Incidence, Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis

Evaluation of clinical and laboratory characteristics of dengue viral infection and risk factors of dengue hemorrhagic fever: a multi-center retrospective analysis

BACKGROUND

Dengue Viral Infection (DVI) has become endemic in Pakistan since the first major outbreak in Karachi in 1996. Despite aggressive measures taken by relevant authorities, Pakistan has been dealing with a worsening dengue crisis for the past two decades. DHF is severe form of dengue infection which is linked with significant morbidity and mortality. Early identification of severe dengue infections can reduce the morbidity and mortality. In this context we planned current study in which we find out the different factors related with DHF as well as clinical laboratory features of DHF and compare them to DF so that patients can be best evaluated for DHF and managed accordingly at admission.

METHODS

Retrospective study conducted over a period of 6 years (2013-2018) in two tertiary care hospitals in Pakistan. Data were collected by using a pre-structured data collection form. Data were statistically analyzed to determine the clinical and laboratory characteristics of DVI and risk factors of dengue hemorrhagic fever (DHF).

RESULTS

A total 512 dengue cases (34.05 ± 15.08 years; Male 69.53%) were reviewed. Most common clinical manifestations of DVI were fever (99.60%), headache (89.1%), chills (86.5%), rigors (86.5%), myalgia (72.3%). Less common clinical manifestations were vomiting (52.5%), arthralgia (50.2%) and skin rashes (47.5%). Furthermore, nasal bleeding (44.1%), gum bleeding (32.6%), pleural effusion (13.9%) and hematuria (13.1%) were more profound clinical presentations among DHF patients. Mortality rate was 1.5% in this study. Logistic regression analysis indicated that delayed hospitalization (OR: 2.30) and diabetes mellitus (OR:2.71), shortness of breath (OR:2.21), association with risk groups i.e., living near stagnant water, travelling to endemic areas, living in endemic regions (OR:1.95), and presence of warning signs (OR:2.18) were identified as risk factors of DHF. Statistically we found that there is strong association of diabetes mellitus (DM) with DHF while the patient suffering from DM individually had higher odds (2.71) of developing DHF than patients without disease.

CONCLUSIONS

The current study demonstrated that the clinical and laboratory profiles of DF and DHF are significantly distinct. Significant predictors of DHF were advanced age, diabetes mellitus, ascites, pleural effusion, thick gallbladder and delayed hospitalization. The identification of these factors at early stage provides opportunities for the clinicians to identify high risk patients and to reduce dengue-related morbidity and mortality.

Prevalence of acute kidney injury among dengue cases: a systematic review and meta-analysis

Numerous studies have shown a correlation between dengue virus (DENV) infection and kidney disease. However, there is no existing meta-analysis on the prevalence of kidney diseases in the dengue population. A thorough systematic review and meta-analysis were undertaken to determine the prevalence of renal problems in people with DENV infection in order to fill this knowledge gap. A rigorous electronic literature search was carried out up to 25 January 2023 in a number of databases, including ProQuest, EBSCOhost, Scopus, PubMed and Web of Science. The search aimed to find articles that reported on the prevalence of kidney diseases in patients with DENV infection. Using the modified Newcastle-Ottawa Scale, the quality of the included studies was assessed. The meta-analysis included a total of 37 studies with 21 764 participants reporting on the prevalence of acute kidney injury (AKI) in individuals with DENV infection. The pooled prevalence of AKI in dengue patients was found to be 8% (95% confidence interval 6 to 11), with high heterogeneity across studies. The studies included are of moderate quality. The study revealed a high AKI prevalence in dengue patients, underlining the need for regular renal examination to detect AKI early and reduce hospitalization risk. Further research is needed to understand the dengue-kidney relationship and develop effective management strategies.

Prevalence, Characteristics, and Outcomes Associated with Acute Kidney Injury among Adult Patients with Severe Dengue in Mainland China

Acute kidney injury (AKI) can occur in adult patients with severe dengue (SD) and have serious clinical outcomes. This study aimed to determine the prevalence, characteristics, risk factors, and clinical outcomes of AKI in adult patients with SD; the correlation of dengue virus (DENV) serological and virological profiles with AKI; and the clinical features of patients with severe AKI who received renal replacement treatment (RRT). This multicenter study was conducted in Guangdong Province, China, between January 2013 and November 2019. A total of 242 patients were evaluated, of which 85 (35.1%) developed AKI and 32 (13.2%) developed severe AKI (stage 3). Patients with AKI had a higher fatality rate (22.4% versus 5.7%; P < 0.001) and longer length of hospital stay (median: 13 versus 9 days; P < 0.001). Independent risk factors for AKI were hypertension (odds ratio [OR]: 2.03; 95% CI: 1.10-3.76), use of nephrotoxic drugs (OR: 1.90; 95% CI: 1.00-3.60), respiratory distress (OR: 4.15; 95% CI: 1.787-9.632), high international normalized ratio (INR) levels (OR: 6.44; 95% CI: 1.89-21.95), and hematuria (OR: 2.12; 95% CI: 1.14-3.95). There was no significant association between DENV serological and virological profiles and the presence or absence of AKI. Among patients with severe AKI, those who received RRT had a longer length of hospital stay and similar fatality rate. Hence, adult patients with SD should be closely monitored for the development of AKI to enable timely and appropriate therapy.

Mechanism of Immune Evasion in Mosquito-Borne Diseases

In recent decades, mosquito-borne illnesses have emerged as a major health burden in many tropical regions. These diseases, such as malaria, dengue fever, chikungunya, yellow fever, Zika virus infection, Rift Valley fever, Japanese encephalitis, and West Nile virus infection, are transmitted through the bite of infected mosquitoes. These pathogens have been shown to interfere with the host's immune system through adaptive and innate immune mechanisms, as well as the human circulatory system. Crucial immune checkpoints such as antigen presentation, T cell activation, differentiation, and proinflammatory response play a vital role in the host cell's response to pathogenic infection. Furthermore, these immune evasions have the potential to stimulate the human immune system, resulting in other associated non-communicable diseases. This review aims to advance our understanding of mosquito-borne diseases and the immune evasion mechanisms by associated pathogens. Moreover, it highlights the adverse outcomes of mosquito-borne disease.

Clinical Characteristics of Acute Kidney Injury Associated with Tropical Acute Febrile Illness

Tropical acute febrile illness (TAFI) is one of the most frequent causes of acute kidney injury (AKI). The prevalence of AKI varies worldwide because there are limited reports available and different definitions are used. This retrospective study aimed to determine the prevalence, clinical characteristics, and outcomes of AKI associated with TAFI among patients. Patients with TAFI were classified into non-AKI and AKI cases based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Of 1019 patients with TAFI, 69 cases were classified as having AKI, a prevalence of 6.8%. Signs, symptoms, and laboratory results were significantly abnormal in the AKI group, including high-grade fever, dyspnea, leukocytosis, severe transaminitis, hypoalbuminemia, metabolic acidosis, and proteinuria. 20.3% of AKI cases required dialysis and 18.8% received inotropic drugs. Seven patients died, all of which were in the AKI group. Risk factors for TAFI-associated AKI were being male (adjusted odds ratio (AOR) 3.1; 95% CI 1.3–7.4), respiratory failure (AOR 4.6 95% CI 1.5–14.1), hyperbilirubinemia (AOR 2.4; 95% CI 1.1–4.9), and obesity (AOR 2.9; 95% CI 1.4–6). We recommend clinicians investigate kidney function in patients with TAFI who have these risk factors to detect AKI in its early stages and offer appropriate management.

A survey of clinical and laboratory characteristics of the dengue fever epidemic from 2017 to 2019 in Zhejiang, China

To explore the epidemic, clinical, and laboratory characteristics of dengue patients in Zhejiang and the possible mechanism. Epidemic, clinical and laboratory data of 231 dengue patients admitted to the Second Affiliated Hospital of Zhejiang Traditional Chinese Medicine University between August 2017 and December 2019 were collected. GSE43777 dataset was downloaded from the Gene Expression Omnibus database and was used for the immune cell infiltration analysis, logistic regression analysis, and nomogram construction. Gene set enrichment analysis (GSEA) was performed to explore the possible regulatory pathways in dengue infection. Further, the receiver operating characteristic curve analysis and decision curve analysis were conducted to evaluate the value of related immune cells in predicting dengue severity. Among the 231 patients, the gender ratio was 1:1.1 (male/female). The patients in the <60 years age group, 60 to 80 years age group, and >80 years age group were 47.2%, 45.5%, and 7.3%, respectively. The major symptoms were fever (100%), weak (98.3%), anorexia (76.6%), muscle and joint pain (62.3%), and nausea (46.8%). In dengue patients, 98.7% of serum samples had decreased platelet levels, 96.5% of them had decreased white blood cell (WBC) levels, 97.8% had elevated aspartate aminotransferase levels, 82.3% had elevated lactate dehydrogenase levels, 49.4% had increased creatinine levels, and 35.5% had increased creatine kinase levels. Pneumonia, pleural effusion, and bilateral pleural reaction were observed in 16.5%, 8.2%, and 4.8%, respectively of dengue patients. Gallbladder wall roughness and splenomegaly accounted for 6.1% and 4.3% of all cases. Moreover, the levels of T cell, B cell, and dendritic cells were significantly higher in the convalescent group and they were involved in immune- and metabolism-related pathways. Of note, low levels of these 3 immune cells correlated with high dengue infection risk, while only dendritic cells exhibited satisfactory performance in predicting dengue severity. Dengue fever patients often onset with fever, accompanied by mild abnormalities of the blood system and other organ functions. Moreover, T cells, B cells, and dendritic cells might be involved in dengue infection and development.

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

OBJECTIVE

To investigate risk factors for mortality in dengue.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute kidney injury associated with dengue virus infection: a review

Acute kidney injury (AKI) is one of the least studied complications of dengue, but it carries high mortality rates and prolonged hospital stay. Due to the severity of this complication, the risk of developing chronic kidney disease (CKD) and the increasing number of dengue cases reported worldwide, particularly in the tropical and subtropical regions of Africa, Southeast Asia and South America, including Brazil, we embarked on this narrative review, aimed to update the epidemiology of AKI associated with dengue, elucidate the main pathophysiological mechanisms of AKI caused by the dengue virus infection, as well as discuss useful information on the prevention and management of AKI in patients with dengue.

Brazilian Dengue Virus Type 2-Associated Renal Involvement in a Murine Model: Outcomes after Infection by Two Lineages of the Asian/American Genotype

Dengue virus type 2 (DENV-2) is, traditionally, the most studied serotype due to its association with explosive outbreaks and severe cases. In Brazil, almost 20 years after the first introduction in the 1990s, a new lineage (Lineage II) of the DENV-2 Asian/American genotype emerged and caused an epidemic with severe cases and hospitalizations. Severe dengue includes multiple organ failure, and renal involvement can be potentially related to increased mortality. In order to better understand the role of DENV infection in renal injury, here we aimed to investigate the outcomes of infection with two distinct lineages of DENV-2 Asian/American genotype in the kidney of a murine model. BALB/c mice were infected with Lineages I and II and tissues were submitted to histopathology, immunohistochemistry, histomorphometry and ultrastructural analysis. Blood urea nitrogen (BUN) was detected in blood sample accessed by cardiac puncture. A tendency in kidney weight increase was observed in mice infected with both lineages, but urea levels, on average, were increased only in mice infected with Lineage II. The DENV antigen was detected in the tissue of mice infected with Lineage II and morphological changes were similar to those observed in human dengue cases. Furthermore, the parameters such as organ weight, urea levels and morphometric analysis, showed significant differences between the two lineages in the infected BALB/c, which was demonstrated to be a suitable experimental model for dengue pathophysiology studies in kidneys.

Evaluation of ventricular systolic dysfunction as a risk factor for acute kidney injury in intensive care unit

Background

Heart failure (HF) is a major health problem. Cardiac and renal diseases interact in a complex bidirectional manner in both acute and chronic settings. Renal dysfunction in the setting of heart failure, termed the cardio renal syndrome (CRS), has been considered consequence of left ventricular dysfunction (LVD), whereby decreasing cardiac output (COP) results in renal under perfusion and consequent decreased glomerular filtration rate (GFR).

Main body of the abstract

This study showed that 500 patients were admitted to internal care unit (ICU), and out of them, 100 (20%) patients developed acute kidney injury (AKI) while 400 (80%) patients did not develop AKI. It is also showed that 67 (67%) of those with AKI and 100 (25%) of those with no-AKI had baseline ventricular systolic dysfunction, left ventricular dysfunction (LVD), right ventricular dysfunction (RVD), and biventricular dysfunction (BiVD)presented in 23 (23%), 16 (16%), and 28 (28%) patients of AKI group, respectively, and presented in 60 (15%), 30 (7.50%), and 10 (2.50%) patients, respectively, in patients without acute kidney injury (AKI)

Short conclusion

Our study revealed that AKI has highest incidence in patient with biventricular dysfunction followed by left ventricular dysfunction and lastly those with right ventricular dysfunction.

Blood glucose promotes dengue virus infection in the mosquito Aedes aegypti

Background

Dengue fever is the most rapidly spreading mosquito-borne viral disease globally. More than 2.5 billion people live in dengue-endemic areas. Previous studies suggested an interrelationship between diabetes mellitus (DM) and dengue hemorrhagic fever (DHF). Conversely, glycolysis is a critical metabolic pathway for optimal dengue virus (DENV) replication. However, little is known concerning the effect of glucose on DENV replication in mosquitoes. In this study, we investigated the impact of glucose on DENV replication in mosquitoes Aedes aegypti.

Methods

Mosquitoes (Ae. aegypti UGAL/Rockefeller strain) were orally infected with DENV (serotype 2, 16681 strain) through infectious blood feeding. The DENV infection and transmission rates were determined by examining mosquito bodies and saliva, respectively, for DENV positivity at different time points after infection. In addition, a reverse genetic approach was applied by introducing double-stranded RNA against genes of interest into the mosquitoes to inhibit gene expression.

Results

Our data revealed a significant increase of DENV genome levels in mosquitoes consuming an infectious blood meal supplemented with glucose, suggesting that blood glucose is an important factor for viral replication. Interestingly, a significant increase of DENV E protein levels was detected in the saliva 4 days faster in mosquitoes that consumed infectious blood meals supplemented with glucose than in those consuming infectious blood meals alone. Furthermore, we perform RNAi to silence AKT or TOR and investigate the molecular mechanism regulating the glucose-mediated enhancement of viral replication. Silencing of AKT or TOR significantly reduced DENV titers in mosquitoes.

Conclusions

This study suggested that blood glucose is beneficial to DENV replication and that it facilitates virus transmission in mosquitoes via AKT and TOR signaling. Therefore, our results strengthen our understanding of dengue fever and DM co-morbidity and possibly reveal new targets for specific antiviral therapies.

Graphical abstract

Predictors and Outcomes of Dengue-Associated Acute Kidney Injury

Dengue viral infections present with a wide clinical spectrum ranging from asymptomatic to severe manifestations with organ involvement. The term "expanded dengue syndrome" has been commonly used to illustrate the unusual or atypical manifestations; acute kidney injury (AKI) is one of the atypical manifestations of this syndrome. The use of heterogeneous criteria to determine the presence of AKI in dengue patients due to the vast diversity in populations led to difficulties in assessing the true incidence of dengue-associated AKI. This review presents a variable, but often high, frequency of dengue-associated AKI among vastly diverse populations with various disease severities. Dengue-associated AKI is not an uncommon complication, and its importance has often been neglected during the management of dengue patients. The risk factors and certain clinical and laboratory findings commonly reported among dengue patients with AKI should be considered to support a timely diagnosis and case management. This review highlights the need for clinicians to be aware of dengue-associated AKI to reduce the morbidity and mortality associated with this common and important tropical disease.

Evaluation of risk factors associated with the development of MDR- and XDR-TB in a tertiary care hospital: a retrospective cohort study

Background

Drug resistant tuberculosis (DR-TB) infringes substantial burden in terms of longer treatment duration, morbidity and mortality. Timely identification of patients at risks of DR-TB will aid individualized treatment. Current study was aimed to ascertain several factors associated with DR-TB among patients attending a tertiary care hospital.

Methods

This retrospective study was conducted among patients with confirmed diagnosis of DR-TB and drug susceptible TB (DS-TB) seeking medical care from a tertiary care hospital during 2014–2019. The types of DR-TB included were rifampicin resistant tuberculosis (RR-TB), Multidrug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB). Appropriate statistical methods were implied to evaluate the factors associated with DR-TB.

Results

Out of 580 patients, DS-TB was diagnosed in 198 (34.1%) patients while DR-TB was present in 382 patients. Of resistance cases, RR-TB, MDR-TB and XDR-TB were diagnosed in 176 (30.3%), 195 (33.6%) and 11 (1.9%) patients, respectively. Significant differences (P < 0.05) in demographics and clinico-laboratory characteristics were observed between patients with DS-TB and DR-TB. Logistic regression analysis revealed age ≤38 years (OR: 2.5), single marital status (OR: 11.1), tobacco use (OR: 2.9), previous treatment (OR: 19.2), treatment failure (OR: 9.2) and cavity on chest X-ray (OR: 30.1) as independent risk factors for MDR-TB. However, XDR-TB was independently associated with age group of ≤38 years (OR: 13.6), students (OR: 13.0), previous treatment (OR: 12.5), cavity on chest X-ray (OR: 59.6). The independent risk factors associated with RR-TB are age ≤38 years (OR: 2.8), females (OR: 5.7), unemployed (OR: 41.5), treatment failure (OR: 4.9), previous treatment (OR: 38.2) and cavity on chest X-ray (OR: 4.3). ROC curve analysis accentuate the excellent predictive accuracy of all logistic regression models as shown by AUC (0.968, P < 0.001) for MDR-TB, AUC (0.941, P < 0.001) for XDR-TB and AUC (0.962, P < 0.001) for RR-TB.

Conclusions

Current study demonstrates a sizeable extent of resistant cases among pulmonary TB patients. This study presaged significant risk of DR-TB among females, young adults, unemployed, smokers, patients with previous treatment failure and cavitation on chest X-ray. Timely identification of high risk patients will give pronounced advantages regarding appropriate choices of prevention, treatment and disease control.

Prevalence, Characteristics, and Factors Associated with Acute Kidney Injury among Adult Dengue Patients in Vietnam

Acute kidney injury (AKI) is a serious and potentially lethal complication of dengue disease; however, the actual incidence in dengue patients in Vietnam is unknown. This study aimed to determine the prevalence, clinical and laboratory characteristics, and risk factors for AKI in adults with dengue. This is a multicenter, cross-sectional study conducted between January and December 2017 in 2,417 adult patients with dengue. Indicators of demographic, clinical, and laboratory findings were evaluated. The prevalence of dengue disease-associated AKI was 2.7% (64/2,417), and dengue patients with AKI had a higher mortality rate than patients without AKI (12.5% versus 0.6%; P < 0.01). Characteristics of AKI were more common in male gender (male: female was 6.1:1), a history of hypertension (7.8% versus 2.3%; P < 0.02), the situations of hemoconcentration (hematocrit > 44%; P < 0.008), hypovolemic shock (21.9% versus 6.8%; P < 0.01), organ failure (42.3% versus 2.3%; P < 0.01), or manifestations of myocarditis (20.3% versus 6.6%; P < 0.01), hyperbilirubinemia (28.7 ± 7.6 versus 12.0 ± 0.9; P < 0.01), elevated enzymes such as ALT (407 ± 151 versus 113 ± 6; P < 0.01) and AST (891 ± 475 versus 172 ± 11; P < 0.01), and prolonged PT (s) (13.9 ± 4.6 versus 12.3 ± 1.5; P < 0.01). Independent risk factors for AKI by multivariate analysis were male gender (OR: 43.6; 95% CI: 2.4-810), severe dengue classification (OR: 25.7; 95% CI: 2-333), and creatine kinase > 190 U/L (OR: 11.7; 95% CI: 1.1-122.4). The study results indicate a need to continue studying the association between AKI and mortality in dengue disease and the need for improved management of AKI with dengue.

Stratification of Acute Kidney Injury in COVID-19

Despite myriad improvements in the care of COVID-19 patients, atypical manifestations are least appreciated during the current pandemic. Because COVID-19 is primarily manifesting as an acute respiratory illness with interstitial and alveolar pneumonia, the possibility of viral invasions into the other organs cannot be disregarded. Acute kidney injury (AKI) has been associated with various viral infections including dengue, chikungunya, Zika, and HIV. The prevalence and risks of AKI during the course of COVID-19 have been described in few studies. However, the existing literature demonstrate great disparity across findings amid variations in methodology and population. This article underscores the propensity of AKI among COVID-19 patients, limitations of the exiting evidence, and importance of timely identification during the case management. The prevalence of AKI is variable across the studies ranging from 4.7% to 81%. Evidence suggest old age, comorbidities, ventilator support, use of vasopressors, black race, severe infection, and elevated levels of baseline serum creatinine and d-dimers are independent risk factors of COVID-19 associated with AKI. COVID-19 patients with AKI also showed unsatisfactory renal recovery and higher mortality rate as compared with patients without AKI. These findings underscore that AKI frequently occurs during the course of COVID-19 infection and requires early stratification and management.

Acute kidney injury in dengue among hospitalized children: A prospective view

Dengue viral infection (DVI) has emerged as one of the most common arthropod borne diseases and is more prevalent in the tropical countries. It has varied clinical spectrum ranging from undifferentiated fever to severe hemorrhagic fever and shock with multi-organ dysfunction. Acute kidney injury (AKI) is lesser known complication in DVI. Although studies report varying reports of AKI in DVI among children, exact incidence is not known as most of the studies are retrospective. Hospital-based observational study in 105 children with DVI requiring admission was studied for the occurrence of AKI along with clinical course and outcome. AKI Network (AKIN) criteria were used to define AKI. The IBM SPSS Statistics software version 21.0 was used for the statistical analysis. Of 105 children with dengue, six (5.71%) cases developed AKI. All six cases had urine output <0.5 mL/kg/h for ≥12 h. Out of six cases with AKI, four had raised serum creatinine (SCr) ≥0.3 mg/dL at admission. One child had normal SCr level at admission which got deranged over the next 12 h, one child had oliguria ( <0.5 mL/kg/h) for about 24 h though the renal function was not deranged. Out of six children with AKI, three (50%) in Stage III and three had AKI Stage II as per the AKIN criteria. Children with AKI (Group A) differed significantly from those without AKI (Group B) in having blood pressure <3^rd centile (P = 0.0023), tachycardia P = 0.008), hyponatremia and hypokalemia (P <0.001 and P = 0.029, respectively) and poor outcome 6% mortality in Group B compared to 66.67% in Group A) with P = 0.001. AKI is not a common complication of DVI but if develops it may lead to significant morbidity and mortality among pediatric age group.

Renal Involvement in Children with Dengue Fever: A Study in Tertiary Care Hospital of Bangladesh

Background and Objective: Dengue has emerged globally as the most relevant viral infection transmitted by a mosquito bite and represents a major threat to public health. Dengue-related renal manifestations such as proteinuria, hematuria, acute kidney injury (AKI), and rhabdomyolysis are not uncommon, and acute kidney injury (AKI) is a serious complication of dengue fever. There is relatively few data on the renal manifestations of dengue fever in children. Hence, this study was conducted to evaluate the incidence, characteristics, and clinical outcome of dengue fever with renal manifestations. Method. This prospective cross sectional study was conducted in Dr. M R Khan Children Hospital and Institute of Child Health, Dhaka, over a period of 1 year from January 2018 to December 2018. The study was approved by the ethical committee of the institute. A total number of 316 patients were admitted with the diagnosis of dengue fever either NS1 positive or antibody IgM positive or both IgM and IgG positive. Data were collected in a structured questionnaire form and were analyzed by SPSS version 20.0. The disease severity was classified according to the World Health Organization criteria. Renal manifestations were divided into AKI groups using pRIFLE criteria. Proteinuria was defined as urinary protein >1+ (30 mg/dL) by dipstick test. Hematuria was defined as red blood cell (RBC) >5/μL in a fresh uncentrifuged urine specimen. Result. Among 316 dengue patients, thirty-one patients (9.8%) had renal involvement. Most of the patients (54.83%) with renal manifestations were aged between 1 and 5 years. A total of 14 patients were found to have proteinuria (4.4%). Nephrotic-range proteinuria was seen in only one patient (0.3%). AKI was defined by pRIFLE criteria and was seen in 13 patients (4.1%); among AKI 6 (46.15%) had risk, three patients (23.07%) had injury and 4 (30.7%) had failure and needed peritoneal dialysis. Death occurred in 3 patients (9.6%) in dengue with AKI who had failure. The incidence of renal manifestations (proteinuria, hematuria, and AKI) is as high as 9.8% among patients with dengue, and those with AKI had significant morbidity and mortality. Conclusion. Renal involvement in children with dengue is not uncommon. Dengue associated with AKI had significant mortality and morbidity.

Associated factors of dialysis-dependence among acute kidney injury patients in intensive care unit

Acute kidney injury (AKI) is a common problem in hospitals and many end up requiring dialysis. The aim was to identify the associated factors of dialysis-dependent of AKI patients admitted to the intensive care units (ICUs). A retrospective cohort study was conducted where a list of 121 AKI patients admitted to ICU in Hospital Universiti Sains Malaysia was retrospectively reviewed. AKI patients aged below 18 years old, had kidney transplantation or chronic dialysis before ICU admission and had incomplete medical record were excluded from the study. Simple and multiple logistic regression analysis were used. The mean [standard deviation (SD)] age of patients was 56 (17.15) years. Majority of patients were males (63.2%) and Malay ethnic (54.1%). 49.3% of patients were in stage I, 48.3% in stage II and 76.2% in stage III. The mean (SD) duration of patients stayed in ICU was 7 days (6.92) for non-dialysis dependent and 12 days (8.37) for dialysis-dependent. The associated factors were male gender [adjusted odds ratio (OR): 3.68; 95% confidence interval [CI]: 1.53, 8.86; P = 0.004], AKI Stage III (adjusted OR: 4.51; 95% CI: 1.28, 15.91; P = 0.019), admitted in ICU (adjusted OR: 3.05; 95% CI: 1.28, 7.29; P = 0.012), and longer length of stay (adjusted OR: 1.10; 95% CI: 1.03, 1.18; P = 0.003). The factors influence of dialysis-requiring AKI were observed to be dependent on the male male gender, suffer from the advanced stage (Stage III), admitted to the ICU and had a longer length of stay in ICU. Therefore, it is important for physicians to identify patients who are at high risk of developing AKI and implement preventive strategies.

Renal Injury in DENV-4 Fatal Cases: Viremia, Immune Response and Cytokine Profile

Dengue virus (DENV) infections may result in asymptomatic cases or evolve into a severe disease, which involves multiple organ failure. Renal involvement in dengue can be potentially related to an increased mortality. Aiming to better understand the role of DENV in renal injury observed in human fatal cases, post-mortem investigations were performed in four DENV-4 renal autopsies during dengue epidemics in Brazil. Tissues were submitted to histopathology, immunohistochemistry, viral quantification, and characterization of cytokines and inflammatory mediators. Probably due the high viral load, several lesions were observed in the renal tissue, such as diffuse mononuclear infiltration around the glomerulus in the cortical region and in the medullary vessels, hyalinosis arteriolar, lymphocytic infiltrate, increased capsular fibrosis, proximal convoluted tubule (PCT) damage, edema, PCT debris formation, and thickening of the basal vessel membrane. These changes were associated with DENV-4 infection, as confirmed by the presence of DENV-specific NS3 protein, indicative of viral replication. The exacerbated presence of mononuclear cells at several renal tissue sites culminated in the secretion of proinflammatory cytokines and chemokines. Moreover, it can be suggested that the renal tissue injury observed here may have been due to the combination of both high viral load and exacerbated host immune response.

Pre-, Intra-, and Post-Operative Factors for Kidney Injury of Patients Underwent Cardiac Surgery: A Retrospective Cohort Study

BACKGROUND Kidney injury is common in patients who have undergone cardiac surgery, and it has high morbidity and mortality. The objective of the study was to identify pre-, intra-, and post-operative risk factors responsible for kidney injury among patients who had undergone cardiac surgery. MATERIAL AND METHODS Patients (n=1468) who had undergone cardiac surgery were stratified into those with kidney injury (n=488) and those without kidney injury (n=980) using the KDIGO (Kidney Disease: Improving Global Outcomes) criteria. Data of pre-, intra- and post-operative variables were collected and analyzed. RESULTS Acute kidney injury occurred in 33.2% of study patients. Patients with post-operative acute kidney injury had older age, comorbidities, higher preoperative serum creatinine, coronary artery bypass grafting, longer operation time, high cardiopulmonary bypass and cross-clamping time, low central venous pressure, and prolonged mechanical ventilation as compared to patients without kidney injury (P<0.05 for all). Age >65 years (OR 1.4), preoperative hypertension (OR 2.0), preoperative anemia (OR 2.3), preoperative low ejection fraction (OR 3.7), Charlson comorbidity index >2 (OR 2.5), longer cardiopulmonary bypass time (OR 4.0), blood transfusions (OR 2.1), postoperative hypotension (OR 5.2), and low central venous pressure (OR 8.1) were responsible for kidney injury. Mortality of patients with kidney injury was significantly higher than those without acute kidney injury (52 versus 1, P<0.001). CONCLUSIONS Appropriate and effective control of pre-, intra-, and post-operative variables can reduce the risk of kidney injury development in patients following cardiac surgeries.

Flaviviruses and Kidney Diseases

The genus Flavivirus comprises approximately 73 viruses, which share several common aspects, such as dimension, structure, nucleic acid properties, and shape in electronic microscopy. Global incidence of flavivirus infection increased dramatically over the last decades, causing large outbreaks in several areas of the world. These viruses are expanding from endemic tropical and subtropical areas to previously nonendemic areas, affecting and causing diseases in millions of individuals worldwide and posing a formidable challenge to public health in several countries. The majority of clinically significant flavivirus-associated infections are mosquito borne (arboviruses-acronym for ARthropod-BOrne VIRUSES), such as dengue, yellow fever, Japanese encephalitis, Zika, and West Nile fever. Most diseases caused by flaviviruses are asymptomatic or manifest as self-limited, mild, undifferentiated febrile diseases. In a limited number of cases, these diseases may evolve to severe inflammatory, multisystem diseases, causing high morbidity and mortality. Some flaviviruses have been consistently identified in kidney tissue and urine and have been clinically associated with kidney diseases. In this review, we will provide an overview of the epidemiology, risk factors, kidney pathology, etiopathogenesis, and outcomes of acute and chronic kidney syndromes associated with dengue, yellow fever, Zika, and West Nile virus disease.

Characteristics and associated factors of acute kidney injury among adult dengue patients: A retrospective single-center study

Severe dengue cases have been increasingly reported in Thailand, and the under-reporting of acute kidney injury (AKI) in cases of dengue viral infection has become an obstacle in obtaining an accurate description of the true nature and epidemiology of AKI. Because AKI may lead to patient morbidity and mortality, an early diagnosis is important in preventing its onset in dengue patients. This study aimed to determine the prevalence, clinical and laboratory characteristics, and associated factors of AKI among adult dengue patients. This retrospective study reviewed admission data from the medical records of adult dengue patients admitted to the Bangkok Hospital for Tropical Diseases between January 2012 and November 2017 and stratified these patients into AKI and non-AKI groups using the Kidney Disease Improving Global Outcomes criteria (KDIGO). A total of 1,484 patients were included in the study, with 71 categorized into the AKI group. The prevalence of AKI was 4.8%. In the AKI group, the predominant age range was 18–40 years (71.8%), with a female to male ratio of 1:2.7. These patients showed significantly (P < 0.05) higher proportions of altered consciousness, dyspnea, low mean arterial blood pressure, high-grade fever, major bleeding, severe thrombocytopenia, hypoalbuminemia, severe transaminitis, coagulopathy, metabolic acidosis, rhabdomyolysis, proteinuria, hematuria, and pyuria. Our study established that older age, male sex, diabetes mellitus, obesity, severe dengue, and coexisting bacterial infection were significant associated factors for AKI in dengue by multivariate analysis. A total of 10 (14.1%) patients with AKI received dialysis, among which 9 (12.7%) patients from the AKI group died. Our findings suggest that an awareness of AKI, its early diagnosis, and evaluation of clinical and laboratory characteristics of dengue patients will help clinicians to initiate appropriate therapy for dengue-associated AKI.

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.

Prognostic Factors in Adult Patients with Dengue: Developing Risk Scoring Models and Emphasizing Factors Associated with Death ≤7 Days after Illness Onset and ≤3 Days after Presentation

Dengue is a mosquito-borne viral disease that is a threat to global health. However, information relating to mortality ≤7 days after dengue onset and ≤3 days after presentation is limited. We retrospectively analyzed 1086 adults with dengue during a 12-year period. Three scoring models were established: model-1 (death ≤3 days after presentation), model-2 (death ≤7 days after illness onset), and model-3 (overall fatality). In total, 39 patients with fatal dengue were identified, of which 17 and 14 patients died ≤7 days after illness onset and ≤3 days after presentation, respectively. In model-1 (range: 0‒4 points), gastrointestinal bleeding ≤72 h after presentation, thrombocytopenia (<50 × 10⁸ cells/L) at presentation, and acute kidney injury after hospitalization, using a cutoff level of 2 points, exhibited good discrimination (area under the receiver curve (AUC): 0.975) between survivors and non-survivors. In model-2, the significant predictors were gastrointestinal bleeding ≤72 h after presentation, and hemoconcentration and leukocytosis after hospitalization. Model-2 (range: 0⁻4 points) showed an AUC of 0.974, with a cutoff value of 2 points. The independent factors in model-2 were the predictors of overall mortality (model-3), which include thrombocytopenia (<50 × 10⁸ cells/L) at presentation. Using a cutoff value of 2 points, model-3 (range: 0⁻7 points) revealed an excellent discrimination between survivors and non-survivors (AUC: 0.963).

Infections and the kidney: a tale from the tropics

Tropical infections are caused by a variety of bacteria, viruses and parasitic organisms across varying geographical regions and are more often reported in adults than in children. Most of the infections are acute, presenting as a febrile illness with involvement of multiple organ systems, including the kidney. The gamut of renal manifestations extends from asymptomatic urinary abnormalities to acute kidney injury and-albeit rarely-chronic kidney disease. Tropical infections can involve the glomerular, tubulointerstitial and vascular compartments of the kidney. Leptospirosis, malaria, dengue, rickettsial fever and schistosomiasis are the most prevalent tropical infections which affect the kidneys of children living in the tropics. In this review we discuss renal involvement in these most prevalent tropical infections.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Septic acute kidney injury patients in emergency department: The risk factors and its correlation to serum lactate

BACKGROUND

Acute kidney injury (AKI) is a common complication in septic patients, imposing a heavy burden of illness in terms of morbidity and mortality. Serum lactate is a widely used marker predicting the severity of sepsis. A paucity of research has investigated septic AKI in emergency departments (EDs) and its correlation with initial serum lactate level. This study aimed at identifying risk factors for septic AKI and clarifying the link between initial serum lactate level and septic AKI in ED patients.

METHODS

A retrospective cohort study was conducted at a single tertiary referral medical center. The medical records of all adult ED patients with measurement of serum lactate and creatinine between January 2012 and December 2016 were reviewed. A total of 696 septic patients were stratified into AKI and non-AKI groups according to Acute Kidney Injury Network (AKIN) criteria for further statistical analysis.

RESULTS

Ninety-nine septic patients (14.2%) had AKI, with AKIN-I, AKIN-II, and AKIN-III in 71.7%, 11.1%, and 17.2% of patients, respectively. Compared with the non-AKI group, the AKI group had a significantly higher mortality rate (71.7% vs. 21.3%, p < 0.001). Independent risk factors for septic AKI included liver disease (adjusted odds ratio [AOR] = 2.02, 95% confidence interval [CI] = 1.16-3.52), diabetes mellitus (AOR = 1.73, 95% CI = 1.11-2.69), chronic kidney disease (AOR = 1.68, 95% CI = 1.06-2.66), and initial serum lactate (AOR = 1.08, 95% CI = 1.02-1.14).

CONCLUSIONS

Patients with septic AKI had an overwhelmingly higher mortality rate. The comorbidities of liver disease, diabetes mellitus, and chronic kidney disease were correlated with septic AKI and in combination with an elevated initial serum lactate level had predictive regarding AKI and further mortality in ED septic patients.

Predicting the severity of dengue fever in children on admission based on clinical features and laboratory indicators: application of classification tree analysis

Background

Dengue fever is a re-emerging viral disease commonly occurring in tropical and subtropical areas. The clinical features and abnormal laboratory test results of dengue infection are similar to those of other febrile illnesses; hence, its accurate and timely diagnosis for providing appropriate treatment is difficult. Delayed diagnosis may be associated with inappropriate treatment and higher risk of death. Early and correct diagnosis can help improve case management and optimise the use of resources such as hospital staff, beds, and intensive care equipment. The goal of this study was to develop a predictive model to characterise dengue severity based on early clinical and laboratory indicators using data mining and statistical tools.

Methods

We retrieved data from a study of febrile illness in children at Angkor Hospital for Children, Cambodia. Of 1225 febrile episodes recorded, 198 patients were confirmed to have dengue. A classification and regression tree (CART) was used to construct a predictive decision tree for severe dengue, while logistic regression analysis was used to independently quantify the significance of each parameter in the decision tree.

Results

A decision tree algorithm using haematocrit, Glasgow Coma Score, urine protein, creatinine, and platelet count predicted severe dengue with a sensitivity, specificity, and accuracy of 60.5%, 65% and 64.1%, respectively.

Conclusions

The decision tree we describe, using five simple clinical and laboratory indicators, can be used to predict severe cases of dengue among paediatric patients on admission. This algorithm is potentially useful for guiding a patient-monitoring plan and outpatient management of fever in resource-poor settings.

Short-term renal outcomes following acute kidney injury among dengue patients: A follow-up analysis from large prospective cohort

BACKGROUND

Despite myriad improvements in the care of dengue patients, acute kidney injury (AKI) remained least appreciated intricacy of dengue infection. Exiting literature does not provide any information on renal outcomes among dengue patients surviving an episode of AKI.

METHODS

Dengue patients who developed AKI were followed up for post-discharge period of three months and renal recovery was assessed by using recovery criteria based on different thresholds of serum creatinine (SCr) and estimated glomerular filtration rates (eGFR).

RESULTS

Out of the 526 dengue participants, AKI was developed in 72 (13.7%) patients. Renal recovery was assessed among AKI survivors (n = 71). The use of less (±50% recovery to baseline) to more (±5% recovery to baseline) stringent definitions of renal recovery yielded recovery rates from 88.9% to 2.8% by SCr and 94.4% to 5.6% by eGFR, as renal function biomarkers. At the end of study, eight patients had AKI with AKIN-II (n = 7) and AKIN-III (n = 1). Approximately 50% patients (n = 36/71) with AKI had eGFR primitive to CKD stage 2, while 18.3% (n = 13/71) and 4.2% (n = 3/71) patients had eGFR corresponding to advanced stages of CKD (stage 3 & 4). Factors such as renal insufficiencies at hospital discharge, multiple organ involvements, advance age, female gender and diabetes mellitus were associated with poor renal outcomes.

CONCLUSIONS

We conclude that dengue patients with AKI portend unsatisfactory short-term renal outcomes and deserve a careful and longer follow-up, especially under nephrology care.

Determinants of mortality and prolonged hospital stay among dengue patients attending tertiary care hospital: a cross-sectional retrospective analysis

OBJECTIVES

Dengue imposes substantial economic, societal and personal burden in terms of hospital stay, morbidity and mortality. Early identification of dengue cases with high propensity of increased hospital stay and death could be of value in isolating patients in need of early interventions. The current study was aimed to determine the significant factors associated with dengue-related prolonged hospitalisation and death.

DESIGN

Cross-sectional retrospective study.

SETTING

Tertiary care teaching hospital.

PARTICIPANTS

Patients with confirmed dengue diagnosis were stratified into two categories on the basis of prolonged hospitalisation (≤3 days and >3 days) and mortality (fatal cases and non-fatal cases). Clinico-laboratory characteristics between these categories were compared by using appropriate statistical methods.

RESULTS

Of 667 patients enrolled, 328 (49.2%) had prolonged hospitalisation. The mean hospital stay was 4.88±2.74 days. Multivariate analysis showed that dengue haemorrhagic fever (OR 2.3), elevated alkaline phosphatase (ALP) (OR 2.3), prolonged prothrombin time (PT) (OR 1.7), activated partial thromboplastin time (aPTT) (OR 1.9) and multiple-organ dysfunctions (OR 2.1) were independently associated with prolonged hospitalisation. Overall case fatality rate was 1.1%. Factors associated with dengue mortality were age >40 years (p=0.004), secondary infection (p=0.040), comorbidities (p<0.05), acute kidney injury (p<0.001), prolonged PT (p=0.022), multiple-organ dysfunctions (p<0.001), haematocrit >20% (p=0.001), rhabdomyolosis (p<0.001) and respiratory failure (p=0.007). Approximately half of the fatal cases in our study had prolonged hospital stay of greater than three days.

CONCLUSIONS

The results underscore the high proportion of dengue patients with prolonged hospital stay. Early identification of factors relating to prolonged hospitalisation and death will have obvious advantages in terms of appropriate decisions about treatment and management in high dependency units.

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

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

Acute kidney injury due to tropical infectious diseases and animal venoms: a tale of 2 continents

South and Southeast Asia and Latin American together comprise 46 countries and are home to approximately 40% of the world population. The sociopolitical and economic heterogeneity, tropical climate, and malady transitions characteristic of the region strongly influence disease behavior and health care delivery. Acute kidney injury epidemiology mirrors these inequalities. In addition to hospital-acquired acute kidney injury in tertiary care centers, these countries face a large preventable burden of community-acquired acute kidney injury secondary to tropical infectious diseases or animal venoms, affecting previously healthy young individuals. This article reviews the epidemiology, clinical picture, prevention, risk factors, and pathophysiology of acute kidney injury associated with tropical diseases (malaria, dengue, leptospirosis, scrub typhus, and yellow fever) and animal venom (snakes, bees, caterpillars, spiders, and scorpions) in tropical regions of Asia and Latin America, and discusses the potential future challenges due to emerging issues.

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

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

Enhanced Surveillance for Fatal Dengue-Like Acute Febrile Illness in Puerto Rico, 2010-2012

BACKGROUND

Dengue is a leading cause of morbidity throughout the tropics; however, accurate population-based estimates of mortality rates are not available.

METHODS/PRINCIPAL FINDINGS

We established the Enhanced Fatal Acute Febrile Illness Surveillance System (EFASS) to estimate dengue mortality rates in Puerto Rico. Healthcare professionals submitted serum and tissue specimens from patients who died from a dengue-like acute febrile illness, and death certificates were reviewed to identify additional cases. Specimens were tested for markers of dengue virus (DENV) infection by molecular, immunologic, and immunohistochemical methods, and were also tested for West Nile virus, Leptospira spp., and other pathogens based on histopathologic findings. Medical records were reviewed and clinical data abstracted. A total of 311 deaths were identified, of which 58 (19%) were DENV laboratory-positive. Dengue mortality rates were 1.05 per 100,000 population in 2010, 0.16 in 2011 and 0.36 in 2012. Dengue mortality was highest among adults 19-64 years and seniors ≥65 years (1.17 and 1.66 deaths per 100,000, respectively). Other pathogens identified included 34 Leptospira spp. cases and one case of Burkholderia pseudomallei and Neisseria meningitidis.

CONCLUSIONS/SIGNIFICANCE

EFASS showed that dengue mortality rates among adults were higher than reported for influenza, and identified a leptospirosis outbreak and index cases of melioidosis and meningitis.