Clinical profile and outcome of dengue fever cases
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《美国医学杂志》
1 Department of Pediatrics, Karnataka Institute of Medical Sciences, Hubli, India
2 PICU, Hubli Children Hospital, Hubli, India
3 National Institute of Virology, Field Station, Bangalore, Karnataka, India
Abstract
Dengue fever is on rise globally. In India, Dengue epidemics are expanding geographically, even into the rural areas. Dengue can present with varied manifestations. The mortality rate has been brought down with high index of suspicion, strict monitoring and proper fluid resuscitation. Herewith, we are presenting clinical features and outcome of Dengue cases seen in and around Hubli (North Karnataka).
Keywords: Dengue fever; Clinical features; Out come
Over the past two decades there has been dramatic global increase in Dengue fever , (DF) Dengue haemorrhagic fever, and Dengue shock syndrome and their epidemics.[1], [2] The number of cases in SE-Asia increased in the last 3-5 years.[3] In India, there is increased proportion of Dengue cases with severe disease. The dengue epidemics in India are cyclical and are more frequent, expanding geographically into the rural areas and all forms of serotypes are circulating in the community.[4] The identification of dengue cases is by distinct clinical features but they can present with varied manifestations.[5] Dengue remains a puzzling disease in many aspects, such as the virus-vector and host-virus relationship, and clinical expression variability. The present study was undertaken to evaluate the clinical features and outcome of serologically confirmed dengue cases at Hubli (N. Karnataka).
A retrospective review of hospital case papers of dengue patients, who were admitted to pediatric ward, K.I.M.S-Hubli and PICU, Hubli children hospital, Hubli between July 2003 to June 2004 (one year) was carried out. Only confirmed Dengue cases by serological study from National Institute of Virology, ICMR, Field station, Bangalore were included. Serological study was carried out using Mac 0 ELISA technique for different serotypes. Clinical, laboratory and outcome of these children were taken for analysis.
Total number of confirmed dengue cases was 23 and all of them were positive to serotype 2 viruses (DEN2). Eight (35%) of these were infants. There was no difference in male to female ratio (11:12) although severity was more noticed in females. By WHO Classification, dengue fever was present in04 (18%) cases, DHF in 14(60%) and DSS in 05 (22%) cases. The common clinical features noted in order of frequency were fever (100%), vomiting (82%), pain abdomen (61%), restlessness(65%), headache (22%), and hepatomegaly (87%). The common bleeding manifestations were G I bleeding (22%) and petechiae (18%). table1 shows the unusual presentation in the present series. The mean duration of fever prior to admission was 5.47 days (2-12 days). Palmo-Planter exfoliation in three cases during defervescence period was noticed.
Among the laboratory investigations, the haematocrit, platelet counts and leukocyte count was sent for all children. Leucopenia (<5000/cumm) was present in 06 (26%), thrombocytopenia (<1lakh/cumm) in 19 (82%) and mean Hct value for Dengue fever, DHF and DSS were 31.5%, 30.75% and 30.4% respectively at the time of admission. Among the imaging studies, chest-X-ray was taken for all children. Pleural effusion was present in 16 (70%) cases and more so, on right side 12 (52%). USG abdomen was done in 13 cases, of which 07 (54%) showed ascites. The mean duration taken for normalization of platelet count was 5 days (3-7days). All these children received crystalloids, antibiotics. None of these children received blood or blood products. There was no mortality in these children.
The most unusual feature noticed in this series was encephalitis. The diagnosis of which was based on clinical features and CSF examination. Dengue infection can cause neurological manifestation ranging from non-specific symptoms to encephalitis and rarely GBS.[6],[7] Any virus serotype may be involved but DEN2 and DEN3 are most frequently reported as the cause of neurological sequelae.[8] Probably we have more encephalitis because of DEN2. The association of other unusual features like URI, Diarrhea, Jaundice and Lymphadenopathy has been described in other studies.[9]
In the present study a low Hct value probably due to high prevalence of anaemia in this part has been noticed. There are no clear cut guidelines for haemoconcentration in Indian population. Gomber et al in their study define the cut off Haematocrit value of 36.3 per cent in the 6-12 year age group as diagnostic of DHF.[10] A study from Chennai by Balasubramanian et al showed an Hct value of =34.8 percent in<5 years and =37.5 percent in>5 years of age, are good predictive indicators for haemo concentration in DHF.[11]
During acute phase of dengue illness, skin manifestations are common but in three of the present cases during defervescence the authors noticed exfoliation of skin restricting to only palms and soles which resolved spontaneously within a week. The reason for this is not clear but probably due to high grade fever.[12]
There was no mortality in the present study group probably due to early diagnosis, strict monitoring and proper fluid management. None of the children received blood or blood products. The study from Kabra et al and See Lun LC et al showed that preventive transfusion with platelets and FFP are not necessary for treating DHF/DSS.[13], [14]
References
1. World Health Organisation. Dengue haemorrhagic fever: diagnosis, treatment, Prevention and control . 2nd ed. Geneva; WHO: 1997.
2. WHO. WHO report on global surveillance of epidemic prone infectious diseases. http://www/who.int/emc.doctments/surveillance/docs/whocdscsrisr 2001.html.
3. Narayanan M, Arvind MA, Thilothammal N, Prema R, Rex CS et al. Dengue fever epidemic in Chennai-A study of clinical profile and outcome. Indian Pediatr 2002; 39: 1027-1033.
4. World Health Organization. Regional guidelines on Dengue/ DHF, prevention and control. (Regional publication 29/1999).
5. Nimmannity S. Clinical manifestation of Dengue/DHF. In monograph on Dengue/DHF. New Delhi; WHO regional publication SEARO22, 1993; 48-54.
6. Garacia-Rivera EJ, Rigan-Perez JG. Encephalitis and Dengue. Lancet 2002; 360: 261.
7. Gubler DJ. Kuno G, Waterman SH.Neurologic disorders associated with Dengue infection: Proceedings of the international conference on Dengue/DHF, Kuala Lumpur, Malaysia, 1983; 290-301.
8. Sulekha C, Kumar S, Philip J. Guillain -Barre Syndrome following Dengue fever: Report of 3 cases. Indian Pediatr 2004; 41: 948-950.
9. Kabra SK, Jain Y, Pandey RM, Madhulika Singhal T et al. Dengue haemorrhagic fever in children in 1996 Delhi epidemic. Trans R Soc Trop Med Hyg 1999; 93(3): 294-298.
10. Gomber S, Ramachandran VG, Kumar S, et al. Hematological observations as diagnostic markers in DHF-A reappraisal. Indian Pediatr 2001; 38: 477-481.
11. Balasubramanian S, Anandnathan K, Shivabalan S, Dutta M, Amalraj E. Cut-off haematocrit value for haemoconcentration in Dengue haemorrhagic fever. J Trop Pediatr 2004; 50:123-124.
12. Desruelles F, Lamaury J, Rondier M, Goursand R, Mahe A et al. Cutaneo mucus manifestations of Dengue. Ann Dermatol Venerol 1997; 124(3): 237-241.
13. Kabra SK, Jain Y,Madhulika et al. Role of platelet transfusion in dengue haemorrhagic fever. Indian Pediatr 1998; 35: 452-454.
14. See Lum LC, Mohd El-Amin AL, Goh AYT, Chan PWK, Lam SK. Preventive transfusion in Dengue shock syndrome-Is it necessary J Pediatr 2003; 143: 682-684.(Ratageri Vinod H, Shepur )
2 PICU, Hubli Children Hospital, Hubli, India
3 National Institute of Virology, Field Station, Bangalore, Karnataka, India
Abstract
Dengue fever is on rise globally. In India, Dengue epidemics are expanding geographically, even into the rural areas. Dengue can present with varied manifestations. The mortality rate has been brought down with high index of suspicion, strict monitoring and proper fluid resuscitation. Herewith, we are presenting clinical features and outcome of Dengue cases seen in and around Hubli (North Karnataka).
Keywords: Dengue fever; Clinical features; Out come
Over the past two decades there has been dramatic global increase in Dengue fever , (DF) Dengue haemorrhagic fever, and Dengue shock syndrome and their epidemics.[1], [2] The number of cases in SE-Asia increased in the last 3-5 years.[3] In India, there is increased proportion of Dengue cases with severe disease. The dengue epidemics in India are cyclical and are more frequent, expanding geographically into the rural areas and all forms of serotypes are circulating in the community.[4] The identification of dengue cases is by distinct clinical features but they can present with varied manifestations.[5] Dengue remains a puzzling disease in many aspects, such as the virus-vector and host-virus relationship, and clinical expression variability. The present study was undertaken to evaluate the clinical features and outcome of serologically confirmed dengue cases at Hubli (N. Karnataka).
A retrospective review of hospital case papers of dengue patients, who were admitted to pediatric ward, K.I.M.S-Hubli and PICU, Hubli children hospital, Hubli between July 2003 to June 2004 (one year) was carried out. Only confirmed Dengue cases by serological study from National Institute of Virology, ICMR, Field station, Bangalore were included. Serological study was carried out using Mac 0 ELISA technique for different serotypes. Clinical, laboratory and outcome of these children were taken for analysis.
Total number of confirmed dengue cases was 23 and all of them were positive to serotype 2 viruses (DEN2). Eight (35%) of these were infants. There was no difference in male to female ratio (11:12) although severity was more noticed in females. By WHO Classification, dengue fever was present in04 (18%) cases, DHF in 14(60%) and DSS in 05 (22%) cases. The common clinical features noted in order of frequency were fever (100%), vomiting (82%), pain abdomen (61%), restlessness(65%), headache (22%), and hepatomegaly (87%). The common bleeding manifestations were G I bleeding (22%) and petechiae (18%). table1 shows the unusual presentation in the present series. The mean duration of fever prior to admission was 5.47 days (2-12 days). Palmo-Planter exfoliation in three cases during defervescence period was noticed.
Among the laboratory investigations, the haematocrit, platelet counts and leukocyte count was sent for all children. Leucopenia (<5000/cumm) was present in 06 (26%), thrombocytopenia (<1lakh/cumm) in 19 (82%) and mean Hct value for Dengue fever, DHF and DSS were 31.5%, 30.75% and 30.4% respectively at the time of admission. Among the imaging studies, chest-X-ray was taken for all children. Pleural effusion was present in 16 (70%) cases and more so, on right side 12 (52%). USG abdomen was done in 13 cases, of which 07 (54%) showed ascites. The mean duration taken for normalization of platelet count was 5 days (3-7days). All these children received crystalloids, antibiotics. None of these children received blood or blood products. There was no mortality in these children.
The most unusual feature noticed in this series was encephalitis. The diagnosis of which was based on clinical features and CSF examination. Dengue infection can cause neurological manifestation ranging from non-specific symptoms to encephalitis and rarely GBS.[6],[7] Any virus serotype may be involved but DEN2 and DEN3 are most frequently reported as the cause of neurological sequelae.[8] Probably we have more encephalitis because of DEN2. The association of other unusual features like URI, Diarrhea, Jaundice and Lymphadenopathy has been described in other studies.[9]
In the present study a low Hct value probably due to high prevalence of anaemia in this part has been noticed. There are no clear cut guidelines for haemoconcentration in Indian population. Gomber et al in their study define the cut off Haematocrit value of 36.3 per cent in the 6-12 year age group as diagnostic of DHF.[10] A study from Chennai by Balasubramanian et al showed an Hct value of =34.8 percent in<5 years and =37.5 percent in>5 years of age, are good predictive indicators for haemo concentration in DHF.[11]
During acute phase of dengue illness, skin manifestations are common but in three of the present cases during defervescence the authors noticed exfoliation of skin restricting to only palms and soles which resolved spontaneously within a week. The reason for this is not clear but probably due to high grade fever.[12]
There was no mortality in the present study group probably due to early diagnosis, strict monitoring and proper fluid management. None of the children received blood or blood products. The study from Kabra et al and See Lun LC et al showed that preventive transfusion with platelets and FFP are not necessary for treating DHF/DSS.[13], [14]
References
1. World Health Organisation. Dengue haemorrhagic fever: diagnosis, treatment, Prevention and control . 2nd ed. Geneva; WHO: 1997.
2. WHO. WHO report on global surveillance of epidemic prone infectious diseases. http://www/who.int/emc.doctments/surveillance/docs/whocdscsrisr 2001.html.
3. Narayanan M, Arvind MA, Thilothammal N, Prema R, Rex CS et al. Dengue fever epidemic in Chennai-A study of clinical profile and outcome. Indian Pediatr 2002; 39: 1027-1033.
4. World Health Organization. Regional guidelines on Dengue/ DHF, prevention and control. (Regional publication 29/1999).
5. Nimmannity S. Clinical manifestation of Dengue/DHF. In monograph on Dengue/DHF. New Delhi; WHO regional publication SEARO22, 1993; 48-54.
6. Garacia-Rivera EJ, Rigan-Perez JG. Encephalitis and Dengue. Lancet 2002; 360: 261.
7. Gubler DJ. Kuno G, Waterman SH.Neurologic disorders associated with Dengue infection: Proceedings of the international conference on Dengue/DHF, Kuala Lumpur, Malaysia, 1983; 290-301.
8. Sulekha C, Kumar S, Philip J. Guillain -Barre Syndrome following Dengue fever: Report of 3 cases. Indian Pediatr 2004; 41: 948-950.
9. Kabra SK, Jain Y, Pandey RM, Madhulika Singhal T et al. Dengue haemorrhagic fever in children in 1996 Delhi epidemic. Trans R Soc Trop Med Hyg 1999; 93(3): 294-298.
10. Gomber S, Ramachandran VG, Kumar S, et al. Hematological observations as diagnostic markers in DHF-A reappraisal. Indian Pediatr 2001; 38: 477-481.
11. Balasubramanian S, Anandnathan K, Shivabalan S, Dutta M, Amalraj E. Cut-off haematocrit value for haemoconcentration in Dengue haemorrhagic fever. J Trop Pediatr 2004; 50:123-124.
12. Desruelles F, Lamaury J, Rondier M, Goursand R, Mahe A et al. Cutaneo mucus manifestations of Dengue. Ann Dermatol Venerol 1997; 124(3): 237-241.
13. Kabra SK, Jain Y,Madhulika et al. Role of platelet transfusion in dengue haemorrhagic fever. Indian Pediatr 1998; 35: 452-454.
14. See Lum LC, Mohd El-Amin AL, Goh AYT, Chan PWK, Lam SK. Preventive transfusion in Dengue shock syndrome-Is it necessary J Pediatr 2003; 143: 682-684.(Ratageri Vinod H, Shepur )