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Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 68-70

Unusual presentation of dengue fever

Department of Pediatrics, JSS Medical College, JSS University, Mysore, Karnataka, India

Date of Web Publication20-Jan-2015

Correspondence Address:
Kalenahalli J Kumar
85/B, 9th Cross, Navilu Road, Kuvempu Nagar, Mysore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-631X.149691

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Dengue infection can present with varying clinical manifestations, which may not conform to the definitions of the World Health Organization (WHO) classification. Flushing, puffiness and cyanosis are some of the features, which are not included in the WHO criteria. Bleeding and thrombocytopenia are conspicuously absent in some children with "true" dengue hemorrhagic fever. Revised classification based on dengue control study, in comparison with WHO classification is definitely exclusive at detecting severe dengue infection. In fact flushing, puffiness and cyanosis are not included in the past or recent WHO classification criteria of dengue fever. It is practically feasible and facilitates real-time case management. All the classifications are only the guidelines and a good clinical acumen is an absolute necessity in diagnosing the criticality of the patient and prioritizing them for specific treatment.

  Abstract in Arabic 

ملخص البحث:
تأخذ عدوى حمى الضنك أشكالا مختلفة من الأعراض والعلامات التي تتواءم مع تعريف منظمة الصحة العالمية وتصنيفها. يعتبر الاحمرار والانتفاخ والازرقاق بعض المظاهر التي لا تدخل في معايير منظمة الصحة العالمية. عند بعض الأطفال المصابين لا يعرض المرض بالنزف وقلة الصفائح. كل تصنيفات المرض ما هي إلا مؤشرات ولكن يبقى الحس السريري هو الأهم في تشخيص الحالة الحرجة لمريض حمى الضنك وهي التي تساعد في تحديد أولوية المعالجة الملائمة.

Keywords: Cyanosis, dengue, thrombocytopenia, World Health Organization, revised classification

How to cite this article:
Kumar KJ, Balachandar P, Anitha C, Kumar MS. Unusual presentation of dengue fever. Saudi J Med Med Sci 2015;3:68-70

How to cite this URL:
Kumar KJ, Balachandar P, Anitha C, Kumar MS. Unusual presentation of dengue fever. Saudi J Med Med Sci [serial online] 2015 [cited 2022 Nov 27];3:68-70. Available from: https://www.sjmms.net/text.asp?2015/3/1/68/149691

  Introduction Top

Dengue infection manifests with a wide clinical spectrum as asymptomatic fever, undifferentiated fever, dengue fever (DF) and dengue hemorrhagic fever (DHF). [1] World Health Organization (WHO) has classified dengue infection as DF, DHF (Grades 1 and 2) and dengue shock syndrome (DSS) (DHF Grades 3 and 4). [2] However, many of the clinical manifestations of dengue infection do not fit into the WHO classification and may not be universally applicable for clinical management. [3] The main pathophysiology is related to plasma leakage rather than to hemorrhage, therefore the existing terminology of hemorrhage-can be misleading for clinical management. [3] Several publications have stressed the need for a new revised classification system for dengue virus infection. [4],[5] The global expert meeting on dengue classification in September 2008 at Geneva recommended a revised case classification such as dengue, dengue with warning signs and severe dengue based on the research evidence from the dengue control (DENCO) study. [3],[6] This revised dengue classification system appears more valuable at detecting severe dengue infection than the WHO classification system. [1],[3],[6],[7] We are hereby reporting a case of DF with compensated shock and five episodes of cyanosis with an accompanying platelet count of 118,000/mm 3 . Our case though presenting with shock could not be classified according to WHO (DF/DHF/DSS) classification and it was categorized as severe dengue according to revised classification.

  Case report Top

This is a case report of a two and a half years old girl presented with fever, cough and vomiting since 12 days. There was no history of myalgia, rashes or bleeding tendencies. On examination, she appeared puffy with flushed face and had pedal edema. Her palms and feet were cold and cyanosed. She was afebrile (98.6°F), respiratory rate (RR) 28/min and blood pressure (BP) of 90/50 of Hg. She was tachycardic (pulse rate 132/min) her pulse was thready and rapid, capillary filling time (CFT) was 5 seconds and SaO 2 95% in room air. Respiratory system examination showed diminished breath sounds on the right side and cardiac examination revealed muffled heart sounds. In view of acute febrile illness with flushing and puffiness, a diagnosis of dengue with compensated shock was made. According to revised classification the case was diagnosed as dengue with warning signs (critical phase). Child was managed with oxygen and intravenous ringer lactate. Her cyanosis disappeared within 3 min investigations - Hb 12.6 g/dL, total lymphocyte count 11,300/mm 3 , platelets 1.18 lakhs/mm 3 and hematocrit 39.8%. Her serum albumin 3.0 g/dL, proteins 6.0 g/dL, aspartate transferase 910 U/L, alanine transferase 373 U/L, creatine phosphokinase-MB 26 U/L and lactate dehydrogenase 1557 U/L. Her kidney function tests, prothrombin time, partial thromboplastin time and arterial blood gases (ABG) were normal. Her chest x-ray and sonography revealed right pleural effusion and ascitis. She was positive for IgM and IgG dengue ELISA. After 12 hours she developed respiratory distress (RR 42/min). Her ABG showed pH 7.48, PO 2 114, PCO 2 22 and BE −5.8. Her platelets started dropping to 84,000/mm 3 on 3 rd day and 74,000/mm 3 on 4 th day. She had 5 intermittent episodes of cyanosis of palms and feet lasting for 30 seconds with normal BP and oxygen saturation and these episodes were present in the first 36 h of admission. At all times cyanosis recovered without any intervention. Arterial and venous color Doppler of the limbs and echocardiography were normal. Her blood culture was sterile and smear for malarial parasites and Widal test were negative. After 72 hours her tachypnea settled with normal respiration, platelets improved and she was discharged.

  Discussion Top

Our case was diagnosed as dengue compensated shock in view of flushing and puffiness in an acutely febrile child. The inexperienced clinician may record a normal systolic pressure and misjudge the critical state of the patient condition. [8] Our child had 5 intermittent episodes of cyanosis of palms and feet for 30 seconds with normal BP and oxygen saturation in the first 36 h of admission. In a study by Kabra et al., 16.7% of children had left ventricular dysfunction by echocardiography. [9] The mechanisms of cardiac dysfunction are not well-known but alternation of autonomic tone and prolonged hypotension may play a role. [10] The old WHO classification and the latest WHO handbook of 2012 for clinical management of Dengue, including Dengue bulletin of 2012 do not mention flushing, cyanosis or puffiness as a criteria for diagnosing DF. [11],[12] However The Philippine Pediatric Society has included flushing as one of the diagnostic criteria of DF. [4],[13] Thrombocytopenia cannot differentiate clearly between DF and DHF. Platelets of ≤100,000/mm 3 are neither specific to DHF nor essential for the diagnosis. In fact bleeding and thrombocytopenia are also absent in some children with "true" DHF. [14] Deen et al. observed that not only bleeding and thrombocytopenia are common in children without apparent DHF, but these features are also absent in some children with "true" DHF. [15] In our case at the time of compensated shock, her platelets were 1.18 lakhs/mm 3 . Our case could not be classified according to WHO (DF/DHF/DSS) classification in spite of presenting with shock and it belonged to severe dengue according to revised classification (comprised of two entities, dengue and severe dengue). [6] In a study by Phuong et al., 57 (18%) of 310 with shock did not fulfill all four criteria considered necessary for a diagnosis of DHF by the WHO. [14] The revised classification does not require the presence of the four criteria to determine severity and the presence of a single criterion is sufficient for defining a severe case, for example shock as in our case. [7] Difficulty encountered in WHO classification is mainly because of the emphasis on hemorrhage rather than on plasma leakage and its dependency on lab findings. [3] As plasma leakage being the main pathophysiology, patients with evidence of vascular leakage who lack other prerequisites can be easily categorized. Plasma leakage is a major component that contributed to the specificity of the case definition and correlated with interventions required in dengue cases. [3] In DENCO study, 18-40% of cases could not be classified by the WHO classification and 22% of shock cases could not fulfill all the criteria for DHF/DSS. It is striking that 28.1% of cases who were classified as DF received Category III intervention, warranting ICU transfer in the same study. They could also identify some signs and symptoms that occurred in cases 1 day before the onset of deterioration. These warning signs allowed early identification of dengue cases who were heading toward a severe dengue state and allowing clinicians to start early fluid therapy and therefore decrease the morbidity. [6] Around 13.7% dengue cases could not be classified under DF/DHF/DSS classification when compared with only 1.6% who did not fit into the revised classification in a study by Barniol et al. [3] The sensitivity and specificity for the detection of severe cases of dengue was 39.0% and 75.5% respectively according to WHO classification, whereas it was 92.1% and 78.5% respectively under revised classification, which infers that the revised classification is more sensitive than the WHO classification, but equally specific. [7] The revised classification does not require four criteria to determine the severity and presence of a single criterion is sufficient. [7] Difficulty in DF/DHF/DSS classification is mainly because the emphasis is on hemorrhage and laboratory reports, rather than on plasma leakage. Plasma leakage is correlated with intervention requirement in dengue cases. [3] Revised classification is definitely better than DF/DHF/DSS classification at detecting severe dengue and is user-friendly and facilitates timely case management. [3],[6],[7]

In summary, it is necessary to include flushing, puffiness and cyanosis in WHO criteria. Inexperienced clinicians may record a normal systolic pressure and misjudge the critical state of the patient's condition. Classifications are only guidelines, but good clinical acumen is necessary in diagnosing the critical condition of the patient and for timely institution of specific treatment.

  References Top

Basuki PS, Budiyanto, Puspitasari D, Husada D, Darmowandowo W, Ismoedijanto, et al. Application of revised dengue classification criteria as a severity marker of dengue viral infection in Indonesia. Southeast Asian J Trop Med Public Health 2010;41:1088-94.  Back to cited text no. 1
World Health Organization. Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control. 2 nd ed. Geneva: World Health Organization; 1997.  Back to cited text no. 2
Barniol J, Gaczkowski R, Barbato EV, da Cunha RV, Salgado D, Martínez E, et al. Usefulness and applicability of the revised dengue case classification by disease: Multi-centre study in 18 countries. BMC Infect Dis 2011;11:106.  Back to cited text no. 3
Balmaseda A, Hammond SN, Pérez MA, Cuadra R, Solano S, Rocha J, et al. Short report: Assessment of the World Health Organization scheme for classification of dengue severity in Nicaragua. Am J Trop Med Hyg 2005;73:1059-62.  Back to cited text no. 4
Bandyopadhyay S, Lum LC, Kroeger A. Classifying dengue: A review of the difficulties in using the WHO case classification for dengue haemorrhagic fever. Trop Med Int Health 2006;11:1238-55.  Back to cited text no. 5
Alexander N, Balmaseda A, Coelho IC, Dimaano E, Hien TT, Hung NT, et al. Multicentre prospective study on dengue classification in four South-east Asian and three Latin American countries. Trop Med Int Health 2011;16:936-48.  Back to cited text no. 6
Narvaez F, Gutierrez G, Pérez MA, Elizondo D, Nuñez A, Balmaseda A, et al. Evaluation of the traditional and revised WHO classifications of Dengue disease severity. PLoS Negl Trop Dis 2011;5:e1397.  Back to cited text no. 7
WHO. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control. A joint publication of the World Health Organization (WHO) and the Special Programme for Research and Training in Tropical Diseases (TDR). New ed. Geneva: Switzerland 2009.  Back to cited text no. 8
Kabra SK, Juneja R, Madhulika, Jain Y, Singhal T, Dar L, et al. Myocardial dysfunction in children with dengue haemorrhagic fever. Natl Med J India 1998;11:59-61.  Back to cited text no. 9
Promphan W, Sopontammarak S, Pruekprasert P, Kajornwattanakul W, Kongpattanayothin A. Dengue myocarditis. Southeast Asian J Trop Med Public Health 2004;35:611-3.  Back to cited text no. 10
World Health Organization. Handbook for Clinical Management of Dengue. Geneva. World Health Organization; 2012. p. 1-10.  Back to cited text no. 11
World Health Organization. Dengue Bulletin. Vol. 36. Regional Office for South-East Asia, New Delhi 2012.  Back to cited text no. 12
Revised Guidelines on Fluid Management of Dengue Fever and Dengue Hemorrhagic Fever. Copyright© 2013. Philippine Pediatrics Society; 2012.  Back to cited text no. 13
Phuong CX, Nhan NT, Kneen R, Thuy PT, van Thien C, Nga NT, et al. Clinical diagnosis and assessment of severity of confirmed dengue infections in Vietnamese children: Is the World Health Organization classification system helpful? Am J Trop Med Hyg 2004;70:172-9.  Back to cited text no. 14
Deen JL, Harris E, Wills B, Balmaseda A, Hammond SN, Rocha C, et al. The WHO dengue classification and case definitions: Time for a reassessment. Lancet 2006;368:170-3.  Back to cited text no. 15


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