Epigastric pain and sonographic assessment of the pancreas in dengue hemorrhagic fever.

PURPOSE: This study reports the sonographic features of the pancreas in children who have dengue hemorrhagic fever (DHF) with epigastric pain, evaluates pancreatic abnormalities as the source of this pain, and relates sonographic findings, DHF status, and serum levels of amylase and lipase. METHODS: Over 3.5 years, real-time sonographic examination of the pancreas was prospectively performed in 148 children (age range, 5 months-14 years) who had DHF with epigastric pain. The DHF diagnosis was confirmed by serologic examination and viral isolation. RESULTS: Of the 142 children included in this study, 72 had mild DHF (grade I or II) and 70 had severe DHF (grade III or IV). An enlarged pancreas was found in 41 patients (29%), 10 (14%) of whom had mild DHF and 31 (44%) of whom had severe DHF. The pancreas was hyperechoic relative to the liver in 36 patients (25%), isoechoic in 98 (69%), and hypoechoic in 8 (6%). CONCLUSIONS: The majority of patients with DHF and epigastric pain do not have an enlarged pancreas, different echogenicity of the pancreas compared with the liver, or a dilated pancreatic duct. Thus, pathologic changes of the pancreas cannot be the only cause of epigastric pain in DHF patients. Increased serum levels of amylase and lipase are commonly seen in patients with severe DHF and an enlarged pancreas.

Dengue haemorrhagic fever: ultrasound as an aid to predict the severity of the disease.

In a prospective study, the relationship between the clinical severity of dengue haemorrhagic fever (DHF) and the sonographic findings was examined. The study comprised 73 cases classified as mild (grades I-II) and 75 as severe (grades III-IV). Ultrasonography in the mild group revealed pleural effusions in 30%, ascites in 34%, gallbladder wall thickening in 32%, hepatomegaly in 49%, splenomegaly in 16%, and pancreatic enlargement in 14%. In the severe group, pleural effusions, ascites and gallbladder wall thickening were found in 95%, pararenal and perirenal fluid collections in 77%, hepatic and splenic subcapsular fluid collections in 9%, pericardial effusion in 8%, hepatomegaly in 56%, splenomegaly in 16%, and pancreatic gland enlargement in 44%. Ultrasound may be useful for early prediction of the severity of DHF in children.

Gallbladder wall thickening in dengue hemorrhagic fever: an ultrasonographic study.

This study attempts to investigate whether gallbladder wall thickening (GBWT) measured by ultrasonography can be used in children as a reliable criterion to predict the onset of severe dengue hemorrhage fever (DHF). In this prospective study, we performed ultrasound examinations focusing on the gallbladder wall and the presence of intraperitoneal free fluid in 48 mild DHF cases (grades I-II) and 48 severe cases (grades III-IV). GBWT varied between 1 mm and 8 mm with a mean of 3.77 mm +/- 2.04 mm. The mean value of DHF grades I and II (2.39 mm +/- 1.48 mm) is significantly lower than that of grades III and IV (5.14 mm +/- 1.54 mm), p < 0.001. GBWT exceeded 3 mm in only 16 of 48 (33.3%) grade I-II patients and in 45 of 48 (93.8%) grade III-IV patients. A significant positive correlation was apparent between GBWT and the severity of illness, p < 0.001. Patients with ascites have significantly thicker gallbladder walls than those without, p < 0.01. In clinically confirmed DHF cases, the sonographic finding of GBWT > 3 mm to 5 mm, with 93.8% sensitivity, can be used as a criterion indicating the need for admission and monitoring. A GBWT of > or = 5 mm, with 91.7% specificity, is useful as a criterion for identifying DHF patients at high risk of developing hypovolemic shock.

Some clinical and epidemiological observations on virologically confirmed dengue hemorrhagic fever.

This study is a part of a one year prospective study on dengue hemorrhagic fever (DHF) carried out in the Department of Pediatrics, Sumber Waras Hospital in West Jakarta. Viral isolation and serologic analysis for DHF were done by Namru-2 in Jakarta. The subjects were 151 virologically confirmed DHF Patients admitted to the Department of Pediatrics during the period of September 1987-June 1988, consisting of 82 boys and 69 girls of 6 months-15 years old. The predominant age group was 5 to 9 years, representing 49.7% subjects. Dengue virus was isolated from sera during the first 8 days of illness and in 139 (42.1%) during the first 5 days of illness. Dengue virus type 1, 2, 3 and 4 were isolated from 16.6%, 13.2%, 69.5% and 0.7% subjects, respectively. The clinical manifestations revealed no striking differences between dengue 3 and others except for thrombocytopenia and shock. High fever, hemoconcentration and thrombocytopenia on admission was observed in 30.5%, 8.6% and 8.6% of subjects, respectively. Dengue shock syndrome (DSS) were observed in 23 (15.2%) with 3 (2%) fatal cases. Dengue virus serotype 3 was observed in 20 out of 23 DSS cases (86.9%) and all fatal cases were associated with dengue type 2. This study revealed that dengue 3 is the predominant virus circulating during recent epidemics and is associated with more severe clinical manifestation and with a higher incidence rate of living area.

Treatment of Reye's syndrome at Sumber Waras Hospital.

Since 1974 we have seen 320 cases of Reye's syndrome in our department. There were 163 boys and 157 girls of a mean age of 20 months. While the number of Reye's syndrome patients admitted increased from 1979 to 1982, it has declined since 1984. Two different approaches to management were used. Prior to 1976 only simple supportive measures were given: Intravenous 10% dextrose solution and electrolytes (Darrow-glucose solution) in equal amounts at a rate of 50-100 ml/kg/day with or without dexamethasone (0.5 mg/kg/day). From 1976, in addition, measures were taken to lower the intracranial pressure by infusing mannitol 1-2 gm and glycerol 1 g/kg given at a frequency related to the severity of the illness, i.e., for grade II, the above combination was given 8 hourly, for grade III 6 hourly, and for grades IV and V 4 hourly, while for grade I only fluid and electrolytes were given. In all cases, clinical progress was closely followed. Intravenous dexamethasone was also given at a dose of 0.5 mg/kg/day. The fatality rate was 50 to 60% prior to 1976 and has fallen to around 20% at present. In contrast to reports from Western countries, we observed more convulsions, respiratory infections and gastrointestinal disorders but less vomiting and no chicken-pox.

Clinical observations on virologically confirmed fatal dengue infections in Jakarta, Indonesia.

Thirty virologically confirmed cases of dengue infection with a fatal outcome were studied clinically in Jakarta, Indonesia, from 1975 to 1978. All 4 dengue virus serotypes were isolated from fatal cases, but dengue type 3 was responsible for 21 (70%) of these isolates, compared to only 47% of isolates from all cases of dengue infection. The majority (60%) of these 30 cases were males in the 5-9-year age group. Nonspecific signs and symptoms in the fatal cases were no different from those in patients who survived dengue infection, but 70% of the patients with fatal outcome had one or more signs of encephalitis, primarily convulsions and somnolence; 3 of them developed spastic tetraparesis before death and 2 died of an illness clinically compatible with viral encephalitis. Other unexpected observations were that only 63% of the patients had classical dengue shock syndrome with haemoconcentration, thrombocytopenia and shock. A high percentage (80%) had gastrointestinal haemorrhage, and in 9 patients (30%) this was severe enough to cause shock and death. In these 9 cases, the gastrointestinal haemorrhage and haematemesis began before the onset of shock and there was no evidence of haemoconcentration or pleural effusion at any time during hospitalization. According to certain widely accepted criteria, these patients would not be diagnosed as dengue haemorrhagic fever (DHF). But as they made up nearly one-third of the confirmed fatal dengue infections in this study and had massive gastrointestinal haemorrhages with thrombocytopenia, the definition of DHF should be changed to include this type of patient. It is proposed that the disease should be more realistically classified as dengue fever with or without haemorrhage and dengue shock syndrome.

Dengue hemorrhagic fever accompanied by encephalopathy in Jakarta.

Forty one cases of dengue hemorrhagic fever, confirmed by viral isolation, accompanied by neurological signs compatible to the diagnosis of acute encephalopathy were observed in 3 University Hospitals in Jakarta during the period November 1975 to December 1977. Two of these children showed typical signs and symptoms of Reye's syndrome confirmed by liver biopsy.

Dipyridamole in the treatment of dengue haemorrhagic fever.

Clinical studies in the treatment of 54 children suffering from DHF with a combination of dipyridamole and ASA as an adjuvant of our standard therapy consisted of fluid, electrolytes, blood, plasma and plasma expanders were evaluated. Heparin was administered in cases of DIC. It appeared that dipyridamole and ASA did not change the mortality significantly, but it prevented the progress of the severity of the disease from grade I and II to grade III and IV.

Virological surveillance for dengue haemorrhagic fever in Indonesia using the mosquito inoculation technique.

A dengue haemorrhagic fever surveillance system in Indonesia, based on virological and clinical observations, is described. The system uses the mosquito inoculation technique for virus isolation and is simple, economical, and well suited for endemic areas where support and facilities are limited. The data suggest that with good cooperation between the hospital and the virology laboratory, new serotypes and possibly even new strains of virus can be identified before the onset of epidemic activity. This type of virological surveillance may make it possible to prevent major epidemics in the future.