Indian J Pediatr (2010) 77:1103–1107
DOI 10.1007/s12098-010-0202-2
ORIGINAL ARTICLE
Clinico-Epidemiological Profile of Children Hospitalized
with Dengue
Manjunath J. Kulkarni & Vijaya Sarathi & Vikas Bhalla &
Deepak Shivpuri & Usha Acharya
Received: 26 November 2009 / Accepted: 16 June 2010 / Published online: 2 October 2010
# Dr. K C Chaudhuri Foundation 2010
Abstract
Objective To study the clinico-epidemiological profile of
children hospitalized with dengue illness.
Methods Prospective study of children hospitalized with
the diagnosis of dengue illness during from September
through November 2006 at a tertiary care centre in Jaipur.
Results A total of 948 children including 671 (70.8%) boys
and 277 (29.2%) girls were diagnosed to have dengue illness
during the outbreak. Two third of children were from urban
areas while 6–12 years was the most commonly affected age
group (45.8%). 58.3% cases had dengue fever (DF) while
41.7% had DHF (dengue hemorrhagic fever). Dengue fever
with bleed (DFB) accounted for 32% of cases. Common
constitutional symptoms were vomiting (35.2%), pain abdo-
men (22.1%) and myalgia (10.1%). Bleeding manifestations
were observed in 44.5% of cases.. Positive tourniquet test was
the most common manifestation which was seen in 300 cases
(31.6%) while in 9.2% cases bleeding was the only
manifestation. Epistaxis (25%) was the most common
spontaneous bleeding manifestation. Thrombocytopenia was
documented in 84% of total cases and bleeding occurred more
often in patients with severe thrombocytopenia. Ten children
expired with a case fatality rate of 1.1%.
Conclusions Children between 6 and 12 yrs were most
affected by dengue with larger number of cases from urban
areas. DFB cases accounted for almost one third cases of
dengue. Epistaxis was the most common spontaneous
bleeding manifestation. Bleeding occurs more often in
patients with severe thrombocytopenia.
M. J. Kulkarni : V. Sarathi (*) : V. Bhalla : D. Shivpuri :
U. Acharya
Department of Pediatrics, Sir Padampat Mother and Child Health
Institute, SMS Medical College,
Jaipur, Rajasthan, India
e-mail: drvijayasarathi@gmail.com
Keywords Dengue . Outbreak . Thrombocytopenia .
Hemorrhagic fever . Children
Introduction
Dengue fever (DF) and especially the more severe
manifestation, dengue hemorrhagic fever (DHF) ranks
highly among the new and newly emerging infectious
diseases in public health significance and is considered as
the most important of the arthropod borne viral diseases [1].
Proliferation in density and geographic distribution of
vector and marked increase in rate and geographic range
of virus transmission have lead to resurgence of dengue in
recent years. Major demographic changes such as uncon-
trolled population growth, unplanned urbanization resulting
in substandard housing and need for water storage has
greatly aided vector proliferation [2].
Indian subcontinent has encountered recurrent dengue
outbreaks from time to time with significant mortality and
morbidity. Disease is more severe in children than adults.
North India had a major dengue outbreak in 2006. The
present study describes the clinical and epidemiological
profile of dengue patients from a tertiary pediatric care
centre.
Material and Methods
This prospective study was conducted at Sir Padampat
Mother and Child Health Institute, Jaipur from September
2006 through November 2006.
Study included children (day 1- 18 yrs of age) that were
admitted with acute febrile illness with 2 or more of the
following manifestations: headache, retro orbital pain,
myalgia, arthralgia, rash, and hemorrhagic manifestations.
1104 Indian J Pediatr (2010) 77:1103–1107

All these children were evaluated with dengue serology
using microwell ELISA method. Serology was considered
positive if antibody titer is ≥1:400 on a late acute or
convalescent phase serum specimen for either IgG or IgM
antibodies.
A detailed history of each case was recorded in
pre-structured case record forms including symptoms, signs
and laboratory investigations. Detailed clinical examination
was done at the time of admission and close follow up of
the child was done to watch for progression of disease.
Blood pressure was measured by using an appropriate age
matched cuff. Tourniquet test was done in those children
who did not have obvious bleeding manifestations.
Complete blood count including differential blood count,
packed cell volume (PCV) and absolute platelet count
(APC) was done by using coulter –counter method. PCV
and APC were monitored serially, at least once a day and if
necessary more frequent intervals. Renal functions and liver
enzymes were done routinely for all patients by using a
semi autoanalyser. Ultrasonography of abdomen and
radiograph chest was done by an experienced pediatric
sonologist and radiograph chest were done for all patients.
Dengue cases were classified according to WHO guidelines
[1]. Fluid management of children was according to WHO
guidelines.
Statistical Analysis
Statistical analysis was done by using SPSS software
version 2001. Different groups were compared with chi
square test. Correlations were calculated using Pearson’s
correlation coefficient.
Results
A total of 948 children including 671 (70.8%) boys and 277
(29.2%) girls were hospitalized with dengue illness during
the study period. Majority of children were from urban
areas (66.4%). Distribution of dengue children with respect
to age and severity is shown in Table 1. Children in
6–12 yrs age group constituted 45.8% of cases forming the
most commonly affected group. Six neonates were also
hospitalized with dengue. Dengue fever was present in
58.34% of cases, DHF 1–2 in 33.3% of cases and dengue
shock syndrome (DSS) in 8.4% of cases. Severity did not
differ significantly among different age groups. Higher
percentage of girls (12%) had DSS compared to boys (6%).
All patients had fever as part of dengue case definition.
Other common constitutional symptoms were vomiting
(35.3%), pain abdomen (22.1%), myalgia (10.1%), cough
(9.1%), anorexia (6.4%), headache (5.6%) and arthralgia
(4%) (Table 2). Bleeding manifestations were observed in
44.5% of all cases including 32.0% of DF cases (DFB).
Epistaxis (25%) was the most common bleeding manifes-
tation. Hematemesis (9%), skin bleed (2%) and gum bleed
(2.6%) were the other bleeding manifestations. Positive
tourniquet test was seen in 300 cases (31.6%) while in 9.2%
cases bleeding was the only manifestation.
Twenty five (2.6%) children had seizures including three
patients with intracranial bleed. Icterus was noticed in nine
patients of whom one had positive anti-HAV IgM.
Hepatomegaly was present in 36.7% of cases and spleno-
megaly in 19.4% of cases. Ascites was found in 29% of all
dengue cases while pleural effusion was found in 25%.
Among the latter group, 57.1% cases had isolated right sided
pleural effusion while 35.83% had bilateral pleural effusion.
Isolated left pleural effusion was seen in only 2.1% of cases.
Both IgG and IgM antibodies were positive in 518 cases
while 148 cases were positive only for IgM and the rest
only for IgG. Anemia was documented in 48.2% cases and
increase in hematocrit by 20% above base line was
observed in 23.2% of DHF cases. 13.7% of cases had
leucopenia and 26.9% of cases had leucocytosis.
Thrombocytopenia was documented in 84% of total cases
(Table 3). Platelet count was less than 20,000/mm3 in
12.8% of cases. 46.3% of cases with platelet count less than
20,000/mm3 had bleeding manifestation. In cases with
platelet count between 20,000 and 50,000/mm3, 50,000 and

Table 1 Age-wise distribution of cases according to WHO classification

DF DFB Total DHF DHF 1 DHF 2 DHF 3 DHF 4 Grand total

<1mt 4 0 2 1 1 0 0 6 (0.63)
1mt-1 yr 57 17 36 14 15 5 1 110 (11.60)
1 yr-3 yr 65 13 48 15 27 6 1 126 (13.29)
3 yr-6 yr 81 28 98 10 67 15 6 207 (21.83)
6 yr–12 yr 187 58 189 43 104 33 8 434 (45.78)
12 yr–18 yr 32 11 22 4 13 4 1 65 (6.86)
Total 426 (44.94) 127 (13.40) 395 (41.67) 87 (22.02) 228 (57.72) 63 (15.95) 17 (4.30) 948 (100.00)

Figures in parenthesis indicate percentage

Indian J Pediatr (2010) 77:1103–1107 1105

Table 2 Frequency of clinical symptoms and laboratory investiga- received whole blood transfusion. Eleven children received
tions (in percentage) according to type of dengue fever
combination of any two of platelet, plasma or whole blood.
DF DHF Total Severe cases of dengue were associated with edematous
gall bladder. 86.6% of cases with edematous gall bladder
Arthralgia 3.98 4.05 4.01 had DHF. Ten out of 948 children expired with a case
Cough 9.04 9.11 9.07 fatality rate of 1.1%. Nine out of 10 patients who received
Jaundice 0.54 1.52 0.95 inotropes for fluid refractory shock expired.
Headache 5.96 5.06 5.59
Myalgia 11.93 7.59 10.13
Rash 11.93 9.87 11.07 Discussion
Pain Abdomen 17.54 28.35 22.05
Nausea 1.45 1.01 1.26 Dengue outbreaks in India have generally occurred between
Vomiting 33.27 37.97 35.23 August and November [3]. The present outbreak occurred
Altered Sensorium 6.50 2.02 4.64 during September–November 2006. The present study
Anorexia 7.41 5.06 6.43 describes clinical manifestations, laboratory abnormalities
Bleeding Manifestation 32.01 60.25 44.51 and outcomes of children that were hospitalized in a tertiary
Epistaxis 23.5 37.2 29.2 care pediatric hospital with dengue illness during an
Gum Bleed 2.17 3.29 2.64 outbreak.
Hepatomegaly 19.26 61.7 36.7 In the present study, more than two third of cases were
Splenomegaly 5.55 29.22 19.4 boys which is in sharp contrast with previously reported
Anemia 69.07 33.13 48.16 data [4–7]. This observation may be due to highly prevalent
Leucocytopenia 21.81 7.91 13.72 gender bias in India. This reasoning was further strength-
Leucocytosis 25.10 28.16 26.93 ened with glaring of this discrepancy among rural children
SGPT>40 86.88 92.66 89.61 (45.26% of cases from urban areas were girls while only
SGOT>40 86.71 93.85 90.08 34%of cases from rural areas were girls). The present study
Platelets also found higher percentage of DSS in girls (12%) than
<20,000/mm3 6.37 19.25 12.81 boys (6%). However, the number of girls and boys did not
20,000–50,000/mm3 35.16 49.36 41.09 differ between DF and DHF groups. Kabra et al. also
50,000–1,00,000/mm3 31.85 27.34 29.97 reported more severe disease among girls [8].
The present study reported more cases from urban areas
than rural areas. Highly urbanized behavior of Aedes aegypti
100,000/mm3 and >1,00,000/mm3 bleeding manifestations to breed in artificial water collections and ongoing urbaniza-
were observed in 41.7%, 38.3%, and 16.4% respectively. In tion in the city may be responsible for the higher incidence of
total, 241 patients received some form of blood component dengue in urban areas [1]. However, location of the hospital
therapy in the form of platelet transfusion, plasma or fresh in the centre of the city which predominantly receives cases
whole blood. All 56 children having platelet count less than from urban areas might have confounded this observation.
20,000/mm3 with bleeding manifestation, eight children Children in the age group of 6–12 years constituted
with platelet count less than 10,000/mm3 without bleeding almost half of dengue cases (45.8%). This is in accordance
manifestations and 148 children (out of 162) with platelet with WHO data that reports modal age of 6–8 years for low
count between 20,000 and 50,000/mm3 received platelet endemic areas [1]. Severity of the disease did not differ
transfusion. Eighteen DSS patients with rising hematocrit, significantly among different age groups. Neonatal dengue
not responding to crystalloid solution received plasma is very rare. During this outbreak, six neonates were also
transfusion whereas 22 DSS patients with falling hematocrit found to be affected by dengue. Four neonates had dengue

Table 3 Severity of thrombocy-

topenia in different grades of DF DHF Total Bleeding present Bleeding absent Total
dengue and frequency of bleeding
manifestations in thrombocyto- <20,000/mm3 35 86 121 56 65 121
penic cases 20,000–50,000/mm3 193 195 388 162 226 388
50,000–1,00,000/mm3 175 108 283 106 177 279
>1,00,000/mm3 127 6 152 25 127 152
Total 549 395 944 349 595 944
1106
fever while two had DHF-2. Unlike the dengue epidemic of
2001 in Rajasthan during which four cases of neonates with
DSS were detected, none of the neonates had DSS during
the present outbreak [9]. All neonates had positive IgM
antibodies and thrombocytopenia and recovered without
need for blood component therapy. However, antibody
status of mothers was assessed in only two of their mothers
who were symptomatic. Both the tested mothers were
positive for both IgM and IgG dengue antibodies.
All patients had fever as part of dengue case definition.
Similar to previous studies other common constitutional
symptoms were vomiting, pain abdomen, myalgia, cough,
anorexia, headache and arthralgia [4–7]. Bleeding manifes-
tations were observed in 44.5% of all cases including
32.0% of DF cases (DFB). Similar to WHO data and a
previous study positive tourniquet test was the most
common manifestation [1, 8] which was seen in 300 cases
(31.6%). Epistaxis (25%) was the most common spontane-
ous bleeding manifestation and its prevalence was similar
to that of Aggarwal et al. study. Hematemesis was less
common (9%) compared to previous studies [6–8]. Higher
prevalence of DFB was found in the present study which
was similar to Narayanan et al. study. However, most of the
other studies report fewer DFB cases [4, 6]. Pain abdomen,
hepatomegaly and bleeding manifestations were signifi-
cantly higher in DHF cases. Pain abdomen and tender
hepatomegaly may predict DHF and should be closely
monitored for signs of DSS. Narayanan et al. also showed
that hepatomegaly predicts DHF.
Intracranial bleed is a rare manifestation of dengue. In
the present outbreak three patients had intracranial bleed
including two with cerebral parenchymal bleed and one
with subdural hemorrhage. Two patients had platelet count
20,000/mm3 and one patient had platelet count of 20,000–
50,000/mm3. All three patients were managed conserva-
tively and survived without any neurological sequelae.
Frequency of bleeding manifestations increased with
decreasing platelet count. However more than one third of
cases with platelet count of 50,000–1,00,000/mm3 and
16.4% of those with normal platelet count also had bleeding
manifestations. This finding emphasizes the presence of
non-thromobocytopenic causes of bleeding in dengue.
However, the role of coagulation abnormalities as a
causative factor for bleeding in non-thromobocytopenic
patients cannot be concluded from the study since coagu-
lation profile was not tested routinely.
Almost one fourth of cases including few cases with
dengue fever with bleed received some form of blood
component therapy. Platelet transfusion was the most
commonly used blood component therapy. Though pro-
phylactic platelet transfusion is not recommended for even
Indian J Pediatr (2010) 77:1103–1107
those with platelet count less than 10,000/mm3 without
bleeding, eight such children in the present series received
platelet transfusion.
Edematous gall bladder was associated with severe
disease in the present study. A tendency for gallbladder
edema in patients with higher increases in hematocrit and a
higher incidence of gallbladder edema in secondary dengue
has been described previously [10]. A recent study has also
highlighted gall bladder wall edema as a useful diagnostic
finding that may help in prognostication in serology proven
pediatric DHF [11].
One of the limitations of the present study is that the
seronegative cases satisfying epidemiological case defini-
tion were not included in the study. This might have
underestimated the number of dengue cases during the
outbreak.
Almost half (44.94%) of the hospitalized dengue
children had dengue fever without bleeding. Though
dengue encephalopathy was the indication for some of
these non DHF cases, majority of the not indicated
admissions were due to apprehension among parents
insisting for admission.
Ten out of 948 children expired, a case fatality rate of
1.1%. The case fatality rate is in accordance with WHO
data [1]. Nine out of these children received inotropic
support compared to 20 children among the rest. Appar-
ently starting inotropes may look as a bad prognostic sign;
however inotropes were started only as an end measure
when children did not respond to fluid management
including colloids and whole blood.
Conclusions
Children between 6 and 12 years were most affected by
dengue with larger number of cases from urban areas.
Almost one third cases with dengue fever had bleeding
manifestations without evidence of plasma leakage (DFB).
Epistaxis was the most common spontaneous bleeding
manifestation. Bleeding occurs more often in patients with
severe thrombocytopenia.
Contributions DS, UA: Concept of study and study design. MJ,
VS, VB: data collection, manuscript drafting and analysis.
Conflict of Interest None.
Role of Funding Source None.
Indian J Pediatr (2010) 77:1103–1107
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