Controversy of Corticosteroid Application in Dengue Hemorrhagic Fever Is In Reality Controversy of Pathogenesis and Pathophysiology of Dengue Infection
Controversy of Corticosteroid Application in Dengue Hemorrhagic Fever Is In Reality Controversy of Pathogenesis and Pathophysiology of Dengue Infection
Taufiq Muhibbuddin Waly / Oral Presentation
Internal Medicine Departement Waled General Hospital, Cirebon, West Java, Indonesia
Abstract
Corticosteroid isn’t advised to be used in Dengue infection case. This policy is in the same direction with WHO guidance and supported by research of corticosteroid application in DHF cases for the last 40 years. Shock, severe thrombocytopenia, platelet rate, hematocrit rate, ascites, bleeding and incidences of ICU submittance weren’t really make any meaningful differences between patients who were given corticosteroid and those who weren’t.
The problem is the type of corticosteroids which have been said as failure all of them are grouped as weak type corticosteroid (hydrocortisone). Oxford faculty of medicine in collaboration with Ho Chi Minh faculty of medicine was in fact really used methylprednisolone in their research. But immunosuppressive dose of methylprednisolone used was only 60 mg, or in Shasidara et all, that gave dexamethasone injection 20 mg/day or the same as 106 mg methylprednisolone injection. Range of immunosuppressive dose of corticosteroid is really wide. For example, methylprednisolone can give immunosuppressive effect starting from 0,5 mg/kgbw/day. But in lupus nephritis case or shock methylprednisolone can be given all the way until 1000 mg/day or 30mg/kgbw/day. Application of corticosteroid in big dose is considered as safe based on literature if the maximum day of application is ≤ 7 day. In corticosteroid researches above which resulted in failure most of corticosteroids were given when severe clinical symptoms had appeared, such as shock and sepsis or given when the disease or fever had been ongoing for > 4 days (recovering phase). In those study above there were not any data related to phenomenons of rapid increase and decrease of platelet, as a sign of success. So is the rate of increase in platelet count to be 100.000/mm3.
Possibility of corticosteroid can give meaningful effect if we brave enough to give corticosteroid in big immunosuppressive dose for example methylprednisolone injection of 125 mg-250 mg/day (2,5-5mg/kgbw/day). And should be given before 4th day of disease or fever and before any signs of shock or sepsis appeared. Because the goal of the corticosteroid research is to prevent death, that comes from reduction in shock, sepsis and severe bleeding. So we can compare clinical symptoms that appeared, which shows tendency to become more severe? The one given corticosteroid or control group. The problem is, are we brave enough to do that kind of research? Because most of us believe that the cause of severity in Dengue infection is viremia as stated in Halstead theory. As a result we are afraid to give corticosteroid from stronger group and bigger immunosuppressive dose can cause increased severity or even death for patient in the said research. We can only be brave enough to do that kind of research if we still give possibility and validation for T.MUDWAL theory (www. Again Let’s Discuss About DHF Pathogenesis and Pathophysiology). Theory which states that the basic of pathogenesis and pathophysiology of Dengue infection depends on the sensitivity of the individual (hypersensitivity type III reaction/immune complex reaction). If the application of strong group corticosteroid with immunosuppressive dose will results in a success, then further consequences from hypersensitivity type III theory which is prolonged autoimmune reactions such as ITP, aplastic anemia, rheumatoid arthritis, autoimmune hepatitis, SLE, etc can be prevented (www. Can Dengue virus infection Provoke The Occurrence of Fulminant Autoimun Hepatitis and SLE)
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