Clinical presentation of dengue among patients admitted to the adult emergency department of a tertiary care hospital in Martinique: implications for triage, management, and reporting.

STUDY OBJECTIVE: During dengue epidemics, emergency physicians face large numbers of patients with acute febrile illness. Triage algorithms and appropriate reporting systems are useful to manage patients and prioritize resources. We identify possible adaptations to these systems to improve the management of patients during epidemics. METHODS: In a prospective observational study in the adult emergency department (ED) of a tertiary care hospital, we enrolled all patients with febrile illness and a confirmed diagnosis of dengue (ribonucleic acid identification). We then retrospectively classified cases according to the initial clinical presentation at the ED. RESULTS: We enrolled 715 patients (332 male patients), aged 14 to 91 years (median 35 years). Severe illness was documented in 332 cases (46.4%) and was mostly caused by serotype 2, or a secondary infection of any serotype. Severe forms included dengue hemorrhagic fever or dengue shock syndrome (104/332; 31.3%), severe bleeding (9/332; 2.7%), and acute organ failure (56/332; 16.9%). The other patients with severe illness (171/332; 51.5%) presented with symptoms of presyncope, intense weakness, prolonged gastrointestinal symptoms, and hypotension. This presentation was common during epidemics and appeared to be associated with dehydration and electrolyte loss that improved markedly within 24 hours with saline solution infusion. This group did not have evidence of plasma leakage, although similar features were observed in patients with dengue hemorrhagic fever/dengue shock syndrome. CONCLUSION: Dengue has a wide range of clinical presentations in the ED. Many patients who appear seriously ill on presentation will respond to intravenous fluids.

Prospective observational study of low thresholds for platelet transfusion in adult dengue patients.

BACKGROUND: The practice of platelet (PLT) transfusions has been adopted into the standard clinical practice in many dengue-endemic countries. Because many patients were found to have received unnecessary PLT transfusions, the development of guidelines for the management of dengue patients with thrombocytopenia has become a necessity. STUDY DESIGN AND METHODS: An emergency department-based prospective observational study was conducted in Martinique during a dengue outbreak in adult patients presenting with an acute febrile illness. Patients with severe bleeding and/or who underwent invasive intensive care procedures or emergency surgery were given PLT transfusion to achieve PLT counts of more than 50 x 10(9)/L. PLT transfusion was also considered for patients with PLT counts of less than 5 x 10(9)/L and for those with associated risk factors and PLT counts of less than 20 x 10(9)/L. RESULTS: A total of 350 patients were admitted with confirmed dengue infections. Most of them had secondary serotype-2 infections. PLT counts of less than 50 x 10(9)/L were recorded in 165 patients (47.1%). PLT transfusion was administered to 9 patients with thrombocytopenia. The indications included severe bleeding (5 cases), invasive procedures (3 cases), emergency surgery (1 case), and/or associated risk factors (2 cases). The median time duration from the onset of fever to PLT transfusion was 6 days (range, 4-10 days). The median amount of PLTs transfused was 3.66 x 10(11) (range, 2.8 x 10(11)-13.2 x 10(11)). The median PLT yield was +12.4% (range, -3.9% to +67.1%). Three patients died. All other patients recovered during the second week after the onset of fever. CONCLUSION: A restrictive strategy for PLT transfusion based on clinical features and low PLT count thresholds proved to be feasible and safe for adult dengue patients.

Multiple cerebral infarctions following a snakebite by Bothrops caribbaeus.

Bothrops caribbaeus, a species of the Bothrops complex, is found only in the island of Saint Lucia, West Indies. Snakebite from this pitviper is very rare. We report the case of a healthy 32-year-old Saint Lucian man who developed multiple cerebral infarctions following envenoming by this snake. This patient developed signs and symptoms very similar to those observed in patients envenomed by Bothrops lanceolatus, a snake found only in Martinique, the neighbor island of Saint Lucia. This clinical presentation differs dramatically from coagulopathies and systemic bleeding observed with the Central and South American bothropic envenomings. The exact mechanism of this thrombogenic phenomenon, leading to a unique envenoming syndrome, remains unknown.

Relationship between nonstructural protein 1 detection and plasma virus load in Dengue patients.

We report data from a prospective observational study performed in Martinique during a co-epidemic of dengue virus serotype 2 (DENV-2) and serotype 4 (DENV-4). Among 70 serum samples from patients with DENV-2 (n = 21) or DENV-4 (n = 49) infections, 47 (67.1%) were positive for dengue nonstructural protein 1 (NS1). Antigenemia correlated with plasma virus load and was independent of immune status and the time of sampling. Increased viremia 4-6 days after onset of illness was associated with NS1 positivity, secondary infection, and severe disease. Testing for NS1 could help identify the potentially most severely ill patients during the critical phase of dengue.

Predictors of severe manifestations in a cohort of adult dengue patients.

BACKGROUND: Key symptoms observed during the febrile phase of dengue may identify patients who are likely to progress to severe disease. OBJECTIVES: To test this hypothesis, we examined the relationships between symptoms reported by patients at presentation and the development of severe outcomes. STUDY DESIGN: Retrospective analysis of data recorded prospectively in 560 adult dengue patients admitted to an emergency department. A logistic regression analysis was used to quantify the association between symptoms reported at presentation and outcome. RESULTS: Plasma leakage was observed in 95 patients (17%), severe thrombocytopenia (platelet counts <20 x 10(9)/L) in 93 patients (16.6%) and acute hepatitis in 42 patients (7.5%). Severe thrombocytopenia developed in 57% of patients with plasma leakage and 40.5% of patients with hepatitis. Patients who developed a plasma leakage syndrome were older, mainly male, and reported more often an abdominal pain and a cough. Diarrhea and taking paracetamol >60 mg/kg/day before admission were associated with the development of acute hepatitis. Seven patients died. The mortality rate was 6/95 (6.3%) in patients who developed plasma leakage, 3/42 (7.1%) in patients who developed hepatitis, 5/93 (5.4%) in patients with severe thrombocytopenia, and 3/12 (25%) in the patients who demonstrated together all these severe manifestations. CONCLUSION: Plasma leakage, severe thrombocytopenia and acute hepatitis identified subgroups of adult dengue patients with increased mortality rates. Key symptoms reported by the patients at presentation such as abdominal pain, cough or diarrhea were significantly associated with the development of severe manifestations and should be considered as warning signs.

Influence of the dengue serotype, previous dengue infection, and plasma viral load on clinical presentation and outcome during a dengue-2 and dengue-4 co-epidemic.

Martinique experienced a dengue outbreak with co-circulation of DENV-2 and DENV-4. In an emergency department-based study, we analyzed whether the clinical presentation and outcome of adult patients were related to serotype, immune status, or plasma viral load. Of the 146 adult patients who had confirmed dengue infection, 91 (62.3%) were classified as having classic dengue fever, 11 (7.5%) fulfilled World Health Organization criteria for dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS), 21 other patients (14.4%) presented with at least one typical feature of DHF/DSS [i.e., internal hemorrhage, plasma leakage, marked thrombocytopenia (platelet count < or = 50,000 platelets/mm(3)) and/or shock], and 23 further patients (15.8%) had unusual manifestations. Four patients died. Severe illness was more frequent in patients with secondary dengue infection (odds ratio, 7.18; 95% confidence interval, 3.1-16.7; P < 0.001). Multivariate regression analysis showed that gastrointestinal symptoms and other unusual manifestations were independently associated with DENV-2 infection, whereas cough and DHF/DSS features were independently associated with secondary immune response. A high plasma viral load was associated with DENV-2 infection, increased serum liver enzymes, and with DHF/DSS features in patients presenting after the third day of illness. The most severe cases of dengue resulted from the combined effects of DENV-2 and secondary infection.