Fatal Dengue Hemorrhagic Fever in Adults: Emphasizing the Evolutionary Pre-fatal Clinical and Laboratory Manifestations

Abstract

BackgroundA better description of the clinical and laboratory manifestations of fatal patients with dengue hemorrhagic fever (DHF) is important in alerting clinicians of severe dengue and improving management.Methods and FindingsOf 309 adults with DHF, 10 fatal patients and 299 survivors (controls) were retrospectively analyzed. Regarding causes of fatality, massive gastrointestinal (GI) bleeding was found in 4 patients, dengue shock syndrome (DSS) alone in 2; DSS/subarachnoid hemorrhage, Klebsiella pneumoniae meningitis/bacteremia, ventilator associated pneumonia, and massive GI bleeding/Enterococcus faecalis bacteremia each in one. Fatal patients were found to have significantly higher frequencies of early altered consciousness (≤24 h after hospitalization), hypothermia, GI bleeding/massive GI bleeding, DSS, concurrent bacteremia with/without shock, pulmonary edema, renal/hepatic failure, and subarachnoid hemorrhage. Among those experienced early altered consciousness, massive GI bleeding alone/with uremia/with E. faecalis bacteremia, and K. pneumoniae meningitis/bacteremia were each found in one patient. Significantly higher proportion of bandemia from initial (arrival) laboratory data in fatal patients as compared to controls, and higher proportion of pre-fatal leukocytosis and lower pre-fatal platelet count as compared to initial laboratory data of fatal patients were found. Massive GI bleeding (33.3%) and bacteremia (25%) were the major causes of pre-fatal leukocytosis in the deceased patients; 33.3% of the patients with pre-fatal profound thrombocytopenia (<20000/µL), and 50% of the patients with pre-fatal prothrombin time (PT) prolongation experienced massive GI bleeding.ConclusionsOur report highlights causes of fatality other than DSS in patients with severe dengue, and suggested hypothermia, leukocytosis and bandemia may be warning signs of severe dengue. Clinicians should be alert to the potential development of massive GI bleeding, particularly in patients with early altered consciousness, profound thrombocytopenia, prolonged PT and/or leukocytosis. Antibiotic(s) should be empirically used for patients at risk for bacteremia until it is proven otherwise, especially in those with early altered consciousness and leukocytosis.

Acute transverse myelitis and subacute thyroiditis associated with dengue viral infection: A case report and literature review

“…The possible pathogenesis may be due to superinfection or co-infection, including urinary tract infection, blood-stream infection and pneumonia. Notably, leukocytosis was identified as a sign of severe dengue infection in a Taiwanese study (14); however, it cannot be ruled out that spinal cord injury was caused directly by dengue virus. According to the comparison of cases shown in Table II, para-infectious transverse myelitis also appears to be associated with flaccid paraparesis, while post-infectious myelitis may be associated with spastic paraparesis.…”

Characteristics and Risk Factors for Fatality in Patients with Dengue Hemorrhagic Fever, Taiwan, 2014

“…Together with global warming, the rapid expansion of DENV to new geographic areas where the elderly remain susceptible to dengue would result in significant morbidity and mortality, especially in the absence of a suitable vaccine and clinical management recommendations specific for the elderly. 20,21 In sharp contrast to other countries where dengue is endemic, most DHF patients in Taiwan are elderly, 6,7,16,[22][23][24][25] probably as a consequence of a higher likelihood of secondary DENV infection, which is a well-known risk factor for DHF. 26,27 We speculate that, despite a higher seroprevalence of dengue among the elderly (> 65 years old; P. Y. Su, unpublished data), they will not be immune to all four DENV serotypes, since Taiwan has not historically been a dengue-endemic area.…”

Predictors of mortality in adult patients with dengue: a study from South India

“…10 Thrombocytopenia is a marker of clinical severity as per WHO guidelines. 11,12 It was found that markedly elevated transaminases (>200U/L) showed a significant association with mortality. The p value calculated was 0.070 and <0.001 for ALT and AST respectively.…”