Dengue: A growing global health threat

@#Dengue infection, one of the most devastating mosquito-borne viral diseases in humans, is now a significant problem in many countries. The disease, caused by the four dengue virus serotypes, ranges from asymptomatic infection to undifferentiated fever, dengue fever (DF), and severe dengue hemorrhagic fever (DHF) with or without shock. DHF is characterized by fever, bleeding diathesis and a tendency to develop a potentially fatal shock syndrome. Dengue infection with organ impairment mainly involves central nervous system and liver. Consistent hematological Findings include vasculopathy, coagulopathy, and thrombocytopenia. Laboratory diagnosis includes virus isolation, serology, and detection of dengue ribonucleic acid. Successful treatment, which is mainly supportive, depends on early recognition of the disease and careful monitoring for shock. A severity-based revised dengue classification for medical interventions has been developed and validated in many countries. Prevent depends primarily on control of the mosquito vector. The feasibility of a dengue vaccine is high.

D-dimer as an indicator of dengue severity.

Background: Dengue infection is a problem of global concern. The clinical spectrum of the disease varies from an acute febrile course accompanied by mild hemorrhagic manifestations with uneventful recovery to refractory shock and massive bleeding with high mortality. Several mechanisms may be involved in the pathogenesis of bleeding, namely: vasculopathy, thrombocytopenia, coagulopathy and dissiminated intravascular coagulopathy (DIC). Objective: To determine the relationship between D-dimer (DD) levels and clinical outcome in dengue patients. Method: Children with suspected dengue infection admitted to King Chulalongkorn Memorial Hospital were enrolled. D-dimer (DD) was sequentially measured during the course of illness using whole blood and a rapid semiquantitative system (SimpliRed). Diagnosis of dengue infection was confirmed by serology and WHO criteria were used for classifying dengue severity. Results: 41 dengue patients, 22 girls and 19 boys were recruited in the study. The mean age was 9.68 years. There were 12 (29.3 %) cases of dengue fever (DF) and 29 (70.7 %) cases of dengue hemorrhagic fever (DHF). DD was more significantly present in the DHF group (87 %) than in the DF group (13%) (P<0.03). The sensitivity and specificity of DD in predicting severe dengue infection (DHF) were 90% and 67 %, respectively. Sequential analysis of DD showed higher levels at all stages of dengue infection. It correlated with the disease severity. Conclusion: Semiquantitative DD assay measurements in children suffering from dengue infection significantly correlated with dengue severity.

Infective endocarditis in pediatric patients: an eighteen-year experience from King Chulalongkorn Memorial Hospital.

OBJECTIVES: To review the clinical features and outcome of the pediatric patients diagnosed with infective endocarditis (IE) at King Chulalongkorn Memorial Hospital over an 18-year period. MATERIAL AND METHOD: From January 1987 to December 2004, 57 pediatric patients; 28 females and 29 males, age ranged from 2 months to 15 years, mean of 8.64 +/- 3.82 years, classified as "definite" IE according to the Duke criteria were reviewed. RESULTS: Of the 57 patients, 42 patients (74%) had underlying congenital heart diseases, 7 patients (12%) had underlying rheumatic heart disease, 8 patients (14%) had previously normal heart. Nine patients had history of previously palliative or corrective surgery. Blood cultures were positive in 26 patients (46%). Streptococci and staphylococci were the most commonly isolated organisms. Two-dimensional echocardiography demonstrated vegetations in 56 patients (98%). The location of the vegetations was in the right heart in 30 patients (54%) and in the left heart in 26 patients (46%). Complications occurred in 28 patients (49%). Common complications included congestive heart failure, cerebral emboli, septic shock, and mycotic aneurysm. The overall mortality was 11% (6 patients). By statistical analysis, vegetations in the left heart had a higher incidence of complication than that in the right heart. The vegetation size of > or =10 mm had a significant higher incidence of embolic events. CONCLUSION: The clinical features and outcomes of the present study have a similar pattern as the earlier studies. The rates of complications and mortality are still high.

Concomitant dengue infection and Kawasaki disease in an infant: a case report and literature review.

A previously healthy 11-month-old girl presented with fever and rash for 6 days. Physical examination revealed an irritable infant with a high fever, injected conjunctivae, red cracked lips, posterior auricular lymphadenopathy, hepatomegaly, generalized erythematous maculopapular rash and petechial hemorrhage on trunk, face and extremities. Complete blood count showed atypical lymphocytosis and thrombocytopenia. Dengue infection was initially diagnosed. The persistent fever and clinical manifestations of Kawasaki disease (KD) were observed on day 8 with high erythrocyte sedimentation rate (56 mm/hr). Treatment of KD included intravenous immunoglobulin on day 9 of the illness. Desquamation of the fingers was found on day 15 of the illness. Ectasia of left coronary artery with small aneurysmal dilatation was detected by echocardiography on day 15 of the illness. Hemagglutination-inhibition test and enzyme-linked immunosorbent assay for dengue virus eventually showed a four-fold rising. According to the literature review, this is the second reported case of dengue infection concomitant with KD. The natural course of each disease may be modified and causes some difficulties in diagnosis and management.

A cost-benefit analysis of intravenous immunoglobulin treatment in children with Kawasaki disease.

To determine the long-term cost-benefit of intravenous immunoglobulin (IVIG) treatment in Children with Kawasaki Disease (KD), a model was made to compare the total cost for management of these children with and without the use of IVIG. Long-term (10-21 years) follow-up of 594 KD patients treated in the pre-IVIG era reported by Kato, et al. was used to calculate cost using previous cost studies from Chulalongkorn Hospital. Reduction of CAA from 25 per cent to 4 per cent with IVIG treatment was assumed based on previous published data. Total cost was slightly lower for the non-IVIG treatment group compared to the IVIG treatment group (33,451,129 baht vs 35,001,195 baht) for the duration of follow-up in Kato's model. Cost per effectiveness analysis showed more effectiveness in the IVIG treatment group (359,576 baht vs 383,614 baht). Net cost analysis similarly demonstrated lower costs in the IVIG treatment group (25,365,215 baht vs 33,451,129 baht). Incremental cost-effectiveness analysis demonstrated supplementary costs of 13,663 baht for one case in the reduction of coronary involvement and 387,517 baht for one life saved in the IVIG-treated group. Estimation of total costs for follow-up and treatment for healthy life (until 60 years old) was more expensive in the non-IVIG treatment than the IVIG treated group (75,482,803 baht vs 29,883,833 baht). The authors conclude that treatment of all KD cases in Thailand with IVIG is likely to result in lower cost and better outcome when compared to no treatment with the IVIG policy.

Selection of coil for transcatheter closure of small patent ductus arteriosus.

The authors reported the results in transcatheter coil occlusion of patent ductus arteriosus (PDA) less than 4 mm, based on a policy in selection of the appropriate type and number of coils for size of PDA. The authors used one 0.035 inch detachable coil, 5 mm in diameter, in PDA less than or equal to 2 mm, and two 0.035 inch detachable coils or one controlled release 0.052 inch Gianturco coil in PDA larger than 2 mm. The present study included 32 pediatric patients. There were 31 cases of successful coil implantation and 1 case failed. Of the 31 successful cases, PDA size varied from 1.4 to 4.0 mm (mean of 2.7 +/- 0.9 mm). Ten patients had a PDA size of less than or equal to 2 mm (group A), while the other 21 patients had a PDA size of larger than 2 mm (group B). In group A, 9 cases had single-detachable-coil occlusion and one case had double-detachable-coil occlusion. In group B, double-detachable-coil occlusion was performed in 17 cases and controlled release 0.052 inch coil in 4 cases. There were no cases of coil migration or other serious complications. The immediate complete occlusion rate was 58 per cent (18 of 31 cases), which rose to 97 per cent (30 of 31 cases) at the mean follow-up of 2.6 +/- 2.5 months (range from 1 day to 9 months). Transcatheter coil occlusion is an alternative to surgical closure of small PDA (less than 4 mm). Selection of type and number of coils appropriate to the size of PDA will allow safe and excellent results.

Dengue infection: a global concern.

Dengue infection, one of the most important mosquito-borne viral diseases of humans, is now a significant problem in several tropical countries. The disease, caused by the four dengue virus serotypes, ranges from asymptomatic infection, undifferentiated fever, dengue fever (DF) to severe dengue hemorrhagic fever (DHF) with or without shock. DHF is characterized by fever, bleeding diathesis and a tendency to develop a potentially fatal shock syndrome. Hematological findings include vasculopathy, coagulopathy and thrombocytopenia as the most constant findings. During the last twenty-five years, there have been increasing reports of dengue infection with unusual manifestations, mainly with cerebral and hepatic symptoms. Laboratory diagnosis includes virus isolation, serology and detection of dengue ribonucleic acid. Successful treatment, which is mainly supportive, depends on early recognition of the disease and careful monitoring for shock. Prevention depends on control of the mosquito vector. More efforts must be made to understand the pathogenesis of DHF in order to develop a safe and effective dengue vaccine.

Endocarditis and pericarditis caused by Salmonella paratyphi A: two case reports and review of the literature.

We report on two children with paratyphoid fever and rare cardiac complications (endocarditis and pericarditis) during an outbreak of Salmonella paratyphi A infection in Bangkok, Thailand, in 1996. Both of the patients had underlying congenital heart disease. Two cases in the literatures of endocarditis and five cases of pericarditis caused by Salmonella paratyphi were reviewed. These rare cardiac complications should be considered among persons who reside in an endemic area of enteric fever or during disease outbreaks, especially in children with underlying heart diseases.