Clinician Survey to Determine Knowledge of Dengue and Clinical Management Practices, Texas, 2014.

Dengue, a mosquito-borne viral disease, is increasingly being identified as a cause of outbreaks in the United States. During July-December 2013, a total of three south Texas counties reported 53 laboratory-confirmed dengue cases; 26 were locally acquired, constituting the largest outbreak in Texas since 2005. Because dengue outbreaks are expected to continue in south Texas and early case identification and timely treatment can reduce mortality, we sought to determine clinicians' knowledge of dengue and its clinical management. A survey was sent to 2,375 south Texas clinicians; 217 (9%) completed the survey. Approximately half of participants demonstrated knowledge needed to identify dengue cases, including symptoms (56%), early indicators of shock (54%), or timing of thrombocytopenia (48%). Fewer than 20% correctly identified all prevention messages, severe dengue warning signs, or circumstances in which a dengue patient should return for care. Knowledge of clinical management was limited; few participants correctly identified scenarios when plasma leakage occurred (10%) or a crystalloid solution was indicated (7%); however, 45% correctly identified when a blood transfusion was indicated. Because of the ongoing threat of dengue, we recommend clinicians in south Texas receive dengue clinical management training.

Reemergence of Dengue in Southern Texas, 2013.

During a dengue epidemic in northern Mexico, enhanced surveillance identified 53 laboratory-positive cases in southern Texas; 26 (49%) patients acquired the infection locally, and 29 (55%) were hospitalized. Of 83 patient specimens that were initially IgM negative according to ELISA performed at a commercial laboratory, 14 (17%) were dengue virus positive by real-time reverse transcription PCR performed at the Centers for Disease Control and Prevention. Dengue virus types 1 and 3 were identified, and molecular phylogenetic analysis demonstrated close identity with viruses that had recently circulated in Mexico and Central America. Of 51 household members of 22 dengue case-patients who participated in household investigations, 6 (12%) had been recently infected with a dengue virus and reported no recent travel, suggesting intrahousehold transmission. One household member reported having a recent illness consistent with dengue. This outbreak reinforces emergence of dengue in southern Texas, particularly when incidence is high in northern Mexico.

Notes from the field: fatal rat-bite fever in a child - San Diego County, California, 2013.

In August 2013, the County of San Diego Health and Human Services Agency was notified of a fatal case of rat-bite fever (RBF) in a previously healthy male, aged 10 years, who owned pet rats. Two days before his death, the patient experienced rigors, fevers, vomiting, headaches, and leg pains. His physician noted a fever of 102.6°F (39.2ºC), documented a normal examination, diagnosed viral gastroenteritis, and prescribed anti-nausea medication. During the next 24 hours, the patient experienced vomiting and persistent fever. He was confused and weak before collapsing at home. Paramedics reported the patient was unresponsive and had dilated pupils; resuscitation was initiated in the field and was continued for >1 hour after arrival at the emergency department but was unsuccessful. A complete blood count performed during resuscitation revealed anemia (hemoglobin 10.0 g/dL [normal = 13.5-18.0 g/dL], thrombocytopenia (platelets 40,000/µL [normal = 140,000-440,000/µL]), leukocytosis (white blood cells 17,900 cells/µL [normal = 4,000-10,500/µL]) with 16% band neutrophils; the patient also had evidence of disseminated intravascular coagulation. No rash or skin breakdown was noted. Lung, liver, and epiglottis tissue collected postmortem was positive for Streptobacillus moniliformis DNA by polymerase chain reaction.