TO THE EDITOR—In a recent issue of Clinical Infectious Diseases, Lam et al reported the outcome of 1719 children admitted over a 10-year period and diagnosed with dengue shock syndrome (DSS) [1]. Patients were described as having had a severe clinical presentation resulting from plasma leakage and pulse pressure ≤20 mm Hg. The definition of DSS used was the 1997 World Health Organization (WHO) definition regarding pulse pressure and hematocrit determinations. However, other diagnostic procedures, such as laboratory tests for liver and renal function, coagulation, and acidbase determination, and the detection of serous effusion by imagery, were not completed in many patients. Finally, as stated by the authors, the main inclusion
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Dengue Shock Syndrome or Dehydration? The Importance of Considering Clinical Severity When Classifying Patients With Dengue
criterion was evidence of impaired perfusion “thought by the treating clinician to be due to vascular leakage and to require volume resuscitation.” In this series, most patients recovered within a few hours with a single infusion of saline and only 8 patients died, resulting in the lowest case-fatality rate in hospitalized dengue patients ever reported in Southeast Asia [2, 3]. Although the rapidity and quality of treatment are key factors in determining the chances of recovery, one can question the representativeness of this group of patients reported as having DSS. It is reasonable to suspect that many of these patients were not actually in shock, and that many patients with a straightforward dehydration associated with the febrile phase of the disease were included in a group of patients diagnosed with a severe plasma leakage. The issue is important when it comes to the inclusion of patients in clinical trials [4]. Describing the clinical forms of dengue is difficult because of the diversity and overlapping nature of the clinical manifestations. The frequency of any given category of patients in a cohort may be confounded by selection bias, and by the misuse of medical terms such as “hemorrhage” in patients who do not have clinically significant bleeding, or “shock” in patients with transient hypotension. Based on our clinical experience of severe dengue in adults [5] and field epidemic experiences in Martinique and in Cape Verde, the 2009 WHO guideline that includes warning signs may be of value for the triage of patients by field clinicians. However, many patients with warning signs do not develop severe disease. Specifically, hypotensive patients who improve dramatically within a few hours with an infusion of saline represent a significant category of intermediate severity that do not deserve to be classified in the same group as that of patients in shock [6]. To meet the requirements of representativeness, consistency, and comparability, the description of the severe forms of dengue should include an assessment using an
internationally validated severity scoring system, such as the Simplified Acute Physiology Score [7] or the Sepsis-Related Organ Failure Assessment score [8], together with indisputable diagnostic features of plasma leakage. Note
Care Medicine. Crit Care Med 1998; 26: 1793–800. Correspondence: Laurent Thomas, MD, 4 bis rue de Le Nostre, Rouen, France ([email protected]). Clinical Infectious Diseases 2014;58(7):1038–9 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/ciu014
Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. Laurent Thomas,1 André Cabié,2 and Rémy Teyssou3
Downloaded from http://cid.oxfordjournals.org/ at University of Utah on December 1, 2014
1
Emergency Department and 2Department of Infectious Diseases and Tropical Medicine, University Hospital, Fort-de-France, Martinique; and 3Partnership for Dengue Control, Fondation Meyrieux, Lyon, France
References 1. Lam PK, Tam DT, Diet TV, et al. Clinical characteristics of dengue shock syndrome in Vietnamese children: a 10-year prospective study in a single hospital. Clin Infect Dis 2013; 57:1577–86. 2. Anders KL, Nguyet NM, Chau NV, et al. Epidemiological factors associated with dengue shock syndrome and mortality in hospitalized dengue patients in Ho Chi Minh City, Vietnam. Am J Trop Med Hyg 2011; 84:127–34. 3. World Health Organization Regional Office for South-East Asia. Comprehensive guideline for prevention and control of dengue and dengue haemorrhagic fever. World Health Organization, 2011. 4. Halstead SB. Dengue: the syndromic basis to pathogenesis research. Inutility of the 2009 WHO case definition. Am J Trop Med Hyg 2013; 88:212–5. 5. Thomas L, Brouste Y, Najioullah F, et al. Predictors of severe manifestations in a cohort of adult dengue patients. J Clin Virol 2010; 48:96–9. 6. Thomas L, Moravie V, Besnier F, et al. 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. Ann Emerg Med 2012; 59:42–50. 7. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993; 270:2957–63. 8. Vincent JL, de Mendonça A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive
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Dengue Shock Syndrome or Dehydration? The Importance of Considering Clinical Severity When Classifying Patients With Dengue
criterion was evidence of impaired perfusion “thought by the treating clinician to be due to vascular leakage and to require volume resuscitation.” In this series, most patients recovered within a few hours with a single infusion of saline and only 8 patients died, resulting in the lowest case-fatality rate in hospitalized dengue patients ever reported in Southeast Asia [2, 3]. Although the rapidity and quality of treatment are key factors in determining the chances of recovery, one can question the representativeness of this group of patients reported as having DSS. It is reasonable to suspect that many of these patients were not actually in shock, and that many patients with a straightforward dehydration associated with the febrile phase of the disease were included in a group of patients diagnosed with a severe plasma leakage. The issue is important when it comes to the inclusion of patients in clinical trials [4]. Describing the clinical forms of dengue is difficult because of the diversity and overlapping nature of the clinical manifestations. The frequency of any given category of patients in a cohort may be confounded by selection bias, and by the misuse of medical terms such as “hemorrhage” in patients who do not have clinically significant bleeding, or “shock” in patients with transient hypotension. Based on our clinical experience of severe dengue in adults [5] and field epidemic experiences in Martinique and in Cape Verde, the 2009 WHO guideline that includes warning signs may be of value for the triage of patients by field clinicians. However, many patients with warning signs do not develop severe disease. Specifically, hypotensive patients who improve dramatically within a few hours with an infusion of saline represent a significant category of intermediate severity that do not deserve to be classified in the same group as that of patients in shock [6]. To meet the requirements of representativeness, consistency, and comparability, the description of the severe forms of dengue should include an assessment using an
internationally validated severity scoring system, such as the Simplified Acute Physiology Score [7] or the Sepsis-Related Organ Failure Assessment score [8], together with indisputable diagnostic features of plasma leakage. Note
Care Medicine. Crit Care Med 1998; 26: 1793–800. Correspondence: Laurent Thomas, MD, 4 bis rue de Le Nostre, Rouen, France ([email protected]). Clinical Infectious Diseases 2014;58(7):1038–9 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/ciu014
Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. Laurent Thomas,1 André Cabié,2 and Rémy Teyssou3
Downloaded from http://cid.oxfordjournals.org/ at University of Utah on December 1, 2014
1
Emergency Department and 2Department of Infectious Diseases and Tropical Medicine, University Hospital, Fort-de-France, Martinique; and 3Partnership for Dengue Control, Fondation Meyrieux, Lyon, France
References 1. Lam PK, Tam DT, Diet TV, et al. Clinical characteristics of dengue shock syndrome in Vietnamese children: a 10-year prospective study in a single hospital. Clin Infect Dis 2013; 57:1577–86. 2. Anders KL, Nguyet NM, Chau NV, et al. Epidemiological factors associated with dengue shock syndrome and mortality in hospitalized dengue patients in Ho Chi Minh City, Vietnam. Am J Trop Med Hyg 2011; 84:127–34. 3. World Health Organization Regional Office for South-East Asia. Comprehensive guideline for prevention and control of dengue and dengue haemorrhagic fever. World Health Organization, 2011. 4. Halstead SB. Dengue: the syndromic basis to pathogenesis research. Inutility of the 2009 WHO case definition. Am J Trop Med Hyg 2013; 88:212–5. 5. Thomas L, Brouste Y, Najioullah F, et al. Predictors of severe manifestations in a cohort of adult dengue patients. J Clin Virol 2010; 48:96–9. 6. Thomas L, Moravie V, Besnier F, et al. 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. Ann Emerg Med 2012; 59:42–50. 7. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993; 270:2957–63. 8. Vincent JL, de Mendonça A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive
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