Int J Clin Pediatr

International Journal of Clinical Pediatrics, ISSN 1927-1255 print, 1927-1263 online, Open Access

Article copyright, the authors; Journal compilation copyright, Int J Clin Pediatr and Elmer Press Inc

Journal website http://www.theijcp.org

Original Article

Volume 2, Number 1, June 2013, pages 12-18

Prognostic Indicators for Dengue Infection Severity

**Table 1.** Grading Dengue Infection Severity (Modified WHO 1997)
DF/DHF	Grade	Symptoms	Laboratory
DF: dengue fever; DHF: dengue hemorrhagic fever; Modified WHO criteria; *DHF Grade III and IV are also called as dengue shock syndrome (DSS).
DF*		Fever with two or more of the following signs: headache, retro-orbital pain, myalgia, arthralgia plus positive tourniquet test	Leucopenia occasionally Thrombocytopenia, may be present, no evidence of plasma loss
DHF	I	Above signs plus positive tourniquet test	Thrombocytopenia ≤ 100,000/µL, hematocrit rise ≥ 20%
DHF	II	Above signs plus spontaneous bleeding	Thrombocytopenia ≤ 100,000/µL, hematocrit rise ≥ 20%
DHF	III**	Above signs plus circulatory failure (weak pulse, hypotension, restlessness)	Thrombocytopenia ≤ 100,000/µL, hematocrit rise ≥ 20%
DHF	IV**	Profound shock with undetectable blood pressure and pulse	Thrombocytopenia ≤100,000/µL, hematocrit rise ≥ 20%

Table 1. Grading Dengue Infection Severity (Modified WHO 1997)

DF/DHF

Grade

Symptoms

Laboratory

DF: dengue fever; DHF: dengue hemorrhagic fever; *Modified WHO criteria; **DHF Grade III and IV are also called as dengue shock syndrome (DSS).

DF*

Fever with two or more of the following signs: headache, retro-orbital pain, myalgia, arthralgia plus positive tourniquet test

Leucopenia occasionally Thrombocytopenia, may be present, no evidence of plasma loss

DHF

Above signs plus positive tourniquet test

Thrombocytopenia ≤ 100,000/µL, hematocrit rise ≥ 20%

DHF

Above signs plus spontaneous bleeding

Thrombocytopenia ≤ 100,000/µL, hematocrit rise ≥ 20%

DHF

III**

Above signs plus circulatory failure (weak pulse, hypotension, restlessness)

Thrombocytopenia ≤ 100,000/µL, hematocrit rise ≥ 20%

DHF

IV**

Profound shock with undetectable blood pressure and pulse

Thrombocytopenia ≤100,000/µL, hematocrit rise ≥ 20%

**Table 2.** Demographic and Clinical Profiles by Types of Dengue Infection
Patient characteristics	DF (n = 391)	DHF (n = 296)	DSS (n = 90)	P-value*
Dengue fever (DF); dengue hemorrhagic fever (DHF); dengue shock syndrome (DSS); P-value from exact probability test or analysis of variance (ANOVA) or ANOVA by rank; *geometric mean and standard deviation (SD); SGOT: serum glutamic oxaloacetic transaminase; SGPT: serum glutamic pyruvic transaminase; PT: prothrombin time; PTT: partial thromboplastin time.
Demographic
Male (n, %)	185 (47.3)	153 (51.7)	38 (42.2)	0.247
Age (year)	9.5 ± 3.4	10.1 ± 3.1	9.0 ± 3.5	0.009
Mode of presentation
Hepatomegaly (n, %)	8 (2.1)	26 (8.8)	55 (61.1)	< 0.001
Headache (n, %)	228 (58.3)	145 (49.0)	35 (38.9)	< 0.001
Myalgia (n, %)	84 (21.5)	30 (10.1)	12 (13.3)	0.001
Vomiting (n, %)	244 (62.4)	216 (73.0)	56 (62.2)	0.009
Cough (n, %)	120 (30.7)	94 (31.8)	32 (35.6)	0.751
Abdominal pain (n, %)	160 (40.9)	181 (61.2)	60 (66.7)	< 0.001
Rash (n, %)	166 (42.5)	132 (44.6)	26 (28.9)	0.026
Pleural effusion	0 (0)	20 (6.8)	34 (37.8)	< 0.001
Petechiae (n, %)	27 (6.9)	26 (8.8)	14 (15.6)	0.039
Any bleeding episodes (n, %)	73 (18.7)	80 (27.0)	51 (56.7)	< 0.001
Hemodynamic
SBP (mmHg)	97.0 ± 9.2	96.9 ± 10.1	91.3 ± 10.3	< 0.001
DBP (mmHg)	58.4 ± 7.7	58.2 ± 8.6	58.6 ± 8.4	0.356
Pulse pressure (mmHg)	33.1 ± 6.7	32.1 ± 7.6	24.0 ± 7.7	< 0.001
Hematological
Hematocrit (%)	38.8 ± 4.5	40.5 ± 4.8	42.4 ± 5.4	< 0.001
Hemoglobin (g/dl)	12.7 ± 1.5	13.4 ± 1.5	14.1 ± 1.8	< 0.001
White cell count (/µL)**	3,348.0 ± 1.6	3,737.5 ± 1.7	4,773.4 ± 1.7	< 0.001
Lymphocytes (%)	44.9 ± 17.3	40.8 ± 15.7	40.0 ± 16.3	< 0.001
Neutrophils (%)	44.7 ± 18.8	49.5 ± 18.1	48.9 ± 17.6	< 0.001
Platelet (/µL)**	106,084.3 ± 1.8	62,533.8 ± 2.2	36,074 ± 2.3	< 0.001
Biochemical
SGOT (U/L)**	84.2 ± 2.4	158.1 ± 2.4	219.4 ± 3.7	< 0.001
SGPT (U/L)**	42.1 ± 2.3	60.6 ± 2.4	78.7 ± 3.7	0.005
PT (sec)	12.0 ± 1.5	12.1 ± 1.8	15.5 ± 9.5	0.159
PTT (sec)	30.4 ± 5.4	42.0 ± 10.0	44.7 ± 12.3	0.011
Case management
Inbound referral (n, %)	43 (11.0)	78 (26.4)	48 (53.3)	< 0.001
Discharged
Alive (n, %)	391 (100.0)	296 (100.0)	88 (97.8)	0.013
Outbound referral (n, %)	0 (0)	0 (0)	2 (2.2)	0.013
In hospital dead (n, %)	0 (0)	0 (0)	0 (0)	0.013

Table 2. Demographic and Clinical Profiles by Types of Dengue Infection

Patient characteristics

DF (n = 391)

DHF (n = 296)

DSS (n = 90)

P-value*

Mean ± SD

Dengue fever (DF); dengue hemorrhagic fever (DHF); dengue shock syndrome (DSS); *P-value from exact probability test or analysis of variance (ANOVA) or ANOVA by rank; **geometric mean and standard deviation (SD); SGOT: serum glutamic oxaloacetic transaminase; SGPT: serum glutamic pyruvic transaminase; PT: prothrombin time; PTT: partial thromboplastin time.

Demographic

Male (n, %)

185 (47.3)

153 (51.7)

38 (42.2)

0.247

Age (year)

9.5 ± 3.4

10.1 ± 3.1

9.0 ± 3.5

0.009

Mode of presentation

Hepatomegaly (n, %)

8 (2.1)

26 (8.8)

55 (61.1)

< 0.001

Headache (n, %)

228 (58.3)

145 (49.0)

35 (38.9)

< 0.001

Myalgia (n, %)

84 (21.5)

30 (10.1)

12 (13.3)

0.001

Vomiting (n, %)

244 (62.4)

216 (73.0)

56 (62.2)

0.009

Cough (n, %)

120 (30.7)

94 (31.8)

32 (35.6)

0.751

Abdominal pain (n, %)

160 (40.9)

181 (61.2)

60 (66.7)

< 0.001

Rash (n, %)

166 (42.5)

132 (44.6)

26 (28.9)

0.026

Pleural effusion

0 (0)

20 (6.8)

34 (37.8)

< 0.001

Petechiae (n, %)

27 (6.9)

26 (8.8)

14 (15.6)

0.039

Any bleeding episodes (n, %)

73 (18.7)

80 (27.0)

51 (56.7)

< 0.001

Hemodynamic

SBP (mmHg)

97.0 ± 9.2

96.9 ± 10.1

91.3 ± 10.3

< 0.001

DBP (mmHg)

58.4 ± 7.7

58.2 ± 8.6

58.6 ± 8.4

0.356

Pulse pressure (mmHg)

33.1 ± 6.7

32.1 ± 7.6

24.0 ± 7.7

< 0.001

Hematological

Hematocrit (%)

38.8 ± 4.5

40.5 ± 4.8

42.4 ± 5.4

< 0.001

Hemoglobin (g/dl)

12.7 ± 1.5

13.4 ± 1.5

14.1 ± 1.8

< 0.001

White cell count (/µL)**

3,348.0 ± 1.6

3,737.5 ± 1.7

4,773.4 ± 1.7

< 0.001

Lymphocytes (%)

44.9 ± 17.3

40.8 ± 15.7

40.0 ± 16.3

< 0.001

Neutrophils (%)

44.7 ± 18.8

49.5 ± 18.1

48.9 ± 17.6

< 0.001

Platelet (/µL)**

106,084.3 ± 1.8

62,533.8 ± 2.2

36,074 ± 2.3

< 0.001

Biochemical

SGOT (U/L)**

84.2 ± 2.4

158.1 ± 2.4

219.4 ± 3.7

< 0.001

SGPT (U/L)**

42.1 ± 2.3

60.6 ± 2.4

78.7 ± 3.7

0.005

PT (sec)

12.0 ± 1.5

12.1 ± 1.8

15.5 ± 9.5

0.159

PTT (sec)

30.4 ± 5.4

42.0 ± 10.0

44.7 ± 12.3

0.011

Case management

Inbound referral (n, %)

43 (11.0)

78 (26.4)

48 (53.3)

< 0.001

Discharged

Alive (n, %)

391 (100.0)

296 (100.0)

88 (97.8)

0.013

Outbound referral (n, %)

0 (0)

2 (2.2)

0.013

In hospital dead (n, %)

0 (0)

0.013

**Table 3.** Multivariable Odds Ratios (OR) and 95% Confidence Interval (CI) of Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS), Compared to Dengue Fever (DF)
Patient characteristics	DHF (n = 296)	DSS (n = 90)
*Odds ratio from multivariable polytomous logistic regression, compare to dengue fever (DF); PP: pulse pressure; WBC: white blood cell count.
Age > 6 year	1.85	1.35 - 2.54	< 0.001	1.80	0.95 - 3.41	0.071
Hepatomegaly	3.49	2.01 - 6.06	< 0.001	43.44	22.71 - 83.09	< 0.001
Any bleeding episodes	1.43	1.10 - 1.85	0.007	5.58	3.43 - 9.10	< 0.001
PP ≤ 20 mmHg	1.22	0.68 - 2.19	0.501	19.09	9.64 - 37.80	< 0.001
SBP < 90 mmHg	1.05	0.77 - 1.43	0.778	2.45	1.41 - 4.25	0.001
Hematocrit > 40%	1.06	0.84 - 1.34	0.600	1.88	1.16 - 3.05	0.010
WBC > 5,000/µL	1.80	1.39 - 2.33	< 0.001	2.36	1.44 - 3.86	0.001
Platelet ≤ 100,000/µL	3.72	2.97 - 4.66	< 0.001	10.60	4.98 - 22.55	< 0.001

Table 3. Multivariable Odds Ratios (OR) and 95% Confidence Interval (CI) of Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS), Compared to Dengue Fever (DF)

Patient characteristics

DHF (n = 296)

DSS (n = 90)

OR*

95%CI

P-value

OR*

95%CI

P-value

*Odds ratio from multivariable polytomous logistic regression, compare to dengue fever (DF); PP: pulse pressure; WBC: white blood cell count.

Age > 6 year

1.85

1.35 - 2.54

< 0.001

1.80

0.95 - 3.41

0.071

Hepatomegaly

3.49

2.01 - 6.06

< 0.001

43.44

22.71 - 83.09

< 0.001

Any bleeding episodes

1.43

1.10 - 1.85

0.007

5.58

3.43 - 9.10

< 0.001

PP ≤ 20 mmHg

1.22

0.68 - 2.19

0.501

19.09

9.64 - 37.80

< 0.001

SBP < 90 mmHg

1.05

0.77 - 1.43

0.778

2.45

1.41 - 4.25

0.001

Hematocrit > 40%

1.06

0.84 - 1.34

0.600

1.88

1.16 - 3.05

0.010

WBC > 5,000/µL

1.80

1.39 - 2.33

< 0.001

2.36

1.44 - 3.86

0.001

Platelet ≤ 100,000/µL

3.72

2.97 - 4.66

< 0.001

10.60

4.98 - 22.55

< 0.001