To the Editors:
Dengue virus is a major public health concern across the globe. The re-emergence of dengue virus resulted in increased morbidity and mortality.1 The dengue epidemics in Central America affect the pediatric population predominantly and incur overwhelming public health expenses.2 Mortality resulting from circulatory collapse and shock caused by severe dengue can be high if intravenous fluid resuscitation is delayed.3 Easily measured clinical indicators of the progression toward shock early in the course are not well defined.3,4
This case series from Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador, during the 2002 dengue epidemic describes the clinical profile of children admitted with severe dengue. Children aged between 6 months and 12 years diagnosed with severe dengue according to World Health Organization guidelines5 and with either positive dengue IgM antibodies or positive viral culture were included. We compared axillary temperature, platelet count, and hematocrit from the day prior to shock versus the day of shock but before the occurrence of clinical shock. We also reviewed recorded gastrointestinal symptoms and results from radiologic reports.
Of the 214 cases of dengue with positive dengue IgM antibodies, 72 cases were severe. Thirty (38%) of the 72 cases were in shock at admission. Median age was 72 months (range: 6–132 months). Both genders were affected equally (53% female vs. 47% of male, P = 0.29). Shock occurred on day 5 ± 1.4 (range: 1–9 days). Shock also resolved on the fifth day of disease.
Median platelet count on the day prior to shock was 70,000/mm3 (range: 10,000–300,000/mm3). The median platelet count was 47,000/mm3 on the day shock occurred (range: 10,000–125,000/mm3) (P = 0.01). Median hematocrit on the day prior to shock was 40% (range: 29%–63%) and 38% for the day shock occurred (range: 26%–66%). Mean nadir for the axillary temperature on the day prior to shock was of 37.2°C versus 36.6°C on the day shock occurred (P = 0.001). Hemoconcentration was 10% to 20% above the baseline value for age.
Abdominal pain developed 3.9 ± 0.2 days following fever in 64 (82%) of patients. Vomiting appeared 2.9 ± 0.3 days following fever in 26 (33%) patients. Sixty-four (92%) of 70 patients with abdominal ultrasound examinations had evidence of serositis as defined by pleural effusion (56), perivesicular edema (53), and/or ascites (52). Serositis was diagnosed 5.0 ± 0.2 days following fever. Abdominal pain was associated with progression to serositis (PPV 90%) and shock (PPV 82%). Emesis was less strongly associated with progression to shock (PPV 33%).
The sharp decrease in platelets could serve as an indicator for impending shock. Initiation of intravenous fluid therapy upon recognition of plunging platelet counts prior to clinical evidence of circulatory collapse might improve outcomes. Close monitoring for the resolution of fever might be a useful indicator of impending circulatory compromise and trigger early intervention. Abdominal pain and emesis were predictive of impending circulatory collapse.
Our patients demonstrated a much smaller degree of hemoconcentration (10%–20%) than expected by the current definitions.5 Other authors have suggested that it may be useful to revise the current cutoff because this could result in delayed diagnosis of severe dengue and delay intervention.6
Gabriela Maria Marón, MD
Hospital Nacional de Niños Benjamin Bloom Department of Infectious Diseases St. Jude Children's Research Hospital email@example.com
Gustavo Adolfo Escobar, MD
Emilia Maria Hidalgo, MD
Alexey Wilfrido Clara, MD
Hospital Nacional de Niños Benjamin Bloom
Timothy Dean Minniear, MD
Department of Infectious Diseases St. Jude Children's Research Hospital Memphis, TN
Eric Martinez, MD
Instituto de Medicina Tropical Pedro Kouri La Habana, Cuba
Ernesto Benjamin Pleites, MD
Hospital Nacional de Niños Benjamin Bloom San Salvador, El Salvador
1. Gubler DJ, Trent DW. Emergence of epidemic dengue/dengue hemorrhagic fever as a public health problem in the Americas. Infect Agents Dis
2. Harris E, Videa E, Perez L, et al. Clinical epidemiologic and virologic features of dengue in the 1998 epidemic in Nicaragua. Am J Trop Med Hyg
3. Almas A, Parkash O, Akhter J. Clinical factors associated with mortality in dengue infection at a tertiary care center. Southeast Asian J Trop Med Public Health
4. Tantracheewathorn T, Trantracheewathorn S. Risk factors of dengue shock syndrome in children. J Med Assoc Thai
5. World Health Organization and the Special Programme for Research and Training in Tropical Diseases. Dengue: diagnosis, treatment, prevention and control. Publications of the World Health Organization; 2009.
6. Kalayanarooj S, Vaughn DW, Nimmannitya S, et al. Early clinical and laboratory indicators of acute dengue illness. J Infect Dis