Acute respiratory distress after metofluthrin insecticide ingestion in a 19-month-old girl

Metofluthrin is a volatile pyrethroid insecticide. Despite being widely used as a safe household insecticide, it could cause severe systemic symptoms. A 19-month-old girl was taken to the emergency department after ingesting 1 mL of a mosquito repellent containing metofluthrin. After the arrival, the girl developed respiratory distress, which worsened progressively despite the administration of oxygen with nebulized salbutamol and budesonide. Additionally, she underwent application of high-flow nasal cannula, and administration of activated charcoal and systemic steroids. Her dyspnea gradually improved, and she was thus discharged on day 4 with oral prednisolone. All medications were discontinued 10 days after the discharge without any complication. Respiratory distress can develop after the ingestion of even a small amount of metofluthrin. Symptomatic and adjunctive steroid therapies can be effective therapeutic options.

Factors predicting meaningful suicide attempts: multiple attempts and index methods

Purpose@#This study investigated the association of the index method, defined as the method used in the first suicide attempt (SA), with the outcome of SAs among adolescents. @*Methods@#The study analyzed medical records of 227 adolescents aged 10-18 years with clear SAs who visited the emergency department of Severance Hospital in Seoul, Korea from January 2007 through February 2021, focusing on the index methods and meaningful SAs defined as hospitalization, death or transfer to another hospital for psychiatric hospitalization. The association of the index method with the meaningful SAs was quantified using logistic regression. @*Results@#Among the 227 adolescents, 80 underwent the meaningful SAs (35.2%). The adolescents with the meaningful SA chose drug intoxication, fall, and hanging as the index methods more frequently than those without the outcome, whereas they showed a reverse pattern in cutting (P < 0.001). The association of fall or cutting with the meaningful SAs remained significant after adjustment (fall: adjusted odds ratio, 6.93 [95% confidence interval, 1.70-28.26]; cutting: 0.39 [0.17-0.91]; compared with those undergoing drug intoxication). Multiple SAs were also associated with the meaningful SA (1.76 [1.04-3.13]). @*Conclusion@#This study identifies the index method and multiple SAs as factors associated with the meaningful SA among adolescents in the emergency department. This finding may be helpful in interviewing adolescents with SAs.

Optimal Use and Need for Therapeutic Drug Monitoring of Teicoplanin in Children: A Systematic Review

Background@#Teicoplanin is a glycopeptide antimicrobial that treats serious invasive infections caused by gram-positive bacteria, such as the methicillin-resistant Staphylococcus aureus. Despite some comparable advantages, there is no guideline or clinical recommendation for teicoplanin in the pediatric population, unlike vancomycin where abundant studies and the recently revised guideline on therapeutic drug level monitoring (TDM) exist. @*Methods@#The systematic review was performed in accordance with the preferred reporting items for systematic reviews. Two authors (JSC and SHY) searched PubMed, Embase, and Cochrane Library databases using relevant terms independently. @*Results@#Fourteen studies were finally included with a total of 1,380 patients. TDM was available in 2,739 samples collected in the nine studies. Dosing regimens varied widely, and eight studies used recommended dosing regimens. Timing for measuring TDM was mostly 72–96 hours or longer after the initiation of the first dose, which was expected to be a steadystate. The majority of studies had target trough levels of 10 µg/mL or above. Three studies reported that the clinical efficacy and treatment success rate of teicoplanin was 71.4%, 87.5%, and 88%. Adverse events associated with teicoplanin use were described in six studies with a focus on renal and/or hepatic impairment. Except for one study, no significant relation was noted between the incidence of adverse events and trough concentration. @*Conclusion@#Current evidence on teicoplanin trough levels in pediatric populations is insufficient due to heterogeneity. However, target trough levels with favorable clinical efficacy are achievable by recommended dosing regimen in the majority of patients.

Delayed Influenza Treatment in Children With False-Negative Rapid Antigen Test: A Retrospective Single-Center Study in Korea 2016–2019

Background@#We aimed to examine the delay in antiviral initiation in rapid antigen test (RAT) false-negative children with influenza virus infection and to explore the clinical outcomes. We additionally conducted a medical cost-benefit analysis. @*Methods@#This single-center, retrospective study included children (aged < 10 years) with influenza-like illness (ILI), hospitalized after presenting to the emergency department during three influenza seasons (2016–2019). RAT-false-negativity was defined as RAT-negative and polymerase chain reaction-positive cases. The turnaround time to antiviral treatment (TAT) was from the time when RAT was prescribed to the time when the antiviral was administered. The medical cost analysis by scenarios was also performed. @*Results@#A total of 1,430 patients were included, 7.5% were RAT-positive (n = 107) and 2.4% were RAT-false-negative (n = 20). The median TAT of RAT-false-negative patients was 52.8 hours, significantly longer than that of 4 hours in RAT-positive patients (19.2–100.1, P< 0.001). In the multivariable analysis, TAT of ≥ 24 hours was associated with a risk of severe influenza infection and the need for mechanical ventilation (odds ratio [OR], 6.8, P = 0.009 and OR, 16.2, P = 0.033, respectively). The medical cost varied from $11.7–187.3/ILI patient. @*Conclusion@#Antiviral initiation was delayed in RAT-false-negative patients. Our findings support the guideline that children with influenza, suspected of having severe or progressive infection, should be treated immediately.

Preliminary comparison of length of stay of patients treated by 3 board-certified physicians and 1 pediatric resident in the emergency department during night shifts

Shortage of doctors in emergency departments (EDs) is a root issue in maintaining ED-based residency programs. This study describes the efficiency of emergency practice according to board certification; 3 board-certified physicians versus a pediatric resident. Of 342 children, we found no differences as per the board certification in the ED length of stay, acuity, and return visits with more frequent hospitalization by the board-certified physicians. This result suggests that with a proper residency program, both board-certified physicians and residents can make a decision on hospitalization.

Delta Neutrophil Index as an Early Marker for Distinguishing Myeloid from Childhood Acute Leukemia / 임상소아혈액종양

BACKGROUND: The accurate and early diagnosis of acute myeloid leukemia (AML) is important to choose proper treatment option depending on the risk stratification. The delta neutrophil index (DNI) is a relatively new blood marker that indicates the proportion of immature granulocytes in peripheral blood circulation. This study aimed to evaluate the diagnostic value of the DNI for detecting AML in the early phase of acute leukemia. METHODS: We retrospectively analyzed laboratory tests and bone marrow study results of 163 pediatric patients with acute leukemia admitted to the emergency department, who were diagnosed with acute leukemia. An automatic analyzer (ADVIA 2120 Hematology System; Siemens Healthcare Diagnostics, Forchheim, Germany) was used to measure the DNI in the peripheral blood of each patient. RESULTS: The mean DNI was significantly different between the AML (N=39) and non-AML (N=124) groups (P < 0.05), and the DNI was the only significant marker for predicting AML in patients with acute leukemia (odds ratio, 1.328; P < 0.05). The DNI more than 4.4% has the highest predictability for distinguishing the patients with AML from the patients with acute leukemia. The mean DNI of the acute promyelocytic leukemia (APL, N=8) group was statistically higher than that of the non-APL group (N=31, P=0.019), but the DNI was not significant in the univariate logistic regression analysis. CONCLUSION: The DNI might be a promising peripheral blood marker for predicting AML in the early work-up of patients with acute leukemia.

A 4-year-old girl presenting with facial palsy, found to have increased delta neutrophil index, and diagnosed with acute myeloid leukemia with extramedullary infiltration

Although Bell's palsy is the most common cause of facial palsy in children, some cases have potentially fatal causes. We report a rare case of isolated facial palsy in a 4-year-old girl whose diagnosis was acute myeloid leukemia with extramedullary infiltration. The findings of laboratory investigations were nonspecific at presentation except that the delta neutrophil index was 34.5% (reference range, 0%–5%). To avoid hasty diagnosis of Bell's palsy in children with isolated facial palsy, vigilant differential diagnosis and workup are recommended.

Usefulness of the RESP, PRESERVE, and ECMOnet scores for extracorporeal membrane oxygenation in children with acute respiratory distress syndrome

PURPOSE: With increasing use of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) in children, development of standardized strategies for survival prediction has become crucial; however, this has not been accomplished yet. We evaluated the adult scoring systems for survival prediction used for their applicability in pediatric ARDS and validated them. METHODS: A total of 11 children with ARDS receiving ECMO from 2013 to 2014 were evaluated with adult scoring systems, including the Respiratory Extracorporeal-membrane-oxygenation Survival Prediction (RESP), the PRedicting dEath for SEvere ARDS on VV-ECMO (PRESERVE), and the ECMOnet scores. We compared the scores on these scales and the clinical characteristics between survivors and nonsurvivors. RESULTS: Eight of the 11 children died (72.7%). The PRESERVE score (survivors vs. nonsurvivors: 2 vs. 5.25, P=0.048), and the ECMOnet score (4.1 vs. 5.63, P=0.048) were lower in survivors than in nonsurvivors. They correctly predicted mortality prediction. There was no significant difference in the RESP score between survivors and non-survivors (−4.33 vs. −2.62, P=0.63). The parameters that showed significant differences in this study were peak inspiratory pressure, platelet, and delta neutrophil index. All children who were under immunocompromised conditions, such as those with tumors, or underwent hematopoietic stem cell transplantation died. The immunocompromised status should be considered an important factor for survival prediction in children with ARDS. CONCLUSION: This is the first pilot study to apply the survival prediction scoring system to pediatric ARDS with ECMO. It is necessary to establish and modify the survival prediction score system for pediatric ARDS with ECMO.

Reappraisal of the Immunogenicity and Safety of Three Hepatitis A Vaccines in Adolescents

Although the overall incidence of hepatitis A in Korea has been decreasing, adolescents remain highly vulnerable to its outbreaks. This study was conducted to compare the immunogenicity and safety of three hepatitis A vaccines in Korean adolescents. Healthy anti-hepatitis A virus seronegative subjects aged 13 to 19 yr were randomized in three equal groups to receive two doses of Avaxim(TM), Epaxal(R), or Havrix(R), 6 to 12 months apart. Seroconversion rates one month after the first dose were 98%, 95%, and 93% for Avaxim(TM), Epaxal(R), and Havrix(R), respectively. Seroconversion rates reached 100% for all vaccine groups one month after the second dose. Anti-HAV geometric mean concentrations (GMCs) were 7,207.7 mIU/mL (95% CI, 6023.1-8684.7), 1,750.5 mIU/mL (95% CI, 1362.9-2248.3), and 1,953.5 mIU/mL (95% CI, 1459.4-2614.7) after two doses of Avaxim(TM), Epaxal(R), and Havrix(R) respectively. Avaxim(TM) was significantly more immunogenic than Epaxal(R) and Havrix(R), whereas there were no significant differences in antibody responses between Epaxal(R) and Havrix(R). Local and systemic solicited adverse events (AEs) were mostly of mild-to-moderate intensity and resolved within 5 days. No serious AEs were reported. In conclusion, all three vaccines are highly immunogenic and well-tolerated in Korean adolescents. (Clinical Trial Registry NCT00483470)

Application of the Berlin definition in children with acute respiratory distress syndrome

PURPOSE: The revised Berlin definition (BD) showed better predictive validity for mortality in adults with acute respiratory distress syndrome (ARDS). We examined the validity of BD for pediatric ARDS as compared to the American-European Consensus Conference definition (AECCD). METHODS: This single-center, retrospective study included 127 patients aged 1 month to 19 years who were admitted to the medical intensive care unit due to acute lung injury (ALI, n=31) or ARDS (n=96) using the AECCD. All patient characteristics and mortality rates were compared between the individual severity groups according to the BD and AECCD. RESULTS: Sixty-four patients (50%) died. Mortality rates increased across the severity groups according to both definitions (26% in mild, 42% in moderate, and 75% in severe by the BD [P<0.001]; 26% in ALI non-ARDS and 58% in ARDS by the AECCD [P=0.002]). The mortality risk increased only for 'severe ARDS' (hazard radio for mortality, 2.56; 95% confidence intervals [CI], 1.14-5.78; P=0.023) after adjusting for confounding factors. The BD better predicted mortality, with an integrated area under the receiver operating characteristic curve (iAUC) of 0.651 (95% CI, 0.571-0.725), than the AECCD, with an iAUC of 0.584 (95% CI, 0.523-0.637). The pediatric risk of mortality (PRISM) III and pediatric index of mortality 3 scores were significantly different across BD severity groups, whereas only PRISM III scores were different according to the AECCD. CONCLUSION: The BD applied to children with ARDS. It could be adopted to severity classifications and predict pediatric ARDS mortality better than the AECCD.

Extracorporeal membrane oxygenation treatment in peanut aspiration with complications

Foreign body aspiration commonly occurs, especially among children younger than 3 years of age. Most endobronchial foreign bodies may be easily removed by bronchoscopy and have a good prognosis. Despite advances in bronchoscopic procedures, difficulties in management of and complications from foreign body aspiration are still noted. We present a foreign body aspiration case with acute respiratory distress syndrome caused aspiration pneumonia, which was successfully treated by bronchoscopy under extracorporeal membrane oxygenation (ECMO). ECMO can be an effective and potentially life-saving method in complicated foreign body aspiration with uncompensated respiratory failure.

Delta Neutrophil Index as a Prognostic Marker in the Pediatric Intensive Care Unit / 대한중환자의학회지

BACKGROUND: The delta neutrophil index (DNI) is a useful marker for diagnosing and predicting the prognosis of sepsis. The purpose of this study was to investigate the usefulness of DNI as a prognostic marker in patients within the pediatric intensive care unit (PICU), as well as its association with other prognostic factors. METHODS: A total of 516 children admitted to Severance Children's Hospital PICU from December 2009 to February 2015 were analyzed. DNI was measured on the day of PICU admission. Mortality was defined as death within 28 days following PICU admission. RESULTS: The median value of DNI was 1.2% (interquartile range [IQR] 0-4.3%) in the survivor group and 9.5% (IQR 2.3-20.8%) in the non-survivor group, and the difference was statistically significant (p < 0.001). DNI was significantly positively correlated with ICU scores such as Pediatric Index of Mortality 3 and Pediatric Risk of Mortality III, as well as with C-reactive protein and lactate levels. The area under the receiver operating characteristic curve of DNI for mortality was 0.748 (95% CI: 0.687-0.808) and the cut-off value was 4.95%. CONCLUSIONS: The initial DNI level can be considered a useful indicator for predicting prognosis in PICU patients.

Association between the serum 25-hydroxyvitamin D level and allergic rhinitis in Korean children

PURPOSE: Vitamin D is known to play an important role in the regulation of the immune system and in the prevention of allergic disease. Herein, we examined the association between vitamin D and allergic rhinitis (AR) in children. METHODS: A total of 72 aeroallergen-proven AR and 57 healthy control subjects who visited Severance Children's Hospital between 2012 and 2014 were evaluated. The mean serum 25-hydroxyvitamin D (25(OH)D) level was measured in all subjects to evaluate their vitamin D status. RESULTS: The mean serum 25(OH)D levels was significantly lower in patients with AR than in controls (19.5±6.4 ng/mL vs. 22.3±5.8 ng/mL, P=0.013). The incidence of AR is higher in the 25(OH)D-insufficient group (15–20 ng/mL) and in the 25(OH)D-deficient group (≤15 ng/mL) compared with the 25(OH)D-sufficient group (>20 ng/mL) (40.3% vs. 84.4% vs. 22.2%, P<0.001). There was no significant difference in the serum 25(OH)D level between subgroups with mild and moderate-to-severe AR symptoms (19.8±6.5 vs. 19.0±6.3, P=0.596). After adjusting for confounding factors, the lower serum vitamin D level groups had increased odds of AR compared with the 25(OH)D-sufficient group (odds ration [95% confidence interval]; 3.67 [1.29–10.38] in the 25(OH)D-insufficient group; P=0.014 and 6.04 [1.49–24.51] in the 25(OH)D-deficient group; P=0.012). CONCLUSION: The serum vitamin D levels were significantly lower in children with AR compared with healthy controls. Therefore, lower serum level of 25(OH)D may be associated with the development of AR.

High-Sensitivity C-Reactive Protein Can Reflect Small Airway Obstruction in Childhood Asthma

PURPOSE: High-sensitivity assays enabled the identification of C-reactive protein (hs-CRP) at levels that were previously undetectable. We aimed to determine if hs-CRP could reflect airway inflammation in children, by comparing hs-CRP with spirometry and impulse oscillometry (IOS) parameters and symptomatic severities. MATERIALS AND METHODS: A total of 276 asthmatic children who visited Severance Children's Hospital from 2012-2014 were enrolled. Serum hs-CRP and pulmonary function tests were performed on the same day. Patients were divided into hs-CRP positive and negative groups (cut-off value, 3.0 mg/L). RESULTS: Of the 276 asthmatic children [median age 7.5 (5.9/10.1) years, 171 boys (62%)], 39 were hs-CRP positive and 237 were negative. Regarding spirometry parameters, we observed significant differences in maximum mid-expiratory flow, % predicted (FEF25-75) (p=0.010) between hs-CRP positive and negative groups, and a negative correlation between FEF25-75 and hs-CRP. There were significant differences in the reactance area (AX) (p=0.046), difference between resistance at 5 Hz and 20 Hz (R5-R20) (p=0.027), resistance at 5 Hz, % predicted (R5) (p=0.027), and reactance at 5 Hz, % predicted (X5) (p=0.041) between hs-CRP positive and negative groups. There were significant positive correlations between hs-CRP and R5 (r=0.163, p=0.008), and X5 (r=0.164, p=0.007). Spirometry and IOS parameters had more relevance in patients with higher blood neutrophil levels in comparison to hs-CRP. CONCLUSION: Hs-CRP showed significant correlation with FEF25-75, R5, and X5. It can reflect small airway obstruction in childhood asthma, and it is more prominent in neutrophil dominant inflammation.

Delta Neutrophil Index as a Prognostic Marker in the Pediatric Intensive Care Unit / 대한구급학회지

BACKGROUND: The delta neutrophil index (DNI) is a useful marker for diagnosing and predicting the prognosis of sepsis. The purpose of this study was to investigate the usefulness of DNI as a prognostic marker in patients within the pediatric intensive care unit (PICU), as well as its association with other prognostic factors. METHODS: A total of 516 children admitted to Severance Children's Hospital PICU from December 2009 to February 2015 were analyzed. DNI was measured on the day of PICU admission. Mortality was defined as death within 28 days following PICU admission. RESULTS: The median value of DNI was 1.2% (interquartile range [IQR] 0-4.3%) in the survivor group and 9.5% (IQR 2.3-20.8%) in the non-survivor group, and the difference was statistically significant (p < 0.001). DNI was significantly positively correlated with ICU scores such as Pediatric Index of Mortality 3 and Pediatric Risk of Mortality III, as well as with C-reactive protein and lactate levels. The area under the receiver operating characteristic curve of DNI for mortality was 0.748 (95% CI: 0.687-0.808) and the cut-off value was 4.95%. CONCLUSIONS: The initial DNI level can be considered a useful indicator for predicting prognosis in PICU patients.

Life-threatening human metapneumovirus pneumonia requiring extracorporeal membrane oxygenation in a 26-month-old child

We present the first case report of a child with human metapneumovirus (hMPV) pneumonia who survived by extracorporeal membrane oxygenation (ECMO) in Korea. A 26-month-old boy with a previous history of Lennox-Gastaut syndrome and delayed development suffered from respiratory failure after 4 days of fever, cough, and sputum. The boy underwent intubation and required ECMO application due to failure of conventional mechanical ventilation. He was on the ECMO support for 7 days. To our knowledge, this is the shortest period reported for ECMO application among successfully treated patients with hMPV infection accompanied by acute respiratory distress syndrome. This case highlights 2 clinical implications: the potentially fatal causative role of hMPV in respiratory failure in a pediatric population and the timely utilization of ECMO.

Molecular Diagnosis of Streptococcus pneumoniae in Middle Ear Fluids from Children with Otitis Media with Effusion

PURPOSE: The long-term administration of antibiotics interferes with bacterial culture in the middle ear fluids (MEFs) of young children with otitis media with effusion (OME). The purpose of this study is to determine whether molecular diagnostics can be used for rapid and direct detection of the bacterial pathogen in culture-negative MEFs. METHODS: The specificity and sensitivity of both polymerase chain reaction (PCR) and loop-mediated isothermal amplification (LAMP) to the lytA gene of Streptococcus pneumoniae were comparatively tested and then applied for pneumococcal detection in the clinical MEFs. RESULTS: The detection limit of the PCR assay was approximately 10(4) colony forming units (CFU), whereas that of LAMP was less than 10 CFU for the detection of S. pneumoniae. Both PCR and LAMP did not amplify nucleic acid at over 10(6) CFU of H. influenzae or M. catarrhalis, both of which were irrelevant bacterial species. Of 22 culture-negative MEFs from children with OME, LAMP positivity was found in twelve MEFs (54.5%, 12/22), only three of which were PCR-positive (25%, 3/12). Our results showed that the ability of LAMP to detect pneumococcal DNA is over four times higher than that of PCR (P<0.01). CONCLUSIONS: As a high-resolution tool able to detect nucleic acid levels equivalent to <10 CFU of S. pneumoniae in MEFs without any cross-reaction with other pathogens, lytA-specific LAMP may be applied for diagnosing pneumococcus infection in OME as well as evaluating the impact of a pneumococcal conjugate vaccine against OME.

Public Acceptance and Willingness to Hepatitis A Vaccination in Children Aged 7-18 Years in Republic of Korea

Hepatitis A can cause serious illness among adolescents and adults with low vaccination coverage. Even though hepatitis A vaccine is one of the strong candidates for Korean national immunization program, adolescents aged older than 12 yr would not benefit. Our purpose was to assess the willingness and analyze the correlates of Korean mothers for hepatitis A (HepA) vaccination to develop strategies for HepA vaccination. A national telephone survey on 800 mothers with children aged 7-18 yr was conducted with random-digit dialing method. Sixty-two percent and 92% of the mothers reported that they were willing to HepA vaccination at current cost and at half of the current cost, respectively. However, at current cost, only 79% wished to vaccinate their child in an epidemic and 32% wished to vaccinate promptly. Having two or more children, not having future plans to send the child overseas, and low family income were significantly associated with not willing to HepA vaccination. Low perception of the susceptibility for hepatitis A and perception of the current cost as barrier increased the odds of unwillingness to vaccination at current cost and to prompt vaccination. The mothers' willingness to HepA vaccination for the children aged 7-18 yr in Korea was not very high at current cost and associated socioeconomic status and health-belief. Targeted intervention or strategies are needed to increase the HepA vaccination rate among children in Korea.

Adolescents' and Parental Knowledge, Health Beliefs Toward Hepatitis A Vaccination / 소아감염

PURPOSE: Although the overall incidence of hepatitis A in Korea has been decreasing recently, the adolescents born before the introduction of the hepatitis A vaccine remain to be highly vulnerable to outbreak. This study examines the unvaccinated adolescents' and their parents' knowledge and health beliefs toward hepatitis A vaccination. METHODS: Healthy adolescents aged 13-19 years old who had no previous history of hepatitis A vaccine and hepatitis A infection, and their parents or legal guardians were the subjects of the study. The survey was conducted using a structured questionnaire based on the Health Belief Model, and examined the subjects' demographics, knowledge, and health beliefs (i.e., perceived susceptibility, severity, benefits, and barriers). RESULTS: We included 157 adolescents and their parents/guardians (mean age: 16.0+/-1.6 and 45.6+/-4.7 years, respectively). The average knowledge item score for adolescents and parents was 6.4+/-3.7 and 7.3+/-3.4 (out of 18), respectively. Similarly, average Health Belief Model item scores were: susceptibility, 5.6+/-1.6 and 5.9+/-1.7 (range: 2-10); severity, 16.3+/-4.1 and 18.3+/-3.6 (range:5-25); benefits, 19.7+/-3.3 and 20.6+/-2.1 (range:5-25); and barriers, 41.3+/-8.9 and 39.0+/-9.1 (range:7-85). The major reason for not undergoing hepatitis A vaccination was lack of knowledge about its importance. CONCLUSIONS: Refresher health lectures about hepatitis A and the vaccine are needed by both the adolescents and their parents. Furthermore, the inclusion of hepatitis A vaccine in the national immunization program should be considered to reduce the risk of hepatitis A outbreak and to raise the vaccination coverage among the adolescents in Korea.

Two Cases of Dengue Fever Due to Dengue Virus-1 Developed in a Family / 이화의대지

We report two cases of dengue fever due to DENV-1 in the family members who returned from Manila, Philippines. Case 1: A 41-year-old female visited the clinic with a general weakness. She had a fever for 5 days. When she came back to Korea, her fever had subsided. The immunoglobulin M (IgM)-capture enzyme-linked immunosorbent assay for dengue virus was positive. Case 2: A 11-year-old female was admitted to the pediatric department after reporting symptoms of fever and abdominal pain upon returning from the Philippines. The RT-PCR result for DENV-1 was positive in blood, but IgM came out negative. Dengue fever should be suspected for those who have returned from an endemic area with reports of febrile illness and rash, particularly if thrombocytopenia, leukopenia, elevated serum aminotransferase are present. Using RT-PCR and serological test, the precise diagnosis should be made and proper management should be given to prevent secondary complications.