Review of Dengue Hemorrhagic Fever Fatal Cases Seen Among Adults: A Retrospective Study

<div><p>Background</p><p>Dengue is a mosquito-borne viral disease endemic in many countries in the tropics and sub-tropics. The disease affects mainly children, but in recent years it is becoming more of an adult disease. Malaysia experienced a large dengue outbreak in 2006 to 2007, involving mostly adults, with a high number of deaths.</p><p>Methodology/Principal Findings</p><p>We undertook a retrospective study to examine dengue death cases in our hospital from June 2006 to October 2007 with a view to determine if there have been changes in the presentation of severe to fatal dengue. Nine of ten fatal cases involved adult females with a median age of 32 years. All had secondary dengue infection. The mean duration of illness prior to hospitalization was 4.7 days and deaths occurred at an average of 2.4 days post-admission. Gastrointestinal pain, vomiting, diarrhea, intravascular leakages and bleeding occurred in the majority of cases. DSS complicated with severe bleeding, multi-organ failure and coagulopathy were the primary causes of deaths. Seven patients presented with thrombocytopenia and hypoalbuminemia, five of which had hemoconcentration and increased ALT and AST indicative of liver damage. Co-morbidities particularly diabetes mellitus was common in our cohort. Prominent unusual presentations included acute renal failure, acute respiratory distress syndrome, myocarditis with pericarditis, and hemorrhages over the brain and heart.</p><p>Conclusions</p><p>In our cohort, dengue fatalities are seen primarily in adult females with secondary dengue infection. The majority of the patients presented with common clinical and laboratory warning signs of severe dengue. Underlying co-morbidities may contribute to the rapid clinical deterioration in severe dengue. The uncommon presentations of dengue are likely a reflection of the changing demographics where adults are now more likely to contract dengue in dengue endemic regions.</p></div

Summary of clinical presentation in dengue fatal cases seen at UMMC between June 2006 to October 2007.

a<p>Brought in dead;</p>b<p>Male;</p>c<p>Child.</p>1<p>Autopsy.</p><p>Bleeding per vaginum (PV); Bleeding per rectum (PR); Gastrointestinal bleeding (GI).</p

Laboratory diagnosis and hematological findings of samples from fatal dengue cases seen at UMMC between June 2006 to October 2007.

<p>‘+’ = Positive; ‘−’ = Negative; N/A = Not available.</p><p>Activated partial thromboplastin time (APTT); Thrombin time (TT); Alanine aminotransferase (ALT); Aspartate aminotransferase (AST).</p

Demographics, co-morbidities, clinical features and postmortem findings of fatal dengue seen at UMMC between June 2006 to October 2007.

a<p>Sex- Female (F); Male (M).</p>b<p>Ethnicity- Malay (M); Chinese (C); Indian (I); Others, Bangladesh (B).</p>c<p>Bleeding Site- Bleeding per vaginum (PV); Bleeding per rectum (PR); Gastrointestinal bleeding (GI); Respiratory tract (RT); Endotracheal tube (ETT); Nasogastric (NG).</p>d<p>Cause of death- Acute liver failure (ALF); Acute pulmonary oedema (APO); Acute renal failure (ARF); Multi-organ failure (MOF); Disseminated intravascular coagulation (DIC); Acute respiratory distress syndrome (ARDS); Hospital acquired pneumonia (HAP); Bronchoalveolar lavage (BAL); Chest X-ray (CXR).</p

Cohorting Dengue Patients Improves the Quality of Care and Clinical Outcome

<div><p>Introduction</p><p>The increasing incidence of dengue among adults in Malaysia and other countries has important implications for health services. Before 2004, in order to cope with the surge in adult dengue admissions, each of the six medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple medical teams was piecemeal and resulted in high variability of care. A restructuring of adult dengue inpatient service in 2004 resulted in all patients being admitted to one ward under the care of the infectious disease unit. Hospital and Intensive Care Unit admission criteria, discharge criteria and clinical laboratory testing were maintained unchanged throughout the study period.</p><p>Objectives</p><p>To evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.</p><p>Methods</p><p>A pre (2003) and post-intervention (2005–6) retrospective study was undertaken.</p><p>Intervention</p><p>Cohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.</p><p>Results</p><p>The number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.</p><p>Conclusion</p><p>Cohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.</p></div

Summary of results: Demographics and dengue IgM serology status.

<p>Summary of results: Demographics and dengue IgM serology status.</p

Summary of results: Clinical parameters, laboratory parameters, treatment and outcome.

<p>Data is expressed as number (%) or median (interquartile range). GI is gastrointestinal, HCT is haematocrit, WBC is total white cell count, IVF is intravenous fluid, LOS is Length of stay.</p><p>Summary of results: Clinical parameters, laboratory parameters, treatment and outcome.</p

Frequency of symptoms, duration and site of myalgia reported by patients (n = 89).

<p>Frequency of symptoms, duration and site of myalgia reported by patients (n = 89).</p

Coronal STIR MRI demonstrating bilateral asymmetrical high signal in deep (arrow head) and superficial (arrow) temporalis muscles (Case 1, Table 3).

<p>Coronal STIR MRI demonstrating bilateral asymmetrical high signal in deep (arrow head) and superficial (arrow) temporalis muscles (Case 1, <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002876#pntd-0002876-t003" target="_blank">Table 3</a>).</p

Axial STIR demonstrating heterogenous increased signal right (Rt) tibialis posterior (arrow) compared to non-oedematous muscles (arrowhead) left (Lt) calf (Case 2, Table 3).

<p>Axial STIR demonstrating heterogenous increased signal right (Rt) tibialis posterior (arrow) compared to non-oedematous muscles (arrowhead) left (Lt) calf (Case 2, <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002876#pntd-0002876-t003" target="_blank">Table 3</a>).</p