Control of massive bleeding in dengue hemorrhagic fever with severe thrombocytopenia by use of intravenous anti-D globulin

Dengue hemorrhagic fever (DHF) is a potentially lethal complication of mosquito borne viral disease, Dengue Fever. Thrombocytopenia is a constant finding in DHF/Dengue Shock Syndrome (DSS). We report two cases that fulfilled the WHO criteria of DSS: high fever, positive tourniquet test, severe thrombocytopenia (<10,000/mm(3)), hemo-concentration (Hematocrit increase >20%), hypotension and bleeding refractory to routine therapeutic measures, who showed dramatic improvement after receiving Intravenous Anti-D globulin (IV anti-D).     

Clinical profile and outcome of dengue fever cases

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).     

An epidemic of dengue fever in a department of paediatrics: report on 58 cases in Lamentin (Martinique).]

Dengue fever is caused by a virus transmitted by an Aedes mosquito, and infects 80 million people in the world annually. 30 000 case fatality of Dengue hemorrhagic fever are estimated each year. The disease, endemo-epidemic in the inter-tropical area, is a public health problem. PATIENTS AND METHODS: An epidemic of dengue fever occurred in Martinique, French department of the Caribbean, in 2001-2002. This work was a clinical and epidemiologic study of dengue and dengue hemorrhagic fever in 58 children. RESULTS: Three children (5%) developed a hemorrhagic dengue, and 13 subjects (24%) presented at least with one hemorrhagic sign. Symptoms were polymorphous, certain forms were only myalgic; the main reason for consultation was the fever (89%). The principal characteristics were a leucopenia (56%) associated with a neutropenia (80%), a thrombocytopenia (54%), a hepatic cytolysis (66%) and sometimes a muscular cytolysis (9/15) and a increase in the ferritinemia (16/27). No death was noted. CONCLUSION: The treatment of the dengue is above all preventive, it consists in the antivector fight.     

Unique neurological manifestations of dengue virus in pediatric population: a case series

Dengue infection is endemic in developing countries posing a major public health problem. Clinical manifestations form a broad spectrum and include uncomplicated dengue fever, dengue hemorrhagic fever and dengue shock syndrome. We report three confirmed cases of dengue infection in pediatric population with central nervous system involvement with certain unreported manifestations resulting in diagnostic dilemma. Increasing evidence of neurotropism by dengue virus emphasizes that clinician be aware of such association and consider dengue infection in cases of febrile encephalitis and myelitis in endemic areas. Early diagnosis and appropriate supportive cars can reverse this potentially fatal disease.     

Patterns of disease in Sri Lankan dengue patients.

BACKGROUND: Dengue is the most important mosquito borne viral infection in the world. Nearly 90% of infections occur in children. At present, prospective information on clinical and laboratory findings in South Asian children with dengue is generally lacking. AIM: To describe patterns of clinical disease in a cohort of children hospitalised with dengue during a major dengue epidemic in Sri Lanka. RESULTS: A total of 104 children were studied during a three month period. Eighteen had dengue fever (DF) and 86 had dengue haemorrhagic fever (DHF). Of those with DHF, 34, 23, 27, and 2 had DHF grade I, II, III, and IV respectively. Based on dengue serology testing, 13 of the DF patients had a primary infection and 5 had secondary dengue infections. In contrast, 68 of the children with DHF had secondary and 18 had primary dengue infections. Oral candidiasis was seen in 19 children. The odds ratio for children with secondary dengue infection to develop DHF was 9.8 (95% CI 3.1 to 31.2). CONCLUSION: Studies on patterns of paediatric dengue disease in different regions should help clinicians and health administrators make more informed and evidence based health planning decisions. It should also help towards mapping out dengue trends on a global scale. Oral candidiasis has not been previously documented in children suffering with acute dengue in Sri Lanka or elsewhere. Studying underlying reasons for this manifestation during future dengue epidemics may provide useful leads in understanding overall dengue pathogenesis.     

Some clinical and epidemiological observations on virologically confirmed dengue hemorrhagic fever

This study is a part of a one year prospective study on dengue hemorrhagic fever (DHF) carried out in the Department of Pediatrics, Sumber Waras Hospital in West Jakarta. Viral isolation and serologic analysis for DHF were done by Namru-2 in Jakarta. The subjects were 151 virologically confirmed DHF Patients admitted to the Department of Pediatrics during the period of September 1987-June 1988, consisting of 82 boys and 69 girls of 6 months-15 years old. The predominant age group was 5 to 9 years, representing 49.7% subjects. Dengue virus was isolated from sera during the first 8 days of illness and in 139 (42.1%) during the first 5 days of illness. Dengue virus type 1, 2, 3 and 4 were isolated from 16.6%, 13.2%, 69.5% and 0.7% subjects, respectively. The clinical manifestations revealed no striking differences between dengue 3 and others except for thrombocytopenia and shock. High fever, hemoconcentration and thrombocytopenia on admission was observed in 30.5%, 8.6% and 8.6% of subjects, respectively. Dengue shock syndrome (DSS) were observed in 23 (15.2%) with 3 (2%) fatal cases. Dengue virus serotype 3 was observed in 20 out of 23 DSS cases (86.9%) and all fatal cases were associated with dengue type 2. This study revealed that dengue 3 is the predominant virus circulating during recent epidemics and is associated with more severe clinical manifestation and with a higher incidence rate of living area.     

Dengue virus infections

Dengue is the most important arthropod-borne viral disease of public health significance. Its geographic distribution includes more than 100 countries worldwide, where more than 2.5 billion people are at risk for dengue infections. Most people will have asymptomatic infections, but the disease manifestations range from an influenza-like disease known as dengue fever to a severe, sometimes fatal disease characterized by hemorrhage and shock, known as dengue hemorrhagic fever/dengue shock syndrome. Dengue fever and dengue hemorrhagic fever/dengue shock syndrome are caused by the dengue viruses (dengue-1, dengue-2, dengue-3, and dengue-4) transmitted from viremic to susceptible humans mainly by the bites of Aedes aegypti. There is no specific management of dengue infections, no vaccine is commercially available, and vector control is the only alternative for stopping the spread of the disease. Knowledge of several aspects of dengue infections, especially of diagnosis and vaccine development, is continuously evolving, but several issues are still unresolved.     

Management of dengue fever in ICU

Dengue virus infection can cause a wide spectrum of illness. Thrombocytopenia with concurrent haemoconcentration differentiates dengue haemorrhagic fever from classical dengue fever. Only cases with shock or unstable vitals signs need admission in the pediatric intensive care. The management is essentially supportive and symptomatic. The key to success is frequent monitoring and changing strategies. A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock. Patients in grade I and II should be closely monitored for signs of shock. The management of dengue shock syndrome (grade III and IV) is a medical emergency needing prompt and adequate fluid replacement for the rapid and massive plasma losses through increased capillary permeability. Early and effective replacement of plasma losses with plasma expanders or fluid and electrolyte solutions results in a favourable outcome in most cases. The ideal fluid management should include both cystalloids and colloids (including albumin). Cystalloids are given as boluses as rapidly as possible, and as many as 2 to 3 boluses may be needed in profound shock. Colloidal fluids are indicated in patients with massive plasma leakage and in whom a large volume of cystalloids has been given. Frequent recording of vital signs and determinations of haematocrit are important in evaluating the results of treatment. Apart from correction of electrolyte and metabolic disturbances, oxygen is mandatory in all patients of shock. Some patients develop DIC and need supportive therapy with blood products (blood, FFP and platelet transfusions). Polyserositis, in the form of pleural effusion and ascitis, are common in cases of dengue shock syndrome, and if possible, drainage should be avoided as it can lead to severe hemorrhages and sudden circulatory collapse. The prognosis depends mainly on the early recognition and treatment of shock.     

Management of severe refractory thrombocytopenia in dengue hemorrhagic fever with intravenous anti-D immune globulin

Dengue hemorrhagic fever (DHF) is a potentially lethal complication of dengue fever due to shock and/or bleeding. Bleeding in DHF is due to thrombocytopenia and/or coagulopathy. The authors present their experience of usage of intravenous anti-D in 5 children with DHF and severe refractory thrombocytopenia (<10,000/mm(3)). It was administered in a dose of 50 to 75 μg/kg. Mean platelet count was 6800/mm(3) before and 33,600, 44,600, and 79,000/mm(3) after intravenous anti-D administration at 24, 48, and 72 hours, respectively. Average drop in hemoglobin after administration of anti-D was 2.28 g/dL. Intravenous anti-D can possibly be a treatment option for refractory thrombocytopenia in DHF.     

Patterns of disease in Sri Lankan dengue patients

Background

Dengue is the most important mosquito borne viral infection in the world. Nearly 90% of infections occur in children. At present, prospective information on clinical and laboratory findings in South Asian children with dengue is generally lacking.

Aim

To describe patterns of clinical disease in a cohort of children hospitalised with dengue during a major dengue epidemic in Sri Lanka.

Results

A total of 104 children were studied during a three month period. Eighteen had dengue fever (DF) and 86 had dengue haemorrhagic fever (DHF). Of those with DHF, 34, 23, 27, and 2 had DHF grade I, II, III, and IV respectively. Based on dengue serology testing, 13 of the DF patients had a primary infection and 5 had secondary dengue infections. In contrast, 68 of the children with DHF had secondary and 18 had primary dengue infections. Oral candidiasis was seen in 19 children. The odds ratio for children with secondary dengue infection to develop DHF was 9.8 (95% CI 3.1 to 31.2).

Conclusion

Studies on patterns of paediatric dengue disease in different regions should help clinicians and health administrators make more informed and evidence based health planning decisions. It should also help towards mapping out dengue trends on a global scale. Oral candidiasis has not been previously documented in children suffering with acute dengue in Sri Lanka or elsewhere. Studying underlying reasons for this manifestation during future dengue epidemics may provide useful leads in understanding overall dengue pathogenesis.     

Transient reticular gallbladder wall thickening in severe dengue fever: a reliable sign of plasma leakage

Background  

Dengue fever (DF) is an acute infection caused by a flavivirus. Although most patients present mild symptoms, some progress to a severe condition characterized by hypovolemic shock and hemorrhagic phenomena. The main feature of this severe form of DF is plasma leakage. Gallbladder wall thickening (GBWT), ascites and pleural effusion represent the sonographic triad of plasma leakage in DF.     

Aspects pédiatriques de la dengue et du chikungunya

Dengue (Df) and Chikungunya fever (Cf) arbovirosis are booming in the world, because of the plasticity of their pathogens, mutant RNA viruses making the acquisition of sustainable herd immunity and vaccination difficult in humans, and the plasticity of their vectors, the female mosquitoes of the genus Aedes (Stegomya), capable of adapting to different environments. This review summarizes the viral life cycle and epidemiology of these arboviruses, pathogenesis and pediatric aspects of their clinical forms and the basic principles of their treatment and prevention.     

La dengue en France métropolitaine

Dengue fever is the most widespread distributed vector borne viral disease. It is transmitted through the bites of Aedes aegypti and Aedes albopictus mosquitoes. With the expansion of Aedes albopictus and increasing travel exchange, it is no longer limited to the tropical zone and transmission has been documented in temperate areas. In mainland France, where Aedes albopictus has been present and disseminating since 2004, 2 episodes of autochthonous transmission occurred in 2010 and in 2013. Control measures against dengue and chikungunya, which shares the same vector, are implemented every year since 2006, in the areas where the vector is present. They aim at preventing or limiting local transmission of these diseases. They are based on epidemiological and entomological surveillance and vector control measures. The diagnosis of dengue, and chikungunya should be considered in case of suggestive symptoms in patients returning from an area of virus circulation. It should also be considered for patients living or having stayed in areas of mainland France where Aedes albopictus is present, during its activity period from May 1 to November 30. The prevention and control system, including vector control measures and the notification of cases to the local health authority should be known, as the risk of autochthonous transmission increases every year.     

Perinatal dengue infection

Dengue is a mosquito-borne viral disease, with worldwide distribution in tropical and subtropical areas. Argentina was certified free of Aedes aegypti in the sixties, however the vector reappered in 1984. In the nineties, small dengue outbreaks occurred with autocthonus diseases at first limited to the northern provinces. In the summer of 2008-2009, autocthonus cases were reported in other parts of the country. Vertical dengue virus transmission has been infrequently described, and the effect on pregnant women and newborn has not been well documented. We review this condition and present a case of perinatal dengue infection in a newborn infant from Salta, Argentina.     

The use of dengue nonstructural protein 1 antigen for the early diagnosis during the febrile stage in patients with dengue infection

BACKGROUND: To evaluate the use of dengue nonstructural protein 1 (NS1) antigen for the early diagnosis during the febrile stage in patients with dengue infection. METHODS: A total of 445 sera obtained from 165 patients [dengue fever (DF): 42, dengue hemorrhagic fever (DHF) grade I: 50, II: 63, III and IV: 10] and 8 other febrile illnesses 5-15 years of age, were assayed for the NS1 antigen, dengue-specific Ig M and Ig G antibodies. RESULTS: The positive rates of NS1 antigen among patients with either DF or DHF was 100% (7 of 7) on day 2, 92.3% (12 of 13) on day 3, 76.9% (40 of 52) on day 4, 56.5% (61 of 108) on day 5 of fever; and declined to 43.1% (59 of 137) on day 6 with defervescence and 29.8% (25 of 84) on day 7 (1 day after defervescence). The positive rates of patients with DF were higher than those with DHF but no statistically significant difference was found. However, patients with primary DHF infection had significantly higher positive rates than those with secondary DHF infection. The positive rates of Ig M antibodies were in reverse proportion to those of NS1 antigen. The additional Ig M antibody determination increased the positive rates to 90.4% (47 of 52) on day 4, 83.3% (90 of 108) on day 5 of fever; 95.6% (131 of 137) on day 6 with defervescence, and 88.1% (74 of 84) on day 7. CONCLUSIONS: Dengue NS1 antigen testing is suggested as a helpful tool for the early diagnosis of dengue infection after the onset of fever. The additional Ig M antibody determination increased the diagnostic rates.     

Randomized comparison of oxygen mask treatment vs. nasal continuous positive airway pressure in dengue shock syndrome with acute respiratory failure

Dengue hemorrhagic fever (DHF) is caused by dengue virus. Patients with DHF grade 3-4, termed Dengue Shock Syndrome (DSS), may develop acute respiratory failure after initial fluid resuscitation. Previously, these patients were treated with oxygen on a nasal cannula, or if necessary with tracheal intubation and mechanical ventilation. In the present prospective randomized study, we compared the effectiveness of oxygen treatment administered by a face mask vs. nasal continuous positive airway pressure (NCPAP). Morbidity, mortality, and supportive treatment was evaluated. Thirty-seven patients with DSS complicated by respiratory failure were enrolled. On admission and after 30 min of treatment, clinical and paraclinical data were obtained. Chest X-ray revealed pleural effusion in 92 per cent and showed interstitial oedema in 33 per cent. After 30 min of treatment the respiratory rate decreased significantly in the NCPAP group (p < 0.05), while SaO2 and PaO2 increased in both groups (p < 0.01). However, subsequently a significant difference of unresponsiveness to treatment between the oxygen mask group and the NCPAP group (13/19 vs. 4/18,p < 0.01) was noted. Complications of NCPAP or oxygen mask treatment were not documented. We conclude that NCPAP is useful in improving the management of acute respiratory failure in children with DHF/DSS in dengue-endemic areas.     

Profile of dengue patients admitted to a tertiary care hospital in Mumbai

Dengue is a mosquito-borne arboviral infection that has become a public health concern in India and particularly Mumbai, where endemicity is on the rise. Fifty-seven children having dengue infection admitted over 12 months (2008) in a child health unit of a teaching hospital in Mumbai and who were positive for IgM antibodies by ELISA test were retrospectively studied for clinical profile and outcome. Common clinical findings were fever (100%), hepatomegaly (66.6%), vomiting (40.3%), and significant bleeding manifestations (38.5%). Common laboratory findings were thrombocytopenia (platelet < 100,000/mm3 in 96.5% patients), increased liver enzymes (59.6%), hypoalbuminemia (50.8%), hyponatremia (40.3%), and deranged prothrombin time/partial thromboplastin time (PT/PTT) (33.3%). Third spacing in the form of ascites and pleural effusion was present in 15.7% and 31.5% of patients, respectively. There was no correlation between platelet count and bleeding manifestation. Patients with dengue shock syndrome required more supportive therapy with blood products and inotropes and had a longer recovery time. Mortality in the study was 3.5%. PT/PTT, serum sodium, albumin, and white blood cell (WBC) counts were predictors of severity of dengue. To summarize, fever, hemorrhagic manifestations, hepatomegaly, thrombocytopenia, and evidence of plasma leakage (hemoconcentration, pleural effusion, ascites or hypoproteinemia) should lead a clinician to suspect dengue infection.     

Dengue and dengue hemorrhagic fever.

Hundreds of thousands of dengue cases are reported worldwide each year. Given the difficulty in obtaining full reporting, the actual number of human infections is probably much higher than the number reported. Dengue is usually a nonspecific febrile illness that resolves with supportive therapy but the clinical spectrum ranges from asymptomatic infection through severe hemorrhage and sudden fatal shock. The pathophysiology of the severe forms of dengue may be related to sequential infection with different serotypes, variations in virus virulence, interaction of the virus with environmental and host factors or a combination of these factors. Control of dengue at the present time is dependent on control of the principal vector mosquito, A. aegypti. Efforts to achieve such control are now focusing on community education and action towards eliminating this mosquito's breeding sites near human dwellings. Vaccine development continues, but at present the only way to avoid dengue in an area where it is endemic or epidemic is to use repellents and mosquito barriers. The movement of people to and from tropical areas makes dengue an important differential diagnosis in any patient with an acute illness and history of recent travel to tropical areas. Because of continued infestation of the southeastern United States with A. aegypti, indigenous transmission in the continental United States remains a public health concern.     

Fever with Rashes

Fever with rashes is one of the commonest clinical problems a general practitioner or pediatrician has to face in day-to-day clinical practice. It can be a mild viral illness or a life-threatening illness like meningococcemia or Dengue hemorrhagic fever or it can be one with a lifelong consequence like Kawasaki disease. It is very important to arrive at a clinical diagnosis as early as possible with the minimum investigational facilities. The common causes associated with fever and rashes are infections, viral followed by other infections. There can be so many non-infectious causes also for fever and rashes like auto immune diseases, drug allergies etc. The type of rashes, their appearance in relation to the fever and pattern of spread to different parts of body and the disappearance, all will help in making a diagnosis. Often the diagnosis is clinical. In certain situations laboratory work up becomes essential.