Clinical Profile and Outcome of Patients with Dengue Syndrome In Hospital Care

Dengue is a viral febrile illness, which has become a major international public health concern including Bangladesh, spectrum of illness ranging from dengue fever (DF) to life threatening dengue haemorrhagic fever (DHF), dengue shock syndrome (DSS) and ultimately death. The clinical profiling and outcome during epidemic dengue outbreak was observed in Dhaka Medical College Hospital in 2000 to 2001. One hundred and fifty patients were systematically observed. Male female ratio was 5:1 with severity of illness in younger patients. Hundred percent patients had fever with 83% having generalized weakness. The severe cases(DHF) were having sudden sustained temperature of 103 degree farenheight. Majority have abdominal symptoms(>80%) while 10% had respiratory only. Sixty percent have hepatomegaly while 40 % spleenomealy while 80% of DHF had ascites. Above 75% cases of Dengue haemorhagic fever had positive tourniquet test while melaena was the commonest mucosal bleeds. No fatality was observed in this study although variability of discharge was seen in different groups. Keyword: Clinical, Profile, Outcome, Dengue, Hospital 1. Assistant Professor of Medicine, Sir Salimullah Medical College 2. Junior Consultant of Medicine, Sir Salimullah Medical College 3. Assistant Professor of Medicine, Dhaka Medical College 4. Medical Officer, Kashba Health Complex, Brammonbaria 5. Professor of Medicine (Rtd) Correspondence : Dr .Md. Robed Amin, Assistant Professor of Medicine, Department of Medicine, Dhaka Medical College, Bangladesh.Apt-C-2, House no-76, Road-5, Block-F, Banani, Dhaka, Bangladesh. e.mail : robedamin@yahoo.com diseases are prevailing in endemic level through mosquitoes and dengue is a similar mosquito vector borne disease.1 All the favourable environments and other related factors are not only present but also developing rapidly further providing an ever-expanding potential field for the dengue endemicity and epidemics. There is no facility in our country to diagnose most of the viral infections specifically by laboratory investigations like virus isolation by culture, so we are lacking the experience of these diseases in detail. Therefore, evaluation of clinical features and management outcome of the subjects with dengue fever is essential for the development of uniform diagnostic criteria, management approach and to identify the risk groups of patients to curtail the morbidity and mortality of this disease. In this study we tried to determine the risk group of patients suffering from dengue syndrome so as to cared and managed promptly, to determine the clinical parameters of the subjects hospitalized for dengue fever, to find out the pattern of presentation of dengue fever in hospital care and to put forward an overview about dengue fever in Bangladesh to the general public, health care providers and professionals. J MEDICINE 2011; 12 : 131-138


Introduction:
Dengue fever pronounced as "Dhen Gey" is a febrile viral illness transmitted by arthropod vectors. 1 Since its first recognition during the last quarter of 18 th century, periodic outbreak has been reported from both the developed and developing countries with Asia always remaining the area of highest endemicity. 2,3In 1964 there was an outbreak of dengue and chikungunya virus infection called "Dacca fever" which was the 1 st.documented outbreak of dengue in Bangladesh. 4 Another epidemic fever with features closely mimicking that of dengue haemorrhagic fever occurred again in 1968 in areas of Bangladesh bordering Myanmar. 5 The associated severe haemorrhagic manifestations took a heavy toll during the outbreak.Dengue has not been a public health problem before July 2000 outbreak, so there was little evidence and awareness in this regard.From hospital record of Dhaka Medical College Hospital it is seen that 1087 dengue subjects were admitted in Dhaka Medical College Hospital from July 2000 to 31 st December 2000, in this 6(six) months of which 15 patient died.It is likely that the dengue epidemic will continue to increase in frequency and magnitude in future.Bangladesh is a country where most infectious Clinical Profile and Outcome of Patients with Dengue Syndrome In Hospital Care HANIF MOHAMMAD 1 , DEVENDRA NATH SARKAR 2 , M ROBED AMIN 3 , A BASHER 4 , T AHMED 5 Abstract: Abstract: Abstract: Abstract: Abstract: Dengue is a viral febrile illness, which has become a major international public health concern including Bangladesh, spectrum of illness ranging from dengue fever (DF) to life threatening dengue haemorrhagic fever (DHF), dengue shock syndrome (DSS) and ultimately death.The clinical profiling and outcome during epidemic dengue outbreak was observed in Dhaka Medical College Hospital in 2000 to 2001.One hundred and fifty patients were systematically observed.Male female ratio was 5:1 with severity of illness in younger patients.Hundred percent patients had fever with 83% having generalized weakness.The severe cases(DHF) were having sudden sustained temperature of 103 degree farenheight.Majority have abdominal symptoms(>80%) while 10% had respiratory only.Sixty percent have hepatomegaly while 40 % spleenomealy while 80% of DHF had ascites.Above 75% cases of Dengue haemorhagic fever had positive tourniquet test while melaena was the commonest mucosal bleeds.No fatality was observed in this study although variability of discharge was seen in different groups.diseases are prevailing in endemic level through mosquitoes and dengue is a similar mosquito vector borne disease. 1 All the favourable environments and other related factors are not only present but also developing rapidly further providing an ever-expanding potential field for the dengue endemicity and epidemics.There is no facility in our country to diagnose most of the viral infections specifically by laboratory investigations like virus isolation by culture, so we are lacking the experience of these diseases in detail.Therefore, evaluation of clinical features and management outcome of the subjects with dengue fever is essential for the development of uniform diagnostic criteria, management approach and to identify the risk groups of patients to curtail the morbidity and mortality of this disease.
In this study we tried to determine the risk group of patients suffering from dengue syndrome so as to cared and managed promptly, to determine the clinical parameters of the subjects hospitalized for dengue fever, to find out the pattern of presentation of dengue fever in hospital care and to put forward an overview about dengue fever in Bangladesh to the general public, health care providers and professionals.bleeding manifestations after the patient has become afebrile usually within 1-2 days of defervescence of fever (Dengue haemorrhagic fever/Dengue shock syndrome usually develop around day 3-7 of illness at the time of defervescence which is an indication for intensified observation. 9,14,15The observation was seen in present study compliments their findings too.

Materials and Methods
All the subjects of group-I and 91.3% of group-II subjects were completely cured of the disease within 14 days from onset of illness, but none of group-III subjects.They started to be cured of the disease after 14 days and only 60% were cured after 20 days and remaining 40% took more than 20 days .Tai-Dy et al. reported the mean hospital stay was 4.2 ± 1.5 days which is much less than that of this study. 16The cause may be that this was the epidemic in our country when we were perplexed and did not feel safe to discharge patients from hospital before patients were physically fit and mentally stable and confident of being cured.In fact when platelet count is on the rising trend and in the absence of clinical bleeding it is reasonably safe to discharge patients.And if so done, this may shorten each patients stay resulting in cost saving and more efficient use of hospital bed.Rigau Perez JG reported that the median duration of hospital stay was 5 days which is inconsistent with this study. 16,17

Conclusion:
Since July 2000 Bangladesh has witnessed the spectacular emergence of Dengue.The nature of the disease, nonacquaintance of the professionals and unfamiliarity on the part of the general people turned the situation into a panic.Patients with dengue virus infection constituted a substantial number of hospital admitted patients in the city hospitals and clinics during the 2 nd half of the calendar year 2000.Patients with dengue syndrome showed varied presentation and the symptoms were non specific.So a large toll has been paid measured in number of death before we become alert and aware of it.
It this study an attempt has been made to find out the clinical features and varied presentations to put forward an overview about dengue fever in Bangladesh 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.Because early recognition and prompt and aggressive management is the mainstay to avert the ultimate danger.Evaluation of clinical features of the subjects with dengue fever may thus help development of uniform diagnostic criteria and management approach.
Dengue has shown its presence in Bangladesh.So before time is elapsed we must be prepared to face the future malady efficiently and appropriately by being acquainted with it.This is a preliminary observational study.Further detailed, meticulous, multi-centered and large-scale study could shed clear light on this proposition and could clearly define the situation.

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the laboratory investigations and patients suffering from other chronic ailments in addition to dengue fever such as chronic renal failure, diabetes mellitus, skin infections, immunocompromised or haematological disorders were excluded from the study.SAMPLE SIZE: 150 subjects on the above criteria was taken for the study as random fashion.Purposive convenient sample was taken.Enrolled patients were seen by the investigators clinically and follow up in hospital until discharge or fatality.Informed written consent was taken from patients or their attendant before enrolment and after discussing the protocol.A prestructured questionnaire were filled up by the investigators after a clinical diagnosis of dengue syndrome and later the groups were encoded after the temporal profile of disease were clear cut.After enrolment 5All the study subjects had fever & in almost all of them onset of fever was sudden.100% of group-I & group-III and 93.77% of group-II subjects had sudden onset of fever.Only a small percentage of subjects i.e 22.2%, 30.7% & 60% of group-I, group-II and group-III respectively experienced chills and rigors.Majority of the subjects (83%) including all three groups experienced severe weakness.III as shown in Table-II.Mean duration of fever were found 5.50±0.51days in group-I, 6.12±0.2days in group-II and 5.00±1.15days in group-III subjects.Twenty patients in group II were seen to have fever more than usual 7 days and one patient had 14 days of fever.Majority subjects i.e more than 77% of all groups experienced different grades of sweating predominantly of moderate grade of sweating.Almost all the subjects of each group suffered from headache (more than 78%) and myalgia (more than 81%).Hundred percent of group-III subjects had the complain of headache, myalgia, low-back pain, retro-orbital pain and arthralgia while retroorbital pain was experienced by one third of group-I (33.3%) and group-II (33.9%) subjects.Low back pain was recorded in 44.4% of group-I and 53.5% of group-III subjects (Table-III).
The course of the disease is a continuum passing from one group to the another and the transient period is during the afebrile phase.Hence the above mentioned grouping was the ultimate classification in the course of time.Pregnancy, patients suspected of suffering from any other febrile illness and revealing on ml blood was taken on admission day for Complete Blood Count including -TC, DC of WBC ESR, Hb%, Malarial Parasite count, Widal test, Urine for routine microscopic examination, Serum ALT, AST, bilirubin, CXR, USG of abdomen, Blood urea, creatinine, Serum electrolytes.Platelet count 12 hourly every day and Haematocrit on every day was done in every patients.Antibody IgM, IgG for dengue were done after 7 days of fever.Few patients of jaundice, serological tests were also done to exclude other hepatrotropic virus infection.Serotype identification and virus isolation could not be done due to lack of facilities.All data were analyzed by SPSS version 10 Illinois-Chicago,USA and expressed in tabulated form.The study was approved by ethical review committee of the institution of Dhaka Medical College and in every step of data collection and patients care, ethical consideration was observed critically.significant.Mean age of group-II subjects were 27.59± 1.18 and 26.75±3.69yearsfor group-1 subjects.Demographic pictures of three groups of patients with comparison of age, hospital stay, temp shown in table1

Table - I
Demographic parameters and comparison between groups of study subjects.

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

Table - V
107nical signs observed in three groups of dengue syndromeAs regards to the age -group-III (DSS) patients were significantly (p<0.05)younger.Kabra Sk et al. and Ibrahim NM et al. in their study showed dengue shock syndrome to occur more in younger age groups, and when compared to other groups of the study 100% were below 20 years of age.6,7Chareonsook 'O et al. showed-the age of highest incidence has increased and adults are now also being affected with dengue haemorrhagic fever/dengue shock syndrome.8WaliJPetal.showedthatcontrary to the popular belief dengue haemorrhagic fever/dengue shock syndrome is not a disease of children only and the mean age of his study was 31 yrs ± 5.2 (SD).9Most of the patients were in the age range of 20-50 years, which is almost similar to this study.All the study subjects had fever and almost in all of them onset of fever was sudden.Only a small number of subjects i.e 22.2%, 30.7% and 60% of group I, group-II and group-III respectively experienced chills and rigor.Anuradha S et al. found in her study that the fever was of high grade associated with chills and rigors and was self limiting.10Majority of patients (>88%) of all groups experienced severe weakness.Rigau JG et al. found that febrile period leaves the patient feeling severely tired for several more days.
9,10Wali JP et al. showed 36.4% of his study subjects had