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All Journal Archives of The Medicine and Case Reports Sriwijaya Journal of Internal Medicine
I Gusti Ayu Wiradari Tedja
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Biochemistry, Genetics & Molecular Biology Health Professions Immunology & microbiology Medicine & Pharmacology Nursing Public Health

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The Diagnostic Utility of Low Neutrophil-to-Lymphocyte Ratio (NLR) as an Indicator of Severity in Adult Dengue Hemorrhagic Fever: A Retrospective Study from Bali Ayu Sandra Manikasari; I Gusti Ayu Wiradari Tedja; Made Ayu Vita Prianggandanni
Archives of The Medicine and Case Reports Vol. 7 No. 1 (2026): Archives of The Medicine and Case Reports
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/amcr.v7i1.839

Abstract

Dengue hemorrhagic fever (DHF) remains a critical public health challenge in tropical regions. Unlike bacterial sepsis, where a high neutrophil-to-lymphocyte ratio (NLR) typically indicates severity, viral kinetics in dengue often present differently due to bone marrow suppression. This study evaluates the association between low NLR and disease severity in an adult cohort in Indonesia, aiming to identify a cost-effective marker for risk stratification. A retrospective cross-sectional study was conducted at Wangaya Regional General Hospital, Denpasar, Indonesia, from January to August 2025. We analyzed 92 confirmed adult DHF patients aged 18 years and older. Severity was graded using standard World Health Organization criteria (Grades 1–4). For the purpose of diagnostic performance analysis, severe DHF was defined as Grade 2 (spontaneous bleeding) and Grade 3 (circulatory failure) combined. The correlation between NLR and severity was analyzed using the Spearman rank test. Receiver Operating Characteristic (ROC) analysis determined the optimal cut-off for identifying severe cases. The cohort was predominantly young adults (18–25 years; 47.8%) with a male preponderance (68.5%). The severity distribution included Grade 1 (n=68; 73.9%), Grade 2 (n=21; 22.8%), and Grade 3 (n=3; 3.3%). A significant, moderate inverse correlation was observed between NLR and severity grade (r = -0.347; p < 0.001). Mean NLR decreased progressively from Grade 1 (2.90) to Grade 2 (1.20) and Grade 3 (0.65). ROC analysis for detecting Grade 2 or higher DHF showed an Area Under the Curve (AUC) of 0.82 (95% CI: 0.75–0.89). An NLR cut-off of less than 0.85 yielded a sensitivity of 87.5% and specificity of 72.0%. In conclusion, a low NLR is significantly associated with higher clinical severity in adult DHF. Unlike bacterial infections, a declining NLR below 0.85 serves as a potential marker for identifying patients at risk of bleeding and circulatory compromise in resource-limited settings.
Cold Agglutinin Disease Presenting with Acute Encephalopathy in an Elderly Patient with Multiple Comorbidities: A Case Report and Laboratory Diagnostic Perspective Desak Agung Indah Praharsini Dewi; I Gusti Ayu Wiradari Tedja; Made Ayu Vita Prianggandanni
Sriwijaya Journal of Internal Medicine Vol. 3 No. 2 (2026): Sriwijaya Journal of Internal Medicine
Publisher : Phlox Institute: Indonesian Medical Research Organization

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59345/sjim.v3i2.246

Abstract

Introduction: Cold agglutinin disease (CAD) is a rare form of autoimmune hemolytic anemia caused by monoclonal immunoglobulin M autoantibodies that bind to red blood cells at temperatures below 37 degrees Celsius. CAD typically manifests with chronic hemolytic anemia in elderly patients, but presentations with acute, severe complications remain infrequent. Case presentation: We report a 70-year-old male patient who presented with acute decreased consciousness lasting 2 hours, preceded by one week of cough and fever. Initial clinical evaluation suggested sepsis-associated encephalopathy. However, a comprehensive laboratory investigation, including peripheral blood smear and direct Coombs test, revealed CAD as the underlying diagnosis. Critical laboratory finding was marked mean corpuscular hemoglobin concentration elevation to 43 g/dL, exceeding physiologic maximum and indicating erythrocyte agglutination interference. Positive Coombs test with immunoglobulin G sensitization and positive cold agglutinin titer confirmed the diagnosis. The patient had significant comorbidities, including chronic kidney disease Stage V, type 2 diabetes mellitus, and heart failure with coronary artery disease. The patient subsequently underwent supportive care with cooling precautions, and clinical improvement was noted. Conclusion: This case exemplifies how careful attention to laboratory pattern recognition, particularly supraphysiologic mean corpuscular hemoglobin concentration values, can facilitate the diagnosis of CAD in elderly patients presenting with acute multisystem complications. The role of clinical pathology in the diagnostic identification of rare hematologic disorders deserves emphasis in medical education and clinical practice.
Co-Authors Ayu Sandra Manikasari Desak Agung Indah Praharsini Dewi Made Ayu Vita Prianggandanni