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DAILY DENGUE SEVERITY SCORE – IMPLICATIONS, BENEFITS AND LIMITATIONS IN OUR SETTING
Abstract
Introduction- Dengue is associated with high morbidity & at times develops potentially fatal complication. Predicting the outcome on the basis of clinical presentation alone is less reliable and complicated owing to variable symptomatology. there is a need for developing and testing a scoring system, for the detection of complicated and severe dengue fever early in the course of infection, to identify those children who may progress to DSS/DHF and succumb to disease subsequently & to triage sick patients for early referral from primary and community health centers to higher center for intensive care management. This Material & methodsProspective observational study was conducted in Department of Pediatrics, SMS Medical College, Jaipur during January 2020 to September 2021. Sample size is calculated at 95 % condence interval expecting sensitivity of 86% using dengue severity score of more than equal to 12 in the assessment of outcome of dengue severity among the dengue fever patients. An absolute allowable error of 15% and at prevalence of 17.4% of severe dengue patients, the required sample size was 125 cases with dengue fever. Statistical analyses were done using computer software (SPSS Trial version 23 and primer). if we use the critical cut off of DDS Results- S >10.5 on day 1 of hospital admission; it was a strong predictor of mortality with p <0.001 and area under curve was 0.906 which is near 1. The sensitivity of score at this cutoff was 100% and specicity was 71.7%. The cutoff was chosen as 10.5 because at this cut off both sensitivity and specicity were reasonably high and below this score although sensitivity remains 100% but specicity decreases i.e., false positive cases would increase and if cutoff is increased then specicity increases but sensitivity decreases i.e., false negative increases. If cutoff was chosen at 16.5 sensitivity of score decreases to 83.3% but specicity increases to 85%. On cutoff of 22 sensitivity decreases to 50% and specicity increases to 90.3%. Conclusions- If critical cutoff more than 10.5 is used, dengue shock syndrome can be predicted with specicity of 82.5% and sensitivity of 94.6%. If critical cutoff of more than 8.5 is used, prolonged length of hospital stay can be predicted with sensitivity and specicity of 51.9% and 53.1% respectively. If critical cutoff of more than 11.5 is used then organ dysfunction in dengue patients can be predicted with sensitivity of 78.9% and specicity of 89.7% respectively. If critical cutoff of more than 10.5 is used then mortality in dengue patients can be predicted with sensitivity100% of and specicity of 71.7%
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[This corrects the article DOI: 10.1371/journal.pntd.0009808.].
Background
The mosquito-borne arboviral disease dengue has become a global public health concern. However, very few studies have reported atypical clinical features of dengue among children. Because an understanding of various spectrums of presentation of dengue is necessary for timely diagnosis and management, we aimed to document the typical and atypical clinical features along with predictors of severity among children with dengue during the largest outbreak in Bangladesh in 2019.
Methods
We conducted a cross-sectional study between August 15 and September 30, 2019. in eight tertiary level hospitals in Dhaka city. Children (aged < 15 years) with serologically confirmed dengue were conveniently selected for data collection through a structured questionnaire. Descriptive, inferential statistics, and multivariable logistic regression were used to analyze data.
Results
Among the 190 children (mean age 8.8 years, and male-female ratio 1.22:1) included in the analysis, respectively 71.1 and 28.9% children had non-severe and severe dengue. All children had fever with an average temperature of 103.3 ± 1.2 F (SD). Gastrointestinal symptoms were the most common associated feature, including mostly vomiting (80.4%), decreased appetite (79.5%), constipation (72.7%), and abdominal pain (64.9%). Mouth sore, a less reported feature besides constipation, was present in 28.3% of children. Atypical clinical features were mostly neurological, with confusion (21.3%) being the predominant symptom. Frequent laboratory abnormalities were thrombocytopenia (87.2%), leucopenia (40.4%), and increased hematocrit (13.4%). Age (AOR 0.86, 95%CI 0.75–0.98, p = 0.023), mouth sore (AOR 2.69, 95%CI 1.06–6.96, p = 0.038) and a decreased platelet count (< 50,000/mm ³ ) with increased hematocrit (> 20%) (AOR 4.94, 95%CI 1.48–17.31, p = 0.01) were significant predictors of severity.
Conclusions
Dengue in children was characterized by a high severity, predominance of gastrointestinal symptoms, and atypical neurological presentations. Younger age, mouth sores, and a decreased platelet with increased hematocrit were significant predictors of severity. Our findings would contribute to the clinical management of dengue in children.
Background:
The study aimed to develop dengue severity score to assess severe manifestations among hospitalized patients with dengue infection.
Method:
Children and adolescents with serologically confirmed dengue infection admitted at Ramathibodi Hospital from 2004 to 2018 and treated by an expert multidisciplinary team were recruited. Medical records were retrospectively reviewed and 14 items, related to clinical parameters and managements during hospitalization, were obtained daily as dengue severity score.
Results:
A total of 191 patients with a mean age of 10.7 years from 2004 to 2013 were recruited. They were classified as dengue fever (35), dengue hemorrhagic fever (DHF) I (53), II (50), III (37) and IV (16). The analysis of 593 daily records revealed the range of daily severity score among patients with DHF grades III (10-20) and IV (31-47) were significantly higher than those of other groups (dengue fever, 5-13; DHF I, 2-10; DHF II, 6-11) with P-values of 0.0001. Using a validity test, a total daily score of ≥12 was an assessment tool for dengue shock syndrome with sensitivity, 86% and specificity, 84%. An additional 51 hospitalized patients with DHF grades II, III and IV with similar ages from 2014 to 2018 were recruited. The number of patients with severe manifestations, having daily score of ≥12, was significantly higher than those without severe manifestations starting from Day -3 to Day +1 of illness.
Conclusions:
Daily dengue severity score of ≥12 was an accurate assessment tool for severe manifestations.
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.
Background
Dengue continues to increase globally. Currently, the highest incidence of primo-infection occurs in the pediatric population, where severe dengue fever is potentially lethal. This study characterizes the clinical profile of pediatric patients with dengue fever in the South of Mexico.
Methods
We undertook a case series study of 133 pediatric inpatients with a clinical diagnosis of non-severe dengue and severe dengue fever. We described univariate analysis as means or percentages using a p < 0.05 as significance level and estimated the prediction of severe dengue using a GLMM (Generalized Linear Mixed Model) considering only clinical signs and symptoms.
Results
58% of patients (77/133) had severe dengue. There were significant differences among the dengue groups in the following signs and symptoms: fever, abdominal pain, epistaxis and platelet count. Children older than four years of age had a higher proportion of severe dengue (p < 0.05). GLMM identified a group of four clinical signs and symptoms (fever ≥39 °C, myalgia, arthralgia and abdominal pain) as predictors of severe dengue.
Conclusions
The results of this exploratory study suggest changes in the frequency of clinical signs and symptoms among pediatric inpatients. Pediatric patients with a presumptive diagnosis of dengue, showing fever of ≥ 39 °C, myalgia, arthralgia and abdominal pain should be considered as potential cases of severe dengue.
Infection with any of the 4 dengue virus serotypes results in a diverse range of symptoms, from mild undifferentiated fever to life-threatening hemorrhagic fever and shock. Given that dengue virus infection elicits such a broad range of clinical symptoms, early and accurate laboratory diagnosis is essential for appropriate patient management. Virus detection and serological conversion have been the main targets of diagnostic assessment for many years, however cross-reactivity of antibody responses among the flaviviruses has been a confounding issue in providing a differential diagnosis. Furthermore, there is no single, definitive diagnostic biomarker that is present across the entire period of patient presentation, particularly in those experiencing a secondary dengue infection. Nevertheless, the development and commercialization of point-of-care combination tests capable of detecting markers of infection present during different stages of infection (viral nonstructural protein 1 and immunoglobulin M) has greatly simplified laboratory-based dengue diagnosis. Despite these advances, significant challenges remain in the clinical management of dengue-infected patients, especially in the absence of reliable biomarkers that provide an effective prognostic indicator of severe disease progression. This review briefly summarizes some of the complexities and issues surrounding clinical dengue diagnosis and the laboratory diagnostic options currently available. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected]/* */
Background Dengue hemorrhagic fever (DHF) is endemic to Indonesia and remains a public health problem, with its highest incidence in children. There have been few reports on the clinical, hematological and serological data in children \\lith dengue.
Objective To assess the clinical and laboratory profiles of children \\lith dengue infection in Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
Methods Clinical, hematological and serological infonnation from children diagnosed v.ith dengue infection in Cipto Mangunkusumo Hospital were collected from 2007 to 2009.
Results Of611 children admitted with dengue, 143 (23.4%) had dengue fever (DF), 252 (41.2%) had DHF grades I and II; and 216 (35.4%) had DHF grades III and IV. Of the 81 cases where dengue serotypes were identified, 12.3% were DENV1, 35.8% were DENV-2, 48.2% were DENV-3 and 3.7% were DENV-4. Mean age of subjects was 8.9 years (SD 4.4), and 48.4% of cases were boys. The mean length of fever before hospital admission was 4.2 days (SD 1.1) and mean length of stay in the hospital was 4 days (SD 2.7). Common symptoms observed were petechiae, hepatomegaly and epistaxis. Complications found mostly in those with dengue shock syndrome (DSS) were hematemesis (30 cases, 4.9% of all patients), encephalopathy (19 cases, 3.1 %) and melena (17 cases, 2.8%).
Conclusion Signs and symptoms of fever, bleeding manifestations and thrombocytopenia were present in children 'With DF and DHF, while signs of increased vascular permeability were found only in those 'With DHF. Encephalopathy and gastrointestinal bleeding were found mostly in DSS cases. At admission, leukopenia was found in more DF patients than in DHF patients. Absence of leukopenia may be a sign of more severe dengue infection.
Objective: To evaluate the validity of clinical and laboratory signs to serious dengue disease in hospitalized children.
Methods: Retrospective cohort of children (19 and negative likelihood ratio
. In India, dengue epidemics are becoming more frequent (WHO, 2008). The majority of dengue viral infections are self-limiting, but complications may cause high morbidity and mortality.
Objectives
. To assess the clinical profile of the dengue infection in children less than 14 years of age and to evaluate the outcomes of dengue fever from September 2013 to August 2015 at the Pediatric Department of Maharaja Krishna Chandra Gajapati Medical College, the largest tertiary care hospital of southern Odisha.
Results
. A total of 97 cases were classified into 84 (86.59%) nonsevere and 13 (13.40%) severe dengue cases. The most common age of presentation was above 11 yrs. The mean age of admission was 8.7 yrs. The most common presenting symptom was fever seen in 100% and hepatomegaly (43.8%), the most common physical finding. Gastrointestinal bleeding was markedly seen in severe dengue (76.9%). Elevation in aspartate transaminase (SGOT) was found in 47.42% and thrombocytopenia in 27.5%. The correlation between hepatomegaly and elevated SGOT was significant (
P
value 0.0346). Case fatality rate (CFR) was 1.03%. The mean duration of hospitalisation was 3.8 days.
Conclusion
. In children, if symptoms like fever, pain, rashes, and vomiting are associated with hepatomegaly and elevated SGOT in context of low TPC, a strong possibility of dengue fever is present, especially in an epidemic setting. Early suspicion and effective management can reduce the severity.
Objectives. To develop a simple scoring system to predict dengue infection severity based on patient characteristics and routine clinical profiles.
Methods. Retrospective data of children with dengue infection from 3 general hospitals in Thailand were reviewed. Dengue infection was categorized into 3 severity levels: dengue infection (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS). Coefficients of significant predictors of disease severity under ordinal regression analysis were transformed into item scores. Total scores were used to classify patients into 3 severity levels. Results. Significant clinical predictors of dengue infection severity were age >6 years, hepatomegaly, hematocrit ≥40%, systolic pressure <90 mmHg, white cell count >5000 /μL, and platelet ≤50000 /μL. The derived total scores, which ranged from 0 to 18, classified patients into 3 severity levels: DF (scores <2.5, n = 451, 58.1%), DHF (scores 2.5–11.5, n = 276, 35.5%), and DSS (scores >11.5, n = 50, 6.4%). The derived score correctly classified patients into their original severity levels in 60.7%. An under-estimation of 25.7% and an over-estimation of 13.5% were clinically acceptable. Conclusions. The derived dengue infection severity score classified patients into DF, DHF, or DSS, correctly into their original severity levels. Validation of the score should be reconfirmed before application of routine practice.
Millions are infected with dengue yearly. We evaluated the epidemiological and clinical characteristics of pediatric patients infected with dengue in the Dominican Republic. The applicability of World Health Organization (WHO) warning signs for predicting severe dengue and mortality was also studied. This study was a cross-sectional retrospective review of patients with a clinical diagnosis of dengue. Univariate and multivariate analyses were performed to evaluate characteristics associated with severity and mortality. The study included 796 subjects: 288 subjects were classified as dengue, 290 subjects had alarm signs, and 207 subjects were classified as severe dengue. Common findings included thrombocytopenia (96%), abdominal pain (71%), and vomiting (59%). The most important factors associated with severe dengue were rash (P < 0.01), severe thrombocytopenia (P < 0.01), and anemia (P < 0.01). These signs and symptoms were also associated with mortality. This study validates the current WHO warning signs of severity. Rash and severe thrombocytopenia may be early warning signs and need additional study.
To study the clinico-epidemiological profile of children hospitalized with dengue illness.
Prospective study of children hospitalized with the diagnosis of dengue illness during from September through November 2006 at a tertiary care centre in Jaipur.
A total of 948 children including 671 (70.8%) boys and 277 (29.2%) girls were diagnosed to have dengue illness during the outbreak. Two third of children were from urban areas while 6-12 years was the most commonly affected age group (45.8%). 58.3% cases had dengue fever (DF) while 41.7% had DHF (dengue hemorrhagic fever). Dengue fever with bleed (DFB) accounted for 32% of cases. Common constitutional symptoms were vomiting (35.2%), pain abdomen (22.1%) and myalgia (10.1%). Bleeding manifestations were observed in 44.5% of cases.. Positive tourniquet test was the most common manifestation which was seen in 300 cases (31.6%) while in 9.2% cases bleeding was the only manifestation. Epistaxis (25%) was the most common spontaneous bleeding manifestation. Thrombocytopenia was documented in 84% of total cases and bleeding occurred more often in patients with severe thrombocytopenia. Ten children expired with a case fatality rate of 1.1%.
Children between 6 and 12 yrs were most affected by dengue with larger number of cases from urban areas. DFB cases accounted for almost one third cases of dengue. Epistaxis was the most common spontaneous bleeding manifestation. Bleeding occurs more often in patients with severe thrombocytopenia.
Dengue is the most important arthropod-borne viral disease of public health significance. Compared with nine reporting countries in the 1950s, today the geographic distribution includes more than 100 countries worldwide. Many of these had not reported dengue for 20 or more years and several have no known history of the disease. The World Health Organization estimates that more than 2.5 billion people are at risk of dengue infection. First recognised in the 1950s, it has become a leading cause of child mortality in several Asian and South American countries.
This paper reviews the changing epidemiology of the disease, focusing on host and societal factors and drawing on national and regional journals as well as international publications. It does not include vaccine and vector issues. We have selected areas where the literature raises challenges to prevailing views and those that are key for improved service delivery in poor countries.
Shifts in modal age, rural spread, and social and biological determinants of race- and sex-related susceptibility have major implications for health services. Behavioural risk factors, individual determinants of outcome and leading indicators of severe illness are poorly understood, compromising effectiveness of control programmes. Early detection and case management practices were noted as a critical factor for survival. Inadequacy of sound statistical methods compromised conclusions on case fatality or disease-specific mortality rates, especially since the data were often based on hospitalised patients who actively sought care in tertiary centres.
Well-targeted operational research, such as population-based epidemiological studies with clear operational objectives, is urgently needed to make progress in control and prevention.
Dengue hemorrhagic fever (DHF) causing by dengue viral infection is endemic in Thailand and Southeast Asian countries where thalassemias are prevalent. Thalassemic patients are also at risk to acquire dengue viral infections and to develop DHF. However, they can have different clinical manifestations and complications as well as more severity than general population requiring special awareness for proper diagnosis and management. We reported 20 thalassemic patients (10 boys and 10 girls) with DHF admitted to Department of Pediatrics, Siriraj Hospital during 1977 to 2001. Their ages ranged from 2-16 years (average 9.5 years). These cases included 5 cases of Hb H disease, 5 cases of Hb H with Hb Constant Spring (CS), 9 cases of beta-thalassemia/Hb E disease and 1 case of beta-thalassemia major. Two cases were in Grade I, 10 cases in grade II, 7 cases in Grade III and one case in grade IV severity of DHF. Though there were evidences of plasma leakage, instead of hemoconcentration, eighteen patients (90 percent) had hematocrit dropped at the range of 11-66% of the initial level. Fifteen patients (75 percent) required at least one packed red cell transfusion. Nine patients (45 percent) had mild bleeding symptoms, one of them had upper gastrointestinal hemorrhage requiring platelet concentrate transfusion. Two patients (10 percent) had serious complications including one with infection-associated hemophagocytic syndrome (IAHS) requiring intravenous immunoglobulin (IVIG) and packed red cell transfusion and the other had generalized seizure due to hyponatremia and hypotension. No mortality was observed among this group of patients. Early recognition of the DHF in thalassemic patients and appropriate packed red cell transfusion in patients with anemic symptoms is warranted to reduce morbidity and mortality in these patients.
The clinical presentations of dengue fever range from mild viral fever to life-threatening manifestations that may be typical or atypical. With the World Health Organization recommending new guidelines for the diagnosis of dengue, it becomes necessary to document clinical spectrum for classification and setting priorities. Therefore, a study was undertaken to document clinical and biochemical profile and outcome in dengue-positive pediatric patients. Records were retrieved from August to November 2015 in a tertiary care hospital in Delhi. Out of 188 dengue-positive patients enrolled, 61.1% were males. Mortality rate was 1%. Apart from the classic triad of fever, vomiting and abdominal pain, there were some atypical presentations, including febrile seizure (5.8%) and acute respiratory distress syndrome (3%). Myalgia was rare in the severe form of the disease. On laboratory investigation, anemia (75%) and thrombocytopenia (73%) were most common findings. Platelet counts were significantly lower in severe dengue than in other types.
Dengue infections are endemic in Thailand. Infants are at risk of developing dengue fever (DF) and dengue hemorrhagic fever (DHF). Many infants have severe DHF with unusual manifestations and may suffer from complications and even death because of difficulties in early diagnosis and improper management.
To study the incidence of infants DHF and to compare clinical and laboratory findings of DHF between infants and children in order to improve diagnosis and management of infants with DHF.
A retrospective review of hospital charts of DHF patients who were admitted to the Children's Hospital between 1995-1999 was carried out. Only confirmed DHF cases, either by serologic or virologic studies were included. Clinical and laboratory findings were compared using the standard software package SPSS.
There were 4,595 confirmed dengue patients admitted to the Children's Hospital during this 5-year period and among these 245 infants were under one year old (5.3%). Unusual presentations of DHF including upper respiratory tract infection (URI) symptoms, diarrhea, convulsions and encephalopathy were found more in the infants (4.5%, 13.1%, 12.7% and 4.1%) than in the children (1.7%, 2.0%, 2.0% and 0.6%) but shock was found less in the infants (25%) than in the children (30.9%). The percentages of Tourniquet test positive and low WBC (< or = 5,000 cells/mm3) which help in the early diagnosis of dengue were less in the infants (50.2% and 26.8%) than in the children (92.2% and 71.9%). Liver involvement and/or dysfunction were found more in the infants as shown by mean aspartate aminotransferase/alanine aminotransferase (AST/ALT) elevation and prolonged prothrombin time. Duration of i.v. fluid was shorter in the infants than in the children (21.9 vs 38.2 hours). Complications of fluid overload were found more often in the infants than in the children (9% vs 3.6%). The case fatality rate was 1.2 in the infants and 0.3 in the children.
Management of infants with DHF is critical because early diagnosis is rather difficult and they sometimes present with unusual manifestations (convulsions, encephalopathy and associated infections). Complications such as hepatic dysfunction and fluid overload are more commonly found in infants than in children and adults and also the case fatality rate is higher. Judicious i.v. fluid resuscitation and replacement is critical to the outcome of infants with DHF. It seems that the degree of plasma leakage is less in infants and the duration of plasma leakage is shorter in infants than in children.
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