Dengue-Related Deaths in Puerto Rico, 1992–1996: Diagnosis and Clinical Alarm Signals

University of Maryland, Baltimore, Baltimore, Maryland, United States
Clinical Infectious Diseases (Impact Factor: 8.89). 06/2006; 42(9):1241-6. DOI: 10.1086/501355
Source: PubMed


Dengue, although endemic in Puerto Rico, is often not mentioned in the death certificates of decedents with laboratory results positive for dengue. Because confirmatory results are usually not available during hospitalization, we examined the utility of 2 instruments for diagnosis on the basis of clinical findings: the definition of dengue hemorrhagic fever (DHF) and the publicized (but unevaluated) clinical alarm signals for impending dengue shock.
We studied data from all patients with laboratory test results positive for dengue who died (23 patients) and from the 8 patients whose death certificates listed dengue as a cause of death but whose laboratory test results were negative for dengue in Puerto Rico from 1992 through 1996. We examined hospital records to determine whether the clinical criteria for DHF were fulfilled and evaluated the incidence and timing of clinical alarm signals (intense, sustained abdominal pain; persistent vomiting; sudden change from fever to hypothermia; and marked restlessness or lethargy) and the hematocrit/hemoglobin ratio as an indicator of hemoconcentration.
A similar proportion of patients with laboratory test results positive for dengue (18 [78%] of 23) and negative for dengue (6 [75%] of 8) fulfilled the criteria for DHF. Clinical alarm signals were found only among patients with laboratory test results positive for dengue and were usually noted on the day that the patient's condition deteriorated. The hematocrit/hemoglobin ratio identified 1 (6%) of 16 patients with dengue who had significant hemoconcentration. Important comorbidities were present in 16 (70%) of the patients with laboratory test results positive for dengue and in 4 (50%) of the patients with dengue-related deaths with laboratory test results negative for dengue.
Dengue-related deaths in Puerto Rico often occur in patients with comorbidities. Among such patients, the DHF definition and the hematocrit/hemoglobin ratio were not useful in identifying patients with laboratory test results positive for dengue. In contrast, the clinical alarm signals for shock supported the dengue diagnosis and should alert clinicians to the severity of the disease.

Full-text preview

Available from:
  • Source
    • "Exact mechanisms are, though, not clearly understood, but it has been suggested that the patients with history of allergies have constantly activated immune system and there is liberation of proinflammatory cytokines in tissues, particularly in endothelium [7]. Similarly, in type-2 diabetes mellitus, there is an activation of T-lymphocytes and release of cytokines like gamma interferon and tumor necrosis factor alpha, which ultimately increase the capillary fragility and permeability [8]. Similar physiopathological mechanism has been observed in development of dengue hemorrhagic fever and dengue shock syndrome. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background. Dengue fever is an emerging public health problem in Pakistan. The aim of this study was to determine the relationship between comorbid conditions in individuals suffering from dengue fever and the development of dengue hemorrhagic fever or dengue shock syndrome. Methods. In this age- and sex-matched case control study, total of 132 cases of dengue hemorrhagic fever/dengue shock syndrome and 249 randomly selected controls were recruited from two major teaching hospitals of Lahore, Pakistan. A semistructured questionnaire was used to collect data through interview and by reviewing clinical records. SPSS version 18 was utilized for statistical analysis including conditional logistic regression. Results. Odds of developing dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) among diabetics are higher than in controls, but this association was not found statistically significant (OR. 1.26; 95% CI. 0.78–2.03; ). Similarly, no association was observed in individuals suffering from hypertension (OR. 0.93; 95% CI. 0.57–1.49; ). Odds of developing DHF and DSS were higher for bronchial asthma (adjusted OR. 1.34) and pulmonary tuberculosis (adjusted OR. 1.41); however P values were insignificant. Conclusion. Presence of diabetes mellitus, hypertension, ischemic heart disease and bronchial asthma among patients contracted dengue fever will not increase the risk of dengue hemorrhagic fever and dengue shock syndrome.
    Full-text · Article · Aug 2013
  • Source
    • "The age of the deceased in our study and two recent studies [5,6] was older than a much earlier report by Chan et al [19] with possible shift of severe disease to older population. In our study, 75% had co-morbidities similar to other studies [7,8]. Asthma, diabetes mellitus and sickle cell disease have been reported risk factors for DHF [20] and await validation in well-designed case control studies. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Dengue re-emerges in Singapore despite decades of effective vector control; the infection predominantly afflicts adults. Severe dengue not fulfilling dengue hemorrhagic fever (DHF) criteria according to World Health Organization (WHO) 1997 guideline was increasingly reported. A new WHO 2009 guideline emphasized warning signs and a wider range of severe dengue manifestations. We aim to evaluate the utility of these two guidelines in confirmed adult dengue fatalities. We conducted a multi-center retrospective chart review of all confirmed adult dengue deaths in Singapore from 1 January 2004 to 31 December 2008. Of 28 adult dengue deaths, median age was 59 years. Male gender comprised 67.9% and co-morbidities existed in 75%. From illness onset, patients presented for admission at a median of 4 days and death occurred at a median of 12 days. Intensive care admission was required in 71.4%. Probable dengue was diagnosed in 32.1% by WHO 1997 criteria and 78.6% by WHO 2009. The earliest warning sign was persistent vomiting at a median of 1.5 days. Hematocrit change ≥20% concurrent with platelet count <20 × 10^9/L was associated with the shortest interval to death at a median of 3 days. Only 35.7% of death cases fulfilled DHF criteria by WHO 1997 versus severe dengue in 100.0% by WHO 2009 criteria. Deaths were due to shock and organ failure. Acute renal impairment occurred in 71.4%, impaired consciousness 57.1% and severe hepatitis 53.6%. In our adult fatal dengue cohort, WHO 2009 criteria had higher sensitivity in diagnosing probable dengue and severe dengue compared with WHO 1997. As warning signs, persistent vomiting occurred early and hematocrit change ≥20% concurrent with platelet count <20 × 10^9/L preceded death most closely.
    Full-text · Article · May 2011 · BMC Infectious Diseases
  • Source
    • "circulating in Northern Brazil, samples of DENV-3 from RJ, and those retrieved from databases. It should be emphasized that only DENV-3 genotype III was identified during the 2002 to 2003 epidemic in samples from Porto Velho (Aquino et al. 2006) and RJ (Nogueira et al. 2005), and this genotype is the only one to have been implicated in DENV-3 epidemics in the Americas (Usuku et al. 2001, Messer et al. 2003, Uzcategui et al. 2003, Peyrefitte et al. 2005, Rigau-Pérez & Laufer 2006, Ocazionez et al. 2006). When samples received from Porto Velho were used to infect C6/36 cells, they displayed a cytotoxic effect not seen with other DENV-3 viral isolates (data not shown). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The reintroduction of dengue virus type 3 (DENV-3) in Brazil in 2000 and its subsequent spread throughout the country was associated with genotype III viruses, the only DENV-3 genotype isolated in Brazil prior to 2002. We report here the co-circulation of two different DENV-3 genotypes in patients living in the Northern region of Brazil during the 2002-2004 epidemics. Complete genomic sequences of viral RNA were determined from these epidemics, and viruses belonging to genotypes V (Southeast Asia/South Pacific) and III were identified. This recent co-circulation of different DENV-3 genotypes in South America may have implications for pathological and epidemiological dynamics.
    Full-text · Article · Sep 2008 · Memórias do Instituto Oswaldo Cruz
Show more