% (n\u0026thinsp;=\u0026thinsp;7) patients and 11.11% (n\u0026thinsp;=\u0026thinsp;3) patients had DM. About 40% (n\u0026thinsp;=\u0026thinsp;11) patients were on some drug prior to dengue infection for their comorbidity. The most common presenting complaint was fever seen in 85.19% patients (n\u0026thinsp;=\u0026thinsp;23).\u003c/p\u003e\u003cp\u003eIn this study, 59.26% patients had epistaxis at presentation while 40.74% developed epistaxis during hospital stay. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) The mean duration of illness at the time of epistaxis was 5.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.56 days (range 2\u0026ndash;14 days). The most common time of epistaxis was around 3\u0026ndash;7 days (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Two thirds of the patients had no bleeding from other site except epistaxis. Of the one third who had bleeding from other sites, oral mucosal bleed was the most common present in 22.22% (n\u0026thinsp;=\u0026thinsp;6) and GI bleeding was seen in 4 patients (14.82%). Among those who had bleeding from other sites, most were males (88.89%). \u003cem\u003e(\u003c/em\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean platelet count on the day of epistaxis was about 30000 (range 6000\u0026ndash;110000). One patient had platelet more than 100,000 and on review the patient was a 14-year old child with lupus nephritis. She was not on antiplatelet agents or blood thinners. The mean hemoglobin (Hb) on the day of bleed was 13.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.66 (range 9 -18.8\u003cem\u003e)\u003c/em\u003e. The mean WBC count on the day of bleed was around 5000. \u003cem\u003e(\u003c/em\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAt the time of epistaxis, most patients had increasing trend in WBC counts (55.56%). The trend could not be ascertained in 8 patients. Of those whose trend of WBC counts could be ascertained, 15/19 (78.95%) had increasing WBC counts. At the time of epistaxis, most patients had decreasing trend of platelets (51.85% of total, 73.68% of those whose trend could be ascertained). \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAST and ALT levels on the day of epistaxis were elevated with a mean AST of 424\u0026thinsp;\u0026plusmn;\u0026thinsp;615 and mean ALT of 166\u0026thinsp;\u0026plusmn;\u0026thinsp;160 U/L. Among 27 patients, 62.96% (n\u0026thinsp;=\u0026thinsp;17) required transfusion. 2 patients required PRBC transfusion (1 patient required only PRBC while the other patient required Platelets and PRBC transfusion. The latter patient had esophageal ulcer and had presented with esophageal ulcer and melena. Among the 16 patients who needed platelet transfusion, the mean was 4.31 pints of PRP (range 2\u0026ndash;8 pints). \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBased on transfusion required or not.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLevel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.70 (16.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.29 (18.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.075\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (82%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of hospital stay, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (4.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.18 (2.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDay of illness at time of epistaxis, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.10 (1.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.88 (2.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlatelet count on day of epistaxis, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45,800 (30,268.429)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22,176.47(13,163.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin on day of bleed, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.3 (2.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.63 (2.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWBC count on day of bleed, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4870 (2352.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5811.76 (2761.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong the 9 patients who had bleeding from other sites, 89% required transfusion and only 11% did not require transfusion. Among those who did not require transfusion were patients who had bleeding from gastrointestinal tract (melena, n\u0026thinsp;=\u0026thinsp;1) and urinary tract (hematuria, n\u0026thinsp;=\u0026thinsp;1). The majority of individuals who experienced bleeding from other sites were male, accounting for 88.89%. \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e) (\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGender predominance on bleeding from other sites\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther bleed\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMean duration of hospital stay was 5.48\u0026thinsp;\u0026plusmn;\u0026thinsp;3.47 days (range 2\u0026ndash;14 days). There was no mortality in these patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is a hospital-based case series study. We evaluated 27 patients presenting with dengue fever disease from Sept 2022 to Nov 2024, in whom NS1 was positive and simultaneously had epistaxis. These patients were admitted and treated at our tertiary center.\u003c/p\u003e\u003cp\u003eThe age distribution of the study sample (N\u0026thinsp;=\u0026thinsp;27) ranges from 14 to 90 years (mean\u0026thinsp;=\u0026thinsp;42.0), indicating a wide age diversity among participants. These findings highlight that the sample is primarily composed of adults, though the presence of both younger (minimum\u0026thinsp;=\u0026thinsp;14) and older individuals (maximum\u0026thinsp;=\u0026thinsp;90) suggests diversity in age. Out of 27 patients 70.4% (n\u0026thinsp;=\u0026thinsp;19) were male and 29.6% (n\u0026thinsp;=\u0026thinsp;8) were female.\u003c/p\u003e\u003cp\u003eIn our study epistaxis occurred from 2nd to 14th day of illness with a mean of 5.6 days (SD\u0026thinsp;=\u0026thinsp;2.56). Half of the patients experienced epistaxis by day 5, and 75% by day 7, suggesting a tendency for epistaxis to occur within the first week of illness. Dengue fever passes through 3 stages: the febrile stage lasting 2 to 7 days, the critical or leakage stage which spans 24 to 48 hours and the recovery phase that takes 2 to 7 days.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) A study in India indicated that the hemorrhagic diathesis was a common complication of dengue fever and usually occurred toward the end of the febrile period, when the symptoms of classic dengue fever resolve. The study also found that bleeding was usually mild and manifests itself as epistaxis, gum bleeding, hematuria, and menorrhagia.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eOut of 27 participants, 9 (33.3%) reported other types of bleeding in addition to epistaxis which included mucosal bleed, gingival bleed, melena, hematemesis, hemoptysis and hematuria.\u003c/p\u003e\u003cp\u003ePrior studies done in India have reported bleeding in the form of purpura, petechiae, ecchymoses, gastrointestinal and retroperitoneal hemorrhage, rectus sheath hematoma, and mild to moderate bleeding from the skin, gums, nose, urinary tract, gastrointestinal tract, lungs, and uterus in dengue patients. (\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eOn the day of epistaxis, platelet count ranged from 6,000 to 110,000/\u0026micro;L, with a mean of about 30,000/\u0026micro;L indicating substantial variability. The median platelet count was 25,000/\u0026micro;L while two-third of the patients had platelets below 39,000 /\u0026micro;L indicating the predominance of moderate to severe thrombocytopenia. These findings highlight that most patients experienced epistaxis at relatively low platelet levels, supporting the role of thrombocytopenia in bleeding risk during illness. Despite platelet count of 110,000, one of our patient had epistaxis, which may be attributed to underlying vascular fragility or immune mediated coagulopathy associated with her history of systemic lupus nephritis.\u003c/p\u003e\u003cp\u003ePlatelet count ranged from 12,000 to 150,000 with mean of 30,760/\u0026micro;L in a clinical study conducted in India which is quite similar to our findings.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) The dengue virus has been isolated from various types of white blood cells, including polymorphonuclear leukocytes, monocyte/macrophages, and dendritic cells. It has also been detected in megakaryocyte progenitors cells and circulating platelets that are present in the bloodstream. This reflects that dengue virus may cause a decrease in platelet count by directly interacting with megakaryocytes and platelets. Therefore, it is likely that two processes contribute to the development of thrombocytopenia in dengue patients: Impaired production of platelets and destruction of platelets in the peripheral regions.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Possible mechanism of low platelets counts in dengue are: disruption of platelet production in the bone marrow by the virus and acceleration of their destruction through activation and apoptosis. This delicate imbalance between reduced production and increased clearance reflects the body\u0026rsquo;s struggle against the infection.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAmong the 27 patients 51.85% (14 patients) had a decreasing platelet trend, suggesting a possible link between falling platelet levels and the occurrence of epistaxis. 18.52% (5 patients) showed an increasing trend, possibly indicating early phase of recovery or a late-stage response. For 29.63% (8 patients), data on platelet trend was not available, limiting complete analysis. Our study found that most patients experienced a moderate level of thrombocytopenia, consistent with results from earlier research. Among the 17 patients involved in a study, all (100%) presented with epistaxis. Additionally, the study noted that a large number of patients showed signs of cutaneous bleeding, primarily in the form of rashes or petechiae. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eHemoglobin levels on the day of bleeding ranged from 9.0 to 18.8 g/dL, with a mean of 13.77 g/dL. A retrospective descriptive study conducted in Brazil showed anemia in 45.0% of the cases, with lowest mean hemoglobin level of all patients who received any type of transfusion during hospitalization was 9.0 g/dL. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe WBC count on the day of epistaxis ranged from 1,600 to 14,700 cells/\u0026micro;L. The median was 4,900 cells/\u0026micro;L indicating that half of the patients had either low normal or low WBC counts. Out of 27 patients 55.56% (15 patients) showed an increasing WBC trend. The observed trend of rising WBC counts accompanied by a declining platelet count may point towards the nadir of platelet levels. This pattern aligns with the finding of \u003cem\u003eAnanda Rao et al.\u003c/em\u003e, who noted that platelets recovery typically follows the resurgence of WBCs. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) This inverse trend could signify the critical turning point \u0026ndash; where platelets are at their lowest and poised to rebound. In 29.63% (8 patients), the trend data was not available which limits full interpretation.\u003c/p\u003e\u003cp\u003eOn the day of epistaxis, the mean AST level was 424.4 IU/L (22\u0026ndash;2170) IU/L and the mean ALT level was 166.7 IU/L (23\u0026ndash;714) IU/L. Similar levels of ALT and AST were reported among dengue patients who presented with epistaxis or bleeding manifestations in Brazil, where more than 80% showed transaminase alterations, with AST ranging from 140.7\u0026ndash;478.7 IU/L and ALT from 105.6\u0026ndash;229.7 IU/L. Evidence suggests a link between elevated levels of these parameters and increased mortality. Association of these laboratory findings with liver dysfunction and acquired coagulopathy reflects the importance of closely monitoring coagulation status and considering the use of fresh frozen plasma (FFP) transfusions when necessary.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAmong 17 patients, who needed transfusion, the amount of PRP transfused ranged from 2 units (minimum) to 8 units (maximum) with an average of 4.31 units and median of 4 units. Most patients (75%) received 5 units or less and 25% received 3 units or less. On average 3\u0026ndash;5 units of PRP were required per patients depending upon clinical severity and institutional protocols. (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) A study reported that 10.6% of patients with dengue hemorrhagic fever required some form of transfusion. Among these, 6.9% received platelet concentrates, 5% were given fresh frozen plasma (FFP), and 3.1% received packed red blood cells. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study observed that epistaxis most frequently occurred between the third and seventh day of illness, a period marked by declining platelets counts, rising white blood cells, and elevated ALT and AST levels. Strikingly, several patients exhibited bleeding from multiple sites in addition to epistaxis. These observations underscore the critical need for vigilant monitoring of dengue patients for hemorrhagic complications, particularly as the illness progress towards the end of the first week. When bleeding is detected at one site, heightened attention should be given to the possibility of hemorrhage at other locations, ensuring timely intervention and comprehensive patient care. Also, not all patients with epistaxis need platelet transfusion hence clinical monitoring is paramount.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWhole Blood Count\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAspartate Transaminase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlanine Transaminase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProthrombin Time\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eINR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Normalized ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePacked Red Blood Cells\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiabetes Mellitus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGastro-intestinal\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate:\u003c/strong\u003e Ethical approval was obtained from Institutional Review Committee, Tribhuvan University, Teaching Hospital and\u0026nbsp;conducted in accordance with the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trail\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e: Written informed consent was obtained from the patient for publication of this research. A copy of the written consent is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material:\u003c/strong\u003e The datasets used during the study are available from corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest:\u003c/strong\u003e The author declares no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.T.: \u0026nbsp;Conception, Design of Work, Analysis, Revison\u003c/p\u003e\n\u003cp\u003eB.B. and D.M.: Writing and Editing of Original Draft\u003c/p\u003e\n\u003cp\u003eS.G. and S.J.: Supervision and Monitoring\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePierson TC, Kielian M. Flaviviruses: braking the entering. 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Assessment of the importance of platelet transfusion in patients with severe dengue: a systematic review. Assess Importance Platelet Transfus Patients Sev Dengue Syst Rev [Internet]. 2024 Mar 7 [cited 2025 Jun 25];6(2):69\u0026ndash;77. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.iberoamericanjm.periodikos.com.br/article/doi/\u003c/span\u003e\u003cspan address=\"http://www.iberoamericanjm.periodikos.com.br/article/doi/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.53986/ibjm.2024.0010\u003c/span\u003e\u003cspan address=\"10.53986/ibjm.2024.0010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePailoor K. Hepatology [Internet]. [cited 2025 Apr 22]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.lww.com/hep/abstract/2023/04000/global_burden_of_liver_cancer_in_males_and.14.aspx\u003c/span\u003e\u003cspan address=\"https://journals.lww.com/hep/abstract/2023/04000/global_burden_of_liver_cancer_in_males_and.14.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dengue Fever, Epistaxis, Warning signs, Nepal","lastPublishedDoi":"10.21203/rs.3.rs-7003641/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7003641/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDengue fever can present with hemorrhagic manifestations such as epistaxis. Despite its clinical significance, the specific profile and outcome of dengue patients presenting with epistaxis remains unexplored in Nepal. We conducted record-based retrospective study to analyze demographic and clinical profile of dengue cases with epistaxis admitted to Tribhuvan University, Teaching Hospital, Kathmandu, Nepal, between 1st September 2022 to 30th November 2024.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA record-based retrospective study was conducted among patients with dengue fever (NS1 positive with symptoms) and concurrent epistaxis, admitted to our tertiary care center. The collected data encompassed patient demographics, underlying comorbidities, prior medication history, duration of hospital stay, additional bleeding manifestations, platelet count, WBC count, PT/INR, and AST/ALT. The requirement for blood or platelet transfusion was also assessed.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eA total of 27 patients with dengue fever and epistaxis were evaluated. The mean age was 42 years and majority (70.37%) were male. Epistaxis was the initial presentation among 59.26% patients while 40.74% developed it during hospitalization. Epistaxis typically occurred around day 4\u0026ndash;7 of illness. At the time of epistaxis, the mean WBC count was 5462.96/\u0026micro;L (range 1,600\u0026thinsp;\u0026minus;\u0026thinsp;14,700/\u0026micro;L) and mean platelets count was around 30,000 /\u0026micro;L. Decreasing trend of WBC counts and increasing trend of platelet counts was seen in majority of patients. AST and ALT were elevated (mean AST 424 U/L, ALT: 166 U/L). One third patients experienced additional bleeding, most commonly from oral mucosal followed by GI bleeding. Overall, 62.96% required transfusion and the mean platelet transfusion was about 4 pints. Among those with bleeding from other sites, 89% required transfusion, highlighting the increased severity in this subgroup.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eEpistaxis in dengue patients most commonly occurred between days 3\u0026ndash;7 of illness, coinciding with thrombocytopenia, rising WBCs, and elevated liver enzymes. Vigilant clinical monitoring is crucial, as not all case required transfusion, but may signal risk of multisite bleeding.\u003c/p\u003e","manuscriptTitle":"Clinical Profile of dengue patients presenting with epistaxis at a tertiary hospital in Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-03 15:10:20","doi":"10.21203/rs.3.rs-7003641/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-14T19:41:30+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"115278107995682291283202513678944284661","date":"2025-07-31T19:33:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-31T07:32:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-30T08:03:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186553218940702215165852365078650992736","date":"2025-07-30T02:09:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104689674818481627921028395757451413204","date":"2025-07-30T00:49:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103718196326264371005281859919713010184","date":"2025-07-29T11:14:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-29T09:35:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-04T19:26:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-02T23:39:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-02T23:39:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-06-29T15:28:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c76a1ca6-364d-48a7-a91d-ec178cc0a88d","owner":[],"postedDate":"August 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T09:56:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-03 15:10:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7003641","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7003641","identity":"rs-7003641","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}