The outcomes of patients with severe dengue admitted to intensive care units

First clinical reports of acute hantavirus and dengue infections among pregnant women in the Caribbean

BACKGROUND

Hantavirus and dengue virus infections lead to diseases causing economic and public health concerns. Acute hantavirus infections can lead to similar clinical haemorrhagic signs as other endemic diseases including dengue and leptospirosis.

METHODS

Using a retrospective case analysis of pregnant dengue and hantavirus disease patients with clinical reports and compatible clinical laboratory information during pregnancy, we report the first evidence of dengue and hantavirus infections and a case of dual dengue and hantavirus infection among pregnant women in the Caribbean. Laboratory testing by enzyme-linked immunosorbent assay (ELISA) and non-structural protein 1 (NS1) for DENV and for hantavirus infection pseudotype focus reduction neutralisation tests (pFRNT), ELISA and immunochromatographic (ICG) strips.

RESULTS

Four pregnant cases with acute DENV infections were identified; however, only one out of the four cases (25%) had a detailed medical record to permit abstraction of clinical data. Six hantavirus infected pregnant cases were identified with gestation periods ranged from 36 to 39 weeks; none of the reported patients exhibited previous pregnancy complications prior to hospitalisation and infection. Acute liver damage was observed in three of the six cases (AST readings) who were subsequently diagnosed with hepatitis in pregnancy and variable clinical outcomes were observed with term and pre-term deliveries.

CONCLUSIONS

Whilst hantavirus infection in pregnancy is rare, consideration should be given to differential diagnosis with fever, kidney involvement, liver involvement, haemorrhagic symptoms and thrombocytopenia in endemic areas with clinically similar diseases such as dengue and leptospirosis.HighlightsFirst recorded case of hantavirus and dengue co-infection in a pregnant woman.First detailed report of clinical hantavirus infection in pregnant women in the Caribbean.First published report of clinical dengue infection in pregnant woman in the Caribbean.Possible complications of pregnancy following hantavirus infection.Pre-term birth and low birth weights.Clinical course of hantavirus infection in a Caribbean population.

Pediatric Profound Dengue Shock Syndrome and Use of Point-of-Care Ultrasound During Mechanical Ventilation to Guide Treatment: Single-Center Retrospective Study, 2013-2021

OBJECTIVES

Profound dengue shock syndrome (DSS) complicated by severe respiratory failure necessitating mechanical ventilation (MV) accounts for high case fatality rates among PICU-admitted patients. A major challenge to management is the assessment of intravascular volume, which can be hampered by severe plasma leakage and the use of MV.

DESIGN

Retrospective cohort, from 2013 to 2021.

PATIENTS

Sixty-seven children with profound DSS supported by MV, some of whom underwent bedside point-of-care ultrasound (POCUS) for assessment and monitoring of hemodynamics and fluid administration.

SETTING

PICU of the tertiary Children's Hospital No. 2 in Vietnam.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed data clinical and laboratory data during PICU stay. In particular, during use of MV (i.e., at times 0-, 6-, and 24-hr after commencement) and fluid resuscitation. The primary study outcome was 28-day in-hospital mortality, and the secondary outcomes were associations with changes in hemodynamics, blood lactate, and vasoactive-inotrope score (VIS). Patients had a median age of 7 years (interquartile range, 4-9). Use of POCUS during fluid management (39/67), as opposed to not using (28/67), was associated with lower mortality (6/39 [15%] vs. 18/28 [64%]; difference 49 % [95% CI, 28-70%], p < 0.001). Use of POCUS was associated with lower odds of death (adjusted odds ratio 0.17 [95% CI, 0.04-0.76], p = 0.02). The utilization of POCUS, versus not, was associated with greater use of resuscitation fluid, and reductions in VIS and pediatric logistic organ dysfunction (PELOD-2) score at 24 hours after MV and PICU discharge.

CONCLUSIONS

In our experience of pediatric patients with profound DSS and undergoing MV (2013-2021), POCUS use was associated with lower odds of death, a higher volume of resuscitation fluid, and improvements in the blood lactate levels, VIS, and PELOD-2 score.

Proceedings of the 6th Asia Dengue Summit, June 2023

The 6th Asia Dengue Summit (ADS) themed "Road Map to Zero Dengue Death" was held in Thailand from 15th-16th June 2023. The summit was hosted by Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand in conjunction with Queen Saovabha Memorial Institute, The Thai Red Cross Society; Faculty of Tropical Medicine, Mahidol University; and the Ministry of Public Health. The 6th ADS was convened by Asia Dengue Voice and Action (ADVA); Global Dengue and Aedes Transmitted Diseases Consortium (GDAC); Southeast Asian Ministers of Education Tropical Medicine and Public Health Network (SEAMEO TROPMED); Fondation Mérieux (FMx) and the International Society for Neglected Tropical Diseases (ISNTD). Dengue experts from academia and research, and representatives from the Ministries of Health, Regional and Global World Health Organization (WHO) and International Vaccine Institute (IVI) participated in the three-day summit. With more than 51 speakers and 451 delegates from over 24 countries, 10 symposiums, and 2 full days, the 6th ADS highlighted the growing threat of dengue and its antigenic evolution, flagged the urgent need to overcome vaccine hesitancy and misinformation crisis, and focused on dengue control policies, newer diagnostics, therapeutics and vaccines, travel-associated dengue, and strategies to improve community involvement.

Aspergillus coinfection in critically Ill patients with severe dengue

In 2014-2015, a significant outbreak of dengue fever occurred in southern Taiwan, with a subsequent decline in dengue incidence. Despite this, there is emerging concern about virus-associated aspergillosis, yet limited research has explored coinfections involving dengue and aspergillosis. We conducted a retrospective study at a single center in Southern Taiwan, specifically focusing on dengue patients admitted to the intensive care unit during the period between July and November 2015. Among the 142 dengue patients studied, only 8.06 % (10/142) underwent serum galactomannan testing, with a single patient undergoing bronchoalveolar lavage (BAL) galactomannan assay. Out of those tested, 20 % (2/10) returned positive serum galactomannan results. Herein, we present two consecutive cases of coinfection involving dengue and pulmonary aspergillosis in immunocompetent patients.

Routine blood parameters of dengue infected children and adults. A meta-analysis

The World Health Organization (WHO) has revised dengue case classification in 2009 to better reflect the severity of the disease. However, there was no comprehensive meta-analysis of pooled routine blood parameters according to the age or the categories of the 2009 WHO classification. This study aimed to meta-analyze the routine blood parameters of dengue infected children and adults. Electronic search was performed with eligible articles included for review. Meta-analysis was conducted for six blood parameters stratified into children, adults and all ages, which were further grouped into the three 2009 WHO case classifications (dengue without warning signs, DwoWS; dengue with warning signs, DwWS; severe dengue, SD), non-severe dengue (non-SD) and 'All' cases. A total of 55 articles were included in the meta-analysis. Fifteen studies were conducted in the children's age category, 31 studies in the adult category and nine studies in all ages. The four selected pooled blood parameters for children were white blood cell (WBC) (×103/L) with 5.11 (SD), 5.64 (DwWS), 5.52 (DwoWS) and 4.68 (Non-SD) hematocrit (HCT) (%) with 36.78 (SD), 40.70 (DwWS), 35.00 (DwoWS) and 29.78 (Non-SD) platelet (PLT) (×103/µL) with 78.66 (SD), 108.01 (DwWS), 153.47 (DwoWS) and 108.29 (non-SD); and aspartate aminotransferase (AST) (/µL) with 248.88 (SD), 170.83 (DwWS), 83.24 (DwoWS) and 102.99 (non-SD). For adult, WBC were 4.96 (SD), 6.44 (DwWS), 7.74 (DwoWS) and 3.61 (non-SD); HCT were 39.50 (SD), 39.00 (DwWS), 37.45 (DwoWS) and 41.68 (non-SD); PLT were 49.62 (SD), 96.60 (DwWS), 114.37 (DwoWS) and 71.13 (non-SD); and AST were 399.50 (SD), 141.01 (DwWS), 96.19 (DwoWS) and 118.13 (non-SD). These blood parameters could not differentiate between each dengue severity according to the WHO 2009 classification, SD, DwoWS, DwWS and non-SD, because the timing of blood drawing was not known and there was an overlapping confidence interval among the clinical classification. Hence, these pooled blood parameter values could not be used to guide clinicians in management and did not correlate with severity as in previous scientific literatures and guidelines.

A case report of dengue shock syndrome complicated with multiorgan failure and hepatitis E virus superinfection

Dengue fever is a vector borne viral disease. It is more prevalent in Southeast Asia. The main symptoms include myalgia, nausea, vomiting and rash, hence, subsequently lead to dengue hemorrhagic fever and dengue shock syndrome. In the current report, we are presenting a case of a 50-year-old female patient who was presented in hospital with the symptoms of fever, vomiting, abdominal pain, productive cough and sore throat. Her serology came positive for dengue NSP1, and she was shifted to intensive care unit because of her aggravating condition. On day 4, the hepatitis E virus infection also was detected and she died after developing hepatic shock and multiorgan failure. This report states the superinfection of hepatitis E and dengue virus and highlights the significance of its early detection for better clinical management.

Mortality Rates of Severe Dengue Viral Infection Before and After Implementation of a Revised Guideline for Severe Dengue

OBJECTIVES

To compare the mortality rate of severe dengue (SD) before and after implementation of a revised SD guideline.

METHODS

Medical records of SD patients <15 years of age hospitalized during 1998-2020 were reviewed. The revised SD guidelines were implemented in 2016, including intensive monitoring of vital signs and intra-abdominal pressure, the release of intra-abdominal pressure in cases of abdominal compartment syndrome (ACS) and the use of N-acetyl cysteine in cases of acute liver failure.

RESULTS

On initial admission, organ failure including severe bleeding, acute respiratory failure, acute kidney injury and acute liver failure was not significantly different between 78 and 23 patients treated in the pre- and postrevised guideline periods, respectively. After hospitalization, the proportions of patients who developed profound shock (68.8% vs. 41.2%), multiorgan failures (60.4% vs. 73.3%), ACS (37.2% vs. 26.1%) and fatal outcome (33.3% vs. 13.0%) were also not significantly different between the pre- and postrevised guideline periods, respectively. In subgroup analysis, the mortality rates in patients with multiorgan failure (44.1% vs. 15.8%), acute respiratory failure and active bleeding (78.1% vs. 37.5%) and ACS (82.8% vs. 33.3%), respectively, were significantly higher in the pre- than the postrevised guideline periods. The durations of time before the liver function tests returned to normal levels, and the mortality rates in acute liver failure patients treated with and without N-acetyl cysteine were not significantly different.

CONCLUSIONS

Although following the revised guidelines could not prevent organ failure, the mortality rates in patients with multiorgan failure and/or ACS decreased significantly when following the revised guidelines.

Does dengue and COVID-19 co-infection have worse outcomes? A systematic review of current evidence

In dengue-endemic regions, the co-infection with SARS-CoV-2 and dengue is a significant health concern. Therefore, we performed a literature search for relevant papers in seven databases on 26 Spetember 2021. Out of 24 articles, the mortality rate and intensive care unit (ICU) admission were 19.1% and 7.8%, respectively. The mean hospital stay was 11.4 days. In addition, we identified two pregnancies with dengue and COVID-19 co-infection; one ended with premature rupture of membrane and intrauterine growth restriction fetus, while the other one ended with maternal mortality and intrauterine fetal death. COVID-19 and dengue co-infection had worse outcomes regarding mortality rates, ICU admission, and prolonged hospital stay. Thus, wise-decision management approaches should be adequately offered to these patients to enhance their outcomes. Establishing an early diagnosis might be the answer to reducing the estimated significant burden of these conditions.

Serum IL-18 Is a Potential Biomarker for Predicting Severe Dengue Disease Progression

Background. Dengue virus (DENV) infection is the most common arboviral disease that affects tropical and subtropical regions. Based on the clinical hallmarks, the different severities of patients range from mild dengue fever (MDF) to severe dengue diseases (SDDs) and include dengue hemorrhagic fever or dengue shock syndrome. These are commonly associated with cytokine release syndrome (CRS). The types and levels of cytokines/chemokines, which are suppressed or enhanced, are varied, indicating CRS's pathogenic and host defensive effects. Principal Finding. In this study, we created an integrated and precise multiplex panel of cytokine/chemokine assays based on our literature analysis to monitor dengue CRS. A 24-plex panel of cytokines/chemokines was evaluated to measure the plasma levels of targeting factors in dengue patients with an MDF and SDD diagnosis without or with comorbidities. As identified in sixteen kinds of cytokines/chemokines, ten were significantly (P < 0.05) (10/16) increased, one was significantly (P < 0.01) (1/16) decreased, and five were potentially (5/16) altered in all dengue patients (n = 30) in the acute phase of disease onset. Compared to MDF, the levels of IL-8 (CXCL-8) and IL-18 in SDD were markedly (P < 0.05) increased, accompanied by positively increased IL-6 and TNF-α and decreased IFN-γ and RANTES. With comorbidities, SDD significantly (P < 0.01) portrayed elevated IL-18 accompanied by increased IL-6 and decreased IFN-α2 and IL-12. In addition, decreased platelets were significantly (P < 0.05) associated with increased IL-18. Significance. These results demonstrate an efficient panel of dengue cytokine/chemokine assays used to explore the possible level of CRS during the acute phase of disease onset; also, we are the first to report the increase of IL-18 in severe dengue with comorbidity compared to severe dengue without comorbidity and mild dengue.

Early Predictors of Mortality in Children with Severe Dengue Fever: A Prospective Study

OBJECTIVE

The aim of the study was to identify early predictors of mortality in children with severe dengue fever admitted to pediatric intensive care unit (PICU).

MATERIALS AND METHODS

All consecutive children with laboratory-confirmed severe dengue fever were enrolled in this prospective observational study. Besides demographic data, disease severity and organ dysfunction scores, laboratory investigations and interventions are done in PICU were recorded and analyzed.

RESULTS

During the study period of 42 months, 172 patients with dengue fever were admitted to PICU. A total of 78 (45.3%) patients with severe dengue fever were included and analyzed. There were 20 (25.6%) deaths. There were significant differences in disease severity and organ dysfunction scores, transaminases, blood lactate level and serum creatinine between survivors and nonsurvivors. A significantly higher number of nonsurvivors required interventions in first 24 hours of admission. Platelet counts (P value 0.22) and hematocrit (P value 0.47) were not statistically different in 2 groups. There was a significantly high vasopressor-inotrope score (VIS) (<0.001) and positive fluid balance >10% (0.002) in nonsurvivors. Multivariate stepwise logistic regression analysis identified serum glutamic pyruvic transaminases (≥ 284 IU/L; odds ratio [OR] 1.002, 95% confidence interval [CI]: 1.001-1.003), blood lactate level (≥2.73 mmol/L; OR 2.08, 95% CI: 1.354-3.202), Pediatric Risk of Mortality score at 12 hours (≥14.5; OR 1.35, 95% CI: 1.077-1.693), VIS (≥22.5, OR 1.129, 95% CI: 1.059-1.204) and positive fluid balance >10% (OR 22.937, 95% CI: 2.393-219.84) at 24 hours of admission as independent predictors of mortality.

CONCLUSION

Disease severity, hyperlactatemia at admission, need for multiple vasoactive drugs and positive fluid balance are predictors of mortality in severe dengue infection in children admitted to PICU.

Comparative analysis of liver involvement caused by two DENV-2 lineages using an immunocompetent murine model

Dengue (DEN) is the most prevalent arbovirus among humans, and four billion people live at risk of infection. The clinical manifestations of DEN are variable, and the disease may present subclinically or asymptomatically. A quarter of patients develop classical dengue (CD) or severe dengue (SD), which is potentially lethal and involves vascular permeability changes, severe hemorrhage and organ damage. The involvement of the liver is a fairly common feature in DEN, and alterations range from asymptomatic elevation of transaminases to acute liver failure. Since its introduction in Brazil in 1990, two strains of Dengue virus (DENV) serotype 2 (DENV-2) have been detected: Lineage I, which is responsible for an outbreak in 1991, and Lineage II, which caused an epidemic greater than the previous one and had a different epidemiological profile. To date, studies on different strains of the same serotype/genotype and their association with disease severity are scarce. In addition, one of the greatest challenges regarding the study of DEN pathogenesis and the development of drug and vaccine therapies is the absence of an animal model that reproduces the disease as it occurs in humans. The main goals of this study were to assess BALB/c mouse susceptibility experimentally infected by two distinct DENV-2 strains and characterize possible differences in the clinical signs and alterations induced in the liver resulting from those infections. Mice infected by the two DENV-2 lineages gained less weight than uninfected mice; however, their livers were slightly heavier. Increased AST and AST levels were observed in infected mice, and the number of platelets increased in the first 72 h of infection and subsequently decreased. Mice infected with both lineages presented leukocytosis but at different times of infection. The histopathological changes induced by both lineages were similar and comparable to the changes observed in DEN fatal cases. The viral genome was detected in two liver samples. The results demonstrate the susceptibility of BALB/c mice to both DENV-2 lineages and suggest that the changes induced by those strains are similar, although for some parameters, they are manifested at different times of infection.

Increased TNF-α Initiates Cytoplasmic Vacuolization in Whole Blood Coculture with Dengue Virus

During the acute febrile phase of dengue virus (DENV) infection, viremia can cause severe systemic immune responses accompanied by hematologic disorders. This study investigated the potential induction and mechanism of the cytopathic effects of DENV on peripheral blood cells ex vivo. At one day postinfection, there was viral nonstructural protein NS1 but no further virus replication measured in the whole blood culture. Notably, DENV exposure caused significant vacuolization in monocytic phagocytes. With a minor change in the complete blood cell count, except for a minor increase in neutrophils and a significant decrease in monocytes, the immune profiling assay identified several changes, particularly a significant reduction in CD14-positive monocytes as well as CD11c-positive dendritic cells. Abnormal production of TNF-α was highly associated with the induction of vacuolization. Manipulating TNF-α expression resulted in cytopathogenic effects. These results demonstrate the potential hematological damage caused by ex vivo DENV-induced TNF-α.

Comparing machine learning with case-control models to identify confirmed dengue cases

In recent decades, the global incidence of dengue has increased. Affected countries have responded with more effective surveillance strategies to detect outbreaks early, monitor the trends, and implement prevention and control measures. We have applied newly developed machine learning approaches to identify laboratory-confirmed dengue cases from 4,894 emergency department patients with dengue-like illness (DLI) who received laboratory tests. Among them, 60.11% (2942 cases) were confirmed to have dengue. Using just four input variables [age, body temperature, white blood cells counts (WBCs) and platelets], not only the state-of-the-art deep neural network (DNN) prediction models but also the conventional decision tree (DT) and logistic regression (LR) models delivered performances with receiver operating characteristic (ROC) curves areas under curves (AUCs) of the ranging from 83.75% to 85.87% [for DT, DNN and LR: 84.60% ± 0.03%, 85.87% ± 0.54%, 83.75% ± 0.17%, respectively]. Subgroup analyses found all the models were very sensitive particularly in the pre-epidemic period. Pre-peak sensitivities (<35 weeks) were 92.6%, 92.9%, and 93.1% in DT, DNN, and LR respectively. Adjusted odds ratios examined with LR for low WBCs [≤ 3.2 (x103/μL)], fever (≥38°C), low platelet counts [< 100 (x103/μL)], and elderly (≥ 65 years) were 5.17 [95% confidence interval (CI): 3.96-6.76], 3.17 [95%CI: 2.74-3.66], 3.10 [95%CI: 2.44-3.94], and 1.77 [95%CI: 1.50-2.10], respectively. Our prediction models can readily be used in resource-poor countries where viral/serologic tests are inconvenient and can also be applied for real-time syndromic surveillance to monitor trends of dengue cases and even be integrated with mosquito/environment surveillance for early warning and immediate prevention/control measures. In other words, a local community hospital/clinic with an instrument of complete blood counts (including platelets) can provide a sentinel screening during outbreaks. In conclusion, the machine learning approach can facilitate medical and public health efforts to minimize the health threat of dengue epidemics. However, laboratory confirmation remains the primary goal of surveillance and outbreak investigation.

A prospective 3 year study of clinical spectrum and outcome of dengue fever in ICU from a tertiary care hospital in North India

Background and Aims:

The incidence of specific complications and adverse outcomes in dengue patients needing admission to intensive care units (ICU) may be quite variable in different regions of India presumably because of different strains of dengue virus or due to re infection.

Methods:

Patients admitted with acute febrile illness (AFI) with either positive IgM antibody or NS1 antigen for dengue were enrolled. Data were collected for 3 years (2015-2017). A total of 313 patients with acute febrile illness were admitted in the study period (2252 total ICU admissions). A total of 137 (43.76%) cases were serologically proven as dengue fever.

Results:

Median age (IQR) of study population was 36.0 (26.0–52.0) years. Liver (65.7%) was the main organ involved followed by acute kidney Injury (AKI) (18.6%). Dengue Shock Syndrome (DSS) was found in 18.6% of cases. Fifty-two patients died and the crude mortality was 38.0%. On multivariate analysis APACHE Score <10, thrombocytopenia, hepatic dysfunction, AKI and dengue shock syndrome (DSS) were associated with the risk of mortality.

Conclusion:

This study in ICU patients showed high mortality in relatively younger patients. Liver (in the form of raised Bilirubin) was the most common organ dysfunction. The need to recognise early warning signs for ICU admission is highlighted.

Atypical Presentation of Methicillin-Susceptible Staphylococcus aureus Infection in a Dengue-Positive Patient: A Case Report with Virulence Genes Analysis

Concurrent bacteraemia in patients with dengue fever is rarely reported. We report a case of a patient who initially presented with symptoms typical of dengue fever but later succumbed to septic shock caused by hypervirulent methicillin-susceptible Staphylococcus aureus (MSSA). A 50-year-old female patient with hypertension and diabetes mellitus presented with typical symptoms of dengue fever. Upon investigation, the patient reported having prolonged fever for four days prior to hospitalization. Within 24 hours post-admission, the patient developed pneumonia and refractory shock, and ultimately succumbed to multiple-organs failure. Microbiological examination of the blood culture retrieved a pan susceptible MSSA strain. Genomic sequence analyses of the MSSA strain identified genes encoding staphylococcal superantigens (enterotoxin staphylococcal enterotoxin C 3 (SEC3) and enterotoxin-like staphylococcal enterotoxins-like toxin L (SElL)) that have been associated with toxic shock syndrome in human hosts. Genes encoding important toxins (Panton-Valentine leukocidins, alpha-haemolysin, protein A) involved in the development of staphylococcal pneumonia were also present in the MSSA genome. Staphylococcus aureus co-infections in dengue are uncommon but could be exceptionally fatal if caused by a toxin-producing strain. Clinicians should be aware of the risks and signs of sepsis in dengue fever, thus allowing early diagnosis and starting of antibiotic treatment in time to lower the mortality and morbidity rates.

Dynamic changes of soluble ST2 levels predicted fatality and were involved in coagulopathy in dengue fever in the elderly

Background

Severe dengue virus (DENV) infection involves plasma leakage and vascular collapse, and leads to significant morbidity and death. Serum soluble ST2 (sST2 [interleukin (IL)-1 receptor like-1 protein: IL-1-RL-1]) levels are high in pediatric cases of DENV infection, and the disease progresses. However, the correlation between serum sST2 levels and the outcomes of DENV infection in the elderly (≥65 years) is unclear. We thus explored the mechanisms of serial sST2 level changes involved in the coagulopathy and bloodstream infections of elderly patients in Taiwan’s 2015 DENV outbreak.

Methods

This retrospective study was done in a tertiary medical center in southern Taiwan during the outbreak. All DENV-infected patients who, between July 1, 2015, and December 31, 2015, provided a written informed consent for at least two blood sample analyses were enrolled and reviewed. The serum levels of sST2 were quantified. ΔsST2 is defined as the “changes of sST2 levels in serially paired samples”. Receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) analyses were used to evaluate the prognostic ability of ΔsST2.

Results

Forty-three patients with DENV infection were enrolled. Mean patient age was 75.0 ± 12.2 years and the case fatality rate was 44.2% (19/43). Significantly more non-survivors than survivors had increased ST2 level (78.9% vs. 12.5%, p < 0.001). The AUC value for serum ΔsST2 level was 0.857 for predicting DENV fatality. Moreover, patients given frozen fresh plasma (FFP) transfusions were significantly (p = 0.025) more likely to have higher serum ST2 level changes than were those who had not. DENV-infected patients with early bloodstream infections (BSIs) seemed to have higher ST2 levels than those who did not have BSIs.

Conclusions

Serum ST2 levels increased in the elderly (≥ 65 years of age) with DENV infection. The changes in serum sST2 levels might be a critical indicator of DENV infection severity for the elderly; sST2 is an important modulator of coagulopathy in severe DENV infections.

Dengue virus (DENV) infection is a mosquito-borne disease that annually affects at least 50 million people worldwide. The cytokine response during DENV infection is mercurial and abstruse. IL-1 receptor-like-1 (IL-1R-L-1 [aka ST2]) protein is associated with the severity of DENV infection, and elevated cytokine levels are important early predictors of dengue hemorrhagic fever and dengue shock syndrome. ST2, a member of the interleukin-1-receptor/toll-like receptor (TLR) superfamily, is an important biomarker of severe forms of pediatric DENV infection. We first confirmed a similar trend in the elderly cohort. Serial changes of soluble ST2 (sST2) levels were a more reliable predictor for dengue fatality than a single measurement was. Patients given fresh frozen plasma (FFP) transfusions had significantly higher serum ST2 levels than those who had not been given FFP transfusions. SerumsST2 might be necessary for modulating coagulopathy in severe DENV infections. The exact molecular mechanism and the optimal timing for sST2 testing need further investigation.

Trajectories of hepatic and coagulation dysfunctions related to a rapidly fatal outcome among hospitalized patients with dengue fever in Tainan, 2015

Background

Hepatic dysfunction and coagulopathy are common in acute dengue illness. We analyzed the trajectories of the above parameters in the survivors and fatal patients in the outbreak in Tainan, 2015.

Methods

A retrospective study was conducted using data from a tertiary hospital between January and December 2015. Multilevel modeling (MLM) was used to identify the changes in aminotransferase (AST), alanine aminotransferase (ALT), activated partial thromboplastin time (aPTT), and platelet counts from Day 0 to Day 7 of the onset of dengue infection. The machine-learning algorithm was used by purity measure assumption to calculate the accuracy of serum transaminases and coagulation variables to discriminate between the fatal and survival groups.

Results

There were 4,069 dengue patients, of which 0.9% died in one week after illness onset (i.e., early mortality). Case fatality rate was the highest for those aged ≥70 years. Both AST and ALT values of the fatal group were significantly higher than those of the survivor group from Day 3 (AST median, 624 U/L vs. 60 U/L, p < 0.001; ALT median, 116 U/L vs. 29 U/L, p = 0.01) of illness onset and peaked on Day 6 (AST median, 9805 U/L vs. 90 U/L, p < 0.001; ALT median, 1504 U/L vs. 49 U/L, p < 0.001). AST ≥ 203 U/L, ALT ≥ 55 U/L, AST²/ALT criteria ≥337.35, or AST/platelet count ratio index (APRI) ≥ 19.18 on Day 3 of dengue infection had a high true positive rate, 90%, 78%, 100%, or 100%, respectively, of early mortality. The platelet counts of the fatal group declined significantly than those of the survivor group since Day 3 of illness onset (median, 19 x10³/μl vs. 91 x10³/μl, p < 0.01), and aPTT values of the fatal group significantly prolonged longer since Day 5 (median, 68.7 seconds vs. 40.1 seconds, p < 0.001).

Conclusions

AST, ALT, and platelet counts should be monitored closely from Day 0 to Day 3 of dengue infection, and aPTT be followed up on Day 5 of infection to identify the individuals at risk for early mortality.

Dengue fever (DF) is currently one of the most severe public health problems. Clinical presentations of dengue are diverse and non-specific, often with unpredictable clinical progression and outcome. Hepatic dysfunction and abnormal coagulation factors are common in acute dengue illness, reflected by abnormal alanine aminotransferase (AST), aspartate aminotransferase (ALT), activated partial thromboplastin time (aPTT), and platelet counts. However, there is no information available about the monitoring frequency required, which could help identify those dengue patients who are likely to die, especially during epidemic outbreaks with limited healthcare resources. We examined all the laboratory-confirmed dengue patients who admitted to the major tertiary hospital in Tainan during the 2015 dengue outbreak, and the different trajectories of hepatic function and coagulation factors between survivors and rapidly fatal dengue patients were analyzed. Although there were no differences in AST, ALT, aPTT, and platelet counts between the survivor and fatal groups on the day DF symptoms first appeared, the differences increased from the early stages of infection and became more prominent during the early stages of the illness. The necessity of monitoring the AST, ALT, aPTT, and platelet count frequently during the febrile phase is emphasized by this study.

Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India

Background

India is one of the seven identified countries in South-East Asia region regularly reporting dengue fever (DF)/dengue hemorrhagic fever (DHF) outbreaks. Even though the dengue prodrome and evolution of illness are most often similar in many patients, progress and outcome may differ significantly depending on the severity of illness as well as treatment instituted. We studied the clinical manifestations, outcome and factors predicting mortality of serology confirmed dengue fever cases admitted in Multidisciplinary Intensive Care Unit (MICU) of a high acuity healthcare facility in India.

Methodology

All patients with serology proven dengue fever admitted to MICU between 1st July 2015 and1st December 2015 were included in the study. Clinical presentation, laboratory findings, severity of illness scores and outcome were recorded.

Results

Majority of the patients (58.4%) belonged to 21–40 year age group. Hepatic (96.8%) followed by hematological (79.2%) involvement were the most common findings. CNS involvement observed among 27%. Survival to hospital discharge was 78.9%. Respiratory and gastrointestinal system involvement was associated with increased mortality. Acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and shock were the clinical syndromes associated with mortality. Serum lactate, aspartate transaminase (AST) and alanine transaminase (ALT) were significantly elevated among non survivors. Significant difference in sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) scores was also observed among survivors and non survivors.

Conclusion

Organ system involvement and higher disease severity scores are strong predictors of mortality. High index of suspicion for atypical manifestations of dengue is warranted.

How to cite this article

Padyana M, Karanth S, Vaidya S, Gopaldas JA. Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India. Indian J Crit Care Med 2019;23(6):270–273.

Prevalence of chronic comorbidities in dengue fever and West Nile virus: A systematic review and meta-analysis

Background

Flavivirus diseases such as dengue fever (DENV), West Nile virus (WNV), Zika and yellow fever represent a substantial global public health concern. Preexisting chronic conditions such as cardiovascular diseases, diabetes, obesity, and asthma were thought to predict risk of progression to severe infections.

Objective

We aimed to quantify the frequency of chronic comorbidities in flavivirus diseases to provide an estimate for their prevalence in severe and non-severe infections and examine whether chronic diseases contribute to the increased risk of severe viral expression.

Methods

We conducted a comprehensive search in PubMed, Ovid MEDLINE(R), Embase and Embase Classic and grey literature databases to identify studies reporting prevalence estimates of comorbidities in flavivirus diseases. Study quality was assessed with the risk of bias tool. Age-adjusted odds ratios (ORs) were estimated for severe infection in the presence of chronic comorbidities.

Results

We identified 65 studies as eligible for inclusion for DENV (47 studies) and WNV (18 studies). Obesity and overweight (i.e., BMI> 25 kg/m², prevalence: 24.5%, 95% CI: 18.6–31.6%), hypertension (17.1%, 13.3–21.8%) and diabetes (13.3%, 9.3–18.8%) were the most prevalent comorbidities in DENV. However, hypertension (45.0%, 39.1–51.0%), diabetes (24.7%, 20.2–29.8%) and heart diseases (25.6%, 19.5–32.7%) were the most prevalent in WNV. ORs of severe flavivirus diseases were about 2 to 4 in infected patients with comorbidities such as diabetes, hypertension and heart diseases. The small number of studies in JEV, YFV and Zika did not permit estimating the prevalence of comorbidities in these infections.

Conclusion

Higher prevalence of chronic comorbidities was found in severe cases of flavivirus diseases compared to non-severe cases. Findings of the present study may guide public health practitioners and clinicians to evaluate infection severity based on the presence of comorbidity, a critical public health measure that may avert severe disease outcome given the current dearth of clear prevention practices for some flavivirus diseases.

The outcomes and prognostic factors of the patients with unplanned intensive care unit readmissions

This retrospective cohort study investigated the outcomes of patients with unplanned intensive care unit (ICU) readmission.All of the patients readmitted to ICU within 48 hours between 2010 and 2016 were enrolled.A total of 99 patients early readmitted to ICU were identified and their mean age of the patients was 68.8 ± 14.8 years. Respiratory failure was the most common cause of ICU readmission (n = 48, 48.5%), followed by acute myocardial ischemia or worsening heart failure (n = 25, 25.3%), sepsis (n = 22, 22.2%), gastrointestinal disease (n = 16, 16.2%), and neurologic disease (n = 11, 11.1%). The median length of stay in the ICU and hospital was 7 (IQR, 4-11.5) and 32 (IQR, 15.5-48.5) days, respectively. A total of 34 patients died during the hospital stay and the rate of in-hospital mortality was 34.3%. Patients with higher APACHE II scores (adjusted odds ratio [OR], 1.17; 95% CI, 1.02-1.33), underlying malignancy (adjusted OR, 4.70; 95% CI, 1.19-18.57), and cardiovascular organ dysfunction (adjusted OR, 5.14; 95% CI, 1.24-21.38) were more likely to die.The mortality rate of ICU readmission patients was high, especially for those with higher APACHE II score, underlying malignancy and cardiovascular organ dysfunction.

Prediction of mortality in severe dengue cases

BACKGROUND

Increasing incidence of dengue cases in Malaysia over the last few years has been paralleled by increased deaths. Mortality prediction models will therefore be useful in clinical management. The aim of this study is to identify factors at diagnosis of severe dengue that predicts mortality and assess predictive models based on these identified factors.

METHOD

This is a retrospective cohort study of confirmed severe dengue patients that were admitted in 2014 to Hospital Kuala Lumpur. Data on baseline characteristics, clinical parameters, and laboratory findings at diagnosis of severe dengue were collected. The outcome of interest is death among patients diagnosed with severe dengue.

RESULTS

There were 199 patients with severe dengue included in the study. Multivariate analysis found lethargy, OR 3.84 (95% CI 1.23-12.03); bleeding, OR 8.88 (95% CI 2.91-27.15); pulse rate, OR 1.04 (95% CI 1.01-1.07); serum bicarbonate, OR 0.79 (95% CI 0.70-0.89) and serum lactate OR 1.27 (95% CI 1.09-1.47), to be statistically significant predictors of death. The regression equation to our model with the highest AUROC, 83.5 (95% CI 72.4-94.6), is: Log odds of death amongst severe dengue cases = - 1.021 - 0.220(Serum bicarbonate) + 0.001(ALT) + 0.067(Age) - 0.190(Gender).

CONCLUSION

This study showed that a large proportion of severe dengue occurred early, whilst patients were still febrile. The best prediction model to predict death at recognition of severe dengue is a model that incorporates serum bicarbonate and ALT levels.

Technical and Alarm signs for referral in adult patients with acute febrile illness: A study from a tertiary care hospital in North India

Context

There is a huge burden of patients with acute febrile illness (AFI) during the post-monsoon season in India. It is very important to have a functioning triage system, whereby patients with high likelihood of developing a severe illness are referred to higher levels of care.

Aim

The objective of this study was to identify the alarm signs which would help in triaging of those patients with AFI without any specific diagnosis.

Methods

This was a retrospective review of records, whereby clinical and laboratory parameters of patients with AFI admitted in our tertiary care center between July 2016 and October 2016 were reviewed.

Statistical Analysis Used

Appropriate tests of significance were applied using SPSS 21(Chicago, IL, USA) to find statistically significant differences between those who required mechanical ventilation, intensive care, ionotropic support, or higher intravenous antibiotics and those who recovered with minimal supportive care.

Results

Presence of comorbidities, dyspnea, altered sensorium, features of myocarditis, hypotension, leukocytosis (>11,000/μL), and acute kidney injury were significantly associated with requirement of higher levels of care, while presence of arthralgia, serositis, and leucopenia indicated a higher likelihood of recovery with minimal support.

Conclusion

This article highlights the possibility of identification of simple alarm signs in patients with AFI which would indicate the need for higher levels of care.

Symptoms associated with adverse dengue fever prognoses at the time of reporting in the 2015 dengue outbreak in Taiwan

BACKGROUND

Tainan experienced the most severe dengue epidemic in Taiwan in 2015. This study investigates the association between the signs and symptoms at the time of reporting with the adverse dengue prognoses.

METHODS

A descriptive study was conducted using secondary data from the Dengue Disease Reporting System in Tainan, Taiwan, between January 1 and December 31, 2015. A multivariate stepwise logistic regression was used to identify the risk factors for the adverse prognoses: ICU admissions and mortality.

RESULTS

There were 22,777 laboratory-confirmed reported cases (mean age 45.6 ± 21.2 years), of which 3.7% were admitted to intensive care units (ICU), and 0.8% were fatal. The most common symptoms were fever (92.8%), myalgia (26.6%), and headache (22.4%). The prevalence of respiratory distress, altered consciousness, shock, bleeding, and thrombocytopenia increased with age. The multivariate analysis indicated that being in 65-89 years old age group [Adjusted Odds Ratio (aOR):4.95], or the 90 years old and above age group (aOR: 9.06), and presenting with shock (aOR: 8.90) and respiratory distress (aOR: 5.31) were significantly associated with the risk of ICU admission. While old age (aOR: 1.11), respiratory distress (aOR: 9.66), altered consciousness (aOR: 7.06), and thrombocytopenia (aOR: 2.55) were significantly associated with the risk of mortality.

CONCLUSIONS

Dengue patients older than 65 and those with severe and non-specific signs and symptoms at the time of reporting were at a higher risk of ICU admission and mortality. First-line healthcare providers need to be aware of the varied presentations between the different age groups to allow early diagnosis and in-time management, which would prevent ICU admissions and fatalities in dengue patients.

Predictors of Dengue-Related Mortality and Disease Severity in a Tertiary Care Center in North India

Background

There is lack of reliable predictors of disease severity and mortality in dengue. The present study was carried out to identify these predictors during the 2015 outbreak in India.

Methods

This prospective observational study included confirmed adult dengue patients hospitalized between August and November 2015 in a tertiary care centre in New Delhi, India. Appropriate statistical tests were used to compare clinicolaboratory characteristics, derive predictors of severe disease and mortality, and compute a predictive score for mortality. Serotyping was done.

Results

Data of 369 patients were analyzed (mean age, 30.9 years; 67% males). Of these, 198 (54%) patients had dengue fever, 125 (34%) had dengue hemorrhagic fever (grade 1 or 2), and 46 (12%) developed dengue shock syndrome (DSS). Twenty-two (6%) patients died. Late presentation to the hospital (≥5 days after onset) and dyspnea at rest were identified as independent predictors of severe disease. Age ≥24 years, dyspnea at rest and altered sensorium were identified as independent predictors of mortality. A clinical risk score was developed (12*age + 14*sensorium + 10*dyspnea), which, if ≥22, predicted mortality with a high sensitivity (81.8%) and specificity (79.2%). The predominant serotypes in Delhi (2015) were dengue virus DENV2 and DENV4.

Conclusion

Age ≥24 years, dyspnea at rest, and altered sensorium were identified as independent predictors of mortality. Platelet counts did not determine outcome in dengue patients. Timely referral/access to healthcare is important. The clinical risk score for mortality prediction that was developed in this study can be used in all healthcare settings, after validation in larger cohorts.

The prognostic value of N-terminal proB-type natriuretic peptide in patients with acute respiratory distress syndrome

We investigated whether N-terminal proB-type natriuretic peptide (NT-proBNP) predicts the prognosis of patients with acute respiratory distress syndrome (ARDS). Between December 1, 2012, and May 31, 2015, this observational study recruited patients admitted to our tertiary medical center who met the Berlin criteria for ARDS and who had their NT-proBNP measured. The main outcome was 28-day mortality. We enrolled 61 patients who met the Berlin criteria for ARDS: 7 were classified as mild, 29 as moderate, and 25 as severe. The median APACHE II scores were 23 (interquartile range [IQR], 18-28), and SOFA scores were 11 (IQR, 8-13). The median lung injury score was 3.0 (IQR, 2.50-3.25), and the median level of NT-proBNP was 2011 pg/ml (IQR, 579-7216). Thirty-four patients died during this study, and the 28-day mortality rate was 55.7%. Patients who die were older and had significantly (all p < 0.05) higher APACHE II scores and NT-proBNP levels than did patients who survived. Multivariate analysis identified age (HR: 1.546, 95% CI: 1.174-2.035, p = 0.0019) and NT-proBNP (HR: 1.009, 95% CI: 1.004-1.013, p = 0.0001) as significant risk factors of death. NT-proBNP was associated with poor outcomes for patients with ARDS, and its level predicted mortality.

Minimizing Spatial Variability of Healthcare Spatial Accessibility-The Case of a Dengue Fever Outbreak

Outbreaks of infectious diseases or multi-casualty incidents have the potential to generate a large number of patients. It is a challenge for the healthcare system when demand for care suddenly surges. Traditionally, valuation of heath care spatial accessibility was based on static supply and demand information. In this study, we proposed an optimal model with the three-step floating catchment area (3SFCA) to account for the supply to minimize variability in spatial accessibility. We used empirical dengue fever outbreak data in Tainan City, Taiwan in 2015 to demonstrate the dynamic change in spatial accessibility based on the epidemic trend. The x and y coordinates of dengue-infected patients with precision loss were provided publicly by the Tainan City government, and were used as our model's demand. The spatial accessibility of heath care during the dengue outbreak from August to October 2015 was analyzed spatially and temporally by producing accessibility maps, and conducting capacity change analysis. This study also utilized the particle swarm optimization (PSO) model to decrease the spatial variation in accessibility and shortage areas of healthcare resources as the epidemic went on. The proposed method in this study can help decision makers reallocate healthcare resources spatially when the ratios of demand and supply surge too quickly and form clusters in some locations.

Fatal Dengue Myocarditis despite the Use of Extracorporeal Membrane Oxygenation

Dengue is an important mosquitoes-borne viral disease which is endemic in tropics and subtropics region. Rapid spreading of disease to previously unaffected region was found in recent years. Atypical manifestations, such as myocarditis, were reported during large outbreak. There is a wide range of clinical manifestations of cardiac involvement in dengue, but rarely fatal. Here we reported a case of fulminant dengue myocarditis in fatal outcome despite cardiac mechanical support.