Singapore anticipates a record high number of dengue cases in 2016. Severe dengue due to plasma leakage, dengue hemorrhagic fever is well recognised. Advanced age and certain comorbidities may also contribute to severe presentation.
Retrospective case series/audit of all confirmed dengue cases (Dengue NS1 positive, compatible clinical presentation) admitted to our institution’s ICU in 2015. The goal is to identify areas to improve management and processes.
14 adult cases were reviewed, 93% had primary dengue. Dengue serotype was identified in 13 patients (5 serotype 1, 8 serotype 2). 8 patients were women. The median age was 52 years (range 21-79). One patient had travelled from India in the preceding two weeks. 9/14 had Charlson score of ≤ 1.
12/14 were admitted to ICU due to shock, and 8 required inotropes/vasopressors (7 received dopamine, 3 noradrenaline, 2 vasopressin). 10/14 were admitted at day 1-3 of fever. Median duration of ICU admission was 3 days (range 2-7). Cardiac involvement was seen in 6 patients (dynamic ECG changes, and/or Troponin increase) with median age 42.5 years (range 21-79). 4/6 patients had echocardiography done, and 3 had depressed systolic function. Thrombocytopenia appeared more severe in those with cardiac involvement compared with those without (mean minimum platelet count 27 vs 74.6 x 109/L). Evidence of plasma leakage was seen in 5 patients (3 patients also had cardiac involvement). Gastrointestinal bleeding occurred in 2 patients. Two patients died.
Important observations from this case series includes shock early in dengue course requiring inotropes. Although plasma leakage was observed for a proportion of cases, a number of patients (including younger patients) had signs of cardiac involvement. Cardiac involvement in dengue has been reported (transient depressed myocardial function, electrical abnormalities).
Shock in early dengue may need to be viewed and managed differently. This will need a multi-disciplinary approach, with appropriate assessment and monitoring (non-invasive methods, echocardiography, cardiac enzymes), judicious and tailored use of fluids and inotropes. Case-control studies are needed to evaluate these observations and trial various approaches.
T. H. Lee, None
L. M. Ling, None
W. Mar Kyaw, None
A. Chow, None
S. Lew, None
Y. S. Leo, None