Early clinical and laboratory risk factors of intensive care unit requirement during 2004-2008 dengue epidemics in Singapore: a matched case-control study

Diabetes mellitus as a risk factor for severe dengue fever and West Nile fever: A meta-analysis

BACKGROUND

Dengue fever (DF) and West Nile fever (WNF) have become endemic worldwide in the last two decades. Studies suggest that individuals with diabetes mellitus (DM) are at a higher risk of developing severe complications from these diseases. Identifying the factors associated with a severe clinical presentation is crucial, as prompt treatment is essential to prevent complications and fatalities. This article aims to summarize and assess the published evidence regarding the link between DM and the risk of severe clinical manifestations in cases of DF and WNF.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic search was conducted using the PubMed and Web of Science databases. 27 studies (19 on DF, 8 on WNF) involving 342,873 laboratory-confirmed patients were included in the analysis. The analysis showed that a diagnosis of DM was associated with an increased risk for severe clinical presentations of both DF (OR 3.39; 95% CI: 2.46, 4.68) and WNF (OR 2.89; 95% CI: 1.89, 4.41). DM also significantly increased the risk of death from both diseases (DF: OR 1.95; 95% CI: 1.09, 3.52; WNF: OR 1.74; 95% CI: 1.40, 2.17).

CONCLUSIONS/SIGNIFICANCE

This study provides strong evidence supporting the association between DM and an increased risk of severe clinical manifestations in cases of DF and WNF. Diabetic individuals in DF or WNF endemic areas should be closely monitored when presenting with febrile symptoms due to their higher susceptibility to severe disease. Early detection and appropriate management strategies are crucial in reducing the morbidity and mortality rates associated with DF and WNF in diabetic patients. Tailored care and targeted public health interventions are needed to address this at-risk population. Further research is required to understand the underlying mechanisms and develop effective preventive and therapeutic approaches.

Diabetes and climate change: current evidence and implications for people with diabetes, clinicians and policy stakeholders

Climate change will be a major challenge for the world's health systems in the coming decades. Elevated temperatures and increasing frequencies of heat waves, wildfires, heavy precipitation and other weather extremes can affect health in many ways, especially if chronic diseases are already present. Impaired responses to heat stress, including compromised vasodilation and sweating, diabetes-related comorbidities, insulin resistance and chronic low-grade inflammation make people with diabetes particularly vulnerable to environmental risk factors, such as extreme weather events and air pollution. Additionally, multiple pathogens show an increased rate of transmission under conditions of climate change and people with diabetes have an altered immune system, which increases the risk for a worse course of infectious diseases. In this review, we summarise recent studies on the impact of climate-change-associated risk for people with diabetes and discuss which individuals may be specifically prone to these risk conditions due to their clinical features. Knowledge of such high-risk groups will help to develop and implement tailored prevention and management strategies to mitigate the detrimental effect of climate change on the health of people with diabetes.

Development and Utility of Practical Indicators of Critical Outcomes in Dengue Patients Presenting to Hospital: A Retrospective Cross-Sectional Study

Global travel and climate change have drastically increased the number of countries with endemic or epidemic dengue. The largest dengue outbreak in Taiwan, with 43,419 cases and 228 deaths, occurred in 2015. Practical and cost-effective tools for early prediction of clinical outcomes in dengue patients, especially the elderly, are limited. This study identified the clinical profile and prognostic indicators of critical outcomes in dengue patients on the basis of clinical parameters and comorbidities. A retrospective cross-sectional study was conducted in a tertiary hospital from 1 July 2015 to 30 November 2015. Patients diagnosed with dengue were enrolled, and the initial clinical presentations, diagnostic laboratory data, details of the underlying comorbidities, and initial management recommendations based on 2009 World Health Organization (WHO) guidelines were used to evaluate prognostic indicators of critical outcomes in dengue patients. Dengue patients from another regional hospital were used to evaluate accuracy. A group B (4 points) classification, temperature < 38.5 °C (1 point), lower diastolic blood pressure (1 point), prolonged activated partial thromboplastin time (aPTT) (2 points), and elevated liver enzymes (1 point) were included in the scoring system. The area under the receiver operating characteristic curve of the clinical model was 0.933 (95% confidence interval [CI]: 0.905–0.960). The tool had good predictive value and clinical applicability for identifying patients with critical outcomes.

Comprehensive analysis of multivariable models for predicting severe dengue prognosis: systematic review and meta-analysis

Dengue fever has often been confused with other febrile diseases, with deterioration occurring in the later state. Many predictive models for disease progression have been developed, but there is no definite statistical model for clinical use yet. We retrieved relevant articles through Global Health, EMBASE, MEDLINE and CINAHL Plus. The Prediction Model Risk of Bias Assessment Tool was adopted to assess potential bias and applicability. Statistical analysis was performed using Meta-DiSc software (version 1.4). Of 3184 research studies, 22 were included for the systematic review, of which 17 were selected for further meta-analysis. The pooled data of predictive accuracy was as follows: the sensitivity was 0.88 (95% CI 0.86 to 0.89), the specificity was 0.60 (95% CI 0.59 to 0.60), the positive likelihood ratio was 2.83 (95% CI 2.38 to 3.37), the negative likelihood ratio was 0.20 (95% CI 0.14 to 0.0.29) and the diagnostic OR was 16.31 (95% CI 10.25 to 25.94). The area under the summary receiver operating characteristic curve value was 0.86 (SE=0.02) with 0.79 (SE=0.02) of the Cochran Q test value. The overall predictive power of models in this study was relatively high. With careful adaption and standardization, the implementation of predictive models for severe dengue could be practical in actual clinical settings.

Risk Factors for Mortality in Patients with Dengue: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate risk factors for mortality in dengue.

METHODS

Systematic review and meta-analysis searching MEDLINE, Embase, SciELO, LILACS Bireme, and OpenGrey to identify eligible observational studies of patients with dengue, of both genders, aged 14 years or older, that analyzed risk factors associated with mortality and reported adjusted risk measures with their respective confidence intervals (CIs). We estimated the pooled weighted mean difference and 95% CIs with a DerSimonian and Laird random-effects model. Methodological quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1,170 citations reviewed, 18 papers, with a total of 25,851 patients, were included in the systematic review and 12 in the meta-analysis. Severe hepatitis (OR 29.222, 95% CI: 3.876-220.314), dengue shock syndrome (OR 23.575, 95% CI 3.664-151.702), altered mental status (OR 3.76, 95% CI 1.67-8.42), diabetes mellitus (OR 3.698, 95% CI 1.196-11.433), and higher pulse rate (OR 1.039, 95% CI 1.011-1.067) are associated with mortality in patients with dengue. All studies included were classified as having a high quality.

CONCLUSIONS

Proper identification and management of these risk factors should be considered to improve patient outcomes and reduce the hidden burden of this neglected tropical disease. Future well-designed studies are needed to investigate the association of other clinical, radiological, and laboratorial findings with mortality in dengue, as well as to develop prognostic models based on the risk factors found in our study.

Factors associated with severe dengue in Savannakhet Province, Lao People's Democratic Republic

This study aimed to describe the socio-demographic and clinical characteristics of dengue inpatients at a provincial hospital, and to identify factors associated with severe dengue. This is a retrospective study involving 402 dengue patients admitted to the Savannakhet Provincial Hospital, Lao People's Democratic Republic (Lao PDR), between January 2018 and April 2019. Socio-demographic factors, clinical signs and laboratory data on admission, final diagnosis, use of health care services before admission, admission date, and hospitalization period were collected from patient records. The number of dengue inpatients was higher in the rainy season than in the dry season. Of the 402 patients, 205 patients (51.0%) were finally diagnosed with severe dengue. Children aged <15 years had more symptoms, higher proportion of severe dengue (69.8% vs. 35.9%), and longer hospitalization (3.5 days vs. 3.0 days) than adults aged ≥15 years. In multivariable analyses, factors associated with severe dengue were nausea on admission (adjusted odds ratio=3.57, 95% CI=1.05-12.09, P=0.04) in children and persistent vomiting on admission (adjusted odds ratio=3.82, 95% CI=1.23-11.92, P=0.02) in adults. In adults, the creatinine level on admission was significantly higher in patients with a final diagnosis of severe dengue compared to the others. The proportion of severe dengue in our study was higher than that in other countries. Nausea and persistent vomiting on admission were suggested to be predictive factors for severe dengue. To reduce the incidence of severe dengue in Lao PDR, improvements in access to health care, referral system, and training of health care workers are needed.

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.

Diagnostic accuracy and predictive value in differentiating the severity of dengue infection

OBJECTIVE

To review the diagnostic test accuracy and predictive value of statistical models in differentiating the severity of dengue infection.

METHODS

Electronic searches were conducted in the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE (complete), PubMed and Scopus. Eligible studies to be included in this review were cohort studies with participants confirmed by laboratory test for dengue infection and comparison among the different severity of dengue infection by using statistical models. The methodological quality of the paper was assessed by independent reviewers using QUADAS-2.

RESULTS

Twenty-six studies published from 1994 to 2017 were included. Most diagnostic models produced an accuracy of 75% to 80% except one with 86%. Two models predicting severe dengue according to the WHO 2009 classification have 86% accuracy. Both of these logistic regression models were applied during the first three days of illness, and their sensitivity and specificity were 91-100% and 79.3-86%, respectively. Another model which evaluated the 30-day mortality of dengue infection had an accuracy of 98.5%.

CONCLUSION

Although there are several potential predictive or diagnostic models for dengue infection, their limitations could affect their validity. It is recommended that these models be revalidated in other clinical settings and their methods be improved and standardised in future.

Platelet function in HIV plus dengue coinfection associates with reduced inflammation and milder dengue illness

HIV-infected subjects under virological control still exhibit a persistent proinflammatory state. Thus, chronic HIV infection changes the host homeostasis towards an adapted immune response that may affect the outcome of coinfections. However, little is known about the impact of HIV infection on inflammatory amplification and clinical presentation in dengue. Platelets have been shown to participate in immune response in dengue and HIV. We hypothesized that altered platelet responses in HIV-infected subjects may contribute to altered inflammatory milieu and disease progression in dengue. We prospectively followed a cohort of 84 DENV-infected patients of whom 29 were coinfected with HIV under virological control. We report that dengue and HIV coinfection progress with reduced inflammation and milder disease progression with lower risk of vascular instability. Even though the degree of thrombocytopenia and platelet activation were similar between dengue-infected and HIV plus dengue-coinfected patients, plasma levels of the platelet-derived chemokines RANTES/CCL5 and PF4/CXCL4 were lower in coinfection. Consistently, platelets from coinfected patients presented defective secretion of the stored-chemokines PF4 and RANTES, but not newly synthesized IL-1β, when cultured ex vivo. These data indicate that platelets from HIV-infected subjects release lower levels of chemokines during dengue illness, which may contribute to milder clinical presentation during coinfection.

Risk Factors Associated with Dengue Virus Infection in Guangdong Province: A Community-Based Case-Control Study

Dengue fever (DF) is a mosquito-borne infectious disease that is now an epidemic in China, Guangdong Province, in particular and presents high incidence rates of DF. Effective preventive measures are critical for controlling DF in China given the absence of a licensed vaccination program in the country. This study aimed to explore the individual risk factors for the dengue virus infection in Guangdong Province and to provide a scientific basis for the future prevention and control of DF. A case-control study including 237 cases and 237 controls was performed. Cases were defined for samples who were IgG-antibody positive or IgM-antibody positive, and willing to participate in the questionnaire survey. Additionally, the controls were selected through frequency matching by age, gender and community information from individuals who tested negative for IgG and IgM and volunteered to become part of the samples. Data were collected from epidemiological questionnaires. Univariate analysis was performed for the preliminary screening of 28 variables that were potentially related to dengue virus infection, and multivariate analysis was performed through unconditioned logistic regression analysis to analyze statistically significant variables. Multivariate analysis revealed two independent risk factors: Participation in outdoor sports (odds ratio (OR) = 1.80, 95% confidence interval (CI) 1.17 to 2.78), and poor indoor daylight quality (OR = 2.27, 95% CI 1.03 to 5.03). Two protective factors were identified through multivariate analysis: 2 occupants per room (OR = 0.43, 95% CI 0.28 to 0.65) or ≥3 occupants per room (OR = 0.45, 95% CI 0.23 to 0.89) and air-conditioner use (OR = 0.46, 95% CI 0.22 to 0.97). The results of this study were conducive for investigating the risk factors for dengue virus infection in Guangdong Province. Effective and efficient strategies for improving environmental protection and anti-mosquito measures must be provided. In addition, additional systematic studies are needed to explore other potential risk factors for DF.

Clinical Indicators of Fatal Dengue in Two Endemic Areas of Colombia: A Hospital-Based Case-Control Study

According to the World Health Organization, 98% of fatal dengue cases can be prevented; however, endemic countries such as Colombia have recorded higher case fatality rates during recent epidemics. We aimed to identify the predictors of mortality that allow risk stratification and timely intervention in patients with dengue. We conducted a hospital-based, case-control (1:2) study in two endemic areas of Colombia (2009-2015). Fatal cases were defined as having either 1) positive serological test (IgM or NS1), 2) positive virological test (RT-PCR or viral isolation), or 3) autopsy findings compatible with death from dengue. Controls (matched by state and year) were hospitalized nonfatal patients and had a positive serological or virological dengue test. Exposure data were extracted from medical records by trained staff. We used conditional logistic regression (adjusting for age, gender, disease's duration, and health-care provider) in the context of multiple imputation to estimate exposure to case-control associations. We evaluated 110 cases and 217 controls (mean age: 35.0 versus 18.9; disease's duration pre-admission: 4.9 versus 5.0 days). In multivariable analysis, retro-ocular pain (odds ratios [OR] = 0.23), nausea (OR = 0.29), and diarrhea (OR = 0.19) were less prevalent among fatal than nonfatal cases, whereas increased age (OR = 2.46 per 10 years), respiratory distress (OR = 16.3), impaired consciousness (OR = 15.9), jaundice (OR = 32.2), and increased heart rate (OR = 2.01 per 10 beats per minute) increased the likelihood of death (AUC: 0.97, 95% confidence interval: 0.96, 0.99). These results provide evidence that features of severe dengue are associated with higher mortality, which strengthens the recommendations related to triaging patients in dengue-endemic areas.

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.

Platelets in Immune Response to Virus and Immunopathology of Viral Infections

Platelets are essential effector cells in hemostasis. Aside from their role in coagulation, platelets are now recognized as major inflammatory cells with key roles in the innate and adaptive arms of the immune system. Activated platelets have key thromboinflammatory functions linking coagulation to immune responses in various infections, including in response to virus. Recent studies have revealed that platelets exhibit several pattern recognition receptors (PRR) including those from the toll-like receptor, NOD-like receptor, and C-type lectin receptor family and are first-line sentinels in detecting and responding to pathogens in the vasculature. Here, we review the main mechanisms of platelets interaction with viruses, including their ability to sustain viral infection and replication, their expression of specialized PRR, and activation of thromboinflammatory responses against viruses. Finally, we discuss the role of platelet-derived mediators and platelet interaction with vascular and immune cells in protective and pathophysiologic responses to dengue, influenza, and human immunodeficiency virus 1 infections.

Critical care for dengue in adult patients: an overview of current knowledge and future challenges

PURPOSE OF REVIEW

This review aims to update and summarize the current knowledge about clinical features, management, and risk factors of adult dengue patients requiring intensive care with consequently higher risk of mortality.

RECENT FINDINGS

Increasingly, there are more adult dengue patients who require intensive care. This may be due to a shift in epidemiology of dengue infection from mainly a pediatric disease toward adult disease. In addition, multiorgan dysfunction was observed to be a key risk factor for ICU admission and mortality. This may be due to older adults having preexisting comorbidities that potentially predispose to have multiple severe organ impairment. Interventions remain largely supportive but also require more evidence-based trials and treatment protocols.

SUMMARY

These findings highlight the common clinical manifestations of adult dengue patients and the challenges of clinical management in ICU. Risk factors for prediction of adult dengue patients who require ICU are available, but they lack validation and consistent study design for meta-analysis in future. Early recognition of these risk factors, with close monitoring and prompt clinical management, remains critical to reduce mortality.

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.

Differences in Mortality and Clinical Manifestations of Dengue Hemorrhagic Fever in Taiwan in Different Years: A Comparison for Cases in 2014 and 2015 Epidemics

People in southern Taiwan experienced two major dengue outbreaks in 2014 and 2015. The mortality and clinical features were very different between these 2 years. Dengue virus serotype 1 (DENV-1) caused epidemic outbreak in 2014 and DENV-2 was predominant in 2015. The characteristics of dengue hemorrhagic fever (DHF) cases in the 2 years was analyzed. We conducted a retrospective chart review to analyze the clinical and laboratory features of 206 adult patients with DHF in southern Taiwan in 2014 and 2015. The mortality rate of DHF cases in 2015 was higher than that of cases in 2014 (38.7% versus 12.4%, P < 0.0001). Compared with cases in 2014, DHF cases in 2015 had more complications, such as gastrointestinal bleeding (78.5% versus 61.9%, P = 0.01), severe hepatitis (30.1% versus 8%, P < 0.0001), and myocarditis (14% versus 0.9%, P < 0.0001). Among the mortality cases, diabetes, chronic renal failure, proton-pump inhibitors using, platelet transfusion, and Charlson comorbidity index score (Charlson score) were also higher in 2015. Multivariate analysis for the mortality cases revealed that the risk factors were Charlson score ≥ 5 (P = 0.02, odds ratio [OR] = 4.07, 95% confidence interval [CI] = 1.244-13.307), severe hepatitis (P < 0.0001, OR = 11.97, 95% CI = 3.831-37.396), and acute renal failure (P < 0.0001, OR = 98.76, 95% CI = 10.847-899.22). DHF cases in 2015 had higher mortality and more complications, such as gastrointestinal bleeding, severe hepatitis, and myocarditis, than in 2014 in southern Taiwan. In the 2-year DHF case series, Charlson score ≥ 5, severe hepatitis, and acute renal failure were independent significant variables for mortality.

The global diabetes epidemic: what does it mean for infectious diseases in tropical countries?

Tropical countries are experiencing a substantial rise in type 2 diabetes, which is often undiagnosed or poorly controlled. Since diabetes is a risk factor for many infectious diseases, this increase probably adds to the large infectious disease burden in tropical countries. We reviewed the literature to investigate the interface between diabetes and infections in tropical countries, including the WHO-defined neglected tropical diseases. Although solid data are sparse, patients with diabetes living in tropical countries most likely face increased risks of common and health-care-associated infections, as well as infected foot ulcers, which often lead to amputation. There is strong evidence that diabetes increases the severity of some endemic infections such as tuberculosis, melioidosis, and dengue virus infection. Some HIV and antiparasitic drugs might induce diabetes, whereas helminth infections appear to afford some protection against future diabetes. But there are no or very scarce data for most tropical infections and for possible biological mechanisms underlying associations with diabetes. The rise in diabetes and other non-communicable diseases puts a heavy toll on health systems in tropical countries. On the other hand, complications common to both diabetes and some tropical infections might provide an opportunity for shared services-for example, for eye health (trachoma and onchocerciasis), ulcer care (leprosy), or renal support (schistosomiasis). More research about the interaction of diabetes and infections in tropical countries is needed, and the infectious disease burden in these countries is another reason to step up global efforts to improve prevention and care for diabetes.

IL-28 and IL-29 as protective markers in subject with dengue fever

About 400 million people every year are estimated to contract dengue virus infection, which causes prolonged morbidity and sometimes mortality. Interleukin (IL)-28 and IL-29 are relatively newly discovered cytokines and play an important role in our immune defense against pathogens, especially for viral infection. In the present study, we investigated serum IL-28 and IL-29 expression and the relationship to clinical and laboratory parameters in patients with dengue virus infection. Adult patients with dengue (n = 45) and control group (n = 24) were included prospectively. Clinical symptoms and laboratory data were collected from every patient. We investigated IL-28 and IL-29 levels in serum by ELISA. The concentrations of serum IL-28 and IL-29 were significantly higher in subjects with dengue when compared to those of control group. The patients with higher serum IL-28 and IL-29 levels had significantly lower ALAT and peripheral blood neutrophil percentage, but higher peripheral platelet, total white blood cell (WBC), monocyte, and lymphocyte counts. Patients with higher serum IL-28 and IL-29 levels also had more flu-like symptoms, but less vomiting. Increased level of IL-28 and IL-29 was associated with better liver function, platelet and WBC numbers and clinical symptom in subjects with dengue and could potentially serve as a protective marker.

A Cohort Study of Adult Patients with Severe Dengue in Taiwanese Intensive Care Units: The Elderly and APTT Prolongation Matter for Prognosis

Background

There was a large dengue outbreak in Taiwan in 2015, in which the ages of the affected individuals were higher than those in other countries. The aim of this study was to explore the characteristics and prognostic factors for adults with severe dengue in intensive care units (ICUs).

Methods

All adults admitted to ICUs with dengue virus infection (DENV) at a medical center from July 1, 2015 to December 31, 2015 were enrolled. DENV was diagnosed by the presence of serum NS1 antigen, IgM antibodies to dengue virus, or dengue virus RNA by real-time reverse transcriptase polymerase chain reaction. Demographic data, clinical features, and lab data were collected, and a multivariate Cox model was used to identify the predictive factors for in-hospital mortality.

Results

Seventy-five patients admitted to ICUs with laboratory-confirmed DENV were enrolled (mean age 72.3±9.3 years). The most common comorbidities included hypertension (72.0%), diabetes (43.7%), and chronic kidney disease (22.7%). The in-hospital case fatality rate (CFR) was 41.3%. The patients who died were predominantly female, had higher disease severity at ICU admission, shorter ICU/hospital stay, longer initial activated partial thromboplastin time (APTT), and higher initial serum aspartate transaminase levels. Cardiac arrest before ICU admission (hazard ratio [HR]: 6.26 [1.91–20.54]), prolonged APTT (>48 seconds; HR: 3.91 [1.69–9.07]), and the presence of acute kidney injury on admission (HR: 2.48 [1.07–5.74]), were independently associated with in-hospital fatality in the Cox multivariate analysis.

Conclusion

During the 2015 dengue outbreak in Taiwan, the patients with severe dengue in ICUs were characterized by old age, multiple comorbidities, and a high CFR. Organ failure (including cardiac failure, and renal failure) and coagulation disturbance (prolongation of initial APTT) were independent predictive factors for in-hospital fatality.

Severe forms of dengue fever (DF) are usually considered as a pediatric disease in southern Asia and are graded from dengue hemorrhagic fever (DHF) to dengue with shock syndrome (DSS). However, the age of affected individuals is increasing in Singapore, Thailand, Mainland China, Taiwan and many other countries. Limited data are available on the elderly with DF in intensive care units (ICUs). DF in the elderly is an emerging infectious disease and poses a new clinical challenge to physicians. We enrolled the patients with laboratory-confirmed dengue in our ICU during the 2015 dengue outbreak in Taiwan. These patients were characterized by old age, multiple comorbidities, and a high case fatality rate (CFR). All of the patients were classified as severe dengue, and the in-hospital CFR was 41.3%. Renal failure and cardiac arrest were associated with fatality. In addition to organ failure, initial prolonged activated partial thromboplastin time (APTT) in our study was consistent with an independent predictive factor for in-hospital fatality. Previous studies have also reported that prolongation of APTT is a clinical predictor of dengue virus infection (DENV) or DHF. Our results highlight that APTT prolongation may be a prognostic factor in critically ill adults with severe dengue.

Diabetes, cardiac disorders and asthma as risk factors for severe organ involvement among adult dengue patients: A matched case-control study

Progression to severe organ involvement due to dengue infection has been associated with severe dengue disease, intensive care treatment, and mortality. However, there is a lack of understanding of the impact of pre-existing comorbidities and other risk factors of severe organ involvement among dengue adults. The aim of this retrospective case-control study is to characterize and identify risk factors that predispose dengue adults at risk of progression with severe organ involvement. This study involved 174 dengue patients who had progressed with severe organ involvement and 865 dengue patients without severe organ involvement, matched by the year of presentation of the cases, who were admitted to Tan Tock Seng Hospital between year 2005 and 2008. Age group of 60 years or older, diabetes, cardiac disorders, asthma, and having two or more pre-existing comorbidities were independent risk factors of severe organ involvement. Abdominal pain, clinical fluid accumulation, and hematocrit rise and rapid platelet count drop at presentation were significantly associated with severe organ involvement. These risk factors, when validated in a larger study, will be useful for triage by clinicians for prompt monitoring and clinical management at first presentation, to minimize the risk of severe organ involvement and hence, disease severity.

Current management of severe dengue infection

INTRODUCTION

Traditionally a disease mainly affecting the pediatric population, dengue burden has increased significantly in recent decades and adults with severe disease may become more common. There is currently no effective anti-viral agent available for the treatment of dengue and supportive care is the mainstay of management. Areas covered: We present a review of current literature on dengue severity classification systems and the management of severe dengue in adults. In particular, emphasis was placed on organ impairment in dengue and management of elderly individuals with multiple medical problems. Expert commentary: There is an urgent need to search for an effective anti-viral agent to treat infected individuals. The commercial availability of a dengue vaccine in older children has provided optimism in reducing the disease burden but long term efficacy and safety are unknown. The results from phase III trials of two new candidate vaccines are eagerly awaited.

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

Outcomes of adult patients with dengue infections requiring intensive care unit (ICU) admissions remain unclear. We assessed the clinical manifestations and prognostic factors of patients critically ill with severe dengue.This retrospective study was done in a tertiary referral hospital with 96 adult ICU beds. All of the patients with laboratory-confirmed severe dengue infections and admitted to the ICU were enrolled between July 31 and November 31, 2015, during the large outbreak period. The medical records of all the recruited patients were reviewed for the following information: age, gender, clinical manifestations, disease severity scores, underlying conditions, laboratory examinations, and outcomes. The primary endpoint was to find the predictors of ICU mortality.During the study period, 4787 patients with dengue infections required ICU admission. One hundred forty-three (2.99%) were critically ill (mean age: 69.7 years). Hypertension (n = 90, 62.9%) and diabetes mellitus (n = 70, 49.0%) were the 2 most common underlying diseases. Eighty critically ill patients (55.9%) had cobacterial infections, and 33 had cobacteremia. The hematologic system failed most often, followed by thoracic and cardiovascular systems. Fever was the most common presentation (n = 112; 78.3%), followed by anorexia (n = 47; 32.9%) and abdominal pain (n = 46; 32.2%). Overall, 33 patients died (mortality rate: 23.1%). Multivariate analysis showed that ICU mortality was significantly associated with lower Glasgow Coma Scale (GCS) scores, lower platelet counts before ICU discharge, and more organ failures.The number of severe dengue patients who require ICU admission remains high. The mortality rate was associated with lower GCS scores, lower platelet counts, and more organ failures. In addition, more than half of the critically ill dengue patients had comorbid bacterial infections.

Characteristics and Risk Factors for Fatality in Patients with Dengue Hemorrhagic Fever, Taiwan, 2014

An unprecedented dengue outbreak involving more than 15,000 infections, including 136 dengue hemorrhagic fever (DHF) cases and 20 fatalities, occurred in Taiwan in 2014. The median age of the DHF cases was 71 years (range: 4-92 years) and most of them (N = 100, 73.5%) had comorbidities, of which the majority were hypertension (56%) and diabetes mellitus (DM; 27%). Only approximately half of the DHF cases (59/136) were classified as severe dengue, based on the 2009 WHO-revised dengue classification. The fatality rate for this DHF outbreak was 14.7%. DM (odds ratio [OR] = 3.60, 95% confidence interval [CI] = 1.22-10.63) and presentation with severe plasma leakage (OR = 6.42, 95% CI = 1.76-23.63) were independent risk factors for fatality.

Clinical Profiles and Factors Associated with Death in Adults with Dengue Admitted to Intensive Care Units, Minas Gerais, Brazil

The purpose of our study was to describe the clinical profile of dengue-infected patients admitted to Brazilian intensive care units (ICU) and evaluate factors associated with death. A longitudinal, multicenter case series study was conducted with laboratory-confirmed dengue patients admitted to nine Brazilian ICUs situated in Minas Gerais state, southeastern Brazil from January 1, 2008, to December 31, 2013. Demographic, clinical and laboratory data; disease severity scores; and mortality were evaluated. A total of 97 patients were studied. The in-ICU and in-hospital mortality rates were 18.6% and 19.6%, respectively. Patients classified as having severe dengue according to current World Health Organization classifications showed an increased risk of death in a univariate analysis. Nonsurvivors were older, exhibited lower serum albumin concentrations and higher total leukocyte counts and serum creatinine levels. Other risk factors (vomiting, lethargy/restlessness, dyspnea/respiratory distress) were also associated with death in a univariate analysis. Multivariate analysis indicated that in-hospital mortality was significantly associated with Acute Physiology and Chronic Health Evaluation II and the Sequential Organ Failure Assessment score. The ICU and in-hospital mortality observed in this study were higher than values reported in similar studies. An increased frequency of ICU admission due to severe organ dysfunction, higher severity indices and scarcity of ICU beds may partially explain the higher mortality.

Differential clinical outcome of dengue infection among patients with and without HIV infection: a matched case-control study

Clinical characteristics and outcome among dengue patients with and without human immunodeficiency virus (HIV) infection remain elusive. A total of 10 dengue virus (DENV)-HIV Chinese patients were compared with 40 Chinese dengue patients without HIV, who were matched for age, gender, type of care received, methods, and year of dengue diagnosis from 2005 to 2008. Univariate and multivariate conditional logistics regression were applied. DENV-HIV patients were significantly associated with the World Health Organization (WHO) 2009 severe dengue (conditional odds ratio [COR] = 5.72; 95% confidence interval [CI] = 1.01-32.64) but not with the WHO 1997 dengue hemorrhagic fever/dengue shock syndrome (COR = 0.40; 95% CI = 0.09-1.71). This is mainly due to severe plasma leakage and the lack of hemorrhagic manifestations. Hospitalization duration was longer for DENV-HIV patients (10.5 days; interquartile range [IQR] = 5.5-26.3 days) compared with dengue patients (5 days; IQR = 4-6 days). There were no significant differences in presentation of clinical warning signs and symptoms at admission and during hospitalization, except for rash (adjusted COR [ACOR] = 0.06; 95% CI = 0.03-0.92). DENV-HIV patients were associated with higher pulse rate (ACOR = 1.13; 95% CI = 1.02-1.25), eosinophils proportion (ACOR = 3.07; 95% CI = 1.12-8.41) and lower hematocrit level (ACOR = 0.79; 95% CI = 0.64-0.98) compared with dengue patients. Even though DENV-HIV patients may present similarly to dengue patients, they may be more likely to have severe dengue outcome. Hence, close monitoring of DENV-HIV patients is highly recommended as part of dengue clinical care and management.