Clinical characteristics of Dengue shock syndrome in Vietnamese children: a 10-year prospective study in a single hospital

Abstract

Background: Dengue shock syndrome (DSS) is a severe manifestation of dengue virus infection that particularly affects children and young adults. Despite its increasing global importance, there are no prospective studies describing the clinical characteristics, management, or outcomes of DSS.

Methods: We describe the findings at onset of shock and the clinical evolution until discharge or death, from a comprehensive prospective dataset of 1719 Vietnamese children with laboratory-confirmed DSS managed on a single intensive care unit between 1999 and 2009.

Results: The median age of patients was 10 years. Most cases had secondary immune responses, with only 6 clear primary infections, and all 4 dengue virus serotypes were represented during the 10-year study. Shock occurred commonly between days 4 and 6 of illness. Clinical signs and symptoms were generally consistent with empirical descriptions of DSS, although at presentation 153 (9%) were still febrile and almost one-third had no bleeding. Overall, 31 (2%) patients developed severe bleeding, primarily from the gastrointestinal tract, 26 of whom required blood transfusion. Only 8 patients died, although 123 of 1719 (7%) patients had unrecordable blood pressure at presentation and 417 of the remaining 1596 (26%) were hypotensive for age. The majority recovered well with standard crystalloid resuscitation or following a single colloid infusion. All cases were classified as severe dengue, while only 70% eventually fulfilled all 4 criteria for the 1997 World Health Organization classification of dengue hemorrhagic fever.

Conclusions: With prompt intervention and assiduous clinical care by experienced staff, the outcome of this potentially fatal condition can be excellent.

Keywords: Vietnam; dengue shock syndrome; pediatrics; prospective descriptive study.

Figure 1.

Box plots describing changes in hematocrit (A) and platelet count (B) during the evolution of the illness. Hematocrit data are presented for the 24 hours following admission, whereas platelet data are presented daily for the first 4 days, together with the discharge day and follow-up values for both parameters. The numbers displayed below each box plot represent the number of patients included within that time interval. If multiple values were recorded during any time interval, we chose the highest hematocrit and the lowest platelet count, respectively, for that patient. The hematocrit graph excludes data from the 73 patients with dengue shock syndrome with mucosal bleeding at presentation.

Figure 2.

Serotype distributions over time for patients with dengue shock syndrome (A), and for children with secondary dengue who were hospitalized at the same facility but did not experience severe complications (B). The numbers below each bar are the total number of patients in whom a serotype was identified (upper line), and the total number of patients enrolled into the corresponding study (lower line). Abbreviations: DENV, dengue virus; PCR, polymerase chain reaction.