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The early clinical features of dengue in adults: challenges for early clinical diagnosis.

Low JG, Ong A, Tan LK, Chaterji S, Chow A, Lim WY, Lee KW, Chua R, Chua CR, Tan SW, Cheung YB, Hibberd ML, Vasudevan SG, Ng LC, Leo YS, Ooi EE - PLoS Negl Trop Dis (2011)

Bottom Line: Patients were followed up over a 3-4 week period to determine the clinical outcome.However, when the cases were stratified into age groups, fewer older adults reported symptoms such as myalgia, arthralgia, retro-orbital pain and mucosal bleeding, resulting in reduced sensitivity of the WHO classification schemes.On the other hand, the risks of severe dengue and hospitalization were not diminished in older adults, indicating that this group of patients can benefit from early diagnosis, especially when an antiviral drug becomes available.

View Article: PubMed Central - PubMed

Affiliation: Communicable Diseases Centre, Tan Tock Seng Hospital, Singapore, Singapore.

ABSTRACT

Background: The emergence of dengue throughout the tropical world is affecting an increasing proportion of adult cases. The clinical features of dengue in different age groups have not been well examined, especially in the context of early clinical diagnosis.

Methodology/principal findings: We structured a prospective study of adults (≥ 18 years of age) presenting with acute febrile illness within 72 hours from illness onset upon informed consent. Patients were followed up over a 3-4 week period to determine the clinical outcome. A total of 2,129 adults were enrolled in the study, of which 250 (11.7%) had dengue. Differences in the rates of dengue-associated symptoms resulted in high sensitivities when the WHO 1997 or 2009 classification schemes for probable dengue fever were applied to the cohort. However, when the cases were stratified into age groups, fewer older adults reported symptoms such as myalgia, arthralgia, retro-orbital pain and mucosal bleeding, resulting in reduced sensitivity of the WHO classification schemes. On the other hand, the risks of severe dengue and hospitalization were not diminished in older adults, indicating that this group of patients can benefit from early diagnosis, especially when an antiviral drug becomes available. Our data also suggests that older adults who present with fever and leukopenia should be tested for dengue, even in the absence of other symptoms.

Conclusion: Early clinical diagnosis based on previously defined symptoms that are associated with dengue, even when used in the schematics of both the WHO 1997 and 2009 classifications, is difficult in older adults.

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Related in: MedlinePlus

Age-group specific WBC in patients with dengue, OFI and influenza in the first 72 hours of illness.Box and whiskers (maximum and minimum) indicate the mean and spread of WBC in the different groups of patients. Dotted line indicates threshold for leukopenia (WBC<4,500 cells/µL). ***indicates p<0.0001 as determined using the Mann Whitney U test.
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pntd-0001191-g001: Age-group specific WBC in patients with dengue, OFI and influenza in the first 72 hours of illness.Box and whiskers (maximum and minimum) indicate the mean and spread of WBC in the different groups of patients. Dotted line indicates threshold for leukopenia (WBC<4,500 cells/µL). ***indicates p<0.0001 as determined using the Mann Whitney U test.

Mentions: We also observed that leukopenia was more marked with increasing age, although this difference was not statistically significant among the dengue patients in different age groups (Figure 1). However, when compared to patients with OFI and influenza in the same age groups, the difference in WBC appeared greater with increasing age (Figure 1). We thus tested if the use of leukopenia alone can differentiate dengue from OFI. Using a receiver operating characteristic (ROC) analysis, the area under the curve (AUC) values increased with age (Table 9). Likewise, the sensitivity of this test increased from 53.1% in the 18–25 year old group to 81.6% in those 56 years old and above. Specificity was over 85% in all age groups (Table 9). Significant differences in the rates of those with leukopenia were also observed across the age groups when comparing dengue and influenza patients (Figure 1). ROC analysis of platelet, neutrophil and lymphocyte counts also showed statistically significant AUC but these were all lower than WBC alone (data not shown).


The early clinical features of dengue in adults: challenges for early clinical diagnosis.

Low JG, Ong A, Tan LK, Chaterji S, Chow A, Lim WY, Lee KW, Chua R, Chua CR, Tan SW, Cheung YB, Hibberd ML, Vasudevan SG, Ng LC, Leo YS, Ooi EE - PLoS Negl Trop Dis (2011)

Age-group specific WBC in patients with dengue, OFI and influenza in the first 72 hours of illness.Box and whiskers (maximum and minimum) indicate the mean and spread of WBC in the different groups of patients. Dotted line indicates threshold for leukopenia (WBC<4,500 cells/µL). ***indicates p<0.0001 as determined using the Mann Whitney U test.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3104968&req=5

pntd-0001191-g001: Age-group specific WBC in patients with dengue, OFI and influenza in the first 72 hours of illness.Box and whiskers (maximum and minimum) indicate the mean and spread of WBC in the different groups of patients. Dotted line indicates threshold for leukopenia (WBC<4,500 cells/µL). ***indicates p<0.0001 as determined using the Mann Whitney U test.
Mentions: We also observed that leukopenia was more marked with increasing age, although this difference was not statistically significant among the dengue patients in different age groups (Figure 1). However, when compared to patients with OFI and influenza in the same age groups, the difference in WBC appeared greater with increasing age (Figure 1). We thus tested if the use of leukopenia alone can differentiate dengue from OFI. Using a receiver operating characteristic (ROC) analysis, the area under the curve (AUC) values increased with age (Table 9). Likewise, the sensitivity of this test increased from 53.1% in the 18–25 year old group to 81.6% in those 56 years old and above. Specificity was over 85% in all age groups (Table 9). Significant differences in the rates of those with leukopenia were also observed across the age groups when comparing dengue and influenza patients (Figure 1). ROC analysis of platelet, neutrophil and lymphocyte counts also showed statistically significant AUC but these were all lower than WBC alone (data not shown).

Bottom Line: Patients were followed up over a 3-4 week period to determine the clinical outcome.However, when the cases were stratified into age groups, fewer older adults reported symptoms such as myalgia, arthralgia, retro-orbital pain and mucosal bleeding, resulting in reduced sensitivity of the WHO classification schemes.On the other hand, the risks of severe dengue and hospitalization were not diminished in older adults, indicating that this group of patients can benefit from early diagnosis, especially when an antiviral drug becomes available.

View Article: PubMed Central - PubMed

Affiliation: Communicable Diseases Centre, Tan Tock Seng Hospital, Singapore, Singapore.

ABSTRACT

Background: The emergence of dengue throughout the tropical world is affecting an increasing proportion of adult cases. The clinical features of dengue in different age groups have not been well examined, especially in the context of early clinical diagnosis.

Methodology/principal findings: We structured a prospective study of adults (≥ 18 years of age) presenting with acute febrile illness within 72 hours from illness onset upon informed consent. Patients were followed up over a 3-4 week period to determine the clinical outcome. A total of 2,129 adults were enrolled in the study, of which 250 (11.7%) had dengue. Differences in the rates of dengue-associated symptoms resulted in high sensitivities when the WHO 1997 or 2009 classification schemes for probable dengue fever were applied to the cohort. However, when the cases were stratified into age groups, fewer older adults reported symptoms such as myalgia, arthralgia, retro-orbital pain and mucosal bleeding, resulting in reduced sensitivity of the WHO classification schemes. On the other hand, the risks of severe dengue and hospitalization were not diminished in older adults, indicating that this group of patients can benefit from early diagnosis, especially when an antiviral drug becomes available. Our data also suggests that older adults who present with fever and leukopenia should be tested for dengue, even in the absence of other symptoms.

Conclusion: Early clinical diagnosis based on previously defined symptoms that are associated with dengue, even when used in the schematics of both the WHO 1997 and 2009 classifications, is difficult in older adults.

Show MeSH
Related in: MedlinePlus