Presentation, Management and Outcome of Dengue Fever – A Study of 200 Cases

Background: Dengue is the most rapidly spreading mosquito-borne viral disease in the world. The rapidly expanding global footprint of dengue is a public health challenge. The endemicity of dengue is also increasing in Bangladesh. This study highlights our current understanding of dengue, including its clinical manifestations, laboratory tests, management and outcome. Objectives: This study was designed to document the presenting features and outcome of Dengue infection in Border Guard personnel. Materials and Methods: It was a prospective observational study which was carried out among outpatient and indoor cases from February 2011 to November 2012 in Border Guard Hospital, Dhaka which is a 300 bedded hospital. Total 200 cases were enrolled. A detailed history, clinical examinations and relevant investigations were done. Data were collected in a predesigned structured questionnaire and analyzed with the help of SPSS-16.0 and Chisquare (X) Test. Results: A total of 200 adult seropositive Dengue cases of various grade were studied. Among these 152(76%) were male and 48 (24%) were female. Male to female ratio was 3.17:1.The age range of the patients was 18 to 60 years and the mean age 39±12.56 years. Among 200 patients, 112(66%) were Dengue Fever (DF) and 88(44%) were Dengue Haemorrhagic Fever (DHF) including 3(1.5%) cases of DHF Grade lII but none (0%) had Grade-IV DHF. All the patients presented with fever 200(100%), general weakness 200(100%) followed by various skin rash 196(98%), headache 192(96%), myalgia/arthralgia 191(95.5%), retroorbital pain 84(42%). Bleeding manifestation showed in 94(47%) cases of which petechiae was most frequent 86(43%), Haematocrit was normal only in 13(6.5%) patients and 82(41%) had a rise of >20%; Leucopenia was found in 187(93.5%) patients.Only 2(1%) patients had normal platelet count and 03(1.5%) patients had platelet count of less than 10X10 /L. Raised serum alanine aminotransferase (ALT) was observed in 184(92%) of cases. All (200%) the patients recovered completely from the disease; however, one patient subsequently developed Guillein Barre Syndrome. Conclusion: High persistent fever, profound general weakness, myalgia, headache and itchy skin rash were the usual presenting features. Most of the patients recovered well with efficient symptomatic and supportive treatment. Very few cases required blood/platelet transfusion. There was no case fatality in this study group.


Introduction
Dengue is a self-limited, systemic viral infection transmitted between humans by mosquitoes.Dengue fever (DF) and its severe forms -dengue haemorrhagic fevers (DHF) and dengue shock syndrome (DSS) have become major international public health concerns.Over the past three decades, there has been a dramatic global increase in the frequency of DF, DHF and DSS. 2 Approximately 2.5 billion people around the world living in dengue endemic countries of which 1.3 billion live in 10 countries of the WHO South-East Asia (SEA) Region which are dengue endemic areas .2An estimated 50 million infections including 250000-50000 cases of dengue haemorrhagic fever (DHF) and 24000 deaths per year occur across approximately 100 countries, 3 In Bangladesh, first documented case of dengue like fever occurred in 1964 popularly known as "Dacca fever" which later serologically proved as Dengue Fever. 4 The magnitude of dengue fever was largely unknown until it took a heavy toll in 2000 (5,555 cases and 93 deaths ); 2001(2,430 cases and 44 deaths) and 2002(6,104 cases and 58 deaths). 2 Symptomatic dengue virus infections can present with a wide range of clinical manifestations, from a mild febrile illness to a life-threatening shock syndrome. 2,5th viral and host factors are thought to contribute to the manifestations of disease in each infected individual.The risk of severe disease is much higher in sequential rather than in primary dengue infection.
The etiologic agent (DENV) belongs to the Flavi viridae family and to the Flavivirus genus, with 4 serotypes. 6is study describes the clinical and biochemical parameters, management and outcome of serologically confirmed dengue cases.

Materials and Methods
This prospective observational study was carried out between both OPD and indoor patients of Dengue Fever at Border Guard Hospital from February 2011 to November 2012.After obtaining informed consent a total of 200 serologically J MEDICINE 2013; 14 : 18-22 .positive patients were selected for the study.Patient with any identified specific infection or febrile illness more than 10days were excluded from the study.Demographic variables, presenting complaints, physical examination findings and laboratory investigation results were recorded on a structured questionnaire.Dengue cases were diagnosed on the basis of clinical definition and the detection of IgM Dengue Ab by ELISA method.The cases were classified according to WHO Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever, 2011.Data were collected in a predesigned structured questionnaire and analyzed with the help of SPSS-16.0 and Chisquare (X 2 ) Test.

Results
A total of 200 patients with Dengue Fever of various grade were studied.Among these 152(76%) were male and 48 (24%) were female.Male to female ratio was 3.17:1.Age ranged from 18 years to 60 with a mean of 39±12.56years.Detailed demographic data is shown in table-I.

Conclusion
In this study we tried to find out the pattern of clinical presentation, management and outcome of the dengue cases.Flushed appearance with skin rash and subconjunctival injection were striking clinical features in classical cases of Dengue fever.Very few patients showed bleeding manifestations and shock was rare.Thrombocytopenia was almost universal.Leucopenia was very common.Raised ALT was observed as a common association.
Patient awareness, efficiency of the physician in early diagnosis and prompt recognition of severe cases, proper management have admirably reduced the panic, morbidity and mortality in dengue cases in our country.Recommendation 1. Dengue cases should be diagnosed clinically.2. Most of the cases can be managed in outpatient departments.3.In general laboratory investigations should be limited to platelet count and haematocrit initially.4. Dengue Ab testing is not required in the management of Dengue fever. 5. Raised SGPT may be considered as a marker of dengue severity.6. Severe Dengue cases must be recognized early to avoid case fatality.7. Health education related to prevention of Dengue incidences in the community is urgently required.

Table - I
Demographic variables 1%).More than one type of bleeding manifestation was observed in 16 (8%) of cases.Torniquette test was positive only in 12 (6%) cases.Table-II shows clinical features in detail.
10scussionA male preponderance with a male to female ratio of 3:2 was observed by Ahmed et al9which is almost similar to our study 3.17:1.Whereas Hanif Mohammad 7 et al found the sex ratio as 5:1.Classical features of Dengue cases in this series are comparable with those of Hanif Mohammad 7 et al and Quazi Tarikul Islam 8 et al.It was almost similar to the study of ABM Shahidul Alam 9 et al.We have not found any patient to have DHF-IV, but ABM Shahidul Alam 9 et al found it 11.1% which is much higher.In this series most common bleeding manifestation was petechiae (43%) which differ from the study of Hanif mommad 7 et al where melaena (59%) was the most common.In our study bleeding from various sites were 16 (8%) cases which was 54% in the study of Agarwal10and 56.4% in that ofWali 11et al and major bleeding manifestations were rare.Fewer bleeding manifestation observed in our study is likely due to less secondary dengue infection or overall reduction of severity of dengue infection.
10erall mortality was nil in our study, but it was 3.8% in Agarwal10et al's study; ABM Shahidul Alam 9 et al found case fatality as 6% and Wali et al as 10.91%.