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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 81-85

Clinical diversity and outcome of dengue fever outbreak-2019 described in a hospital of Dhaka


1 Department of Pediatrics, Kurmitola General Hospital, Dhaka, Bangladesh
2 Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University Hospital (BSMMU), Dhaka, Bangladesh
3 Department of Pediatrics, Colonel Malek Medical College, Dhaka, Bangladesh

Date of Submission28-Sep-2021
Date of Acceptance02-Dec-2021
Date of Web Publication28-Feb-2022

Correspondence Address:
Dr. Ferdousi Hasnat
Department of Pediatrics, Kurmitola General Hospital, Dhaka Cantonment, Tongi Diversion Rd, Dhaka 1206,
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pnjb.pnjb_16_21

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  Abstract 

Objectives: This study aimed to discuss demographic profile, variation in clinical feature, laboratory analysis, clinical severity, and consequences of treatment in dengue fever. Materials and Methods: This was a prospective observational study. All patients included in the study were admitted with fever and diagnosed with dengue fever either by serological test or antigen test. Results: The majority (92.85%) of children came from urban areas. Male children were predominately (59.52%) affected. Common clinical features were fever (100%), vomiting (65.8%), abdominal pain (31.7%), rashes (41.6%), loose motion (34.1%), and bleeding manifestation (30.50%). Tourniquet test was positive in 34.12% of cases. Pleural effusion was present in 15.87% and ascites were present in 13.49% of cases. Peritonitis developed in 2.38% of patients. Approximately 7.93% of the patients had central nervous system involvement and 1.5% of cases came with active convulsion. Regarding investigations, leukopenia (42.85%), thrombocytopenia (69.84%), increased hematocrit (35.7%), and elevated serum glutamic-pyruvic transaminase (SGPT) (42.06%) were present. Approximately 43.65% of children came with dengue fever, 30.95% of children came with dengue hemorrhagic fever and 25.39% of children came with DSS. In DSS 100% of patients came with hypotension and tachycardia and 78.12% of patients came with compensated shock. Leukopenia (55.55%) and raised hematocrit (60%), elevated SGPT (45.28%), and decreased albumin level (60%) were prominent in DSS. There was no case fatality. Conclusion: Dengue fever’s severity and clinical variation increase day by day. As there is no vaccine against dengue in our country, we will try to improve our public awareness for prevention and continuous serological surveillance will be needed to achieve the goal.

Keywords: Dengue fever, dengue hemorrhagic fever, dengue shock syndrome


How to cite this article:
Hasnat F, Mutanabbi M, Noman F, Nurullah M, Anne RT, Morshed J. Clinical diversity and outcome of dengue fever outbreak-2019 described in a hospital of Dhaka. Paediatr Nephrol J Bangladesh 2021;6:81-5

How to cite this URL:
Hasnat F, Mutanabbi M, Noman F, Nurullah M, Anne RT, Morshed J. Clinical diversity and outcome of dengue fever outbreak-2019 described in a hospital of Dhaka. Paediatr Nephrol J Bangladesh [serial online] 2021 [cited 2022 May 27];6:81-5. Available from: http://www.pnjb-online.org/text.asp?2021/6/2/81/338566




  Introduction Top


Dengue fever is an important worldwide health-related problem including in Bangladesh. Dengue is a systemic and dynamic infectious disease caused by an RNA virus of Flaviviridae family, which has four serotypes that are designated as DENV-1, DENV-2, DENV-3, and DENV-4.[1]

It is an important arthropod transmitted viral disease. Aedes aegypti and A. albopictus are the two most important vectors of dengue but A. aegypti is highly domesticated and strongly anthropophillic. Infection with one serotype of DENV provides lifelong immunity to that serotype but the other three serotypes show transient protection against subsequent infection.[2],[3] Subsequent infection with different serotypes enhance chances of occurring more severe form of the disease.[2],[3] Before 1970, dengue occurred only in nine countries and they experienced severe dengue.[1] Now, it is endemic in 112 countries around the world and many countries experienced epidemics.[4],[5],[6] Approximately 100 million of dengue fever cases and 50 million of dengue hemorrhagic fever (DHF) cases occur each year in the world and case fatality in Asian countries is 0.5%–3.5%.[3] Majority of infections in children under age 15 years are asymptomatic or minimally symptomatic to DHF and life-threatening dengue shock syndrome (DSS).[7] Fever, rash, retro-orbital pain, photophobia, headache, myalgia, and abdominal pain are more common features. The presence of muscle and joint pain gives an alternative name to dengue fever as breakbone fever.[8],[9] Classical dengue sometimes may develop DHF, critical phase with plasma leakage is the hallmark of DHF which occurs soon to develop DSS due to plasma leakage.[1] DHF passes through the three phases of the febrile phase, the critical phase, and the convalescence phase.[1] Severe leakage may develop shock, which may be complicated with organ impairment, metabolic acidosis, and disseminated intravascular coagulation. Early detection of critical period and appropriate fluid management are of paramount importance.[1] There are few reports on newer presentations especially with cerebral and hepatic symptoms in recent years.[10],[11],[12] Patients with dengue illness can sometimes develop unusual manifestations such as involvement of liver, kidney, brain, or heart with or without evidence of fluid leakage termed as expended dengue syndrome. For the management of dengue cases classified by severity: (a) dengue without a warning sign, (b) dengue with a warning sign, and (c) severe dengue.[1] Rapid fluid replacement with warning signs is key to prevent progression to the shock state. In this study, we analyzed the variation of clinical features and outcomes of patients.


  Materials and Methods Top


This prospective observational study was done in Kurmitola General Hospital from July to September 2019 in 130 children of both sexes up to 15 years of age. All patients who were admitted in KGH with documented fever and dengue fever confirmed by NS1 antigen or positive antibody test were included in the study. Co-infection with another disease along with dengue and fever for more than 2 weeks were excluded from the study. Particulars of children were collected in the preformed questionnaire; these comprise demographic data, clinical features, and laboratory parameters of the blood. The recorded profile of the child was also documented in the form. Regarding clinical features, they included current symptoms, duration of symptoms, any bleeding manifestation, tourniquet test, and pleural effusion, ascites. Vitals of children, urinary output, and features of shock were entirely surveyed and documented. Laboratory profile included dengue NS1 antigen, dengue antibody test, total blood count, platelet count, hematocrit (HCT), and liver function test. Serum albumin and serum creatinine levels were also tested. Clinical case definition and grading of severity of study population were done based on the national guideline of Bangladesh. Children under study were categorized as group B (dengue patients with a warning sign) and patient group C (severe dengue). Written consent was taken from the guardian of the children and permission was taken from the local authority. Data were analyzed by using the Statistical Package for the Social Sciences (SPSS) software program, version 26.0.


  Results Top


Initially, 130 dengue-positive patients were enrolled in this study. Due to coinfection with typhoid fever, four children were excluded from the study. So finally, 126 children were in the study among them male children were 59.52% and female children were 40.47%. The mean age of the children was 6.5 years, of which 36.50% were 0–5 years and 47.61% were >5–10 years, and 15.87% were >10–15 years [Figure 1]. Approximately 92.85% of children came from urban areas. The maximum number of children came in August. In [Figure 2], clinical manifestation showed that 100% of children had a fever which was high grade and continued in 82.53% of cases. Approximately 65.8% had vomiting, abdominal pain 31.7%, loose stool 34.1%, rash 41.6%, bleeding manifestation 30.50%, headache 23.8%, myalgia 24.7%, retro-orbital pain 9.3%, itching 12.6%, and cough 2.3%. Regarding bleeding manifestation, gastrointestinal bleeding was more prominent (15.83%) than gum bleeding (6.34%) and epistaxis (8.73%), and the tourniquet test was positive in 34.12% of cases. Pleural effusion was present in 15.87% of cases and ascites were present in 13.49% of cases, peritonitis developed in 2.38% of patients, 7.93% of patients came with central nervous system (CNS) involvement, and 1.5% cases came with active convulsion.
Figure 1: Demographic distribution of studied children

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Figure 2: Clinical presentation of studied children

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[Table 1] shows dengue NS1 antigen positive in 88.88% children and dengue antibody positive in 11.12% children, leukopenia in 42.85%, thrombocytopenia in 69.84%, HCT elevated in 35.7% and reduced in 19.04%, and serum glutamic-pyruvic transaminase (SGPT) increased in 42.06% children. Serum albumin level was decreased in 11.90% of patients.
Table 1: Distribution of investigation of total studied children (n = 126)

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According to clinical manifestation and severity, distribution of dengue infection is shown in [Table 2], where dengue fever was seen in 43.65% of children, DHF in 30.95%, DSS in 25.39%, and according to severity, 74.60% of patients were in the group B and 25.39% of patients were in the group C, respectively.
Table 2: Distribution of studied children according to clinical manifestation and severity of dengue fever (n = 126)

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[Table 3] shows that out of 32 cases of DSS 55.55% had leukopenia, 38.88% had thrombocytopenia, 45.28% had elevated SGPT, 60% had elevated HCT, and 60% had reduced albumin. In 39 cases of DHF, 54.54% had thrombocytopenia, 66.66% had reduced HCT, 32.07% had elevated SGPT, and 33.33% had leukopenia. In 55 cases of dengue fever, 21.59% had thrombocytopenia.
Table 3: Distribution of investigation according to clinical manifestation of cases

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The outcome of the patient is shown in [Table 4], where 97.61% of patients were recovered from dengue and 2.3% were referred to a higher center. There was no death in our study. All children were treated with normal saline according to the guideline. Besides, normal saline patients were also treated with crystalloid solution, dextran, fresh frozen plasma, whole blood, and albumin.
Table 4: Outcome of treatment of studied patient (n = 126)

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  Discussion Top


This prospective observational study showed that dengue fever affects children of different age group from 0 to 15 years of which the mean age was 6 years. In our study out of 126 children, 100 children were under 10 years of age. There were published data from Thailand which showed the main affected group were children under 10 years of age;[13] similar results were also seen in a study of Karachi.[4] In our study, male preponderance was observed (1.4:1); similar results were seen in some other studies like Kamrun Nahar Sultana et al.,[2] Agarwal et al.,[14] Narayan et al.,[15] Abm Shahidul et al.,[16] and Ahmed et al.[17] The majority of our children in this study came from an urban area, which was also seen in other studies.[2],[18]

Regarding clinical presentation, our study showed 100% of children had fever. Approximately 82.53% of children had fever, which was high grade and continued in nature. Fever is the main symptom shown in different studies in Bangladesh.[2],[4],[19] Vomiting (65.8%), loose stool (34%), abdominal pain (31.7%), myalgia (24.7%), headache (23.8% retro-orbital pain (9.3%), and cough 3% were common clinical feature in our study. These findings were also present in different studies.[2],[4] In our study, 41.6% of children had rash with itching, and rash was also reported in different studies.[4],[16],[20] In this study, spontaneous bleeding occurred in 30.9% of children in the form of gastrointestinal bleeding (15.83%), gum bleeding 6.34%, and epistaxis 8.73%; similar results were described by Abm Shahidul et al.[16] and Rahman et al.[21] of a dengue patient. In this study, the tourniquet test was positive in 34.12% of patients; other studies showed the same type of results.16] In this study, ascites was present in 33.14% of patients and pleural effusion was present in 16.34% of patients. Setiwan et al.,[22] and Mehedi et al.[23] also reported the presence of ascites and pleural effusion in severe dengue cases. Out of 126 patients, 35.74% of patients showed the feature of plasma leakage which was consistent with other studies.[2],[4],[16] Approximately 7.93% of the patient came with CNS involvement and 1.5% had a convulsion in our study, other studies also showed CNS involvement.[24] In our study, 2.38% of children had peritonitis but other different studies showed that dengue patients reported abdominal pain and vomiting.[2],[4],[16]

Regarding laboratory findings, 42.85% had leukopenia and 69.84% had thrombocytopenia in this study similar to a descriptive study of Srilanka.[10] The level of HCT has given early features of DHF and DSS;[10] in our study, 35.7% had elevated levels of HCT and 19.04% of patients had reduced HCT in case of DHF which were similar to other related studies.[4],[10] The elevated level of SGPT was seen in 42.06% of cases; these were similar to Shahidul Alam Abm et al.[16] and Mr Mubarak et al.[25] Serum albumin is regarded as a prognostic marker in a study done by Nimmannitya et al.,[26] whereas our study showed that 11.90% of patients had decreased levels of albumin.

In our study, it was found that 43.65% of children had DF, 30.95% DHF, and 25.39% had DSS, whereas Kamrunnahar et al.[2] showed 74.15% of patients had DF, 6.74% had DHF, and 10.10% had DSS. Ratageri et al.[27] showed 18% DF, 60% DHF, and 22% DSS. In DSS patients of the study, hypotension and shock were important clinical features which were similar to the findings of the study done by Chako and Subramanian.[28] In this study, thrombocytopenia was found in 38.88% of patients with DSS and 54.54% of DHF patients, while in another study, Ratageri[27] showed that thrombocytopenia was prominent in severe dengue cases. The HCT level was found to be elevated in severe dengue patients in a study done by Pongpan et al.,[29] in our study, we found elevated HCT levels in 60% of cases of DSS. Here, SGPT increased in both DHF (32.07%) and DSS (45.28%), Giri et al.[30] also found elevated SGPT in DHF and DSS.

Results showed that 97.61% of patients recovered from dengue and 2.3% were referred to higher center for intensive care unit management; there was no death in our study which was similar to study of Mubarak et al.,[25] but the case fatality rate was different in many other studies.[2],[10],[16]


  Conclusion Top


Dengue fever is a wide spectrum disease; life-threatening hemorrhage to DSS was seen in our study. In this study, a significant number of patients came with hypotension and DSS. The rapid rise of HCT, a large number of patients with decreased albumin, and elevated SGPT level were seen in this study. Thrombocytopenia was also seen in DHF and DSS in this study. Some patients developed sudden shock syndrome with a feature of plasma leakage. Due to the diversity of clinical pattern in dengue fever, our treatment protocol will have to be more dynamic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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