Evaluation of Cardiac Involvement in Children with Dengue by Serial Echocardiographic Studies

Association of Neutrophil Mediators With Dengue Disease Severity and Cardiac Impairment in Adults

BACKGROUND

Cardiac impairment contributes to hypotension in severe dengue (SD). However, studies examining pathogenic factors affecting dengue-associated cardiac impairment are lacking. We examined the role of neutrophil mediators on cardiac impairment in clinical dengue.

METHODS

We prospectively enrolled adult patients with dengue and controls. Cardiac parameters were measured using a bioimpedance device. Neutrophils mediators were measured, including myeloperoxidase (MPO) and citrullinated histone H3.

RESULTS

We recruited 107 dengue patients and 30 controls. Patients with dengue were classified according to World Health Organization 2009 guidelines (44 with dengue fever [DF], 51 with DF with warning signs, and 12 with SD). During critical phase, stroke index (P < .001), cardiac index (P = .03), and Granov-Goor index (P < .001) were significantly lower in patients with dengue than in controls. During critical phase, MPO was significantly higher in patients with dengue than in controls (P < .001) and also significantly higher in patients with SD than in those with DF. In addition, MPO was inversely associated with the stroke, cardiac, and Granov-Goor indexes, during the critical phase, and longitudinally as well.

CONCLUSIONS

Cardiac function was decreased, and MPO increased, during with critical phase in patients SD compared with those with DF and controls. MPO may mediate dengue-associated cardiac impairment.

Potential role of transthoracic echocardiography for screening LV systolic dysfunction in patients with a history of dengue infection. A cross-sectional and cohort study and review of the literature

Background

Dengue virus can affect the cardiovascular system and men may be at higher risk of severe complications than women. We hypothesized that clinical dengue virus (DENV) infection could induce myocardial alterations of the left ventricle (LV) and that these changes could be detected by transthoracic echocardiography.

Methodology/Principal findings

We examined individuals from Acre in the Amazon Basin of Brazil in 2020 as part of the Malaria Heart Study. By questionnaires we collected information on self-reported prior dengue infection. All individuals underwent transthoracic echocardiography, analysis of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). We included 521 persons (mean age 40±15 years, 39% men, 50% urban areas) of which 253 (49%) had a history of dengue infection. In multivariable models adjusted for clinical and sociodemographic data, a history of self-reported dengue was significantly associated with lower LVEF (β = -2.37, P < 0.01) and lower GLS (β = 1.08, P < 0.01) in men, whereas no significant associations were found in women (P > 0.05). In line with these findings, men with a history of dengue had higher rates of LV systolic dysfunction (LVEF < 50% = 20%; GLS < 16% = 17%) than those without a history of dengue (LVEF < 50% = 7%; GLS < 16% = 8%; P < 0.01 and 0.06, respectively).

Conclusions/Significance

The findings of this study suggest that a clinical infection by dengue virus could induce myocardial alterations, mainly in men and in the LV, which could be detected by conventional transthoracic echocardiography. Hence, these results highlight a potential role of echocardiography for screening LV dysfunction in participants with a history of dengue infection. Further larger studies are warranted to validate the findings of this study.

Clinical features and management of children with dengue-associated obstructive shock syndrome: A case report

RATIONALE

Dengue obstructive shock syndrome is a fatal complication commonly observed in the late critical phase of dengue infection and is associated with a high mortality rate. The main pathogenesis involves a dramatic increase in chest pressure, owing to severe plasma leakage and mechanical respiratory support, hampering the heart's ability to pump effectively and impeding adequate blood venous return to the heart chambers. To date, there is a paucity of clinical data about Dengue obstructive shock syndrome reported.

PATIENT CONCERNS

The 2 reported patients presented with prolonged and decompensated dengue shock with critical multi-organ failures and mechanical ventilation. The patients' hemodynamics were profoundly affected by high pressure in the thoracic and abdominal cavities resulting from Dengue-induced severe plasma leakage and mechanical ventilation.

DIAGNOSES

Clinical presentations, laboratory data, mini-fluid challenge test, and point-of-care (POCUS) were used to make diagnoses and guide management.

INTERVENTIONS

Clinical monitoring, judicious fluid (colloids and blood products) administration guided by repeated POCUS to properly assess the adequacy of the intravascular volume, homeostasis adjustments by plasma exchange, and continuous renal replacement therapies.

OUTCOMES

The patients had favorable outcomes.

LESSONS

Our study highlights the clinical manifestations and management of children with dengue obstructive shock syndrome and underscores the importance of monitoring hemodynamics by consecutive POCUS at the bedside in order to make a timely diagnosis and assess intravascular fluid volume inadequacy accurately as well as closely monitor the fluid management responses.

Heart Disease and Arboviruses: A Systematic Review and Meta-Analysis

Dengue fever, chikungunya, and zika are highly prevalent arboviruses transmitted by hematophagous arthropods, with a widely neglected impact in developing countries. These diseases cause acute illness in diverse populations, as well as potential cardiovascular complications. A systematic review was carried out to investigate the burden of cardiac involvement related to these arboviruses. Multiple databases were searched for articles that investigated the association of cardiovascular diseases with arboviruses, published up to March 2022. Relevant articles were selected and rated by two independent reviewers. Proportion meta-analysis was applied to assess the frequency-weighted mean of the cardiovascular findings. A total of 42 articles were selected (n = 76,678 individuals), with 17 manuscripts on dengue and 6 manuscripts on chikungunya undergoing meta-analysis. The global pooled incidence of cardiac events in dengue fever using a meta-analysis was 27.21% (95% CI 20.21–34.83; I² = 94%). The higher incidence of dengue-related myocarditis was found in the population younger than 20 years old (33.85%; 95% CI 0.00–89.20; I² = 99%). Considering the studies on chikungunya (n = 372), the global pooled incidence of cardiac involvement using a meta-analysis was 32.81% (95% CI 09.58–61.49, I² = 96%). Two Zika studies were included that examined cases of infection by vertical transmission in Brazil, finding everything from structural changes to changes in heart rate variability that increase the risk of sudden death. In conclusion, cardiac involvement in arboviruses is not uncommon, especially in dengue fever.

Cardiovascular sequelae of dengue fever: a systematic review

BACKGROUND

: Dengue is the most important viral diseases globally and a majority of symptomatic infections result in a benign course. However, a small number of patients develop severe manifestations, including myocardial impairment, arrhythmias, and fulminant myocarditis.

AREAS COVERED

This review outlines the incidence of cardiovascular (CV) manifestations of dengue. Electronic databases, including PubMed/MEDLINE, EMBASE, Scopus, and CINAHL were searched for articles incorporating cardiac manifestations of dengue fever (DF).

EXPERT OPINION

: Included studies involved 6,773 patients and 3,122 (46.1%) exhibited at least one cardiac manifestation with DF. Electrocardiogram (ECG) abnormalities (30.6%) included sinus bradycardia (8.8%), non-specific ST-T changes (8.6%), ST depression (7.9%), and T-wave inversion (2.3%). Mechanical sequelae were present in 10.4%, including left ventricular (LV) systolic dysfunction (5.7%), and myocarditis (2.9%). Pericardial involvement was noted as pericarditis (0.1%), pericardial effusion (1.3%), and pericardial tamponade (0.1%). Apart from that, the cardiac injury was depicted through a rise in cardiac enzymes (4.5%). The spectrum of CV manifestations in dengue is broad, ranging from subtle ST-T changes to fulminant myocarditis. This can be a cause of hemodynamic collapse during the critical phase of capillary leakage. Use of contemporary techniques in diagnosing cardiac involvement should be employed for rapid diagnosis and treatment in DF.

Early cardiovascular involvement in dengue fever: A prospective study with two-dimensional speckle tracking echocardiography

Cardiac abnormalities in dengue infection have been conventionally identified by clinical manifestations. The primary objective of our prospective observational study was to assess true cardiovascular involvement and early myocarditis in 150 hospitalised, confirmed cases of dengue fever, through myocardial strain detection using two-dimensional speckle tracking echocardiography. Myocarditis was defined on the basis of European Society of Cardiology (ESC) 2013 criteria. Cardiac biomarkers, namely, creatine phosphokinase myocardial band was elevated in 28.6% and Troponin-T in 23.3% patients. Electrocardiography was abnormal in 64.6% while 6% patients had two-dimensional structural echocardiographic abnormalities. Myocardial dysfunction was suspected in 27.3% based on ESC criteria and strain analysis. The severe dengue group had lower longitudinal strain [−16.4 (6.3)] and circumferential strain [−15.7 (6.7)]. Two-dimensional speckle tracking echocardiography was found to be useful in improving the understanding of early myocardial mechanics in dengue fever.

Plasma leakage in dengue: a systematic review of prospective observational studies

Plasma leakage is a precursor to life-threatening complications of dengue, but this group is poorly defined and not often reported in literature. Patients with Dengue haemorrhagic fever (DHF) as defined in the 1997 World Health Organization classification are often reported, and they all have plasma leakage, but some patients with plasma leakage do not meet the definition of DHF. The study aims to estimate the frequency of plasma leakage and DHF (as a surrogate of plasma leakage) in dengue and its variations based on virus serotype, geography, patient gender and pre-existing immunity to dengue. PUBMED, Scopus, EMBASE, CINAHL and Web of Science were searched for prospective observational studies reporting on plasma leakage or DHF. Quality of data was assessed using the NIH quality assessment tool for cohort studies. Forty-three studies that recruited 15,794 confirmed dengue patients were eligible. Cumulative frequency of plasma leakage was 36.8% (15 studies, 1642/4462, 95% CI 35.4-38.2%), but surprisingly the estimated cumulative frequency of DHF was higher (45.7%, 32 studies, 4758/10417, 95% CI 44.7-46.6%), indicating that current medical literature over-reports DHF or under-reports plasma leakage. Therefore, a reliable estimate for the proportion of dengue patients developing plasma leakage cannot be derived from existing medical literature even after applying rigorous inclusion criteria to select homogenous studies. Plasma leakage is an important marker of "at-risk" dengue patients and standardizing its definition, diagnosis and reporting should be a priority in research and global policy.

Cardiac evaluation in adults with dengue virus infection by serial echocardiography

Background

Dengue virus infection (DVI) is a major health problem in many parts of the world. Its manifestations range from asymptomatic infections to severe disease. Although cardiac involvement has been reported in DVI, its incidence has not yet been well established.

Methods

From July 2016 to January 2018, patients hospitalized at the Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Thailand, with dengue virus infection confirmed by positive NS1 or positive dengue immunoglobulin M findings, participated in the study. We characterized the incidence and change in cardiac function by serial echocardiography and levels of troponin-T and creatine kinase-myocardial band (CK-MB) on the day of admission, the day of defervescence, the first day of hypotension (if any), and at 2 week follow-up.

Results

Of the 81 patients evaluated, 6 (7.41%) exhibited elevated biomarker levels. There was no difference in clinical presentation amongst dengue fever, dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS), except for the amount of bleeding. Cardiac involvement was found in 22.2% of patients: 3 (3.70%) had left ventricular systolic dysfunction, 3 (3.70%) had transient diastolic dysfunction, 6 (7.41%) had increased levels of at least one cardiac biomarker (troponin-T or CK-MB), and 6 (7.41%) had small pericardial effusion. Myocarditis was suspected in only two patients (with DHF); thus, myocarditis was uncommon in patients with dengue virus infection. Three patients developed DSS during admission and were transferred to the intensive care unit.

Conclusion

Cardiac involvement in adults with dengue infection was common, ranging from elevated cardiac biomarker to myocarditis. Abnormalities in cardiac function had resolved spontaneously by the day of follow-up, without specific treatment. We found that DHF was a significant risk factor for cardiac involvement. Echocardiography is the investigation of choice for evaluating the haemodynamic status of patients with DVI, especially in severe dengue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06639-x.

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.

Dengue hemorrhagic fever and cardiac involvement

Dengue viral infection (DVI) is one of the world’s most significant viral infections spreading. Most of the patients have been asymptomatic, with relatively benign clinical manifestations and outcomes. However, a small number of patients have progressed to severe dengue diseases, including hemorrhage, multi-organ impairment, and increased vascular leakage causing hypovolemic shock, which can cause cardiovascular collapse and death. Numerous lines of evidence have demonstrated that DVI could also cause cardiac dysfunction, arrhythmias, and severe myocarditis. The treatment for dengue hemorrhagic fever (DHF) patients remains symptomatic and supportive, with close monitoring of hemodynamic status. The contributory role of cardiac dysfunction in DHF patients has potentially critical implications on the management. This review will address the current knowledge of cardiac involvement in DHF patients and the management strategy to reduce the fatality outcome.

Incidence of Cardiac Manifestations in Children with Dengue Fever: A Cross-sectional Study

OBJECTIVE

The aim of our study was to explore the incidence of cardiac involvement in children with dengue infection admitted in a tertiary care hospital and to evaluate the features of cardiac involvement with the severity of dengue fever.

METHODS

This was a cross-sectional study conducted from September 2014 to August 2016. A total of 130 patients with confirmed dengue NS1 antigen or IgM antibody positivity between the ages of 1 month and 18 years were evaluated. On the third day of admission, blood samples for cardiac markers were collected, and electrocardiograms (ECG) and echocardiograms were performed for each patient.

RESULTS

Of the 130 dengue patients in the study, 60 (46.2%) were males and 70 (53.8%) were females (male to female ratio, 1:1.16). Cardiac involvement was present in 60 (46.2%) children and was more prominent in children with severe dengue (72.7%), followed by dengue with warning symptoms (53.8%) and dengue fever (28.6%). There was no significant correlation between cardiac involvement and primary/secondary dengue. Both ECG and echocardiography changes were significantly correlated with dengue severity, as opposed to cardiac markers.

CONCLUSIONS

Cardiac involvement was present in children with dengue. Evaluation with ECG, echocardiography, and cardiac markers such as creatine phosphokinase-myocardial band (CPK-MB) are required for the management of cardiac complications in children with dengue. Our study showed an association between cardiac involvement and the severity of dengue. Further studies should be framed, and follow-up of dengue patients with cardiac involvement is necessary for therapeutic management.

Cardiovascular disorders in hospitalized patients with dengue infection

INTRODUCTION

Cardiac complications in dengue patients are not uncommon and are not diagnosed, since they are usually mild and self-limiting.

OBJECTIVES

To characterize the cardiovascular manifestations in hospitalized patients with dengue infection.

METHODS

We conducted an observational, analytical, longitudinal, prospective epidemiological study, which included 427 patients treated at Manuel Fajardo Clinical-Surgical Teaching Hospital with diagnosis of dengue infection since April 2017 to April 2018.

RESULTS

Cardiovascular manifestations (19.7%), mainly heart rate disorders (sinus bradycardia [13.8%], atrial [4.9%] and ventricular [4.0%] extrasystoles) were frequent in dengue infection patients. Pericarditis and myocarditis were diagnosed in 1.6% and 0.2% respectively. These disorders were self-limiting in 83.3% of cases and occurred in the first days of the onset of fever in 75.0%. Advanced age (OR=1.70), male sex (OR=1.94), decreased platelet count (OR=1.13) and dengue with warning signs (OR=3.29) were related to a higher probability of presenting cardiovascular disorders in the course of a dengue infection.

CONCLUSIONS

Cardiovascular manifestations in dengue patients are frequent, and are related to advanced age, male sex, as well as severe forms of the disease.

Myocarditis Prevalence in Paediatric Dengue Infection: A Prospective Study in Tertiary Hospital in Yogyakarta, Indonesia

Awareness of cardiac involvement in dengue infection has potentially valuable management implications. To determine the prevalence of myocarditis in dengue severity, we conducted prospective study of paediatric dengue illness at Dr. Sardjito General Hospital, a tertiary hospital in Yogyakarta, Indonesia, from period of July 2015 to May 2016. World Health Organization (WHO) Dengue Guideline 2011 classification system was used. Diagnosis of dengue infection was made based on either by dengue serology and/or NS1 test. Myocarditis was assessed based on elevation of cardiac enzymes, as creatine kinase (CK), creatine kinase-MB (CK-MB), Troponin I (TnI) and by electrocardiography (ECG). Proportion between groups was compared using the Fisher's exact test. We analysed 50 children with diagnosis of dengue fever (DF), 12 of dengue haemorrhagic fever (DHF) and 23 of dengue shock syndrome (DSS). Myocarditis diagnosed in 53%, 75% and 96% of DF, DHF and DSS, respectively. We found that myocarditis was more prevalent significantly in DSS than DF (p = 0.003).

Severe dengue in travellers: pathogenesis, risk and clinical management

RATIONALE FOR REVIEW

Dengue is a frequent cause of febrile illness among travellers and has overtaken malaria as the leading cause of febrile illness for those traveling to Southeast Asia. The purpose is to review the risk of dengue and severe dengue in travellers with a particular focus on the pathogenesis and clinical management of severe dengue.

RISK, PATHOGENESIS AND CLINICAL MANAGEMENT

The risk of travel-acquired dengue depends on destination, season and duration of travel and activities during travel. Seroconversion rates reported in travellers, therefore, vary between <1% and >20%. The most common life-threatening clinical response to dengue infection is the dengue vascular permeability syndrome, epidemiologically linked to secondary infection, but can also occur in primary infection. Tertiary and quaternary infections are usually associated with mild or no disease. Antibody-dependent enhancement, viral factors, age, host factors and clinical experience of the managing physician modulate the risk of progressing to severe dengue. The relative risk of severe dengue in secondary versus primary infection ranges from 2 to 7. The absolute risk of severe dengue in children in highly endemic areas is ~0.1% per year for primary infections and 0.4% for secondary infections. About 2-4% of secondary infections lead to severe dengue. Severe dengue and death are both relatively rare in general travellers but more frequently in those visiting friends and relatives. Clinical management of severe dengue depends on judicious use of fluid rehydration.

CONCLUSIONS

Although dengue is a frequent cause of travel illness, severe dengue and deaths are rare. Nevertheless, dengue infections can interrupt travel and lead to evacuation and major out-of-pocket costs. Dengue is more frequent than many other travel-related vaccine preventable diseases, such as hepatitis A, hepatitis B, rabies, Japanese encephalitis and yellow fever, indicating a need for a dengue vaccine for travellers.

Case Report: Cardiac Tamponade in Dengue Hemorrhagic Fever: An Unusual Manifestation of a Common Disease

Dengue hemorrhagic fever is one of the most commonly encountered mosquito-borne viral infections of humans worldwide with multiple reported outbreaks. Cardiac involvement is a known manifestation of the disease usually presenting as rhythm abnormalities, myocarditis, or pericardial effusion, which may be clinically asymptomatic. We describe a case of a 30-year-old woman who presented to us with high-grade fever, headache, retro-orbital pain, generalized maculopapular rash with bilateral pleural effusion, and hypotension. Dengue non-structural protein 1 (NS1) antigen and IgM antibodies were positive on admission, supporting a diagnosis of dengue hemorrhagic fever. Cardiac troponin-I was elevated on admission (65 ng/L) with diffuse convex ST segment elevations on electrocardiogram, suggestive of possible myopericarditis. Echocardiogram on admission revealed minimal pericardial effusion with preserved ejection fraction. Despite administration of fluids and inotrope use, the patient's hypotension progressively deteriorated over the next 6 hours, associated with decreased urine output and worsening sensorium. Clinical examination revealed muffled heart sounds and raised jugular venous pressure. A repeat echocardiogram confirmed an increase in the pericardial effusion manifesting as cardiac tamponade. Ultrasound-guided pigtail catheter insertion led to a prompt removal of the excessive pericardial fluid and correction of hypotension. Early identification of this uncommon but important complication of dengue hemorrhagic fever led to a good outcome in our case.

Cardiac Involvement by Yellow Fever(from the PROVAR+ Study)

Incidence of Yellow Fever (YF) has increased in Brazil, and cardiac findings such as bradyarrhythmias and conduction abnormalities have been described. We aimed to perform a comprehensive cardiac evaluation of patients with YF, and to assess the association between cardiac involvement and disease severity. Patients hospitalized with YF from February to March 2018 underwent clinical and laboratory evaluation, focused bedside echocardiography (GE Vivid IQ), electrocardiogram and, in case of alterations, 24-hours Holter. Patients were divided into 2 groups according to YF severity. Five patients underwent magnetic resonance imaging and 3 had necropsy. Seventy patients had confirmed YF, 69% with severe form. Mean age was 48 ± 14 years, 63 (90%) were males and 5 (7%) died. Significant electrocardiogram abnormalities were present in 52% of patients with mild/moderate form of YF (G1) and 77% of those with severe form (G2), p = 0.046. Sinus bradycardia was observed in 24% (N = 17): G1 23% versus G2 25%, p = 0.67. Among 32 patients who underwent Holter, 14 (44%) had mean HR <60 beats per minute, being 8 from G2. Echocardiogram revealed left ventricular dysfunction in 4 (6%) patients, from G2. Left ventricular wall thickening with a hyper-refringent myocardial texture suggesting infiltration was observed in 17 patients (G1 18% vs G2 27%, p = 0.55). One magnetic resonance (G2) was suggestive of myocarditis, and one necropsy revealed areas of myocardial necrosis and acute myocarditis. In conclusion, cardiac involvement was observed in patients with YF, most commonly bradycardia and myocardial hyper-refringent texture suggestive of infiltration.

Beyond thrombocytopaenia, haemorrhage and shock: the expanded dengue syndrome

Dengue infection classically presents with fever, thrombocytopaenia, and varying degrees of plasma leakage, giving rise to shock. However, a myriad of other manifestations, involving the cardiovascular system, the nervous system, the liver, the kidneys, the gut and the haematological system have been reported in dengue. This review summarizes these varied presentations.

Elevated cardiac biomarkers and echocardiographic left ventricular dysfunction at admission in patients with dengue fever: report from a tertiary care center in Northwest India

Cardiac involvement is not an uncommon manifestation in dengue fever and diagnosing it has always been a challenge to physicians owing to its constellation of clinical features and lack of standard screening methods. We studied the prevalence of cardiac involvement among fifty sequential adult patients of dengue fever admitted in our emergency department, PGIMER, Chandigarh, India, who were assessed clinically and classified based on the severity. They were studied for possible cardiac involvement by means of point-of-care testing for serum cardiac biomarkers (quantitative troponin-I, creatinine kinase - MB Isoform and cardiac myoglobin) and two-dimensional transthoracic echocardiogram (2D-echo). Evidence of myocardial involvement was present in 16% and 30% patients based on 2D-echo and biomarker testing respectively. On univariate analysis, the presence of cardiac symptoms (p = 0.009) and of shock (p = 0.003) showed statistically significant association with biomarker elevation. However, this and evidence of myocardial dysfunction by 2-D echo showed poor inter-correlation.

Cardio-haemodynamic assessment and venous lactate in severe dengue: Relationship with recurrent shock and respiratory distress

Background

Dengue can cause plasma leakage that may lead to dengue shock syndrome (DSS). In approximately 30% of DSS cases, recurrent episodes of shock occur. These patients have a higher risk of fluid overload, respiratory distress and poor outcomes. We investigated the association of echocardiographically-derived cardiac function and intravascular volume parameters plus lactate levels, with the outcomes of recurrent shock and respiratory distress in severe dengue.

Methods/Principle findings

We performed a prospective observational study in Paediatric and adult ICU, at the Hospital for Tropical Diseases (HTD), Ho Chi Minh City, Vietnam. Patients with dengue were enrolled within 12 hours of admission to paediatric or adult ICU. A haemodynamic assessment and portable echocardiograms were carried out daily for 5 days from enrolment and all interventions recorded.

102 patients were enrolled; 22 patients did not develop DSS, 48 had a single episode of shock and 32 had recurrent shock. Patients with recurrent shock had a higher enrolment pulse than those with 1 episode or no shock (median: 114 vs. 100 vs. 100 b/min, P = 0.002), significantly lower Stroke Volume Index (SVI), (median: 21.6 vs. 22.8 vs. 26.8mls/m², P<0.001) and higher lactate levels (4.2 vs. 2.9 vs. 2.2 mmol/l, P = 0.001). Higher SVI and worse left ventricular function (higher Left Myocardial Performance Index) on study days 3–5 was associated with the secondary endpoint of respiratory distress. There was an association between the total IV fluid administered during the ICU admission and respiratory distress (OR: 1.03, 95% CI 1.01–1.06, P = 0.001). Admission lactate levels predicted patients who subsequently developed recurrent shock (P = 0.004), and correlated positively with the total IV fluid volume received (rho: 0.323, P = 0.001) and also with admission ALT (rho: 0.764, P<0.001) and AST (rho: 0.773, P<0.001).

Conclusions/Significance

Echo-derived intravascular volume assessment and venous lactate levels can help identify dengue patients at high risk of recurrent shock and respiratory distress in ICU. These findings may serve to, not only assist in the management of DSS patients, but also these haemodynamic endpoints could be used in future dengue fluid intervention trials.

Dengue is a viral illness that can lead to severe and potentially fatal complications. The most common complication is fluid leakage from blood vessels, which can cause low blood pressure or dengue shock syndrome (DSS). The majority of patients recover with simple intravenous fluid replacement, however in approximately 30% of DSS cases, recurrent episodes of shock occur, and these patients have a higher risk of fluid overload, respiratory distress and death. We investigated whether using portable echocardiograms (Echo) in the intensive care unit (ICU) to assess cardiac function and intravascular volume parameters as well as blood lactate levels, can help identify these patients. We found patients who developed recurrent shock had higher heart rates and lower Stroke Volume Index (SVI), and higher lactate levels at enrolment than those with 1 episode or no shock. Higher SVI and worse cardiac function after 3 days in ICU was associated with respiratory distress. Admission lactate levels predicted patients who subsequently developed recurrent shock and correlated positively with the total IV fluid volume received. These results demonstrate that Echo-derived intravascular volume assessment and venous lactate levels can help identify dengue patients at high risk of poor outcomes in the ICU, and could assist in the management of severe dengue.

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.