Choice of colloidal solutions in dengue hemorrhagic fever patients.

BACKGROUND: DHF is characterized by plasma leakage and abnormal hemostasis. About 20% of DHF patients do require colloidal solution in addition to conventional crystalloid solution for the treatment. There is only one colloidal solution, 10% Dextran-40 in NSS that proved to be effective for this group of DHF patients. OBJECTIVE: To compare 10% dextran-40 in NSS with 10% Haes-steril in NSS in the management of DHF cases with severe plasma leakage for their effectiveness and impact on renal function, hemostasis, disease severity, and complications. MATERIAL AND METHOD: DHF patients admitted to Dengue Unit, QSNICH, who do not respond to conventional crystalloid solution, are randomly assigned to receive either dextran or haes-steril. Clinical and laboratory comparison are recorded and analyzed using SPSS for Window version 14.0. RESULTS: There are 104 DHF patients enrolled in the study; 57 are assigned in dextran and 47 in haes-steril group. The mean ages are 8.6 +/- 3.9 years. About half of the patients in both groups require one dose of colloidal solution and 25% require 2 and 3 doses (p = 0.138). The average amount of IV fluid infused in dextran and haes-steril group are 119.4 and 129.3 ml (p = 0.227). The average drop in Hct after the bolus dose of both colloid are 7.9 and 8.5% (p = 0.381). About 80% of the patients in each group have shock (p = 0.843). The mean elevation of AST are 598 and 822 U (p = 0.548) while ALT elevation are 182 and 306 U (p = 0.265) in dextran and haes-steril group, respectively. BUN and creatinine are within normal limits and are decreased after the use of colloidal solutions. The amount of urine on day 1, 2 and 3 after the use of both colloidal solutions are not different. Coagulogram studies (PT, PTT and TT) in both groups are not different. Patients with significant bleeding and who require blood transfusions are 15.8 and 19.2% in dextran and haes-steril group (p = 0.423).The incidence of fluid overload in dextran and haes-steril group are 35.1 and 40.4% (p = 0.360). Other complications are not different between dextran and haes-steril group as follows: hypocalcaemia, hyponatremia, hypokalemia and acidosis. The overall severity and complications in both groups of patients are much higher than in DHF patients who respond to conventional crystalloid solution. No allergic reaction was found after the use of both colloidal solutions. CONCLUSION: 10% Haes-steril is as effective as 10% dextran-40 in the treatment of DHF patients who have severe plasma leakage. There are no differences in DHF disease severity and complications in both groups but the disease severity and complications, especially fluid overload are observed to be more comparative with admitted DHF patients. Both colloidal solutions are safe in DHF patients with no allergic reaction observed and no interference in renal functions and hemostasis.

Relationship between body size and severity of dengue hemorrhagic fever among children aged 0-14 years.

A hospital based case-control study was conducted from October 2002 to November 2003 among children aged 0-14 years at Queen Sirikit National Institute of Child Health (Children's Hospital), Bangkok, Thailand. This study focused on body size and severity of dengue hemorrhagic fever (DHF) in children. One hundred five patients diagnosed as having DHF grade III or IV were the cases and 105 diagnosed as having DHF grade I or II were controls. They were matched at a ratio of 1:1 by their gender and age (within 5 years). Normal growth charts were used to differentiate child body size into normal, thin and obese. Data were collected using face to face interviews with caregivers, questionnaires, laboratory and physical examination reports as research tools. Multiple logistic regression analysis revealed that only two variables were related to severity of DHF: obesity (OR = 3.00, 95 % CI = 1.20-7.48) and dengue virus type II (OR = 4.94, 95 % CI = 2.57-9.47), respectively. Other variables were childhood factors: duration of breast-feeding, education, and parity; caregivers factors: age, gender, marital status, education, occupation, family income, knowledge of DHF, antipyretic type, treatment before hospitalization, and duration of fever; environmental factors: history of DHF patients in house, house pattern, time from house to hospital, and residence; and etiological factors: type of infection and history of DHF among children. These factors showed no significant association (p > 0.05). This result can be utilized in a preventive and control program, particularly in more aggressive management of overweight children. Health personnel should continue to provide health education, particularly, signs and symptoms of shock, to the community and private sectors. Government and Non-Government Protective Projects in primary schools (5-9 years children) should be continued in the high risk groups.

Genetic variations and relationship among dengue virus type 3 strains isolated from patients with mild or severe form of dengue disease in Indonesia and Thailand.

Sequence analysis was conducted on structural and non-structural genes of 7 strains of dengue virus type-3 (DENV-3 virus) isolated in Indonesia and Thailand in the year 1973, 1994, and 1998 from patients with different clinical manifestations. In general, sequence similarity among isolates was greater than 93%, indicating that the mutation rate of DENV-3 circulating in this region was not more than 7% in the last 3 decades and suggesting that sequences that may responsible for viral architectures and/or biological function were strictly conserved. Mutations unique to viral strains associated with specific clinical manifestations were not found. Alignment of PrM/M and E nucleic acid sequences followed by parsimony analysis of sequences obtained in this study and published elsewhere allowed generation of phylogenetic trees, demonstrating that DENV-3 strains isolated in Indonesia in 1998 belonged to a separate cluster (subtype 2) from those isolated between 1973-1985 (subtype 1).

Is dengue severity related to nutritional status?

A retrospective review of dengue patients admitted to Queen Sirikit National Institute of Child Health (previously known as Children's Hospital) from 1995 to 1999 revealed 4,532 confirmed cases of dengue infection; 80.9% were dengue hemorrhagic fever (DHF) and 19.1% were dengue fever cases (DF). Among the DHF patients; 30.6% had shock. The majority of them, 66.6%, had a normal nutritional status, while 9.3% were malnourished and 24.2% had obesity as classified by weight for age. Compared with control patients with other diagnoses (excluding HIV/AIDS patients), malnourished children had a lower risk of contracting dengue infection (odds ratio = 0.48, 95% Cl = 0.39-0.60, p = 0.000) while obese children had a greater risk of infection with dengue viruses (odds ratio = 1.96, 95% Cl = 1.55-2.5, p = 0.000). The clinical signs, symptoms and laboratory findings of dengue were almost the same among the 3 groups of malnourished, normal, and obese patients. The minor differences observed were that in obese children liver enlargement was found less often; maculopapular/convalescence rash and elevations of alanine aminotransferase were found more often. Malnourished patients had a higher risk of developing shock (37.8%) than normal (29.9%) and obese patients (30.2%) (p = 0.000). Obese patients had more unusual presentations: encephalopathy (1.3%) and associated infections (4.8%), than normal (0.5% and 2.7%) and malnourished patients (1.2% and 3.1%). Complications of fluid overload were found more in obese patients (6.5%) compared to normal (3.2%) and malnourished patients (2.1%) (p = 0.000). The case-fatality rates (CFR) in malnourished patients and obese patients were 0.5% and 0.4%, respectively, while in normal patients the CFR was 0.07%. Under and over nutrition DHF patients had either a greater risk of shock or unusual presentations and complications, which can lead to severe disease or complications and probably a higher CFR.

Severity of measles: a study at the Queen Sirikit National Institute of Child Health.

INTRODUCTION: Thousands of measles cases are reported annually in Thailand even though measles vaccine has been introduced in the expanded program of immunization for every 9-month-old infant for nearly 20 years. Severe cases are admitted to the hospital, usually with complications, some cases lead to death. OBJECTIVES: To study the clinical presentations of severe cases of measles and its complications and find the correlations of severity of pneumonia with age, nutritional status and history of vaccination. MATERIAL AND METHOD: The hospital charts of measles patients admitted to the Queen Sirikit National Institute of Child Health (QSNICH) during 1998-2002 were retrospectively reviewed. Demographic data, history including history of measles vaccination, physical examinations, laboratory investigations, treatment and hospital course which were relevant were recorded. Paired t-test and Pearson's correlation were used for data analysis. RESULTS: There were 156 cases of measles admitted to the QSNICH. There were 95 boys and 61 girls and the male to female ratio was 1.56:1. The age range was 2 months to 14.8 years, median = 1.5 years, mode 8 months. Fifty-nine percent of the cases were under 2 years of age; 40% under one year and 23.9% were under 9 months. About 44% of the cases had one dose of previous measles vaccination, no history of measles vaccination in 91.4% of cases whose age was under 1 year in contrast to 80% of cases over 5 years that had a history of measles vaccination. Sixty-six percent of the cases had normal nutritional status while 12.4%, 4.8% and 2.1% had mild, moderate and severe protein calorie malnutrition. Fourteen cases (9%) had underlying diseases. At least 3 of the classical signs and symptoms of measles (rash, cough and coryza) were found in 92.3% of the cases. The mean duration of fever at the time of admission was 5.3 days. The common complications in admitted measles cases were pneumonia (62.2%) and diarrhea (38.1%). The likely causes of pneumonitis were measles viruses (52.6%) and bacteria (47.4%). There was one dead case with severe pneumonia, with ARDS and respiratory failure. Young infants had a higher incidence of diarrhea with dehydration (p = 0.000) but severity of pneumonia was not different from older children (p = 0.512). The severity of pneumonia was not correlated with the age (r = 0.087), nutritional status (r = 0122) or the history of receiving measles vaccine (r = 0.116). CONCLUSION: Measles is one of the important diseases of in-patients admitted to the QSNICH, because of the severity of the diseases due to pneumonia and diarrhea. One severe case died because of severe pneumonia that lead to ARDS and respiratory failure. Young infants had a higher incidence of diarrhea and dehydration, while there was no correlation between severe pneumonia with age, nutritional status and history of vaccination.

Antibody response after measles immunization.

RATIONALE: Measles is still an important public health problem in Thailand despite measles vaccination being practiced since 1984. Vaccine failure is one of the suspected reasons for the high incidence of measles. OBJECTIVE: To study the seroconversion rate of 9-month-old infants and to study the antibody level in 18 month-old and 4 year-old children who had measles vaccination at 9 months of age. MATERIAL AND METHOD: Enrolled infants and children who attended the child health clinic for routine immunization at the Queen Sirikit National Institute of Child Health from March 1, 1994 to May 31, 1995. They were divided into 3 groups. Group A, 9 month-old infants who came for measles vaccination. Blood samples were drawn twice from these infants, before measles vaccination and 3 months later for measles antibody level. Group B and C were 18 month-old and 4-year-old children who came for their first and second DTP (Diphtheria, Tetanus, Pertussis vaccine) booster. One blood sample for measles antibody was drawn from the latter group of children. Measles antibody was determined by micro-neutralization technic at the National Institute of Health (NIH). The geometric mean antibody titer before and after measles vaccination was compared by using the paired t-test. RESULTS: There were 30, 31 and 34 infants/children in group A, B and C respectively. No significant measles antibody (NT antibody was less than 1:4) was detected in 93.5 per cent of 9-month-old infants. The seroconversion rate at 3 months after vaccination in group A children was 68.75 per cent while in group B, 9 months after vaccination it was 53.3 per cent. Ninety seven per cent of children in group C had NT antibody above 1:4. The geometric mean titer (GMT) of measles antibody in 9-month (before vaccination), 12-month, 18-month infants and 4 year old children was 1:2.5; 1:14.8, 1:8.2 and 1:73.8, respectively (p < 0.05). CONCLUSION: Almost 70 per cent of vaccinees at 9 months of age had seroconversion to measles vaccine with GMT of 1:14.8 while fifty three per cent of 18 month old children had an average GMT of 1:8.2. The GMT of the two groups was significantly different (p < 0.05). At 4 years of age almost all the children had NT antibody to measles with a GMT of 1:73.8 (p < 0.05) Vaccine failure is likely to be one factor responsible for the high incidence of measles after the introduction of measles vaccine into the Expanded Program of Immunization (EPI). The authors suggest giving a booster dose of measles at 15 months of age to boost the antibody level before waning of measles antibody at 18 months old, in order to protect this group of children from contracting measles.

Vertical transmission of dengue infection in Thai infants: two case reports.

Dengue infection is hyperendemic in tropical countries especially in Thailand. Most dengue infections occur during childhood but some adults may remain susceptible to infection. About 30 per cent of dengue infection are reported in patients > 15 years old. Some pregnant women may also be susceptible to dengue and if they experience dengue infection, they can transmit the dengue viruses to their babies. The authors report two babies who developed mild dengue illness, dengue hemorrhagic fever (DHF) grade II, beginning on their 6th day of life. Both of them had low grade fever, hepatomegaly and generalized petechial rash. The first baby had Hct ranging from 46 to 40 per cent with minimal right pleural effusion. The lowest platelet count was 19,000 cells/mm3. His mother had dengue shock syndrome with masssive post partum bleeding. The second baby had dengue 2 infection while his mother had dengue fever. His Hct had also risen from 52 per cent to 61 per cent with right pleural effusion. His lowest platelet count was 7,000 cells/mm3. Both mothers and their babies had a complete recovery although the first baby had prolonged thrombocytopenia for two months.

Clinical presentations of dengue hemorrhagic fever in infants compared to children.

BACKGROUND: Dengue infections are endemic in Thailand. Infants are at risk of developing dengue fever (DF) and dengue hemorrhagic fever (DHF). Many infants have severe DHF with unusual manifestations and may suffer from complications and even death because of difficulties in early diagnosis and improper management. OBJECTIVE: To study the incidence of infants DHF and to compare clinical and laboratory findings of DHF between infants and children in order to improve diagnosis and management of infants with DHF. MATERIAL AND METHOD: A retrospective review of hospital charts of DHF patients who were admitted to the Children's Hospital between 1995-1999 was carried out. Only confirmed DHF cases, either by serologic or virologic studies were included. Clinical and laboratory findings were compared using the standard software package SPSS. RESULTS: There were 4,595 confirmed dengue patients admitted to the Children's Hospital during this 5-year period and among these 245 infants were under one year old (5.3%). Unusual presentations of DHF including upper respiratory tract infection (URI) symptoms, diarrhea, convulsions and encephalopathy were found more in the infants (4.5%, 13.1%, 12.7% and 4.1%) than in the children (1.7%, 2.0%, 2.0% and 0.6%) but shock was found less in the infants (25%) than in the children (30.9%). The percentages of Tourniquet test positive and low WBC (< or = 5,000 cells/mm3) which help in the early diagnosis of dengue were less in the infants (50.2% and 26.8%) than in the children (92.2% and 71.9%). Liver involvement and/or dysfunction were found more in the infants as shown by mean aspartate aminotransferase/alanine aminotransferase (AST/ALT) elevation and prolonged prothrombin time. Duration of i.v. fluid was shorter in the infants than in the children (21.9 vs 38.2 hours). Complications of fluid overload were found more often in the infants than in the children (9% vs 3.6%). The case fatality rate was 1.2 in the infants and 0.3 in the children. CONCLUSION: Management of infants with DHF is critical because early diagnosis is rather difficult and they sometimes present with unusual manifestations (convulsions, encephalopathy and associated infections). Complications such as hepatic dysfunction and fluid overload are more commonly found in infants than in children and adults and also the case fatality rate is higher. Judicious i.v. fluid resuscitation and replacement is critical to the outcome of infants with DHF. It seems that the degree of plasma leakage is less in infants and the duration of plasma leakage is shorter in infants than in children.