CLINICAL PRESENTATION OF DENGUE IN 150 ADMITTED CASES IN DHAKA MEDICAL COLLEGE HOSPITAL

Dengue fever was not recognized as a major public health hazard in Bangladesh before 1999 outbreak, so there was little evidence and awareness in this regard. A prospective observational study was carried out to determine the risk group of patients suffering from dengue syndrome; clinical parameters of the subjects for hospitalization and the pattern of presentation of dengue fever in hospital care in different medicine units of Dhaka Medical College hospital from July 2000 to March 2001. Total 150 cases were selected randomly and diagnosed clinically as dengue, and were classified into 3 groups, i.e. 18 cases of classical dengue fever, 127 cases of dengue hemorrhagic fever (DHF-I and DHF-II) and 5 cases of dengue shock syndrome (DSS), and were discharged uneventfully. Among them 125(83.3%) were male and 25(16.7%) were female. Mean ages of the subjects were 26.75 ±3.69, 27.59 ± 1.18 and 10.67 ± 2.33 years in respective groups. Mean temperature was 103.45±0.28, 103.08±0.13, and 104.00±1.00 °F with mean duration was 5.50±0.51 days, 6.12±0.2 days, and 5.00±1.15 in respective groups. Majority had profound weakness, headache, myalgia, anorexia, nausea, and vomiting. Diarrhoea, abdominal pain, organomegaly, ascites, and pleural effusion were frequent complaints in group-3 patients, whereas infrequent complaints in other groups. Haemorrhagic manifestations were common in group 2 and 3 patients, melaena being the most common manifestations. 1. Assistant Professor of Medicine, BSMMU. 2. Junior Consultant, Shibpur Health Complex, Narsingdhi 3. Associate Professor of Medicine, Dhaka Medical College, Dhaka 4. Consultant (Medicine), Central Police Hospital, Dhaka 5. Chairman and Professor, Department of Medicine, BSMMU, Dhaka deaths2,3. More than two fifths of the world’s population (2.5 billion) lives in areas potentially at risk for dengue3. Dengue is considered to be one of the most important infectious diseases in these regions4. DF is a severe, flulike illness that affects infants, young children and adults, but seldom causes death2. The first documented outbreak of DF in Bangladesh was in 1965 when it was called “Dhaka fever”5. The 1st sero-epidemiological study of Bangladesh to detect dengue infection was done at Chittagong Medical College hospital (CMCH), Chittagong in 1996 through 1997, and was found that 13.75% cases of fever were seropositive for dengue infection6. In Bangladesh, an outbreak of DF and DHF occurred in and around Dhaka city during the summer of 19997.Since then dengue cases are reported every year in different media and series6-9. The clinical features of dengue vary with the age of the patient and, in addition to clinically inapparent J MEDICINE 2006; 7: 3-9


Introduction:
Dengue is the most important arthropod-borne viral disease, and it is a major public health problem in subtropical and tropical regions.The virus is transmitted to humans by the bite of infected female mosquitoes of the genus Aedes.The global resurgence of dengue is thought to be due to failure to control the Aedes populations, uncontrolled urbanization, population growth, climate change, and increased airplane travel 1 .Dengue is caused by one of the four closely related, but antigenically distinct, virus serotypes 1 to 4(DEN-1, DEN-2, DEN-3, and DEN-4), and is a frequent cause of febrile illness in the tropical and subtropical areas of the world 2 .Dengue viruses, single stranded RNA viruses of the family Flaviviridae, are the most common cause of arboviral disease in the world.They are found virtually throughout the tropics and cause an estimated 50-100 million illnesses annually, including 250 000-500 000 cases of dengue haemorrhagic fever a severe manifestation of dengue and 24 000

Abstract:
Dengue fever was not recognized as a major public health hazard in Bangladesh before 1999 outbreak, so there was little evidence and awareness in this regard.A prospective observational study was carried out to determine the risk group of patients suffering from dengue syndrome; clinical parameters of the subjects for hospitalization and the pattern of presentation of dengue fever in hospital care in different medicine units of Dhaka Medical College hospital from July 2000 to March 2001.Total 150 cases were selected randomly and diagnosed clinically as dengue, and were classified into 3 groups, i.e. 18 cases of classical dengue fever, 127 cases of dengue hemorrhagic fever (DHF-I and DHF-II) and 5 cases of dengue shock syndrome (DSS), and were discharged uneventfully.Among them 125(83.3%).More than two fifths of the world's population (2.5 billion) lives in areas potentially at risk for dengue 3 .Dengue is considered to be one of the most important infectious diseases in these regions 4 .
DF is a severe, flu-like illness that affects infants, young children and adults, but seldom causes death 2 .The first documented outbreak of DF in Bangladesh was in 1965 when it was called "Dhaka fever" 5 .The 1 st sero-epidemiological study of Bangladesh to detect dengue infection was done at Chittagong Medical College hospital (CMCH), Chittagong in 1996 through 1997, and was found that 13.75% cases of fever were seropositive for dengue infection 6 .In Bangladesh, an outbreak of DF and DHF occurred in and around Dhaka city during the summer of 1999 7 .Since then dengue cases are reported every year in different media and series [6][7][8][9] .
The clinical features of dengue vary with the age of the patient and, in addition to clinically inapparent J MEDICINE 2006; 7: 3-9

ORIGINAL ARTICLES
infections, can be classified into five presentations: non-specific febrile illness, classic dengue (DF), dengue haemorrhagic fever (DHF), dengue haemorrhagic fever with dengue shock syndrome (DSS), and other unusual syndromes such as encephalopathy and fulminant liver failure 10,11 .
Young children with dengue often have an undifferentiated febrile illness with a maculopapular rash.Upper respiratory infections, especially pharyngitis, are common.Most infections in children under 15 years are asymptomatic or minimally symptomatic; a study of school children in Thailand found only 13% of those infected missed more than one day of school because of illness 12 .Classic dengue is more commonly seen among older children, adolescents, and adults.They are less likely to be asymptomatic.Dengue is abrupt in onset, typically with high fever accompanied by severe headache, incapacitating myalgia and arthralgia, nausea and vomiting, and rash.Rash, typically macular or maculopapular, often becoming confluent and sparing small islands of normal skin, has been reported in over half of infected people.Other signs and symptoms include flushed facies, sore throat, cough, cutaneous hyperaesthesia, and taste aberrations.Recovery may be prolonged and include depression 13 .
The hallmark of dengue hemorrhagic fever is capillary leakage, accompanied by hemorrhagic manifestations.The presentation of patients in the first days of the illness is similar to that seen in dengue fever, but plasma leakage develops four to seven days after the onset of the disease, at approximately the time of deffervescence.Abdominal pain and vomiting, restlessness, a change in the level of consciousness, and a sudden change from fever to hypothermia may be the first clinical warning signs and are often associated with a marked decrease in the platelet count 13 .
The diagnosis of dengue hemorrhagic fever is made on the basis of the following triad of symptoms and signs: hemorrhagic manifestations; a platelet count of less than 100,000 per cubic millimeter; and objective evidence of plasma leakage, shown either by fluctuation of packed-cell volume (>20% during the course of the illness) or by clinical signs of plasma leakage, such as pleural effusion, ascites, or hypoproteinemia.Hemorrhagic manifestations without capillary leakage do not constitute dengue hemorrhagic fever.A positive tourniquet test is incorporated in the WHO clinical case definition of dengue hemorrhagic fever, but the definition differentiates poorly between dengue and dengue hemorrhagic fever and is not very specific 14 .Mortality rates from dengue hemorrhagic fever can range as high as 10 to 20 percent, but they are as low as 0.2 percent in hospitals with staff experienced in the management of the disease 2,13,15 .
Dengue shock syndrome is characterized by a rapid, weak pulse with a narrowing pulse pressure of less than 20 mm Hg, or profound hypotension (systolic pressure of less than 90 mm Hg among those five years of age or older).The duration of shock is short.Typically, patients either recover rapidly after appropriate volume-replacement therapy is administered or die within 12 to 24 hours; the mortality rate is up to 40 percent 13,15 .
In most of the cases the disease can be managed well according to the guideline provided by WHO 16 .In this guideline severity of dengue is stratified on the basis of fluid leakage and bleeding.

Materials and Method:
The study was carried out at DMCH from July 2000 to March 2001.A total of 150 dengue patients were recruited who were diagnosed on the basis of WHO criteria and confirmed by the presence of antidengue IgM and IgG antibody.Study subjects are classified into 03 (three) groups depending on the clinical and laboratory findings.Subjects are selected according to the selection criteria and excluded following the exclusion criteria.Statistical analysis were done using SPSS to see correlation between clinical manifestations and severity of dengue infection.

Selection criteria:
Group-1(DF): Subjects with acute febrile illness for not more than 2-7 days having the manifestations like 1. Sudden onset of fever plus 2. 2 or more of the following features i.e. a) severe headache, b) retro orbital pain, c) severe myalgia, arthralgia, backache, and d) leucopoenia plus 3. Absence of convincing evidence of any other febrile illness.

Group-2 (DHF):
Group 1 manifestations plus hemorrhagic manifestation evidenced by one or more of the followings.

Conclusion:
During the initial outbreak, the nature of the disease, non-acquaintance of the professionals and unfamiliarity on the part of the general people has made the situation a panic.Patients with dengue syndrome showed varied presentation and the symptoms are non specific.So it necessitates clinical awareness to combat mortality and morbidity.In this study, we tried to find out the clinical parameters with varied presentations to create better awareness and clinically diagnostic skills among the health care providers and people to identify and refer the patients promptly to proper health care facilities to avert the ultimate danger.

Table - II
Distribution of study subjects according to the age interval.

Table - 3
Distribution of the study subjects according to the highest temperature.

Table - 4
Distribution of the study subjects according to pain pattern experienced by them.

Table - 5
Abdominal complains of the study subjects.

Table - 6
Different types of rash and hemorrhagic manifestations.Majority of the group-3 also had ascites (80%) and 40% had pleural effusion (table-7).Only three (two of group-2 & one in group-3) patients had jaundice, none had hepatic encephalopathy.