Evaluation of remote radiologist-interpreted point-of-care ultrasound for suspected dengue patients in a primary health care facility in Colombia.

BACKGROUND: Early identification of plasma leakage may guide treatment decisions in dengue patients. This study evaluated the value of point-of-care ultrasound (POCUS) to detect plasma leakage and predict hospitalization or referral to a higher level of care in suspected dengue patients under routine conditions at a primary care facility in Colombia. METHODS: We conducted a cohort study between April 2019 and March 2020 in a primary care hospital in Cali, Colombia. We prospectively included and followed 178 patients who were at least 2 years old with fever of less than 10 days and clinician-suspected dengue. A trained general practitioner performed a standardized POCUS protocol. Images were quality-rated and overread by an expert radiologist, and her results and those of the general practitioner were compared using the Kappa index. Logistic regression was used to identify factors associated with plasma leakage at enrollment and explore its prognostic value regarding hospital admission or referral to a higher level of care. RESULTS: Half (49.6%) POCUS images were of suitable quality to be interpreted. The proportion of plasma leakage reported by the radiologist was 85.1% (95% CI: 78.6-90.2%) and 47.2% by the study physician (Kappa = 0.25, 95% CI: 0.15-0.35). The most frequent ultrasound findings were ascites (hepatorenal 87.2%, splenorenal 64%, or pelvic 21.8%) and gallbladder wall thickening (10.5%). Plasma leakage was higher in subjects with thrombocytopenia (aOR = 4, 95% CI: 1.3-12.1) and lower in patients 30-59 years old (aOR = 0.1, 95% CI: 0.0-0.4) than in those 18 years old or younger. POCUS evidence of plasma leakage (aOR = 8.2, 95% CI: 2.2-29.9), thrombocytopenia (aOR = 6.3, 95% CI: 2.4-16.0) and pulse pressure (aOR = 1.1, 95% CI: 1.07-1.2) were associated with hospital admission or referral to a higher level of care. CONCLUSIONS: Ultrasound is useful to detect plasma leakage in primary care and, challenges remain to guarantee high-quality images and diagnostic accuracy, for which a standardized dengue POCUS protocol and training program is needed.

Achados ultrassonográficos abdominais relacionados à dengue em um hospital do noroeste paulista / Abdominal ultrasound findings related to dengue in a hospital in northwest são paulo

Introdução: De evolução aguda, a dengue é uma doença infecciosa febril, arbovirose provocada pela picada do mosquito aedes aegypt, atualmente representada por quatro sorotipos virais. A infecção pelo vírus da dengue pode ser assintomática ou sintomática. Quando sintomática causa doença de amplo espectro clínico, incluindo desde formas oligossintomáticas até quadros graves, podendo levar ao óbito. Trata-se, portanto, de um problema de saúde pública nacional, responsável por inúmeras hospitalizações e óbitos, anualmente. Objetivos: A proposta do atual estudo baseia se em descrever os principais achados ultrassonográficos abdominais encontrados em pacientes com quadro sugestivo de dengue e demonstrar o valor da ultrassonografia como ferramenta preditiva na avaliação de casos de agravo. Material e Método: Estudo retrospectivo, descritivo por meio do qual se realizou a análise dos laudos de imagem abdominal de pacientes com casos sugestivos de dengue, atendidos em um hospital-escola, em Catanduva-SP, no primeiro semestre de 2022, submetidos a ultrassom abdominal na data de atendimento e cujos valores obtidos foram compilados em tabelas. Resultados: Os achados de 102 ultrassonografias analisadas apontam espessamento da parede da vesícula biliar (15,8%), líquido livre na cavidade abdominal e/ou pélvica (10,9%), esplenomegalia (10,0%), hepatomegalia (2,0%) e dilatação das vias biliares intra e extra-hepáticas (1,0%). Conclusão: Os achados ultrassonográficos abdominais são uma ferramenta adjuvante útil na avaliação de sinais de alarme, como ascite e visceromegalias, em pacientes com quadro sugestivo de dengue, especialmente a hemorrágica, bem como na detecção precoce da gravidade e da progressão da doença, portanto, um preditor de severidade.

Introduction: Of acute evolution, dengue is a febrile infectious disease, arbovirose caused by the bite of the mosquito Aedes aegypt, currently represented by four viral serotypes. Dengue virus infection may be asymptomatic or symptomatic. When symptomatic causes disease of broad clinical spectrum, including from oligosymptomatic forms to severe conditions, which can lead to death. It is therefore a national public health problem, responsible for numerous hospitalizations and deaths, annually. Objectives: The proposal of the current study is based on describing the main abdominal ultrasound findings found in patients with suggestive of dengue and demonstrate the value of ultrasound as a predictive tool in the evaluation of cases of illness. Material and Method: Retrospective, descriptive study through which the analysis of abdominal imaging reports of patients with cases suggestive of dengue, attended at the Padre Albino Hospital, Catanduva-SP, in the first half of 2022, was performed submitted to abdominal ultrasound at the date of care and whose values were compiled in tables. Results: The findings of 102 ultrasonographies analyzed indicate thickening of the gallbladder wall (15.8%), free fluid in the abdominal and/or pelvic cavity (10.9%), splenomegaly (10.0%), hepatomegaly (2.0%) and dilation of the extra biliary ways (1.0%). Conclusion: Abdominal ultrasonographic findings are a useful adjuvant tool in the evaluation of warning signs, such as ascites and visceromegaly, in patients with suggestive of dengue, especially hemorrhagic, as well as in the early detection of disease severity and progression, therefore a predictor of severity

Introducción: Con una evolución aguda, el dengue es una enfermedad infecciosa febril, un arbovirus causado por la picadura del mosquito Aedes aegypt, actualmente representado por cuatro serotipos virales. La infección por el virus del dengue puede ser asintomática o sintomática. Cuando es sintomático, provoca una enfermedad con un amplio espectro clínico, que incluye desde formas oligosintomáticas hasta casos graves, que pueden conducir a la muerte. Es, por tanto, un problema de salud pública nacional, responsable de numerosas hospitalizaciones y muertes anualmente. Objetivos: El propósito del presente estudio se basa en describir los principales hallazgos ecográficos abdominales encontrados en pacientes con síntomas sugestivos de dengue y demostrar el valor de la ecografía como herramienta predictiva en la evaluación de casos de enfermedad. Material y Método: Estudio descriptivo retrospectivo mediante el cual se analizó los informes de imágenes abdominales de pacientes con casos sugestivos de dengue, atendidos en el Hospital Padre Albino, Catanduva-SP, en el primer semestre de 2022, a quienes se les realizó ecografía abdominal en la fecha del servicio, y cuyos valores obtenidos fueron recopilados en tablas. Resultados: Los hallazgos de 102 ecografías analizadas indican engrosamiento de la pared vesicular (15,8%), líquido libre en cavidad abdominal y/o pélvica (10,9%), esplenomegalia (10,0%), hepatomegalia (2,0%) y dilatación de las vías biliares intra y extrahepáticas (1,0%). Conclusión: Los hallazgos de la ecografía abdominal son una herramienta coadyuvante útil en la evaluación de signos de alarma, como ascitis y visceromegalia, en pacientes con cuadro sugestivo de dengue, especialmente dengue hemorrágico, así como en la detección precoz de la gravedad y progresión de la enfermedad, por lo tanto, un predictor de gravedad.

Frequency of pleural effusion in dengue patients by severity, age and imaging modality: a systematic review and meta-analysis.

BACKGROUND: Identification of pleural effusion (PE) in dengue infection is an objective measure of plasma leakage and may predict disease progression. However, no studies have systematically assessed the frequency of PE in patients with dengue, and whether this differs across age and imaging modality. METHODS: We searched Pubmed, Embase Web of Science and Lilacs (period 1900-2021) for studies reporting on PE in dengue patients (hospitalized and outpatient). We defined PE as fluid in the thoracic cavity detected by any imaging test. The study was registered in PROSPERO (CRD42021228862). Complicated dengue was defined as hemorrhagic fever, dengue shock syndrome or severe dengue. RESULTS: The search identified 2,157 studies of which 85 studies were eligible for inclusion. The studies (n = 31 children, n = 10 adults, n = 44 mixed age) involved 12,800 patients (30% complicated dengue). The overall frequency of PE was 33% [95%CI: 29 to 37%] and the rate of PE increased significantly with disease severity (P = 0.001) such that in complicated vs. uncomplicated dengue the frequencies were 48% and 17% (P < 0.001). When assessing all studies, PE occurred significantly more often in children compared to adults (43% vs. 13%, P = 0.002) and lung ultrasound more frequently detected PE than conventional chest X-ray (P = 0.023). CONCLUSIONS: We found that 1/3 of dengue patients presented with PE and the frequency increased with severity and younger age. Importantly, lung ultrasound demonstrated the highest rate of detection. Our findings suggest that PE is a relatively common finding in dengue and that bedside imaging tools, such as lung ultrasound, potentially may enhance detection.

Potential role of transthoracic echocardiography for screening LV systolic dysfunction in patients with a history of dengue infection. A cross-sectional and cohort study and review of the literature.

BACKGROUND: Dengue virus can affect the cardiovascular system and men may be at higher risk of severe complications than women. We hypothesized that clinical dengue virus (DENV) infection could induce myocardial alterations of the left ventricle (LV) and that these changes could be detected by transthoracic echocardiography. METHODOLOGY/PRINCIPAL FINDINGS: We examined individuals from Acre in the Amazon Basin of Brazil in 2020 as part of the Malaria Heart Study. By questionnaires we collected information on self-reported prior dengue infection. All individuals underwent transthoracic echocardiography, analysis of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). We included 521 persons (mean age 40±15 years, 39% men, 50% urban areas) of which 253 (49%) had a history of dengue infection. In multivariable models adjusted for clinical and sociodemographic data, a history of self-reported dengue was significantly associated with lower LVEF (ß = -2.37, P < 0.01) and lower GLS (ß = 1.08, P < 0.01) in men, whereas no significant associations were found in women (P > 0.05). In line with these findings, men with a history of dengue had higher rates of LV systolic dysfunction (LVEF < 50% = 20%; GLS < 16% = 17%) than those without a history of dengue (LVEF < 50% = 7%; GLS < 16% = 8%; P < 0.01 and 0.06, respectively). CONCLUSIONS/SIGNIFICANCE: The findings of this study suggest that a clinical infection by dengue virus could induce myocardial alterations, mainly in men and in the LV, which could be detected by conventional transthoracic echocardiography. Hence, these results highlight a potential role of echocardiography for screening LV dysfunction in participants with a history of dengue infection. Further larger studies are warranted to validate the findings of this study.

Cardiac evaluation in adults with dengue virus infection by serial echocardiography.

BACKGROUND: Dengue virus infection (DVI) is a major health problem in many parts of the world. Its manifestations range from asymptomatic infections to severe disease. Although cardiac involvement has been reported in DVI, its incidence has not yet been well established. METHODS: From July 2016 to January 2018, patients hospitalized at the Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Thailand, with dengue virus infection confirmed by positive NS1 or positive dengue immunoglobulin M findings, participated in the study. We characterized the incidence and change in cardiac function by serial echocardiography and levels of troponin-T and creatine kinase-myocardial band (CK-MB) on the day of admission, the day of defervescence, the first day of hypotension (if any), and at 2 week follow-up. RESULTS: Of the 81 patients evaluated, 6 (7.41%) exhibited elevated biomarker levels. There was no difference in clinical presentation amongst dengue fever, dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS), except for the amount of bleeding. Cardiac involvement was found in 22.2% of patients: 3 (3.70%) had left ventricular systolic dysfunction, 3 (3.70%) had transient diastolic dysfunction, 6 (7.41%) had increased levels of at least one cardiac biomarker (troponin-T or CK-MB), and 6 (7.41%) had small pericardial effusion. Myocarditis was suspected in only two patients (with DHF); thus, myocarditis was uncommon in patients with dengue virus infection. Three patients developed DSS during admission and were transferred to the intensive care unit. CONCLUSION: Cardiac involvement in adults with dengue infection was common, ranging from elevated cardiac biomarker to myocarditis. Abnormalities in cardiac function had resolved spontaneously by the day of follow-up, without specific treatment. We found that DHF was a significant risk factor for cardiac involvement. Echocardiography is the investigation of choice for evaluating the haemodynamic status of patients with DVI, especially in severe dengue.

Lung Ultrasound Findings of Patients with Dengue Infection: A Prospective Observational Study.

Lung ultrasound (LUS) is a more sensitive method of detecting pathological pulmonary changes than chest X-ray. Therefore, LUS for patients with dengue could be an important tool for the early detection of pleural effusions and pulmonary edema signifying capillary plasma leakage, which is the hallmark of severe dengue pathophysiology. We conducted a prospective observational study of pulmonary changes identifiable with LUS in dengue patients admitted to the Hospital for Tropical Diseases in Mahidol University, Bangkok, and the Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand. The LUS findings were described according to standard criteria, including the presence of A, B1, B2, and C patterns in eight chest regions and the presence of pleural effusions. From November 2017 to April 2018, 50 patients with dengue were included in the study. LUS was performed during the febrile phase for nine patients (18%) and during the critical-convalescence phase for 41 patients (82%). A total of 33 patients (66%) had at least one abnormality discovered using LUS. Abnormal LUS findings were observed more frequently during the critical-convalescence phase (N = 30/41; 73%) than during the febrile phase (N = 3/9; 33%) (P = 0.047). Abnormal aeration patterns were observed in 31 patients (62%). Only B patterns with only multiple B lines were observed in 21 patients (42%); of these patients, three had already exhibited B patterns during the febrile phase (N = 3). C patterns (N = 10; 24%), pleural effusion (N = 10; 24%), and subpleural abnormalities (N = 11; 27%) were observed only during the critical-convalescence phase. LUS can detect signs of capillary leakage, including interstitial edema and pleural effusions, early during the course of dengue.

Anti-GM1 IgM antibody positive axonal variant of Guillain-Barre-syndrome in a pediatric patient with dengue fever.

INTRODUCTION: While children of all ages may be affected by Guillain-Barre-Syndrome (GBS), there are no reports of Dengue Fever (DF) as the preceding or concurrent infection in this age group. In addition, the presence of anti-GM1 IgM antibody, commonly seen in Multifocal Motor Neuropathy, is rarely encountered in both axonal and demyelinating variants of GBS. Moreover, only few neuromuscular ultrasound findings of the axonal variant in children were reported in the literature. CASE: Here we present a nine-year-old female who developed the classic signs, symptoms and neurophysiologic findings of axonal type of GBS during DF. She had elevated anti-GM1 IgM antibody atypical of this variant and diffusely enlarged nerves via neuromuscular ultrasound. CONCLUSION: In a pediatric patient with DF and acute flaccid paralysis, GBS should always be one of the considerations. Although rare, anti-ganglioside GM1 IgM antibody can still be found in axonal variant of GBS.

Admission ultrasonography as a predictive tool for thrombocytopenia and disease severity in dengue infection.

BACKGROUND: Ultrasound (US) is an investigation available in many acute care settings. Thrombocytopenia is a well-described complication of dengue infection and has been shown to correlate with disease severity. The purpose of this study was to assess the utility of admission ultrasonography in predicting thrombocytopenia and disease severity in patients infected with dengue virus. METHODS: Data were collected prospectively on 176 patients (male, n=86; female, n=90) admitted to the Nawaloka Hospital, Sri Lanka with dengue infection between December 2016 and August 2018. All patients had an US scan on admission and disease severity was determined using the World Health Organization 2009 classification. RESULTS: There were 106 (60.2%) cases of dengue with/without warning signs and 70 (39.8%) cases of severe dengue. Patients with an abnormal US on admission were more likely to have severe dengue. Gallbladder wall thickening was the most common US abnormality. Abnormal US findings significantly correlated with more pronounced thrombocytopenia from day 2 of admission. CONCLUSIONS: An abnormal US scan on admission can aid in identification of patients at risk of developing severe dengue and can be used as a novel clinical tool to identify patients at risk of severe thrombocytopenia.

Spectrum of cardiac involvement in patients with dengue fever.

BACKGROUND: Dengue fever (DF) is an infectious disease of viral origin common in the tropics. Studies on a large number of patients with dengue infection to assess associated cardiac involvement are rare. METHODS: We analyzed the incidence and spectrum of cardiac abnormalities in 320 patients with dengue fever admitted to our hospital located in an endemic area for dengue infection. All patients were evaluated following the WHO guidelines. Those confirmed to have dengue infection by serology had detailed clinical evaluation, 12­lead electrocardiography (ECG), assay for cardiac markers (troponin T, CK-MB, NT Pro BNP) and 2-D echocardiography. RESULTS: Among the 320 patients selected for the study 112 (35%) had changes of cardiac involvement as detected by investigations. Changes in ECG were seen in all of them. Sinus bradycardia in spite of fever was the most common abnormality (n = 63;19.7%). Forty-two (13.1%) patients had left ventricular ejection fraction less than 40%. Forty-eight patients (15%) had increased serum levels of troponin-T. Serum levels of CK-MB were elevated in 34 (10.6%) and serum levels of NT-pro BNP was increased in 19 (5.9%). Fourteen patients died and all of them had abnormalities in electrocardiogram, echocardiogram and serum markers. CONCLUSION: Our study reveals that cardiac involvement in patients with dengue infection is not uncommon. We found that ECHO or ECG abnormalities or elevated serum levels of markers of cardiac injury are predictors of risk for adverse outcome. Absence of these abnormalities has a 100% negative predictive value.

Ultrasound findings of plasma leakage as imaging adjunct in clinical management of dengue fever without warning signs.

INTRODUCTION: Plasma leakage is a major cause of morbidity and mortality in dengue fever. Few studies have shown the sensitivity of thoracoabdominal ultrasound in detecting plasma leakage in severe dengue, however its sensitivity in the early presentation of dengue fever without warning signs remains unknown. This study is aimed to determine the role of serial ultrasound in order to detect plasma leakage in dengue fever without warning signs. METHODS: This prospective cohort study was conducted at Hospital Universiti Sains Malaysia (USM) from 1st October 2016 to 30th November 2017. Serial bedside ultrasound procedures were performed for 83 patients who were diagnosed as having dengue fever without warning signs and were initially treated as outpatients. Ultrasonography evidence of plasma leakage either pleural effusion, thickened gallbladder wall, ascites or pericardial effusion were compared with clinical findings and laboratory parameters for plasma leakage. RESULTS: Of the 83 dengue patients, eventually 72.3% had dengue fever with warning signs and 6.0% had severe dengue fever. There were 38 patients who had subclinical plasma leakage at initial presentation, 84.2% and 7.9% of them then progressed to dengue fever with warning signs and severe dengue respectively. There was a minimal agreement between serial bedside ultrasound and haematocrit level in the detection of plasma leakage (observed kappa 0.135). CONCLUSIONS: Serial bedside ultrasound is an adjunct procedure to physical examination and may detect plasma leakage earlier compared to haemoconcentration. The early usage of serial ultrasound is of paramount importance in detecting dengue patients who are at risk of progressing to severe dengue.

Pattern Recognition Approach to Brain MRI Findings in Patients with Dengue Fever with Neurological Complications.

BACKGROUND AND PURPOSE: Dengue can present with variable neurological complications including encephalitis, encephalopathy, acute disseminated encephalomyelitis (ADEM), and ischemic and hemorrhagic stroke. Our study describes a pattern-based approach to recognize different brain MRI findings in dengue-seropositive patients with neurological symptoms. MATERIALS AND METHODS: Thirty-six serologically proven dengue patients with neurological symptoms and undergoing brain MRI over a 6-month period were included in this study. The diagnosis of dengue encephalopathy or encephalitis was established by presence of signs/symptoms of acute encephalitic syndrome with the presence of Immunoglobin M (IgM) antibody against dengue antibody in the serum and/or presence of dengue antigen (NS1) in serum. The MRI brain along with diffusion weighted imaging and susceptibility weighted imaging sequences were evaluated by an experienced neuroradiologist. RESULTS: Eleven patients had normal MRI finding. In the rest 25 patients, 12 were found to have encephalitic pattern, 4 had encephalopathic (seizure related/metabolic) pattern, 3 had features of ADEM, and isolated micro- or macro-hemorrhages were found in 6 patients. In the encephalitis group, eight had concomitant involvement of brainstem, cerebellum, and ganglio-thalamic complexes with additional involvement of cortex and subcortical white matter (WM) found in three. Isolated brainstem and cerebellar involvement were seen in three in this group, whereas one had isolated cerebellar involvement. Interspersed hemorrhage was noted in the structures involved in eight patients in encephalitis group. CONCLUSION: Radiologists should be aware of various MRI brain findings in dengue and a pattern recognition approach often helps in reaching the correct diagnosis albeit after exclusion of other differentials based on laboratory studies.

Case Report: Acute Vision Loss in a Young Returning Traveler with Dengue Fever.

Ocular complications are rare in patients with dengue fever, but may cause permanent loss of vision. We present the case of a 29-year-old German woman who developed severe acute vision loss because of dengue-associated maculopathy after traveling to Vietnam and Cambodia. Initially, the optical coherence tomography showed detachment of the retinal pigment epithelium, a central shift in the retinal pigmentation and intraretinal cysts. The patient was hospitalized and treated with a short course of intravenous prednisolone. Vision improved, and the patient showed full recovery at 9 months after the onset. This case highlights the importance of awareness and adequate management for ocular involvement in patients with dengue fever, including travelers.

Precursors to non-invasive clinical dengue screening: Multivariate signature analysis of in-vivo diffuse skin reflectance spectroscopy on febrile patients in Malaysia.

Dengue diagnostics have come a long way. Attempts at breaking away from lab-oriented dengue detection, such as NS1 antigen, IgM or IgG antibodies detection have extensively received numerous coverage. As a result, rapid detection tests (RDTs) have started to gain inroads in medical practice. Rapid detection tests notwithstanding, analysis of blood serum is still a relatively complicated task. This includes the necessity of phlebotomy, centrifugation for blood serum, and other reagent-based tests. Therefore, a non-invasive method of dengue detection was considered. In this study, we present the utility of diffuse reflectance skin spectroscopy (bandwidth of 200-2500nm) on the forearm during the triaging period for dengue screening potential. This is performed with multivariate analysis of 240 triaged febrile/suspected dengue patients. The data is then scrutinized for its clinical validity to be included as either confirmed or probable dengue, or a control group. Based on discriminant analysis of several data normalization models, we can predict the patients' clinical dengue-positivity at ranges of accuracy between ~93-98% depending on mode of the data, with a probably optimal sensitivity and specificity to the clinical diagnosis of ~89% and ~100% respectively. From the outcomes of this study, we recommend further trials with cautious optimism. With these findings, it is hoped that the elusive non-invasive detection of tropical diseases may gain platform in the near future.

Panophthalmitis in a patient with dengue fever.

Dengue fever is known for its life-threatening complications of bleeding and capillary leak syndrome. We report an unusual complication of dengue fever causing panophthalmitis, leading to rapidly progressive painful visual loss within days. Later on, the patient developed secondary bacterial infection of the eyeball and developed multiple brain abscesses due to spread of infection from the eyeball. Culture from pus swab of the right eye grew Staphylococcus epidermidis. The patient was promptly treated with broad spectrum antibiotics and after stabilisation, evisceration of the affected eye was done. Supportive therapy in the form of mechanical ventilation in view of poor sensorium, platelet transfusions for thrombocytopenia and guided fluid therapy was also provided. After multiple challenges in the management of the patient, fortunately, the patient survived but we failed to save his right eye. Therefore, it is necessary to carefully examine all vital organs at an early stage to prevent unfortunate outcome.