Envenomation by the invasive Pterois volitans species (lionfish) in the French West Indies--a two-year prospective study in Martinique.

CONTEXT: The invasion of the lionfish (Pterois volitans) in the French West Indies represents one of the most important marine invasions by alien species in history. Since its first recognition in Martinique in February 2011, the lionfish presence has strongly progressed, resulting in increasing envenomation cases. Our objective was to report features of lionfish envenomation and outcome. METHODS: A prospective study conducted at the Martinique University Hospital by the emergency departments, general practitioners, and the pre-hospital emergency ambulance service included all the patients referred from November 2011 to February 2014 for one or several stings by lionfish, as strongly suggested by the fish description and the association with marked local pain and edema. Recommended management included immersion of the affected body part in hot water at 35-40 °C for 60 min, analgesics, tetanus toxoid, and antibiotics. RESULTS: 117 patients [98M/19F; age: 42 ± 14 years [mean ± SD]; with significant past morbidities (16%)] were included. Envenomation resulted in marked pain and local edema (100%), paresthesia (90%), abdominal cramps (62%), extensive edema (53%), tachycardia (34%), skin rash (32%), gastrointestinal disorders (28%), fainting (27%), transient weakness (24%), hypertension (21%), hypotension (18%), hyperthermia (9%), bradycardia (3%), hypophosphatemia (12%), elevated aspartate aminotransferase (AST) (10%), and thrombocytopenia (3%). The sting was complicated by local infection (18%) including skin abscess (5%), cellulitis (3%), skin necrosis (3%), and septic arthritis (2%). 26 patients (22%) were hospitalized requiring surgery (8%). Lionfish stings were single (81%) or multiple (19%). Localization was preferentially at one upper (67%) or lower limb (32%). All patients actually improved. Based on multivariate analyses, pain duration > 24 h was significantly associated with skin eruption (p = 0.001) and muscle cramps (p = 0.0002). Local infectious complications occurred more frequently in patients presenting multiple stings (p = 0.008). Immersion in hot water (44%, performed less than 3 h after the sting in 36% of the cases) significantly reduced pain duration (p = 0.02) and local infection (p = 0.02). CONCLUSION: Lionfish represents a major health threat in Martinique with increasing envenomation and significant morbidities. Outcome is favorable if promptly managed, with possible reduction in pain duration and local infections with the rapid immersion of the stung body part in hot water. Our data encourage the authorities to develop investigations on the exact extent of the lionfish invasion and set up a regional taskforce to inform the ecosystem users and register all lionfish-attributed incidents.

Clinical presentation of dengue among patients admitted to the adult emergency department of a tertiary care hospital in Martinique: implications for triage, management, and reporting.

STUDY OBJECTIVE: During dengue epidemics, emergency physicians face large numbers of patients with acute febrile illness. Triage algorithms and appropriate reporting systems are useful to manage patients and prioritize resources. We identify possible adaptations to these systems to improve the management of patients during epidemics. METHODS: In a prospective observational study in the adult emergency department (ED) of a tertiary care hospital, we enrolled all patients with febrile illness and a confirmed diagnosis of dengue (ribonucleic acid identification). We then retrospectively classified cases according to the initial clinical presentation at the ED. RESULTS: We enrolled 715 patients (332 male patients), aged 14 to 91 years (median 35 years). Severe illness was documented in 332 cases (46.4%) and was mostly caused by serotype 2, or a secondary infection of any serotype. Severe forms included dengue hemorrhagic fever or dengue shock syndrome (104/332; 31.3%), severe bleeding (9/332; 2.7%), and acute organ failure (56/332; 16.9%). The other patients with severe illness (171/332; 51.5%) presented with symptoms of presyncope, intense weakness, prolonged gastrointestinal symptoms, and hypotension. This presentation was common during epidemics and appeared to be associated with dehydration and electrolyte loss that improved markedly within 24 hours with saline solution infusion. This group did not have evidence of plasma leakage, although similar features were observed in patients with dengue hemorrhagic fever/dengue shock syndrome. CONCLUSION: Dengue has a wide range of clinical presentations in the ED. Many patients who appear seriously ill on presentation will respond to intravenous fluids.

Relationship between nonstructural protein 1 detection and plasma virus load in Dengue patients.

We report data from a prospective observational study performed in Martinique during a co-epidemic of dengue virus serotype 2 (DENV-2) and serotype 4 (DENV-4). Among 70 serum samples from patients with DENV-2 (n = 21) or DENV-4 (n = 49) infections, 47 (67.1%) were positive for dengue nonstructural protein 1 (NS1). Antigenemia correlated with plasma virus load and was independent of immune status and the time of sampling. Increased viremia 4-6 days after onset of illness was associated with NS1 positivity, secondary infection, and severe disease. Testing for NS1 could help identify the potentially most severely ill patients during the critical phase of dengue.

Prospective observational study of low thresholds for platelet transfusion in adult dengue patients.

BACKGROUND: The practice of platelet (PLT) transfusions has been adopted into the standard clinical practice in many dengue-endemic countries. Because many patients were found to have received unnecessary PLT transfusions, the development of guidelines for the management of dengue patients with thrombocytopenia has become a necessity. STUDY DESIGN AND METHODS: An emergency department-based prospective observational study was conducted in Martinique during a dengue outbreak in adult patients presenting with an acute febrile illness. Patients with severe bleeding and/or who underwent invasive intensive care procedures or emergency surgery were given PLT transfusion to achieve PLT counts of more than 50 x 10(9)/L. PLT transfusion was also considered for patients with PLT counts of less than 5 x 10(9)/L and for those with associated risk factors and PLT counts of less than 20 x 10(9)/L. RESULTS: A total of 350 patients were admitted with confirmed dengue infections. Most of them had secondary serotype-2 infections. PLT counts of less than 50 x 10(9)/L were recorded in 165 patients (47.1%). PLT transfusion was administered to 9 patients with thrombocytopenia. The indications included severe bleeding (5 cases), invasive procedures (3 cases), emergency surgery (1 case), and/or associated risk factors (2 cases). The median time duration from the onset of fever to PLT transfusion was 6 days (range, 4-10 days). The median amount of PLTs transfused was 3.66 x 10(11) (range, 2.8 x 10(11)-13.2 x 10(11)). The median PLT yield was +12.4% (range, -3.9% to +67.1%). Three patients died. All other patients recovered during the second week after the onset of fever. CONCLUSION: A restrictive strategy for PLT transfusion based on clinical features and low PLT count thresholds proved to be feasible and safe for adult dengue patients.

Influence of the dengue serotype, previous dengue infection, and plasma viral load on clinical presentation and outcome during a dengue-2 and dengue-4 co-epidemic.

Martinique experienced a dengue outbreak with co-circulation of DENV-2 and DENV-4. In an emergency department-based study, we analyzed whether the clinical presentation and outcome of adult patients were related to serotype, immune status, or plasma viral load. Of the 146 adult patients who had confirmed dengue infection, 91 (62.3%) were classified as having classic dengue fever, 11 (7.5%) fulfilled World Health Organization criteria for dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS), 21 other patients (14.4%) presented with at least one typical feature of DHF/DSS [i.e., internal hemorrhage, plasma leakage, marked thrombocytopenia (platelet count < or = 50,000 platelets/mm(3)) and/or shock], and 23 further patients (15.8%) had unusual manifestations. Four patients died. Severe illness was more frequent in patients with secondary dengue infection (odds ratio, 7.18; 95% confidence interval, 3.1-16.7; P < 0.001). Multivariate regression analysis showed that gastrointestinal symptoms and other unusual manifestations were independently associated with DENV-2 infection, whereas cough and DHF/DSS features were independently associated with secondary immune response. A high plasma viral load was associated with DENV-2 infection, increased serum liver enzymes, and with DHF/DSS features in patients presenting after the third day of illness. The most severe cases of dengue resulted from the combined effects of DENV-2 and secondary infection.