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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 215-216

Dengue fever in children-identify the devils hidden

1 Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Pediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission01-Sep-2021
Date of Acceptance06-Sep-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Dr. Ramachandran Rameshkumar
Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcc.jpcc_76_21

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How to cite this article:
Rameshkumar R, Bhowmick R. Dengue fever in children-identify the devils hidden. J Pediatr Crit Care 2021;8:215-6

How to cite this URL:
Rameshkumar R, Bhowmick R. Dengue fever in children-identify the devils hidden. J Pediatr Crit Care [serial online] 2021 [cited 2021 Oct 16];8:215-6. Available from: http://www.jpcc.org.in/text.asp?2021/8/5/215/326871

Dengue fever is one of the most important tropical diseases that pose an enormous burden on the health system, especially in India.[1] Worldwide, annually, almost 390 million people get affected by the dengue virus, and nearly 20000 patients succumb due to this illness.[2] According to the National Vector Borne Disease Control Programme data, 39419 cases and 56 deaths due to dengue have been reported from India in 2020. The spectrum of illness can vary from dengue fever, dengue with warning signs, and severe dengue. Abdominal tenderness or persistent pain, vomiting, mucosal bleeding, fluid accumulation, lethargy or restlessness, hepatomegaly, and an elevated hematocrit concurrent with the rapid decrease in the platelet count are the warning signs seen in pediatric patients.

Warning signs can help diagnose the severity of illness, but during dengue epidemics, these signs may increase unnecessary admissions.[3] Plasma leakage, one of the warning signs, can manifest as a late phenomenon or sometimes became difficult to detect in small children. Manifestation of plasma leakage leading to clinical fluid accumulation such as ascites and pleural effusion can be a marker of disease progression.[4] A meta-analysis in the past has been conducted to address the variability of presentation.[5] Plasma leakage, one of the warning signs, can manifest as a late phenomenon or sometimes became difficult to detect in small children. During the current pandemic, where the health-care system is under enormous pressure, timely and appropriate identification of risk factors to predict the severity of dengue illness is of paramount importance.

In the current issue of Journal of Pediatric Critical Care, Naaraayan and Sundar[6] conducted a nested case − control study to identify the risk factors of severe dengue. The author, identifying the risk factors pertinent to our population can help transfer suitable patients to a referral hospital with pediatric intensive care units or manage patients in high-dependency units in a busy government hospital accordingly. They found that out of 370 children, 192 (51.9%) had dengue without warning signs and 168 (45.4%) had dengue with warning signs. The prevalence of severe dengue was 2.7% (95% confidence interval, 1.3%–4.9%), which corroborated with the lower end of the broad spectrum found in a recently conducted systemic review.[7] Abdominal pain or tenderness, facial puffiness, hepatomegaly, and pleural effusion are identified as the risk factors of severe dengue comparable to previous studies on this topic.[8],[9],[10],[11] A study conducted by Jayarajah et al. found low white blood cell count as an additional risk factor in children.[12] The authors highlighted the low sample size and shock as the only severe form of dengue as the limitations of this study. However, the robustness of the nested case − control study was highly admirable.

In the current era of the COVID-19 pandemic, a high index of suspicion needs to be considered to identify one of our old tropical enemies such as dengue fever. Modern medicine shows the domain of biomarkers, hence novel biomarkers relevant to dengue viral infection, point of care testing including ultrasound to detect early pleural effusion/ascites, and the clinical and laboratory parameters are the road ahead identify the risk factors of severe dengue. The multicentric study involving a large sample on risk factors, outcome, and biomarkers is the road ahead to decrease mortality related to pediatric dengue.


We acknowledge the contribution of Mrs. S. Raja Deepa B.Com, MCA (JIPMER Campus, Puducherry, India) review and editing of the manuscript.

  References Top

Murhekar MV, Kamaraj P, Kumar MS, Khan SA, Allam RR, Barde P, et al. Burden of dengue infection in India, 2017: A cross-sectional population based serosurvey. Lancet Glob Health 2019;7:e1065-73.  Back to cited text no. 1
Stanaway JD, Shepard DS, Undurraga EA, Halasa YA, Coffeng LE, Brady OJ, et al. The global burden of dengue: An analysis from the global burden of disease study 2013. Lancet Infect Dis 2016;16:712-23.  Back to cited text no. 2
Barniol J, Gaczkowski R, Barbato EV, da Cunha RV, Salgado D, Martínez E, et al. Usefulness and applicability of the revised dengue case classification by disease: Multi-centre study in 18 countries. BMC Infect Dis 2011;11:106.  Back to cited text no. 3
Sreenivasan P, Geetha S, Sssikala K. Development of a prognostic prediction model to determine severe dengue in children. Indian J Pediatr 2018;85:433-9.  Back to cited text no. 4
Huy NT, Van Giang T, Thuy DH, Kikuchi M, Hien TT, Zamora J, et al. Factors associated with dengue shock syndrome: A systematic review and meta-analysis. PLoS Negl Trop Dis 2013;7:e2412.  Back to cited text no. 5
Naaraayan SA, Sundar KC. Risk factors of severe dengue in children – A nested case control study. J Pediatr Crit Care 2021;8:224-8.  Back to cited text no. 6
  [Full text]  
Ganeshkumar P, Murhekar MV, Poornima V, Saravanakumar V, Sukumaran K, Anandaselvasankar A, et al. Dengue infection in India: A systematic review and meta-analysis. PLoS Negl Trop Dis 2018;12:e0006618.  Back to cited text no. 7
Zhang H, Zhou YP, Peng HJ, Zhang XH, Zhou FY, Liu ZH, et al. Predictive symptoms and signs of severe dengue disease for patients with dengue fever: A meta-analysis. Biomed Res Int 2014;2014:359308.  Back to cited text no. 8
Majumdar I, Mukherjee D, Kundu R, Niyogi P, Das J. Factors affecting outcome in children with dengue in Kolkata. Indian Pediatr 2017;54:778-80.  Back to cited text no. 9
Pothapregada S, Kamalakannan B, Thulasingham M. Risk factors for shock in children with dengue fever. Indian J Crit Care Med 2015;19:661-4.  Back to cited text no. 10
[PUBMED]  [Full text]  
Sangkaew S, Ming D, Boonyasiri A, Honeyford K, Kalayanarooj S, Yacoub S, et al. Risk predictors of progression to severe disease during the febrile phase of dengue: A systematic review and meta-analysis. Lancet Infect Dis 2021;21:1014-26.  Back to cited text no. 11
Jayarajah U, Madarasinghe M, Hapugoda D, Dissanayake U, Perera L, Kannangara V, et al. Clinical and biochemical characteristics of dengue infections in children from Sri Lanka. Glob Pediatr Health 2020;7:2333794X20974207.  Back to cited text no. 12


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