To the Editors:
A retrospective study was conducted in 328 adolescents (158 females, 170 males) with serologic confirmation of dengue infection. Adolescents account for almost half of the total patients with dengue fever and dengue hemorrhagic fever (DHF).1 The mean ages of female and male adolescents were similar at 12.6 ± 1.6 years. The bleeding manifestations among adolescents with dengue fever and DHF were similar except for gastrointestinal and vaginal bleeding which were significantly more commonly found in DHF patients with P-values of 0.004 and 0.012, respectively. A pictorial blood loss assessment chart (PBAC) score2 was used for estimating the amount of menstrual bleeding. Each sanitary pad was graded to be lightly, moderate, or heavily soiled equal to the scores of 1, 5, and 20 points, respectively. A blood clot on the pad was allocated an additional scored of 5 points. Hypermenorrhea is defined as the total score in the cycle of ≥100 points which is equal to blood loss of 80 mL. Vaginal bleeding occurred in 45 of 158 female adolescents (29%); 42 patients mainly with DHF were defined as having excessive menstrual bleeding while 2 patients with DHF were defined as having mild ovulation bleeding and 1 patient with DHF had incomplete data. Patients with excessive menstruation bleeding were divided into 2 groups according to the duration of menstruation before hospitalization. Group 1 included 34 patients with the ongoing menstruation bleeding requiring hormonal therapy and group 2 included 8 patients with near cessation of menstruation at the time of hospitalization and not requiring hormonal therapy. Group 1 had a shorter pretreatment (prehospitalization) duration of menstruation of 2 days than that of group 2, 4 days (P = 0.01). Also, the median pretreatment PBAC score of group 1 (62.5, interquartile range 32.5–108.8) was half that of group 2 (136.0, interquartile range 46.3–317.5). Hormonal therapy including premarin, primulute N, or oral contraceptive pills3 were given to 34 patients in group 1. The efficacy of medication in controlling excessive menstruation was effective, partially effective and ineffective in 10, 22, and 2 patients, respectively. Also, the median pretreatment PBAC score in group 1 was significantly higher than that of post-treatment (11.5, interquartile range 6.0–34.3) with a P-value of 0.001. Finally, the median total PBAC score in group 1 (83.5, interquartile range 46.8–127.0) tended to be lower than that of group 2 (141.0, interquartile range 81.5–333.8) with a P-value of 0.051.
In conclusion, excessive menstrual bleeding and hypermenorrhea were not uncommon manifestations in female adolescents with DHF similar to the adult patients.4,5 Early hormonal therapy is suggested in females exhibiting excessive menstrual bleeding with PBAC scores approaching 30. The occurrence of bleeding has obscured the status of hemoconcentration (an increased in hematocrit of ≥20%), one of the clinical diagnostic criteria according to World Health Organization. These patients not only had no hemoconcentration but also had a further decrease in hematocrits. Therefore, the medical personnel should be aware of and alert to this serious condition since appropriate and prompt treatment will lead to a favorable outcome.
Kanchana Tangnararatchakit, MD
Ampaiwan Chuansumrit, MD
Department of Pediatrics Ramathibodi Hospital Bangkok, Thailand
Wathanee Chaiyaratana, MSc
Research Center Ramathibodi Hospital Bangkok, Thailand
Sarapee Lertwongrath, BSc
Narumol Gajaseeni, MNS
Rungnapa Udomchaisakul, BNS
Department of Nursing Ramathibodi Hospital Bangkok, Thailand
Pratak O-Prasertsawat, MD
Department of Obstetrics and Gynecology Ramathibodi Hospital Bangkok, Thailand
Sutee Yoksan, MD, PhD
Center of Vaccine Developmental Institute of Science and Technology for Research and Development Mahidol University, Bangkok, Thailand
Disclosure: A grant from the Thailand Research Fund-Senior Research Scholar 2006 was awarded to A.C.
1. World Health Organization. Dengue Hemorrhagic Fever: Diagnosis, Treatment, Prevention and Control
. 2th ed, chap 2. Geneva: WHO; 1997:12–23.
2. Higham JM, O'Brien PM, Shaw RW. Assessment of menstrual blood loss using a pictorial chart. Br J Obstet Gynaecol
3. Oehler MK, Rees MC. Menorrhagia: an update. Acta Obstet Gynecol Scand
4. Gonzalez D, Castro OE, Kouri G, et al. Classical dengue hemorrhagic fever resulting from two dengue infections spaced 20 years or more apart: Havana, Dengue 3 epidemic, 2001–2002. Int J Infect Dis
5. Lee MS, Hwang KP, Chen TC, et al. Clinical characteristics of dengue and dengue hemorrhagic fever in a medical center of Southern Taiwan during the 2002 epidemic. J Microbiol Immunol Infect