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.

Neonatal dengue infection: report of dengue fever in a 1-day-old infant.

A male infant was admitted because of fever. He was born at 37-weeks' gestation. His mother had experienced acute febrile illness with headache and myalgia. Her illness persisted with onset of active labor pain on day 5, which prompted cesarean section; postoperatively, the hematocrit decreased, requiring transfusion. The infant was well until fever developed at 16 hours after birth. There were petichiae on his face and trunk and the liver was enlarged. Fever subsided on day 5 without evidence of plasma leakage or severe hemorrhage. He made an uneventful recovery after 8 days of illness. Leukopenia and thrombocytopenia were present in the mother and infant. Both were diagnosed as dengue fever. Dengue type 1 was recovered from the infant by polymerase chain reaction. The dengue enzyme-linked immunoassay showed secondary infection in the mother and primary infection in the infant. In dengue-endemic areas, clinicians should be alert to dengue fever/dengue hemorrhagic fever in pregnant women presenting with acute febrile illness, and be prepared for proper management.

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.

Clinical features of diphtheria in thai children: a historic perspective.

To study the clinical and laboratory features of childhood diphtheria, the cases of 381 children with clinical and bacteriological diagnoses of diphtheria who were treated at the Children's Hospital between 1976 and 1985 were reviewed. Of these, 191 were males and 190 were females. The mean age was 4.6 years. Approximately 75% of the patients had no history of immunization. Common manifestations of diphtheria included patch (100%), fever (92.4%), upper respiratory tract infection (91.6%), upper airway obstruction (42.3%), hoarseness (36.7%), and bull neck (11.3%). The mean duration of fever prior to admission was 3.3 days with a range of 0-11 days. Patch sites included the tonsils (91.9%), the pharynx (55.9%), the larynx (27.8%) and others (24.4%). Complications included upper airway obstruction (42.3%), cardiac complications (10.0%) and neurological complications (4.7%). The mortality rate was 5.8%. There were significant associations between death and the presence of bull neck, laryngeal patch, airway obstruction and cardiac complications. Early recognition and prompt treatment will decrease complications and mortality in this group of patients.