The Role of Neutrophil to Lymphocyte Ratio in Dengue Hemorrhagic Fever and Dengue Shock Syndrome: A Narrative Systematic Review
Keywords:
Biomarkers (MeSH), Blood Cell Count (MeSH), Disease Progression (MeSH), Hemorrhage (MeSH), Humans (MeSH), Immunity (MeSH), Lymphocytes (MeSH), Neutrophils (MeSH), Prognosis (MeSH), Risk Asessment (MeSH), Severe Dengue (MeSH)Abstract
This systematic review aimed to evaluate the diagnostic and prognostic utility of the neutrophil-to-lymphocyte ratio (NLR) in distinguishing disease severity among patients with dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). The review emphasizes the biomarker’s role in early detection and risk stratification. Literature searches were conducted in PubMed, Scopus, ScienceDirect, Cochrane Library, and manual searching from inception to May 2025. Only articles published in English and involving human subjects were considered. Studies were included if they reported NLR values among patients with DHF or DSS and assessed the relationship between NLR and clinical severity. The initial database search yielded 1.794 records. After removing duplicates and screening titles, abstracts, and full texts, 15 eligible studies were selected. Quality appraisal was performed using the Joanna Briggs Institute (JBI) and Newcastle–Ottawa Scale (NOS) checklists. Two independent reviewers extracted data on study design, sample size, NLR measurement, severity classification, and key statistical outcomes. Disagreements were resolved by consensus. The majority of studies reported a significant association between higher NLR and increased dengue severity, particularly in patients with DSS. However, there was notable heterogeneity in cut-off values, timing of NLR measurement, and reference standards used. A few studies suggested that lower NLR may occur at critical or late stages. NLR demonstrates potential as a simple, cost-effective biomarker for identifying severe dengue, including DHF and DSS. Nonetheless, variation in methodologies and inconsistent cut-offs limit its generalizability. Further standardized, prospective studies are warranted to establish its diagnostic thresholds and timing of use.
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