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See KC. Dengue-Associated Hemophagocytic Lymphohistiocytosis: A Narrative Review of Its Identification and Treatment. Pathogens 2024; 13:332. [PMID: 38668287 PMCID: PMC11053942 DOI: 10.3390/pathogens13040332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024] Open
Abstract
Dengue's lack of specific treatments beyond supportive care prompts a focus on uncovering additional pathophysiological factors. Dengue-associated hemophagocytic lymphohistiocytosis (HLH), characterized by dysregulated macrophage activation and cytokine storm, remains underexplored despite its potential to worsen disease severity and mortality. While rare, dengue-associated HLH disproportionately affects severe cases, significantly impacting mortality rates. To mitigate high mortality, early identification and familiarity with dengue-associated HLH are imperative for prompt treatment by clinicians. This narrative review therefore aims to examine the current clinical and therapeutic knowledge on dengue-associated HLH, and act as a resource for clinicians to improve their management of HLH associated with severe dengue. Dengue-associated HLH should be considered for all cases of severe dengue and may be suspected based on the presence of prolonged or recurrent fever for >7 days, or anemia without intravascular hemolysis or massive bleeding. Diagnosis relies on fulfilling at least five of the eight HLH-2004 criteria. Treatment predominantly involves short courses (3-4 days) of high-dose steroids (e.g., dexamethasone 10 mg/m2), with additional therapies considered in more severe presentations. Notably, outcomes can be favorable with steroid therapy alone.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
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2
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Ramamoorthy L, Sivakumar N, Murugesan L, Kumar A. Hemophagocytic Lymphohistiocytosis Secondary to Dengue Fever in a Pediatric Patient: A Case Report. Cureus 2024; 16:e59165. [PMID: 38803771 PMCID: PMC11129876 DOI: 10.7759/cureus.59165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
Dengue fever, an arboviral illness, exhibits a broad range of symptoms, ranging from flu-like symptoms to serious hemorrhagic complications. Hemophagocytic lymphohistiocytosis (HLH) is an uncommon pathological state caused by excessive activation of the immune system, culminating in organ dysfunction. HLH can be primary or secondary, with infection being the most common cause. The association between dengue fever and dengue-induced HLH is becoming widely acknowledged as a lethal complication. We present the case of a two-year-old male child referred for the management of dengue infection. The patient's condition failed to ameliorate despite appropriate treatment. On further investigation, he was diagnosed with HLH. Following the initiation of steroid therapy, the patient demonstrated gradual improvement with normalization of laboratory parameters. Differentiating between HLH and severe dengue hemorrhagic fever poses a significant challenge, emphasizing the importance of prompt diagnosis for favorable outcomes. Early identification and commencement of corticosteroid therapy are imperative for successful management.
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Affiliation(s)
| | | | | | - Arul Kumar
- Pediatric Medicine, Government Tiruppur Medical College and Hospital, Tiruppur, IND
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Tso ACY, Acharyya S, Fong SZ, Lee LK, Sreekanth SV, Fan BE, Chan SWS, Ong KH. A Retrospective Review of Secondary Hemophagocytic Lymphohistiocytosis (HLH) and Dengue-associated HLH from a Teaching Hospital in Singapore. Clin Hematol Int 2024; 6:116-127. [PMID: 38817699 PMCID: PMC11086992 DOI: 10.46989/001c.94954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/23/2023] [Indexed: 06/01/2024] Open
Abstract
Real-world data on the outcome of Asian patients with secondary hemophagocytic lymphohistiocytosis (HLH), especially on dengue-associated HLH, are limited to small case series. This is a retrospective records review of adult patients with secondary HLH between 2015 and 2020. Thirty-two adult patients were followed up for a median of 6.6 months (range 0.1 - 75 months). 15 had underlying lymphomas, and 12 had viral infections. Hemophagocytosis was seen in 28 of 29 patients with a bone marrow biopsy. 100% and 76.5% of patients with and without an underlying malignancy required HLH-directed therapy and blood product transfusion. 12 of 15 patients with lymphomas were treated with additional chemotherapy. Patients with malignancy-associated HLH had poorer survival than non-malignancy-associated HLH (median overall survival (OS) 1.5 months versus not reached, p-value 0.003). The 1-year survival rates of patients with malignancy-associated HLH, HLH with unknown etiologies, and infection-associated HLH were 0.133 (95% CI: 0.036 - 0.484), 0.400 (95% CI: 0.137 - 1.000) and 0.833 (95% CI: 0.647 - 1.000), respectively. Malignancy significantly increased the risk of death compared to infection-associated HLH (HR 9.37, p-value 0.003). Eight patients were diagnosed with dengue-associated HLH with a median HSCORE of 240 (98-99% probability of HLH). Their mean ferritin was 34,740 ng/mL. Three patients required blood product transfusion, 5 required corticosteroids and/or etoposide, with a median duration of treatment of 31 days. Their overall survival rate was 87.5%. Our study highlights the stark contrast in the survival of secondary HLH patients with and without an underlying malignancy. We also present one of the world's most extensive case series of dengue-associated HLH.
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Montero-Vázquez RA, Valdes-Mosso A, Mendez-Contreras CM. [Síndrome hemofagocítico linfohistiocitario secundario a Dengue en una paciente de 6 años: reporte de caso]. REVISTA ALERGIA MÉXICO 2023; 70:204. [PMID: 37933945 DOI: 10.29262/ram.v70i3.1253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
Background Dengue fever is a mosquito-borne infectious disease endemic in over 100 countries around the world. Among the complications that dengue can cause the Hemophagocytic Lymphohistiocytosis is one of great concern for its severity and complex diagnosis. Case report Hereby we document a case of this disease expressed on a previously healthy 6-year-old female patient whose dengue infection was so severe that needed intensive care management with vasoactive drugs and diuretics. After a short period of wellness began newly with fever, pancytopenia, hepatitis, and inflammatory response symptoms. Conclusions A Dengue associated Hemophagocytic Lymphohistiocytosis syndrome was suspected and treated with intravenous corticosteroids on a 3-day scheme at no signs of malignancy with excellent response. The health care professionals must know about this not novel entity in order to reach an efficient diagnosis and treatment mostly, but not only, those in tropical and sub-tropical regions of the word were dengue virus is endemic.
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Shukla S, Jadhav SM, Gurav YK, Parashar D, Alagarasu K. Serum ferritin level as a prognostic biomarker for predicting dengue disease severity: A systematic review and meta-analysis. Rev Med Virol 2023; 33:e2468. [PMID: 37347209 DOI: 10.1002/rmv.2468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023]
Abstract
Serum ferritin levels serves as biomarkers in many inflammatory and infectious diseases. This current systematic review and meta-analysis evaluated whether serum ferritin levels are associated with severe dengue and its utility as a biomarker of disease severity. Literature searches were conducted in PubMed, Scopus, ScienceDirect, the Cochrane library, and Google Scholar. A total of 18 studies examining the serum ferritin levels in dengue cases in the context of disease severity (nine studies having dengue classification as non-severe vs. severe dengue cases, and nine studies having dengue classification as dengue without warning signs (DwoWS), dengue with warning signs (DwWS), and severe dengue cases) were included and the quality of the studies was assessed using the Quality in Prognostic Factor Studies tool. The meta-analysis was performed using STATA software to calculate the effect size as a standardized mean difference (SMD) or Hedges 'g' for the continuous outcome. Higher serum ferritin levels were found in severe dengue cases compared to non-severe cases [SMD (Hedges 'g') 4.05 (95% C.I. 2.09-6.00), (I2 = 98.8%)]. In the second group, DwWS cases showed high serum ferritin levels compared to DwoWS [SMD 2.01 (95% C.I. 0.92-3.10), (I2 = 97.89%)], and severe dengue cases showed higher levels of serum ferritin compared to DwWS [SMD 2.66 (95% C.I. 1.72-4.48), (I2 = 98.78%)] and DwoWS cases [SMD 6.65 (95% C.I. 1.72-11.59), (I2 = 99.78%]. Subgroup analysis for the country of study (India vs. others), ferritin testing methods, and ferritin measurement day revealed testing method as a significant contributor to heterogeneity. To conclude, the present study suggests serum ferritin as a prognostic marker for dengue disease severity. Multi-centric studies involving a large number of dengue patients with a uniform case definition accounting for all the confounding variables might help in determining a universal cut-off value to discriminate between non-severe and severe dengue.
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Affiliation(s)
- Shridhar Shukla
- Diagnostic Reagent Facility, ICMR-National Institute of Virology, Pune, Maharashtra, India
| | - Santosh M Jadhav
- Bioinformatics and Data Management Group, ICMR-National Institute of Virology, Pune, Maharashtra, India
| | - Yogesh K Gurav
- Health Technology Assessment Group, ICMR-National Institute of Virology, Pune, Maharashtra, India
| | - Deepti Parashar
- Diagnostic Reagent Facility, ICMR-National Institute of Virology, Pune, Maharashtra, India
- Dengue and Chikungunya Group, ICMR-National Institute of Virology, Pune, Maharashtra, India
| | - Kalichamy Alagarasu
- Dengue and Chikungunya Group, ICMR-National Institute of Virology, Pune, Maharashtra, India
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Valerie IC, Prabandari AASM, Wati DK. Ferritin in pediatric critical illness: a scoping review. Clin Exp Pediatr 2023; 66:98-109. [PMID: 36229027 PMCID: PMC9989723 DOI: 10.3345/cep.2022.00654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/17/2022] [Indexed: 11/27/2022] Open
Abstract
This scoping review aimed to elucidate and summarize the predictive role of serum ferritin in critical pediatric illness. The Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology was employed to conduct a scoping review of 5 databases (MEDLINE, CENTRAL, ProQuest, ScienceDirect, and Epistemonikos) from the date of inception through January 24, 2022. Primary research studies involving subjects aged <18 years and serum ferritin levels were screened and reviewed independently following an a priori defined protocol. Of the 1,580 retrieved studies, 66 were analyzed. Summary statistics of serum ferritin levels for overall and condition-specific studies were reported in 30 (45.4%) and 47 studies (71.2%), respectively. The normal range was defined in 16 studies (24.2%), whereas the threshold was determined in 43 studies (65.1%). A value of <500 ng/mL was most often the upper limit of the normal range. Serum ferritin as a numerical variable (78.9%) was usually significantly higher (80.8%) in the predicted condition than in controls, while as a categorical variable with preset thresholds, ferritin was a significant predictor in 84.6% of studies. A total of 22 predictive thresholds predicted mortality (12 of 46 [26.1%]), morbidity (18 of 46 [39.1%]), and specific (16 of 46 [34.8%]) outcomes in 15 unique conditions. Increased precision in serum ferritin measures followed by close attention to the threshold modeling strategy and reporting can accelerate the translation from evidence to clinical practice.
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Affiliation(s)
- Ivy Cerelia Valerie
- Department of Child Health, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Bali, Indonesia
| | | | - Dyah Kanya Wati
- Department of Child Health, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Bali, Indonesia
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Arora A, Verma S, Khot N, Chalipat S, Agarkhedkar S, Kiruthiga KG. A Case Report on CNS Hemophagocytic Lymphohistiocytosis in an Infant With Dengue Hemorrhagic Fever. Cureus 2023; 15:e34773. [PMID: 36909089 PMCID: PMC10003475 DOI: 10.7759/cureus.34773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2023] [Indexed: 02/10/2023] Open
Abstract
India is an endemic country for dengue. The incidence of hemophagocytic lymphohistiocytosis (HLH) with dengue in children has been well-reported. However, central nervous system (CNS) HLH associated with dengue has not been described in the literature yet. We hereby report a novel case of CNS HLH triggered by dengue infection. An eight-month-old, well-grown male infant with uneventful antenatal, perinatal, and neonatal history was admitted with a history of febrile illness associated with cough, cold, vomiting, and loose motions and one episode of hematochezia and hepatosplenomegaly on examination. Investigations revealed bi-cytopenia, hyper-ferritinemia, deranged coagulation profile, liver function test, and hypo-fibrinogenemia. Dengue non-structural protein 1 ( NS1) antigen was positive. The child was given dexamethasone and continued supportive care with a diagnosis of dengue shock syndrome. The child showed an overall transient improvement, however, he had rebound fever followed by right focal convulsion on Day 9 of steroids. MRI brain revealed areas of diffusion-restricted embolic infarcts with diffuse leptomeningeal enhancement and mild cerebral edema, and CSF showed a total leukocyte count of 80 cells with 75% lymphocytic picture, histiocytes with hemophagocytosis, confirmatory of CNS HLH. Intrathecal methotrexate, hydrocortisone, and intravenous (IV) etoposide were started. However, the child succumbed to his illness. CNS involvement in dengue-triggered HLH needs to be suspected despite subtle neurological signs and aggressively managed following a multi-departmental approach to ensure the best clinical and neuro-developmental outcomes.
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Affiliation(s)
- Amodini Arora
- Pediatrics, Dr. D.Y. Patil Medical College, Pune, IND
| | - Sarita Verma
- Pediatric Oncology, KEM Hospital & Research Centre, Pune, IND.,Pediatric Oncology, Dr. D.Y. Patil Medical College, Pune, IND
| | - Nikita Khot
- Pediatrics, Dr. D.Y. Patil Medical College, Pune, IND
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Dahman HAB, Aljabry AO. Paediatric haemophagocytic lymphohistiocytosis: clinical presentation and outcome of 20 patients at a single institution. Sudan J Paediatr 2023; 23:199-213. [PMID: 38380413 PMCID: PMC10876277 DOI: 10.24911/sjp.106-1659160002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 02/18/2023] [Indexed: 02/22/2024]
Abstract
Paediatric haemophagocytic lymphohistiocytosis (pHLH) is a potentially life-threatening condition with significant diagnostic and therapeutic difficulties. The purpose of this study was to describe the clinical presentation, the diagnostic challenges, and the outcomes of haemophagocytic lymphohistiocytosis (HLH) in children assessed at Mukalla Hospital, Yemen. Data from 20 medical records of HLH patients admitted between January 2010 and May 2022 were retrospectively analysed. The median age at presentation was 3.5 ± 5.1 years. Male: female ratio was 1:1. The median time for referral to the hospital was 30 ± 64 days. The most common clinical manifestations were fever and pallor in 95% of cases, and splenomegaly (85%). Hepatomegaly, chest, renal and neurological manifestations were detected in 80%, 45%, 15% and 20% of cases, respectively. Bone marrow haemophagocytosis was detected in 60% of cases. Sixteen patients fulfilled the HLH diagnostic criteria, and 11 patients (55%) received the HLH 2004 protocol. Out of the 20 patients, three (15%) patients are alive. Fourteen patients died, with overall mortality of 82.35%. All mortalities were due to HLH disease with multi-organ failure. Relapse was noticed in five patients either during treatment or after full recovery. pHLH is a challenging emergency with a high mortality rate. High clinical suspicion is essential for early detection and intervention to improve the prognosis.
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Affiliation(s)
- Haifa Ali Bin Dahman
- Associate Professor, Pediatric Department, Hadhramout University College of Medicine (HUCOM), Al-Mukalla, Yemen
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Ahmed AE, Almarhabi MA, Shami MO, Alhazemi AA, Alsharif HM, Abu Hayyah AE, Alhazmi WA, Alfaifi MA, Abdali AQ, Alshihri MS, Alhazmi AH, Qasem HA, Alhazmi MA, Abdelwahab SI. Knowledge, Attitudes, and Practices of the Population in Jazan Region, Saudi Arabia Regarding Dengue Fever and Its Prevention Measures: A Community-Based Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192416812. [PMID: 36554693 PMCID: PMC9779683 DOI: 10.3390/ijerph192416812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/03/2022] [Accepted: 12/09/2022] [Indexed: 06/10/2023]
Abstract
In previous studies, there was an apparent lack of health education about dengue fever (DF) among the Saudi population. Therefore, we conducted this study to assess the knowledge, attitude, and practices (KAP) about dengue fever among the Jazan region population, which is one of the most prevalent diseases in the region in Saudi Arabia (KSA). This was a cross-sectional and community-based study. The adult population was divided into governorates according to the regions that were close to each other, and then a convenient stratum was selected from each region. Next, random sampling was applied. Data were collected using a self-administered questionnaire. Exclusion criteria were young people (<18 years old) and health workers. Data analysis was performed using descriptive statistics, the Pearson's correlation coefficient, and multiple linear regression. Of the 392 participants in this cross-sectional study, 59.18% were male, 76.28% were aged 18-35 years, 72.96% had a university degree, and 63% had a monthly income of less than SAR 5000 (USD1 = 3.76). The scores (mean ± SD) for KAP regarding DF among the responders were 22.77 ± 7.9, 22.68 ± 7.24, and 25.62 ± 9.4, respectively. KAP constructs were positively correlated according to the Pearson's coefficient. In multiple linear regression analysis, males were favorably and substantially linked with attitude score (β = 2.76, p = 0.001) and negatively associated with practice score (β = -2.45, p = 0.023). No-degree participants scored lower on knowledge (β = -2.78, p = 0.003). There is potential for more research in Saudi Arabia to increase the generalizability to reduce the impact of dengue epidemics.
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Affiliation(s)
- Anas Elyas Ahmed
- Faculty of Medicine, Jazan University, GGGD6622, Jazan 45142, Saudi Arabia
| | | | - Mohammed O. Shami
- Faculty of Medicine, Jazan University, GGGD6622, Jazan 45142, Saudi Arabia
| | | | - Hassan M. Alsharif
- Faculty of Medicine, Jazan University, GGGD6622, Jazan 45142, Saudi Arabia
| | | | | | | | | | | | - Ali H. Alhazmi
- Faculty of Medicine, Jazan University, GGGD6622, Jazan 45142, Saudi Arabia
| | - Halimah A. Qasem
- Faculty of Medicine, Jazan University, GGGD6622, Jazan 45142, Saudi Arabia
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Rescue therapy with intravenous immunoglobulin in severe refractory dengue: A pilot study. Med J Armed Forces India 2022; 78:204-212. [PMID: 35463535 PMCID: PMC9023533 DOI: 10.1016/j.mjafi.2020.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 12/31/2020] [Indexed: 11/23/2022] Open
Abstract
Background Severe dengue causes more than 22,000 deaths annually worldwide. Complicated dengue has high mortality of 44-72%. Disordered immune system with capillary leak and thrombocytopenia are hallmark of complicated dengue. Intravenous immunoglobulin (IV Ig) therapy has shown to be effective in complicated dengue in pediatric age group with refractory shock, but studies in adults are lacking. Its immunoresuscitative role is not yet fully explored in critically ill patients with severe dengue. Methods This is retrospective observational study of patients with complicated dengue fever who were administered IV Ig therapy in a tertiary care hospital of southern India from 01 Jan 2018 to 31 Dec 2019. Results A total of 999 patients with dengue were admitted; 754 (75.47%) were males, and 245 (24.53%) were females. A total of 402 (40.24%) patients presented with warning signs. Bleeding was seen in 121 patients (12.11%); 102 (10.21%) had shock; 29 (2.90%) had acute kidney injury and 24 (2.40%) had adult respiratory distress syndrome. Overall, four people died (mortality rate: 0.40%). IV Ig in the dose of 0.4 g/kg for 5 days was used in 13 critically ill patients where standard therapy failed, 9 patients with refractory shock (which included three with myocarditis with refractory shock), 2 with encephalitis, 2 in hemophagocytic lymphohistiocytosis. Two patients died, one with myocarditis with refractory shock and another with refractory shock. Conclusion IV Ig therapy in critically ill patients with complicated dengue can be used as a rescue therapy.
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Munshi A, Alsuraihi A, Balubaid M, Althobaiti M, Althaqafi A. Dengue-Induced Hemophagocytic Lymphohistiocytosis: A Case Report and Literature Review. Cureus 2021; 13:e20172. [PMID: 35003998 PMCID: PMC8724679 DOI: 10.7759/cureus.20172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncommon fatal disease of otherwise normal but hyperactive lymphocytes and histocytes. HLH could be primary (hereditary) or secondary (acquired). Fever, hepatosplenomegaly, lymphadenopathy, and neurologic dysfunction are among the common symptoms of HLH. The diagnosis of HLH is based on clinical and biochemical findings. We report here a case of a patient infected with the dengue virus who developed HLH during hospitalization. A 63-year-old female known case of asthma on inhalers, chronic hepatitis B virus, gastritis on proton pump inhibitors, and hemoglobin H disease presented to the emergency department (ED) with a history of high-grade fever (highest recorded temperature 40° C/ 104° F), which was relieved partially by antipyretics, generalized fatigability, body aches, headache and mosquito bites for four days. The physical examination was significant for hepatomegaly of 4 cm below the right costal margin. Investigations revealed pancytopenia with elevated ferritin levels (> 40000 µg/L). Viral serology was positive for dengue NS1 antigen. After hematology consultation, a bone marrow biopsy was done, which showed trilineage hematopoiesis with increased histiocytes and occasional hemophagocytosis. Given that the patient was clinically stable and there was a clear triggering condition, we opted for supportive measures rather than HLH-specific therapy. The patient was given 2 units packed red blood cells for anemia. On the following days, the patient has no recurrence of fever, with marked improvement in the biochemical profile including ferritin level (1165 µg/L). HLH is a deleterious disease with a high fatality rate, which requires the clinician to have a low threshold for suspicion in the differentials of children and adults with symptoms of persistent fever, hepatosplenomegaly, and cytopenia. Dengue-associated HLH diagnosis is challenging, but it is very important to be recognized, as early recognition is associated with better outcomes. Physicians must work in collaboration with pathologists and microbiologists for the proper diagnosis.
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Jose PMM, Paola ZS, Eduardo DG, Arturo SMMO, Fernando BG. A case of coinfection of a pediatric patient with acute SARS-COV-2 with MIS-C and severe DENV-2 in Mexico: a case report. BMC Infect Dis 2021; 21:1072. [PMID: 34663252 PMCID: PMC8521498 DOI: 10.1186/s12879-021-06765-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/01/2021] [Indexed: 11/27/2022] Open
Abstract
Background COVID-19 cases have been increasing since the epidemic started. One of the major concerns is how clinical symptomatology would behave after coinfection with another virus. Case presentation In this case report, a pediatric native patient from Estado de Mexico (EDOMEX), MEX had severe DENV-2 and acute SARS-CoV-2 at the same time. The clinical features were severe thrombocytopenia, secondary septic shock, cerebral edema, pericardial effusion, fluid overload that exhibited bipalpebral edema in all four extremities, hemophagocytic lymphohistiocytosis (HLH), coronary artery ectasia (CAE), multisystemic inflammatory syndrome in children (MIS-C), and probable COVID-19 pneumonia or acute respiratory distress syndrome (ARDS) that triggered patient intubation. The patient presented unusual symptomatology according to the literature. After 15 days of intubation and 15 more days under surveillance, he was released without respiratory sequelae and without treatment after major clinical improvement. Conclusion The aim of this manuscript is to present clinical challenges that coinfection may cause in pediatric patients, even though COVID-19 in children does not tend to be as severe as in other sectors of the population.
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Affiliation(s)
- Perez-Mendez Maria Jose
- Laboratorio de Medicina Traslacional, Escuela Superior de Medicina, Instituto Politecnico Nacional, Salvador Díaz Mirón esq. Plan de San Luis S/N, Miguel Hidalgo, Casco de Santo Tomas, 11340, Mexico, CDMX, Mexico.,Laboratorio de Biología Molecular, Laboratorio Estatal de Salud Pública del Estado de México, Tollocan S/N Colonia Moderna de la Cruz, 50180, Toluca,, Mexico
| | - Zarate-Segura Paola
- Laboratorio de Medicina Traslacional, Escuela Superior de Medicina, Instituto Politecnico Nacional, Salvador Díaz Mirón esq. Plan de San Luis S/N, Miguel Hidalgo, Casco de Santo Tomas, 11340, Mexico, CDMX, Mexico
| | - Davila-Gonzalez Eduardo
- Laboratorio de Biología Molecular, Laboratorio Estatal de Salud Pública del Estado de México, Tollocan S/N Colonia Moderna de la Cruz, 50180, Toluca,, Mexico
| | - Servin-Monroy Monroy Osvaldo Arturo
- Departamento de Epidemiología del Instituto de Seguridad Social del Estado de México y Municipios, ISSEMyM, Av. Hidalgo Pte. No. 600, Col. La Merced, 50080, Toluca, Estado de México, Mexico
| | - Bastida-Gonzalez Fernando
- Laboratorio de Biología Molecular, Laboratorio Estatal de Salud Pública del Estado de México, Tollocan S/N Colonia Moderna de la Cruz, 50180, Toluca,, Mexico.
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Bonheur AN, Thomas S, Soshnick SH, McGibbon E, Dupuis AP, Hull R, Slavinski S, Del Rosso PE, Weiss D, Hunt DT, McCabe ME, Dean AB, Folkerth R, Laib AM, Wong SJ. A fatal case report of antibody-dependent enhancement of dengue virus type 1 following remote Zika virus infection. BMC Infect Dis 2021; 21:749. [PMID: 34348665 PMCID: PMC8334327 DOI: 10.1186/s12879-021-06482-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dengue virus (DENV) is endemic in many parts of the world. Antibody dependent enhancement (ADE) in DENV infections occurs when a person with primary immunity is infected by a second, different DENV strain. Antibodies to Zika virus (ZIKV), which emerged in the Western Hemisphere in 2015, are cross reactive with DENV and theoretically could provoke ADE in a DENV naïve individual. CASE PRESENTATION DENV infection was suspected in a child who had recently returned from a one-month stay in the Dominican Republic. The child presented with fever, vomiting, abdominal pain, and in hypovolemic shock. Volume and pressor resuscitation were unsuccessful, and the child died less than 24 h after hospitalization. Laboratory results suggested an early acute first DENV infection since serum, plasma, and spinal fluid had DENV1 detected by polymerase chain reaction (PCR), yet the serum lacked IgG antibodies to DENV nonstructural protein 1 (NS1) of all four DENV serotypes. This acute DENV infection occurred in the presence of a remote ZIKV infection as determined by antibodies to ZIKV NS1 envelope by multiplex microsphere immunoassay and an exceptionally high plaque reduction neutralization titer to ZIKV. ZIKV IgG avidity index was high, confirming a past infection. DENV1 RNA was detected in all ten organs and tissues examined by PCR. The severe and fatal complications reported here suggest that a remote ZIKV infection may provoke an exaggerated immune response leading to hypovolemic shock when primarily infected by DENV1. CONCLUSION We report the first known patient in the United States with a rapidly progressive and fatal case of travel-associated DENV in which prior exposure to ZIKV likely played a role in triggering an ADE phenomenon. This association of prior ZIKV immunity and subsequent new dengue infection is a worrisome phenomenon and an important contribution to the body of knowledge on immunity to flaviviruses.
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Affiliation(s)
- Ashley N Bonheur
- Division of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sarah Thomas
- Office of the New York City Chief Medical Examiner, New York, NY, USA
| | - Sara H Soshnick
- Division of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Emily McGibbon
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Alan P Dupuis
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rene Hull
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Sally Slavinski
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Paula E Del Rosso
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Don Weiss
- New York City Department of Health and Mental Hygiene, Queens, NY, USA.
| | - Danielle T Hunt
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Megan E McCabe
- Division of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amy B Dean
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rebecca Folkerth
- Office of the New York City Chief Medical Examiner, New York, NY, USA
| | - Anne M Laib
- Office of the New York City Chief Medical Examiner, New York, NY, USA
| | - Susan J Wong
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
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Kan FK, Tan CC, Von Bahr Greenwood T, Khalid KE, Supramaniam P, Hed Myrberg I, Tan LH, Henter JI. Dengue Infection Complicated by Hemophagocytic Lymphohistiocytosis: Experiences From 180 Patients With Severe Dengue. Clin Infect Dis 2021; 70:2247-2255. [PMID: 31188423 PMCID: PMC7245144 DOI: 10.1093/cid/ciz499] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/11/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Globally, ~500 000 people with severe dengue (SD) require hospitalization yearly; ~12 500 (2.5%) die. Secondary hemophagocytic lymphohistiocytosis (sHLH) is a potentially fatal hyperinflammatory condition for which HLH-directed therapy (as etoposide and dexamethasone) can be life-saving. Prompted by the high mortality in SD and the increasing awareness that patients with SD may develop sHLH, our objectives were to (1) determine the frequency of dengue-HLH in SD, (2) describe clinical features of dengue-HLH, (3) assess mortality rate in SD and dengue-HLH, and (4) identify mortality-associated risk factors in SD. METHODS A 5-year retrospective single-center study in all adult patients with SD admitted to a tertiary intensive care unit in Malaysia. RESULTS Thirty-nine of 180 (22%) patients with SD died. Twenty-one of 180 (12%) had HLH defined as an HLH probability ≥70% according to histo score (HScore); 9 (43%) died. Similarly, 12 of 31 (39%) fulfilling ≥4 and 7 of 9 (78%) fulfilling ≥5 HLH-2004 diagnostic criteria died. Peak values of aspartate aminotransferase (AST), alanine aminotransferase, lactate dehydrogenase, and creatinine correlated to fatality (odds ratios [ORs], 2.9, 3.4, 5.8, and 31.9; all P < .0001), as did peak ferritin (OR, 2.5; P = .0028), nadir platelets (OR, 1.9; P = .00068), hepatomegaly (OR, 2.9; P = .012), and increasing age (OR, 1.2; P = .0043). Multivariable logistic regression revealed peak AST (OR, 2.8; P = .0019), peak creatinine (OR, 7.3; P = .0065), and SOFA (Sequential Organ Failure Assessment) score (OR, 1.4; P = .0051) as independent risk factors of death. CONCLUSIONS Be observant of dengue-HLH due to its high mortality. A prospective study is suggested on prompt HLH-directed therapy in SD patients with hyperinflammation and evolving multiorgan failure at risk of developing dengue-HLH.
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Affiliation(s)
- Foong Kee Kan
- Department of Medicine, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Cheng Cheng Tan
- Department of Anesthesiology and Intensive Care, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Tatiana Von Bahr Greenwood
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute.,Theme of Children's and Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Khairil E Khalid
- Department of Medicine, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | | | - Ida Hed Myrberg
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute
| | - Lian Huat Tan
- Sunway Medical Centre, Petaling Jaya, Selangor, Malaysia
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute.,Theme of Children's and Women's Health, Karolinska University Hospital, Stockholm, Sweden
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15
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A Curious Case of Dengue Fever: A Case Report of Unorthodox Manifestations. Case Rep Med 2020; 2020:1701082. [PMID: 32774384 PMCID: PMC7399777 DOI: 10.1155/2020/1701082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/24/2020] [Indexed: 11/18/2022] Open
Abstract
Dengue is the major cause of arthropod-borne viral disease in the world. It presents with high fever, headache, rash, myalgia, and arthralgia and it is a self-limiting illness. Severe dengue can occur in some cases resulting in dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). We present a case of a 32-year-old male patient of high-grade fever, bilateral subconjunctival hemorrhages, swelling on hands and lips, and nasal bleeding. After investigations, he was diagnosed with dengue fever and it was observed that he developed systemic fungal infection secondary to Candida tropicalis infection. The patient's bone marrow biopsy showed hemophagocytic activity. He also developed hepatitis E infection while hepatitis A, B, or C serology profile showed no active infection. The bilateral iliopsoas hematoma was also observed on CT scan manifested by decreased power in bilateral lower limbs and pain in the right leg. The patient was treated in the hospital with antibiotics (ceftriaxone 2 g once daily for 14 days) and antifungal (fluconazole 200 mg per oral initially for one day then 100 mg daily for 13 days) medicines, and his condition improved on discharge. There is evidence of variable presentations of dengue fever after the disease burden is increased, and thus, diagnosing with such manifestations can be very challenging.
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16
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Nandhakumar D, Loganatha A, Sivasankaran M, Sivabalan S, Munirathnam D. Hemophagocytic Lymphohistiocytosis in Children. Indian J Pediatr 2020; 87:526-531. [PMID: 32056194 DOI: 10.1007/s12098-020-03190-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/08/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To study the profile of children with Hemophagocytic Lymphohistiocytosis (HLH) in a tertiary care hospital for children. METHODS A retrospective analysis of case records of 52 children diagnossed with HLH was performed. RESULTS Of the 52 children 13% (n = 7) had Familial HLH and 87% (n = 45) had secondary HLH (sHLH). Common manifestations were fever (100%), organomegaly (87%), respiratory distress (54%), neurological symptoms (31%) and skin rashes (26.2%). Anemia and thrombocytopenia were present in 51% and 73% respectively. Hyperferritinemia was present in 96% and hypofibrinogenemia in 42% and high lactate dehydrogenase (LDH) in 91%. Bone marrow examination showed hemophagocytosis in 80%. Most common etiology among infections was viral infections (67%), of which Dengue was the most common (52%). Among children with sHLH 51% received supportive care only. Thirty-seven percent (n = 17) received intravenous (IV) immunoglobulin and steroids. Of these 77% (n = 35) recovered completely. Children with familial HLH were initiated on HLH 2004 protocol but all of them expired due to disease progression. CONCLUSIONS Identifying HLH early and managing it, poses a significant challenge. Prompt recognition and initiation of immunosuppressive therapy is extremely important for the better outcome; hence high clinical suspicion and structured work up including immunological, and genetic studies is required. It may be difficult to differentiate primary and secondary HLH in many instances unless genetic analysis is done. Identification of familial HLH is necessary for early referral to Hematopoietic Stem Cell Transplantation (HSCT). Hence screening for primary HLH needs to be considered in all children with HLH.
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Affiliation(s)
- Divya Nandhakumar
- Department of Pediatrics, Kanchi Kamakoti CHILDs Trust Hospital, Numgambakkam, Chennai, Tamil Nadu, India
| | - Ajietha Loganatha
- Department of Pediatric Hemato-Oncology, Kanchi Kamakoti CHILDs Trust Hospital, Numgambakkam, Chennai, Tamil Nadu, 600 034, India
| | - Meena Sivasankaran
- Department of Pediatric Hemato-Oncology, Kanchi Kamakoti CHILDs Trust Hospital, Numgambakkam, Chennai, Tamil Nadu, 600 034, India.
| | - Somu Sivabalan
- Department of Pediatrics, Kanchi Kamakoti CHILDs Trust Hospital, Numgambakkam, Chennai, Tamil Nadu, India
| | - Deenadayalan Munirathnam
- Department of Pediatric Hemato-Oncology, Kanchi Kamakoti CHILDs Trust Hospital, Numgambakkam, Chennai, Tamil Nadu, 600 034, India
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17
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Bhattacharya D, Angurana SK, Nallasamy K, Iyer R, Jayashree M. Severe Dengue and Associated Hemophagocytic Lymphohistiocytosis in PICU. Indian J Pediatr 2019; 86:1094-1098. [PMID: 31353429 DOI: 10.1007/s12098-019-03040-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/10/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To study the clinico-laboratory profile and outcome of children with severe dengue and dengue-associated hemophagocytic lymphohistiocytosis (HLH). METHODS In this retrospective study, 22 children with laboratory confirmed severe dengue admitted to pediatric intensive care unit (PICU) were enrolled. Clinical features, laboratory parameters, and outcome were noted and compared between cases fulfilling HLH-2004 criteria and those without HLH. RESULTS Median (IQR) age was 8 (5-10.3) y. Fever was present for mean (SD) duration of 5.3 (2.1) d. Vomiting, respiratory distress, pain abdomen and hepatomegaly were other clinical features. Thrombocytopenia, anemia and elevated serum transaminases were noted in 91%, 41% and 30% respectively; coagulopathy and hypoalbuminemia were seen in 36% each. Half (n = 11, 50%) had dengue shock syndrome. Acute respiratory distress syndrome (ARDS) (n = 7, 32%) and acute kidney injury (AKI) (n = 6, 28%) were other major organ dysfunctions. Mean (SD) duration of PICU stay was 3.6 (1.5) d with 13.6% mortality. HLH was noted in 7 (32%) cases at a median (IQR) hospital stay of 5 (2-8) d. Children with HLH had significantly higher Pediatric Index of Mortality 2 (PIM 2) score at admission and higher frequency of pain abdomen, anemia, hypoalbuminemia, elevated alanine aminotransferase (ALT) and ARDS. Length of PICU stay (5.1 vs. 2.9 d) and mortality (28.6% vs. 6.7%) were higher in HLH group, however the difference was not statistically significant. Steroids were used in 4 cases with HLH and all survived, whereas among 3 who did not receive steroids, 2 died (p = 0.23). CONCLUSIONS Severe dengue presents with life-threatening organ dysfunctions. HLH is increasingly recognized in dengue infection and maybe considered as a differential diagnosis in children with lower hemoglobin, hypoalbuminemia, elevated ALT and severe organ dysfunction.
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Affiliation(s)
- Deepanjan Bhattacharya
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Suresh Kumar Angurana
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Karthi Nallasamy
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India.
| | - Rajalakshmi Iyer
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
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18
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Abstract
This is a selective review of recent publications on dengue clinical features, epidemiology, pathogenesis, and vaccine development placed in a context of observations made over the past half century. Four dengue viruses (DENVs) are transmitted by urban cycle mosquitoes causing diseases whose nature and severity are influenced by interacting factors such as virus, age, immune status of the host, and human genetic variability. A phenomenon that controls the kinetics of DENV infection, antibody-dependent enhancement, best explains the correlation of the vascular permeability syndrome with second heterotypic DENV infections and infection in the presence of passively acquired antibodies. Based on growing evidence in vivo and in vitro, the tissue-damaging DENV non-structural protein 1 (NS1) is responsible for most of the pathophysiological features of severe dengue. This review considers the contribution of hemophagocytic histiocytosis syndrome to cases of severe dengue, the role of movement of humans in dengue epidemiology, and modeling and planning control programs and describes a country-wide survey for dengue infections in Bangladesh and efforts to learn what controls the clinical outcome of dengue infections. Progress and problems with three tetravalent live-attenuated vaccines are reviewed. Several research mysteries remain: why is the risk of severe disease during second heterotypic DENV infection so low, why is the onset of vascular permeability correlated with defervescence, and what are the crucial components of protective immunity?
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Affiliation(s)
- Scott Halstead
- Emeritus Professor, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
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19
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Rajapakse S, Wattegama M, Weeratunga P, Sigera PC, Fernando SD. Beyond thrombocytopaenia, haemorrhage and shock: the expanded dengue syndrome. Pathog Glob Health 2018; 112:404-414. [PMID: 30507366 DOI: 10.1080/20477724.2018.1552645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Senaka Rajapakse
- a Department of Clinical Medicine, Faculty of medicine , University of Colombo , Colombo , Sri Lanka
| | - Milanka Wattegama
- b Department of Endocrinology , North Colombo Teaching Hospital , Ragama , Sri Lanka
| | - Praveen Weeratunga
- a Department of Clinical Medicine, Faculty of medicine , University of Colombo , Colombo , Sri Lanka
| | - P Chathurani Sigera
- c Department of Parasitology, Faculty of medicine , University of Colombo , Colombo , Sri Lanka
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20
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Giang HTN, Banno K, Minh LHN, Trinh LT, Loc LT, Eltobgy A, Tai LLT, Khan A, Tuan NH, Reda Y, Samsom M, Nam NT, Huy NT, Hirayama K. Dengue hemophagocytic syndrome: A systematic review and meta‐analysis on epidemiology, clinical signs, outcomes, and risk factors. Rev Med Virol 2018; 28:e2005. [DOI: 10.1002/rmv.2005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/01/2018] [Accepted: 07/07/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Hoang Thi Nam Giang
- The University of Da Nang Da Nang Vietnam
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
| | - Keita Banno
- School of Tropical Medicine and Global HealthNagasaki University Nagasaki Japan
| | - Le Huu Nhat Minh
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- University of Medicine and Pharmacy at Ho Chi Minh City Ho Chi Minh City Vietnam
| | - Lam Tuyet Trinh
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- Department of Infectious DiseaseCity Children's Hospital Ho Chi Minh City Vietnam
| | - Le Thai Loc
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- Department of Infectious DiseaseCity Children's Hospital Ho Chi Minh City Vietnam
| | - Asmaa Eltobgy
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- Al‐Azhar Medical University for Girls Cairo Egypt
| | - Luu Lam Thang Tai
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- Pham Ngoc Thach University of Medicine Ho Chi Minh City Vietnam
| | - Adnan Khan
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- Rehman Medical Institute Peshawar Pakistan
| | - Nguyen Hoang Tuan
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- University of Medicine and Pharmacy at Ho Chi Minh City Ho Chi Minh City Vietnam
| | - Yaser Reda
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- Faculty of PharmacyAl‐Azhar University Cairo Egypt
| | - Maryan Samsom
- Online Research Club (http://www.onlineresearchclub.org/) Nagasaki Japan
- Faculty of MedicineBeni‐Suef University Beni‐Suef Egypt
| | - Nguyen Tran Nam
- Department of Infectious DiseaseCity Children's Hospital Ho Chi Minh City Vietnam
| | - Nguyen Tien Huy
- Evidence Based Medicine Research Group & Faculty of Applied SciencesTon Duc Thang University Ho Chi Minh City Vietnam
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Leading Graduate School Program, and Graduate School of Biomedical SciencesNagasaki University Nagasaki Japan
| | - Kenji Hirayama
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Leading Graduate School Program, and Graduate School of Biomedical SciencesNagasaki University Nagasaki Japan
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21
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Shankar MB, Rodríguez-Acosta RL, Sharp TM, Tomashek KM, Margolis HS, Meltzer MI. Estimating dengue under-reporting in Puerto Rico using a multiplier model. PLoS Negl Trop Dis 2018; 12:e0006650. [PMID: 30080848 PMCID: PMC6095627 DOI: 10.1371/journal.pntd.0006650] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 08/16/2018] [Accepted: 06/29/2018] [Indexed: 12/24/2022] Open
Abstract
Dengue is a mosquito-borne viral illness that causes a variety of health outcomes, from a mild acute febrile illness to potentially fatal severe dengue. Between 2005 and 2010, the annual number of suspected dengue cases reported to the Passive Dengue Surveillance System (PDSS) in Puerto Rico ranged from 2,346 in 2006 to 22,496 in 2010. Like other passive surveillance systems, PDSS is subject to under-reporting. To estimate the degree of under-reporting in Puerto Rico, we built separate inpatient and outpatient probability-based multiplier models, using data from two different surveillance systems—PDSS and the enhanced dengue surveillance system (EDSS). We adjusted reported cases to account for sensitivity of diagnostic tests, specimens with indeterminate results, and differences between PDSS and EDSS in numbers of reported dengue cases. In addition, for outpatients, we adjusted for the fact that less than 100% of medical providers submit diagnostic specimens from suspected cases. We estimated that a multiplication factor of between 5 (for 2010 data) to 9 (for 2006 data) must be used to correct for the under-reporting of the number of laboratory-positive dengue inpatients. Multiplication factors of between 21 (for 2010 data) to 115 (for 2008 data) must be used to correct for the under-reporting of laboratory-positive dengue outpatients. We also estimated that, after correcting for underreporting, the mean annual rate, for 2005–2010, of medically attended dengue in Puerto Rico to be between 2.1 (for dengue inpatients) to 7.8 (for dengue outpatients) per 1,000 population. These estimated rates compare to the reported rates of 0.4 (dengue outpatients) to 0.1 (dengue inpatients) per 1,000 population. The multipliers, while subject to limitations, will help public health officials correct for underreporting of dengue cases, and thus better evaluate the cost-and-benefits of possible interventions. The number of global cases of dengue has increased an estimated 30-fold from 1962 to 2012, and two-fifths of the world’s population are thought to be at risk for dengue. It has been recently estimated that the global incidence of dengue is between 50 and 100 million cases per year. These estimates of burden and impact are, however, are not considered very reliable. It has been previously established and reported that there is notable under-reporting of clinical cases of dengue, even those who sought medical treatment. This includes under-reporting of those hospitalized with laboratory-confirmed dengue. This lack of reliable estimates hampers efforts of public health officials in determining the of burden of disease and the costs-and-benefits of potential interventions. We estimated that multiplication factors ranging from 5 to 9 must be used to correct for under-reporting of laboratory-positive dengue inpatient cases reported to public health officials in Puerto Rico. Multiplication factors ranging from 21 to 115 must be used to correct for the underreporting of laboratory-positive dengue outpatients. Our results illustrate the need for, and thus potential benefits of, using our methodology to estimate the degree of under-reporting in passive dengue systems during epidemic and non-epidemic years.
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Affiliation(s)
- Manjunath B. Shankar
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Rosa L. Rodríguez-Acosta
- Dengue Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Tyler M. Sharp
- Dengue Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Kay M. Tomashek
- Dengue Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Harold S. Margolis
- Dengue Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Martin I. Meltzer
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- * E-mail:
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22
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Kam KQ, Soh SY, Bhattacharyya R. Dengue-associated Hemophagocytic Lymphohistiocytosis: A Rare Complication of a Common Infection in Singapore. J Pediatr Hematol Oncol 2018; 40:e377-e379. [PMID: 29200153 DOI: 10.1097/mph.0000000000001000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) can progress rapidly, often leading to multisystem organ failure and death. Prompt recognition of the syndrome and institution of appropriate treatment are crucial steps in improving the outcome. Dengue virus infection is not commonly known to be associated with secondary HLH. We present a case of a child with dengue fever who subsequently developed classical features of HLH. He was treated successfully with 4 weeks of steroid monotherapy instead of the multidrug therapy proposed in the HLH 2004 protocol. There was prompt response to the treatment with resolution of clinical and biochemical features. He remains in complete remission 3 years from the diagnosis.
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Affiliation(s)
| | - Shui Yen Soh
- Haematology/Oncology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Rajat Bhattacharyya
- Haematology/Oncology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
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23
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Salinas JL, Major CG, Pastula DM, Dirlikov E, Styczynski A, Luciano CA, Wojna V, Sharp TM, Sejvar JJ, Rivera-Garcia B. Incidence and clinical characteristics of Guillain-Barré syndrome before the introduction of Zika virus in Puerto Rico. J Neurol Sci 2017; 377:102-106. [PMID: 28477675 DOI: 10.1016/j.jns.2017.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Zika virus has been associated with increases in Guillain-Barré syndrome (GBS) incidence. A GBS incidence estimation and clinical description was performed to assess baseline GBS epidemiology before the introduction of Zika virus in Puerto Rico. METHODS Hospitalization administrative data from an island-wide insurance claims database and U.S. Census Bureau population estimates provided a crude GBS incidence for 2013. This estimate was adjusted using the proportion of GBS cases meeting Brighton criteria for confirmed GBS from nine reference hospitals. Characteristics of confirmed GBS cases in the same nine hospitals during 2012-2015 are described. RESULTS A total of 136 GBS hospitalization claims were filed in 2013 (crude GBS incidence was 3.8 per 100,000 population). The adjusted GBS incidence was 1.7 per 100,000 population. Of 67 confirmed GBS cases during 2012-2015, 66% had an antecedent illness. Median time from antecedent illness to GBS onset was 7days. Most cases (67%) occurred during July-September. CONCLUSIONS Puerto Rico's GBS incidence for 2013 was estimated using a combination of administrative data and medical records review; this method could be employed in other regions to monitor GBS incidence before and after the introduction of GBS infectious triggers.
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Affiliation(s)
| | - Chelsea G Major
- Office for State, Tribal, Local, and Territorial Support, CDC, Atlanta, Georgia
| | - Daniel M Pastula
- National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia; University of Colorado Denver, Aurora, CO, United States
| | - Emilio Dirlikov
- Epidemic Intelligence Service, CDC, Atlanta, Georgia; Puerto Rico Department of Health, San Juan, Puerto Rico
| | | | | | | | - Tyler M Sharp
- National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
| | - James J Sejvar
- National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
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