Abstract
Objective
To review clinical features and outcome of children with severe forms of dengue hemorrhagic fever (DHF) presenting to a pediatric intensive care unit (PICU) with particular focus on clinical presentation and outcome.
Methods
Retrospective chart review of patients admitted to the Pediatric Intensive Care Unit (PICU) of a referral children's hospital in South India with DHF over 1.5 years (2001–January 2003).
Results
Of 858 patients with dengue fever/DHF admitted to the hospital during the study period, 109 cases with severe forms of disease required PICU admission, of which 9 patients died. 77 were under 5 years of age. The commonest indication for PICU admission was persistent shock (39 patients) followed by requirement for positive pressure ventilation in 29 patients (10 of whom had Acute Respiratory Distress Syndrome [ARDS]) and neurological symptoms in 24 patients. An important finding was the presence of diastolic dysfunction in 3 children. Six deaths of refractory shock included 4 who had ARDS and DIC and 2 who had shock with DIC 3 patients had abdominal compartment syndrome (ACS) has not been previously described in children with DSS and may lead to fluid refractory shock if not corrected. All patients had thrombocytopenia which was a defining feature of the syndrome, while 74 were also coagulopathic and 6 had severe fatal DIC. Hepatic dysfunction was more severe in children with prolonged shock, however, only a fifth of cases (5/24) with neurological manifestations were in shock. Other significant reasons for neurological presentation included cerebral edema, and encephalopathy secondary to hepatic dysfunction. 2 children had features of Acute Disseminated Encephalomyelitis (ADEM), previously only described in adults with dengue.
Conclusion
It was found that complications such as DIC, diastolic dysfunction, abdominal compartment syndrome, ARDS and hepatic dysfunction were more frequent in severe established shock. However, most neurological events were unrelated to the perfusion status. Children referred late were harder to resuscitate. There were 9 PICU deaths (case fatality rate of 8.35%). Severe refractory shock, DIC, ARDS, hepatic failure and neurological manifestations singly or in combination were the commonest causes of death in the present study.
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References
WHO.Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control, 2nd edn. Geneva: WHO, 1997.
Prevention and control of Dengue and Dengue haemorrhagic fever. Comprehensive guidelines.WHO SEARO, New Delhi: WHO1999; 23: 10–15.
Rodhain F. Situation of dengue in the world.Bull Soc Pathol Exot 1996;89(2): 87–90.
Gibbons RV. Dengue: an escalating problem.BMJ 2002;324: 1563–1566.
Bernard GR, Artigas A, Brighan KLet al. The American-European Consensus Conference on ARDS.Am J Respir Crit Care Med 1994;149: 818.
Beck R, Halberthal M, Zonis Z al. Abdominal compartment syndrome in children.Pediatr Crit Care Med 2001;2(1): 51–56.
Dale RC. Acute Disseminated Encephalomyelitis.Semin Pediatr Infect Dis 2003;14(2): 90–95.
Pena JA, Montiel-Nava C. Disseminated Acute encephalomyelitis in children.Rev Neurol 2002;34(2): 163–168.
Pancharoen C, Thisyakorn U. Dengue virus infection during infancy.Trans R Soc Trop Med Hyg 2001;95: 307–308.
Hongisiriwon S. Dengue hemorrhagic fever in infants.Southeast Asian J Trop Med Public Health 2002;33(1): 49–55.
Guzman MG, Kauri G, Bravo J, Valdes L, Vazquez S, Halstead SB. Effect of age on outcome of secondary dengue virus 2 infection.Int J Infect Dis 2002;6(2): 118–124.
Kabilan K, Balasubramanian S, Keshava SM, Satyanarayana K. The 2001 dengue epidemic in Chennai.Indian J Pediatr 2005; 72: 919–923.
Methods for obtaining quantitative information from the echocardiographic examination. In Snider AR,et al. Echocardiography in Pediatric Heart Disease. 2nd ed. St Louis. Mosby-year book, 1997; 195–224
Ranjit S, Kissoon N, Jayakumar I. Aggressive management of dengue shock syndrome may decrease mortality rate: a suggested protocol.Pediatr Crit Care Med 2005;6(4): 412–419.
Graham TP. Disorders of the circulation. In: Fuhrman BP, Zimmerman JJ eds.Pediatric Critical Care 2nd ed, St Louis Mosby, 1998; 261–271.
Khongphathanayothin A, Suesaowalak M, Muangmingsook S, Bhattarakosol P, Pancharoen C. Hemodynamic profiles of patients with dengue hemorrhagic fever during toxic stage: an echocardiographic study.Intensive Care Med 2003;29(4): 570–574.
Kabra SK, Juneja R, Madhulikaet al. Myocardial dysfunction in children with dengue haemorrhagic fever.Natl Med J India 1998;11(2): 59–61.
Wali JP, Biswas A, Chandra S. Cardiac involvement in dengue hemorrhagic fever.Intl J Cardiol 1998;64(1): 31–36.
Pellupessy JM, Allo ER, Jota S. Pericardial effusion in dengue haemorrhagic fever.Pedaitr Indones 1989;29(3–4): 72–75.
Tassniyom S, Vasanawathana S, Chirawatkul A, Rojanasuphot S. Failure of high-dose methylprednisolone in established dengue shock syndrome: a placebo-controlled, double-blind study.Pediatrics 1993;92(1): 111–115.
Gomber S, Ramachandran VG, Kumar Set al. Hematological observations as diagnostic markers in Dengue hemorrhagic fever—a reappraisal.Indian Pediatr 2001;38(5): 477–481.
Aggarwal A, Chandra J, Aneja S, Patwari AK, Datta AK. An epidemic of dengue hemorrhagic fever and dengue shock syndrome in children in Delhi.Indian Pediatr 1998;(35): 727–732.
Narayanan M, Aravind MA, Thilothammal Net al. Dengue Fever epidemic in Chennai—A study of clinical profile and outcome.Indian Pediatr 2002;39: 1027–1033.
Chua MN, Molanida R, de Guzman M, Laberiza F. Prothrombin time and partial thromboplastin time as a predictor of bleeding in dengue hemorrhagic fever.Southeast Asian J Trop Med Public Health 1993;24Suppl 1: 141–143.
Hathirat P, Isarangkura P, Srichaukul P, Suvatte V, Mitrakul C. Abnormal hemostasis in dengue hemorrhagic fever.Southeast Asian J Trop Med Public Health 1993;24Suppl 1: 80–85.
Srichaikul T, Nimmanitya. Hematology in dengue and dengue haemorrhagic fever.Baillieres Best Pract Res Clin Haematol 2000 Jun; 13(2): 261–276.
Wills BA, Oragui EE, Stephens ACet al. Coagulation abnormalities in dengue hemorrhagic fever: Serial investigations in 167 Vietnamese children with dengue shock syndrome.Clin Infect Dis 2002;35(3): 277–285.
Mairuhu AT, Macgillavry MR, Setiati TE. Is clinical outcome of dengue-virus infections influenced by coagulation and fibrinolysis? A critical review of the evidence.Lancet Infect Dis 2003;3(1): 33–41.
Krishnamurti C, Kaalayanarooj S, Cutting MAet al. Mechanisms of hemorrhage in dengue without circulatory collapse.Am J Trop Med Hyg 2001;65(6): 840–847.
George R, Lam SK. Dengue viral infection-the Malaysian experience.Ann Acad Med Singapore 1997;26(6): 815–819.
Lum LC, Thong MK, Cheah YKet al. Dengue—associated adult respiratory distress syndrome.Ann Trop Pediatr 1995;15(4): 335–339.
Nimmannitya S, Thisyakorn U, Hemsrichart V. Dengue hemorrhagic fever with unusual manifestations.Southeast Asian J Trop Med Public Health 1987;18(3): 398–405.
George R, Liam CK, Chna CT. Unusual clinical manifestations of dengue virus infection.Southeast Asian J Trop Med Public Health 1988;19: 585–590.
Kalayanarooj S, Chansiriwongs V, Nimmanitya S.Dengue Bulletin 2002;26: 33–43.
Mohan B, Patwari AK, Anand VK. Hepatic dysfunction in childhood dengue infections.J Trop Pediatr 2000;46(1): 40–43.
Kuo CH, Tai DI, Chang-Chien CS, Lan CK, Chiou SS, Liaw YF. Liver biochemical tests and dengue fever.Am Trop Med Hyg 1992;47(3): 265–270.
Wahid SF, Sanusi S, Zawawi MM, Ali RA. A comparison of the pattern of liver involvement in dengue hemorrhagic fever with classic dengue fever.Southeast Asian J Trop Med Public Health 2000;31(2): 259–263.
Lum LCS, Lam CK, George R. Fulminant hepatitis in dengue infection.Southeast Asian J Trop Med Public Health 1993;24(3): 467–471.
Couvelard A, Marianneau P, Bedel Cet al. Report of a fatal case of dengue infection with hepatitis: demonstration of dengue antigens in hepatocytes and liver apoptosis.Hum Pathol 1999;30(9): 1106–1110.
Janssen HL, Bienfait HP, Jansen CLet al. Fatal cerebral edema associated with primary dengue infection.J Infect 1998;36(3): 344–346.
Lum LC, Lam SK, Choy YS. Dengue encephalitis: a true entity?Am J Trop Med Hyg 1996;54: 256–259.
Kankirawatana P, Chokephaibulkit K, Puthavathana P, Yoksan S, Apintanapong S, Pongthapisit V. Dengue infections presenting with central nervous system manifestations.J Child Neurol 2000;15(8): 544–547.
Cam BV, Fonsmark L, Hue NB, Phuong NT, Poulsen A, Heegaard ED. Prospective case—control study of encephalopathy in children with dengue hemorrhagic fever.Am J Trop Med Hyg 2001;65(6): 848–851.
Thisyakorn U, Thisyakorn C, Limpitikul W, Nisalak A. Dengue infection with central nervous system manifestations.Southeast Asian J Trop Med Public Health 1999;30(3): 504–506.
Pancharoens C, Thusyakorn U. Neurological manifestations in dengue patients.Southeast Asian J Trop Med Public Health 2001; 32: 341–345.
Hendarto SK, Hadinegoro SR. Dengue encephalopathy.Acta Pedaitr Jpn 1992;34(3): 350–357.
Yamamoto Y, Takasaki T, Yamada Ket al. Acute Disseminated Encephalomyelitis following dengue fever.J Infect Chemother 2002;8(2): 175–177.
Sulekha C, Kumar S, Philip J. Guillain-Barre Syndrome following Dengue Fever: Report of 3 Cases.Indian Pediatr 2004; 41: 948–950.
Pancharoen C, Thisyakorn U. Coinfection with dengue patients.Pediatr Infect Dis J 1998;17: 81–82.
Cherian T, Ponnuraj E, Kuruvilla Tet al. An epidemic of Dengue haemorrhagic fever and Dengue shock syndrome in and around Vellore.Indian J Med Res 1994;100: 51–56.
Pande JN, Kabra SK. Dengue haemorrhagic fever and shock syndrome.Natl Med J India 1996;9: 256–258.
Agarwal R, Kapoor S, Nagar Ret al. A clinical study of patients with dengue haemorrhagic fever during the epidemic of 1996 at Lucknow, India.Southeast Asian J Trop Med Public Health 1999;30(4): 735–740.
Deen JL. Late presentation and increased mortality in children with dengue hemorrhagic fever.Trop Doct 2000;30(4): 227–228.
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Kamath, S.R., Ranjit, S. Clinical features, complications and atypical manifestations of children with severe forms of dengue hemorrhagic fever in South India. Indian J Pediatr 73, 889–895 (2006). https://doi.org/10.1007/BF02859281
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DOI: https://doi.org/10.1007/BF02859281