You are on page 1of 13

CLINICAL SPECTRUM OF DENGUE FEVER AND DENGUE HEMORRHAGIC FEVER

AMONG CHILDREN AT SANGLAH HOSPITAL DENPASAR:


A THREE YEARS RETROSPECTIVE STUDY

Dyah, BNP Arhana


Departement of Child Health, Medical School, Udayana University, Sanglah Hospital Denpasar

INTRODUCTION

Dengue fever (DF) and Dengue hemorrhagic fever (DHF) are increasingly important
public health problem in the tropicS and subtropics. 1,2 Dengue has been recognized in
over 100 countries and 2-5 billion people live in areas where dengue is endemic. Yearly,
an estimated 50-100 million cases of DF and several hundred thousand cases of DHF
occur, depending on epidemic activity. About 250, 000 -500, 000 cases of DHF are
officially notified annually; however, the true incidence is not very well known.3,4 Case
fatality rates vary from 0.5% to 3.5% in Asian countries. 1 In Indonesia, since 1968,
morbidity rate of DHF has gradually increased from 0.05 (1968) to
8.14(1973),8.65(1983) with a peak rate in 1988, 27.09 every 100, 000 persons.
Influence of seasons is not clearl but the number of patients increase between
September until February and peaches its in January. In urban areas number of patients
is in June or July.5
DF and DHF are caused by one of the four serotypes of dengue virus (serotypes
1-4). It is transmitted from human to human by the mosquito.Aedes aegypti. Infection
with one of these viruses characacteristically results in fever, headache and rashes. The
clinical spectrum can vary, from asymptomatic to more severe infections with bleeding
and shock.1,2 Although some lower primates can be infected with dengue viruses,
humans are by far the predominant host. Once inoculated into a host, dengue has an
incubation period of 3 – 14 days. Following incubation, a 3 to 7 day acute febrile illness
ensues. Recovery usually is complete by 7-10 days.2,3
Hemorrhagic manifestations, which are invariable present in dengue hemorrhagic
fever (DHF), are usually mild and most commonly found as scattered tiny petechiae in
the skin and occasionally, submucosa. A positive tourniquet test, which indicates
increased capillary fragility, is the common finding that appears early. Massive bleeding
that requires blood transfusion is less common and ussualy occurs after onset of shock.6

1
Leucopenia is a common finding both in DF and DHF. The leukocyte counts may
be normal or slightly increased with predominant neutrophils initially. Towards the end of
the febrile phase there is a reduction in number of total leukocytes and neutrophils. The
leucopenia usually reaches its peak shortly before or at the time of drop in temperature
and returns to normal 2-3 days after defeverscence.2,6,7
Dengue viruses affect both sexes and all ages. DHF usually affects children
younger than 15 years. Death from DHF is more frequent in female than in male. 2,8,9Only
a small proportion of patients with DHF develops DSS. It is not clear whether this results
from increase in vascular permeability as found in all patients or whether its pathology
of DSS is distinct from that of the milder form of the disease. 1,10-12
It is difficult to diagnose DF and DHF in the first week because clinical
manifestations are similar meanwhile laboratories result such is rapid serologic test for
dengue, could be give a false negative and need a longer times times to give the best
result.1-4 It is important to evaluated clinical findings in several times to makes diagnosed
DF and DHF.13 Recently many study were done about clinical manifestation of DF and
DHF but study at three years especially in local areas were not to be done. It is
important to know about clinical spectrum DF and DHF in our region so diagnosed DF
and DHF from clinical spectrum could be done early. Distributions of cases is important
also to make preparation if the out break comes in our region.
Concerns about all things above, we are conducted this study to determine
clinical spectrum of DF and DHF and also to determine the distribution of cases DF and
DHF each month for three years at Sanglah Hospital Denpasar.

PATIENTS AND METHODS


This was a retrospective study carried out in Jempiring and Pudak wards of the Sanglah
Hospital Denpasar. Data were collected from medical records of hospitalized patients at
Jempiring and Pudak wards, Sanglah Hospital, between January 2002 and December
2004.

Patient
Patients who were diagnosed of having DF and DHF who had been discharged from
hospital collected from medical record were also included. Patients with DHF were
divided into DHF and DHF with shock based on WHO criteria. Data included gender,

2
clinical manifestations and the number of patients. All medical records which could
conducted were recruite.

The Operational definition of variables


1. DF was defined as a syndrome of 2-7 days of fever with 2 or more manifestation
such as: headache, retroorbital pain, myalgia, bone/joint pain and bleeding
manifestations and leucopoenia. DF can differentiated from DHF, in DF
diagnosis can establish with criteria manifestations above without sign of
3
plasma leakage.
2. DHF was defined as diagnosis criteria from WHO (1997):5,6
Clinical criteria:
a. High continuous fever for 2 to 7 days in most cases
b. Hemorrhagic manifestations: a positive tourniquet test, petechiae,
epistaxis and gastrointestinal bleedings
c. Hepatomegaly
d. Circulatory disturbances (shock in severe cases)
Laboratories criteria:
a. Trombocytopenia
b. Hemoconcentration : rising hematocrit from baseline of 20% or more
Degrees of disease:
Grade 1 : Fever without specific symptom and only 1 bleeding
manifestation : tourniquet test positive
Grade 2 : The same as grade 1 with spontaneous bleeding
Grade 3 : Grade1 or 2 with circulation failure : rapid and week pulse,
narrow pulse pressure (<20 mmhg), hypotension, cool, clammy
skin, altered mental status.
Grade 4 : Profound shock.
DHF (without shock) : DHF grade 1 or 2
DHF with shock : DHF grade 3 or 4
Diagnosis of DHF can establish with 2 clinical symptom and 2 laboratories findings
3. Gender was difined as male and female
4. Fever was defined as the body temperature more than 37.2 ◦C, which is checked
by thermometer in the patients axilla patients .14

3
5. Days of fever was defined as the length of fever since the first day until the
patients admission to hospital
6. Age was defined as age based on chronological age
7. Clinical manifestation was defined clinical syndrome which in recruit from
medical record : days of fever, headache, retro orbital pain, vomiting, arthralgia,
abdominal pain, hepatomegaly and laboratories findings
8. Trombocytopenia was defined as the count of trombosit 100.000 cells/mm 3 or
less .9
9. Leucopenia was defined as count of leucosit less than 5 K/µl.2,9
10. Hemorrhagic manifestations was define small amounts of bleeding from skin,
nose, gums to melena or hematemesis.7
11. Tourniquet test was defined as the test performed by inflating a blood pressure
cuff on the upper arm to midway between diastolic and systolic blood pressure
for 5 minutes. The result is considered positive if more than 20 petechiae
2
persquare inch are observed on one inch square area skin of the arm.

Statistical analysis
The statistical analysis was done using SPSS soft ware (SPSS for Window 11.5 version)
and the data were presented in table, figure description.

RESULTS:

We collected 837 cases of DF, DHF, DHF with shock during 2002 – 2004 582
completely data were found in Medical Recording. Five hundred eighty two (303 male
and 279 female) children had DF, DHF and DHF with shock in this periods. Patients
diagnosed with DF 417 (71%), DHF 95 (16.3%) and DHF with Shock 70 (12.0%). Five
patient died (0.8%) because of DHF with shock at three years and four of them is female
(Not shown in the table).

4
Clinical manifestations

Table 1. Clinical manifestations of patients DF, DHF dan DHF with shock
Clinical DF DHF DHF with shock Total
manifestations n=417(%) n=95(%) n=70(%) n=582(%)
Gender
Male 221 (52.9) 48 (50.5) 34 (48.5) 303 (52.1)
Female 196 (47.0) 47 (49.4) 36 (51.4) 279 (47.9)
Fever on admission 37 ± 0.9 38.1 ± 0.9 36.9 ± 0.7 37.3 ± 0.8
( ◦Celsius)
Days of fever on 4.16 ± 0.7 4.14 ± 0.7 4.13 ± 0.7 4.1 ± 0.7
admission (days)
Age (years) 5.3 ± 2.8 5.2 ± 2.8 5.3 ± 2.7 5.2 ± 2.7
Symptom
Headache 206 (49.4) 50 (52.6) 39 (55.7) 295 (50.6)
Arthralgia 19 (4.5) 4 (4.2) 4 (5.7) 27 (0.04)
Retro orbital pain 2 (0.2) 0 (0) 1 (1.4) 3 (0.05)
Sign
Vomiting 283 (67.8) 66 (69.4) 48 (50.2) 397 (68.2)
Hepatomegaly 117 (28.0) 44 (46.3) 61 (87.1) 276 (47.4)
Abdominal pain 48 (11.5) 28 (29.4) 59 (84.2) 135 (23.1)
Petechiae 310 (74.3) 63 (66.3) 42 (60) 415 (71.6)
Epistaxis 55 (13.1) 17 (17.8) 8 (11.4) 80 (13.7)
Melena 0 (0) 0 (0) 7 (10.0) 7 (1.2)
Gum bleeding 3 (0.7) 0 (0) 2 (2.8) 5 (0.8)
Tourniquet test (+) 397 (95.2) 84 (88) 51 (72.8) 532 (91.4)
Laboratories findings
Hemoconsentratio 0 (0) 78 (82) 56 (80) 195 (33.5)
n
Thrombocytopenia 276 (66.2) 84(88.4) 64 (91.4) 424 (72.9)
Leucopenia 406 (97.3) 91 (95) 70( 100) 567 (97.5)

Plus minus values are means ± SD

Patient for all cases majority came in fourth days of fever 337 (57.9%), not
shown in table. According from table 1, vomiting 283 (67.8%), 66 (69.4%) was majority
symptom of patient with DF and DHF, respectively, hepatomegaly 61 (87.1%) and
abdominal pain 59 (84.2%) were majority symptom of DHF with shock. Only a few
patient of DF, DHF and DHF with shock complained about retro orbital pain 3 (0.05),
arthralgia 27 (0.04).

5
Bleeding manifestations were majority came from petechiae 415 (71.6%) for all
cases. Only 1 patients with DHF with shock had melena in 5 days of stays in hospital.
Five hundred thirty two (91.4%) cases had positive tourniquet test on admission.
Thrombocytopenia and leucopenia was majority findings from all cases 424
(72.9%) and 567 (97.5%), respectively.
Distribution of cases during January 2002- December 2004
The among 837 cases which recorded in medical record in Jempiring, Pudak room, peak
incident were on March every years at 3 years.

Figure 1.Distribution of cases January 2002- December 2002

Figure 2.Distribution of cases January 2003- December 2003

6
Figure 3.Distribution of cases January 2004- December 2004

At three years majority patients admission at 2003 with 347 patients and the
peak incidence were on March with 87 patients, 67 with DF, 10 with DHF and 9 patient
DHF with shock .

Figure 4.Distribution of cases January 2002- December 2004

DISCUSSION

7
Dengue viruses affect both sexes with no different proportion between male and
female.2,8 Our study found the same result with 303 (52.1%) male and 279 (47.9%)
female for all cases, distribution for each cases were not much different also . In
Southeast Asia DF affect people of all ages, where dengue is hyper endemic, DHF
usually affects children younger than 15 years. 2 In Indonesia DHF affect children with 5-
11 by age but proportion more than 15 years increase gradually since 1984. 8 This is
accordance to our study in which found mean ages of patients with DF, and DHF were 5
years, 5.2 (SD 2.7) .
A fever occurs in nearly all dengue infections in children. The other most
common symptom a red throat, a (usually mild) runny nose, cough and mild.
Gastrointestinal symptom which course may present simultan to pharingitis, influenza
and upper respiratory infections. The presentation of dengue in the younger child is
much less characteristic than the older child and adult.1,15 In this study patients which is
had symptom similar to pharingitis, influenza and upper respiratory infections were 360
(61%) patients (not shown in the table) for all cases.
Fever in symptomatic DF may be as 41 0 C. The fever typically last 2-7 days.
Occasionally, the fever abates for day only to return, a patterns that has been called
sadle back fever. Patients with DF have clinical manifestations as follows: headache
usually is generalized, retro orbital pain is common, nausea, myalgia, arthralgia,
hemorrhagic manifestations may range from small amount of bleeding from nose or
mosquito to melena or hematemesis, abdominal pain is reported also.1,6,7,8 On physical
rash of DF present as many as half of the patient. The rash variable and maybe
scarlatinaform or maculapapularform. Petechiae and purpura may develop as
hemorrhagic manifestations.2 All patient with dengue in this study had history of fever
and majority came in the fourth days 337 (57.9%) with duration of fever on admission 4.1
± 0.7. Temperature on admission for DF, 37◦C (SD 0,9) were not so high because
Sanglah Hospital centre of reference patients in Bali, there for mostly patient came with
already taken antipyretic from other medical centre. But for DHF with shock temperature
were 36.9◦C (SD 0,7) because in shock condition body temperature will be decrease.
About 206 (49.4%) patient complained about headache and the others 211 (50.5%) were
not. This conditions could be happened because children can describes headache very
well, according of this, we only found retro orbital pain only complained by 2 (0.3%)
patient maybe because children can describe retro orbital pain very well also. Vomiting

8
complained by 283 (67.8%) patients but Hepatomegaly and abdominal pain were found
on 117 (28%) and 48 (11.5%) respectively.
Hemorrhagic manifestations include the following petechiae, tourniquet test (+),
other hemorrhagic manifestations include nasal or ginggival bledding, melena or
hematemesis.1,16,17 Hemorrhagic manifestations for DF in this study majority from
petechiae 310 (74.3%) and follow by epitaxis 55 (13.1%) and gum bleeding 3 (0.7%).
This findings similar with Ahmed study13 which found petechiae and or skin bleeding
was majority (75%) hemorrhagic manifestations from patient with dengue. Lan et all 12
found spontaneous bleeding in patients with DHF older than one year such is petechiae,
epistaxis, gum bleeding, gastrointestinal bleeding were seen in 57%, 14%,7% and 12%
of the patients, respectively. This is accordance to our study which in found petechiae
were majority hemorrhagic manifestation for DHF and DHF with shock following by
epistaxis. Meanwhile, melena 7(10%) and gum bleeding 2 (2.8%) only complained by
patients with DHF with shock a tourniquet test often positive in dengue virus
infection.1,2,9,11,14 Tourniquet test is capillary fragility test there for are not specific for DHF
but if one children clinically suspected DHF and tourniquet test positive in this case
diagnosis more closely and must be completely by complete blood test for confirm
diagnosed.2,6,8,18 This accordance to this study, we were found 397 (95.2%), 84 (88%) for
DF and DHF respectively have tourniquet positive, but only 51 (72.8%) patient with DHF
with shock have tourniquet positive because in shock condition tourniquet test could
make negative result for tourniquet test.
DHF most affect in small children and elderly adults. This can sometimes be a
serious illness. If DHF with shock occurs it will usually do so by day 3-5 of the fever. 10,15
In this study all DHF with shock occurs by day 4 (4.13 ± 0.7 ) but DHF with shock occurs
in children mostly between 5-8 years of age. The fatality rate for DHF with shock varies
by country from 12-44%2. In Indonesia case fatality rate (CFR) was decrease from
41.3% in 1968 to 3% in 1968. Since 1991 CFR stable lower than 3%. 5 Sri Wahyuni et al19
reporting CFR in Child department Dr Hasan Sadikin Bandung Hospital were 11,5% in
1998 meanwhile Andayani and Arhana20 reporting CFR in Child Department Sanglah
Hospital were 7% our study found only 5 (0,8%) patient died in the three years and four
of them were female.
There are no immediately useful test for dengue fever which unequivocally
accurate. However the laboratory can be used to aid confirmation of a clinical suspicious
use. The white cell count is often low unlike bacterial cause of fever. 7,15,16 In this study we

9
were findings leucopenia from 567 (97.5%) patients.The dengue blot test can give both
false positive and false negative results especially the first week of the disease. 12 There
for in this study we didn’t include IgG and IgM result. The diagnosis will in the large
proportion of cases be basis on clinical presentation and a characteristic drop of platelet
in the blood.2,15,18 In this study thrombocytopenia were found from 424 (72.9%) patients.
In children the progression of disease is not always characteristic. A relatively
mild first phase with an abrupt onset of fever. Malaise, vomit, headache, anorexia and
cough is succeed 2-5 days later by weakness and sometimes, physical collapse.
Frequently, spot appear on tibia. Liver enlargement is observed on day 3-4 illness in
over 90% cases of cases in children. Patient may complaint of abdominal pain. 6,7 In this
study all clinical presentation of DF, DHF and DHF with shock were are not much
different except vomiting were majority symptom of DF and DHF, hepatomegaly ,
abdominal pain were majority clinical symptom of DHF with shock. The same conditions
were reported by Andayani and Arhana20 in 3 years retrospective study (January 1995-
December 1997) were found abdominal pain and hepatomegaly were 35.1% and 100%
respectively, meanwhile Suparyatha and Arhana21 reported abdominal pain and
hepatomegaly were 62.5%, 75% respectively for patient DHF with shock, Bethel et al 10
also found hepatomegaly (89%) and abdominal pain (54%) were majority clinical
symptom of DHF with shock but only abdominal pain have significant different from DHF
without shock.
DF and DHF can be differentiated with a few clinical symptom. Headache and
vomiting are most seen in DF.21,22 This is conflicting with our study, we found only
vomiting most seen in DF and headache, vomiting for DHF. The other symptom were
arthralgia, hepatomegaly and abdominal pain are less in DF. 22,23 In this study we found
the same result. We also found petechiae more frequent in DF this is accordance to
Leangpibul, Thongcharoen22 and Nimmantya study23.
Dengue fever is a relatively common problem in Indonesia and periodically
reaches epidemic proportions in Jakarta and other part of Indonesia every 4-5 years. 15
The amount of patient with DF and DHF in this study were 837 with reaches proportions
at 2003. During 2002 – 2004 they had peak level in March with approximately 40 – 80
patients for months (figure 1-4). This is in accordance to the weekly report in 2004 from
DKI-Jakarta, Bali and West Nusa Tenggara in which the outbreak was found in mid
March.24 This trends was unlike the previous trend cases in which the peak level was
during January –February.

10
The limitation of our study were a descriptive retrospective study, may have
limitation that could make a little bias, we took data from medical record may be were
not accurate.

CONCLUSIONS
Clinical presentation of DF, DHF and DHF with shock were are not much different except
vomiting was majority symptom of DF and DHF, hepatomegaly , abdominal pain were
majority clinical symptom of DHF with shock. The amount of patient with DF and DHF in
this study was 837 with reaches proportions at 2003. During 2002 – 2004 they had peak
level on March.

Acknowledgements
We gratefully acknowledge technical support for this study from Division of Medical
Recording and Information Sanglah Hospital Denpasar. We also thanks to dr Raka
Widiana, SpPD for continued supervising and statistical support.

References:

11
1. McBride JHW, Ohmann HB. Dengue viral infections: patogenesis and epidemiology.
Microbes and infection 2000; 2:1041-1050.
2. Suzanne Shepherd. Dengue fever. eMedicine 2002: 1-10.
3. WHO. Strengthening implementation of the global strategy for dengue fever and
dengue hemorrhagic fever, prevention and control. Report of the informal
consultation, Geneva, 18-19 October 1999.
4. WHO. Scientific working group on dengue. Meeting report, Geneva, Switzerland, 3-5
April 2000.
5. Soedarmo SSP. Masalah demam berdarah dengue. In: Hadinegoro SR, Satari HI,
Editors. Naskah lengkap demam berdarah dengue. 3th ed. Balai penerbit FKUI,
2002.p.1-13.
6. Nimmannitya S. Dengue hemorrhagic fever: disorders of hemostasis. Ishapd (serial
on line) 1999 0ktober (cited 2005 March 14). Available from: URL:
hhtp://www.ishapd.org.
7. Krisnamurti C, Kalayanarooj S, Cutting MA, Peat RA, Rothwell SW, Reid TJ et all.
Mechanism of hemorrhage in dengue without circulatory collapse. Am.J. Trop. Med.
Hyg 2001; 65:840-847.
8. Tumbelaka AR. Tata laksana demam berdarah dengue. In: Panitia lulusan dokter
FKUI, Editors. Updates in pediatric. 1st ed. Jakarta: Balai penerbit FKUI, 2002.p.95-
113.
9. Guzman MG, Kouri G. Dengue: an update. Lancet Infect Dis 2002; 2:33-42.
10. Bethell DB, Gamble J, Loc P, Dung NM, Chau TTH, Loan HT, et al. Non invasive
measurement of microvascular leakage in patients with dengue hemorrhagic fever.
CID 2001; 32:243-253.
11. WHO. Dengue fever/dengue hemorrhagic fever in the WHO western pacific region.
WPRO communicable diseases bulletin 2000; Issues no 3:1-23.
12. WHO. Dengue/DHF. Dengue bulletin 1998; 22:1-6.
13. Ahmed FU, Mahmood CB, Sharma JD, Hoque SM, Zaman R, Hasan MS. Dengue
and dengue haemorrhagic fever in children during the 2000 outbreak in chittagong,
Bangladesh. Dengue bulletin 2001; 25:33-39.
14. Darmowandoyo W. Demam tanpa kausa yng jelas. In: Soedarmo SSP, Garna H,
Hadinegoro SR, Editors. Buku ajar ilmu kesehatan anak: infeksi & penyakit tropis.
1st Ed. Jakarta: Balai penerbit FKUI, 2002.p.52-63.

12
15. Anonymous. Dengue fever (cited 2005 March 4). Available from: URL:
www.expat.or.id/medical/dengue.html.
16. WHO. Dengue/DHF: Fact sheet on dengue fever and dengue haemorrhagic fever.
Last updated 2004 July 23 (cited 2005 March 16). Available from: URL:
www.cdc.gov/ncidod/dvbid/dengue/
17. Gorp VECM, Suharti C, Cate HT, Dolmans WMV, Meer JWM, Cate JW, Brandjes
DPM. Review: Infectious disease and coagulation disorders. JID 1999; 180:176-186.
18. Hadinegoro. Kesenjangan dalam diagnosis dan tata laksana DBD. In: PKB IKA,
Editors. Current management of pediatrics problem. Jakarta: Balai penerbit FKUI,
2004.p.63-72.
19. Sri Wahyuni, Djatnika S, Dadang HS, Azhali. Pasien dss yang dirawat di ruang picu
DR Hasan Sadikin Bandung tahun1997-1998. Presented at KONIKA XI, Jakarta, 4-7
July, 1999.
20. Andayani P, Arhana BNP. Karakteristik pasien demam berdarah dengue yang
mengalami renjatan di RSUP Sanglah Denpasar. Presented at KONIKA XI, Jakarta,
4-7 July 1999.
21. Suparyatha IB, Arhana BNP. Faktor-faktor prediktor renjatan pada demam berdarah
dengue.2001.
22. LeangpibulP, Thongcharoen P. Clinical laboratory investigation. In monograph on
dengue/dengue hemorrhagic fever. World Health Organization, SEARO, New
Delhi:1993.p.62-71.
23. Nimmannitya S. Clinical manifestation of dengue hemorrhagi fever. In monograph on
dengue/dengue hemorrhagic fever. World Health Organization, SEARO, New
Delhi:1993.p.48-54.
24. Anonymus. WHO update on dengue fever in Indonesia. Pharmacy-online (serial
online)2004 april 8 (cited 2005 April 4). Available from: URL:
www.who.int/csr/don/2004.

13

You might also like