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ISRN Pediatrics
Volume 2013, Article ID 845876, 6 pages
http://dx.doi.org/10.1155/2013/845876
Clinical Study
Development of Dengue Infection Severity Score
Surangrat Pongpan,1,2 Apichart Wisitwong,3 Chamaiporn Tawichasri,4
Jayanton Patumanond,5 and Sirianong Namwongprom6
1
Program in Clinical Epidemiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
Department of Occupational Medicine, Phrae Hospital, Phrae 54000, Thailand
3
Department of Social Medicine, Sawanpracharak Hospital, Nakorn Sawan 60000, Thailand
4
Clinical Epidemiology Society at Chiang Mai, Chiang Mai 50200, Thailand
5
Clinical Epidemiology Unit, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
6
Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
2
1. Introduction
Dengue infection has become an international public health
burden. Half of the world population are presently at risk
of dengue infection. Approximately 50100 million infected
cases were reported annually. Among those infected, 500000
patients had severe infection and required hospital admission; most were children. Approximately 2.5% died from the
infection [1]. The cost of care was as high as $US 2.1 billion
per year in The United States of America [2]. No specific
treatments are available except for symptomatic [3], which
are effective in early detection [4]. In patients with severe
infection, shock and hemorrhage usually follow [4, 5]. If
not treated, death may be a consequence. Early detection or
correct prognostication may avoid such severe complications
[4, 6].
ISRN Pediatrics
Table 1: Patient profiles by types of dengue infection: dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome
(DSS).
Patient profiles
Demographic
Male (, %)
Age (year)
Mode of presentation
Hepatomegaly (, %)
Headache (, %)
Myalgia (, %)
Vomiting (, %)
Cough (, %)
Abdominal pain (, %)
Rash (, %)
Pleural effusion (, %)
Petechiae (, %)
Any bleeding episodes (, %)
Hemodynamic
SBP (mmHg)
DBP (mmHg)
Pulse pressure (mmHg)
Hematological
Hematocrit (%)
Hemoglobin (g/dL)
White cell count (/L)
Lymphocytes (%)
Neutrophils (%)
Platelet (/L)
Biochemical
AST (U/L)
ALT (U/L)
PT (sec)
PTT (sec)
Case management
Inbound referral (, %)
Discharged
Alive (, %)
Outbound referral (, %)
In hospital dead (, %)
DF ( = 391)
Mean SD
DHF ( = 296)
Mean SD
DSS ( = 90)
Mean SD
value
185 (47.3)
9.5 3.4
153 (51.7)
10.1 3.1
38 (42.2)
9.0 3.5
0.888
0.903
8 (2.1)
228 (58.3)
84 (21.5)
244 (62.4)
120 (30.7)
160 (40.9)
166 (42.5)
0 (0)
27 (6.9)
73 (18.7)
26 (8.8)
145 (49.0)
30 (10.1)
216 (73.0)
94 (31.8)
181 (61.2)
132 (44.6)
20 (6.8)
26 (8.8)
80 (27.0)
55 (61.1)
35 (38.9)
12 (13.3)
56 (62.2)
32 (35.6)
60 (66.7)
26 (28.9)
34 (37.8)
14 (15.6)
51 (56.7)
<0.001
<0.001
0.001
0.187
0.425
<0.001
0.124
<0.001
0.016
<0.001
97.0 9.2
58.4 7.7
33.1 6.7
96.9 10.1
58.2 8.6
32.1 7.6
91.3 10.3
58.6 8.4
24.0 7.7
<0.001
0.084
<0.001
38.8 4.5
12.7 1.5
3748.0 1706.5
44.9 17.3
44.7 18.8
122693.6 9763.9
40.5 4.8
13.4 1.5
4271.3 1821.8
40.8 15.7
49.5 18.1
81869.0 7975.7
42.4 5.4
14.1 1.8
5479.3 2063.4
40.0 16.3
48.9 17.6
50481.5 6262.9
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
126.7 313.7
60.1 216.1
12.0 1.5
30.4 5.4
269.0 457.1
95.0 271.7
12.1 1.8
42.0 10.0
558.9 659.0
219.8 413.2
15.5 9.5
44.7 12.3
<0.001
0.001
0.012
0.004
43 (11.0)
78 (26.4)
48 (53.3)
<0.001
391 (100.0)
0 (0)
0 (0)
296 (100.0)
0 (0)
0 (0)
88 (97.8)
2 (2.2)
0 (0)
1.000
ISRN Pediatrics
3
Table 2: Significant predictors of dengue infection severity and assigned item scores.
Predictors
Age (year)
Hepatomegaly
Hematocrit (%)
SBP (mmHg)
White cell count (/L)
Platelet (/L)
Category
>6
6
Yes
No
40
<40
<90
90
>5000
5000
50000
>50000
OR
1.46
12.31
1.34
1.70
1.40
3.95
95% CI
1.121.91
Ref
8.8417.15
Ref
1.101.64
Ref
1.322.17
Ref
1.131.75
Ref
3.144.96
Ref
value
Coefficient
0.005
0.38
<0.001
2.51
0.003
0.30
<0.001
0.53
0.002
0.34
<0.001
1.37
Score
1
0
8.5
0
1
0
2
0
1
0
4.5
0
Coefficients from multivariable ordinal logistic regression. OR: odds ratio; CI: confidence interval; ref: reference category; SBP: systolic blood pressure.
Table 3: Severity score levels, severity levels, and risk estimation validity.
Severity score levels
Mean SD
IQR
DF ( = 451)
DHF ( = 276)
DSS ( = 50)
Score range
<2.5
2.511.5
>11.5
DF ( = 391)
3.6 2.1
2.04.8
297
94
0
Severity levels
DHF ( = 296)
5.1 3.2
3.85.8
149
136
11
DSS ( = 90)
11.0 4.1
6.813.3
5
46
39
Total
12.1
1.4
13.5
38.2
17.5
5.0
60.7
19.8
5.9
25.7
ISRN Pediatrics
(i) rapid and weak pulse,
(ii) pulse pressure 20 mmHg,
or manifested by
(i) hypotension,
(ii) cold body temperature or irritable.
3. Results
A total of 777 patients with dengue infection were classified
based on the above criteria into 3 severity levels: DF ( =
391), DHF ( = 296), and DSS ( = 90).
3.1. Significant Predictors. Under the univariable analysis, the
three severity groups were similar in gender ( = 0.888), age
( = 0.903), presence of vomiting ( = 0.187), cough ( =
0.425), rash ( = 0.124), and DBP ( = 0.084) but were difference according to the presence of hepatomegaly, headache,
myalgia, abdominal pain, pleural effusion, petechiae, bleeding episodes, SBP, pulse pressure, hematocrit, hemoglobin,
white cell count, lymphocytes, neutrophils, platelets, AST,
ALT, PT, and PTT (Table 1).
Under the multivariable analysis, the clinical characteristics with significant predictive ability for dengue severity
included age > 6 years (OR = 1.46, 95% CI = 1.121.91, =
4. Discussions
Dengue infection is an urgent condition requiring prompt
diagnosis and treatment before patients enter into bleeding
or shock states. Previous scoring systems trying to evaluate or
forecast disease severity included the Dengue Fever Scoring
System based on epidemiological information and clinical
signs or symptoms, which might be useful in detecting
DF very early prior to laboratory results [25]. Other scoring systems were the Pediatric Logistic Organ Dysfunction
(PELOD) Score and the Pediatric Risk of Mortality III
(PRISM III), used to evaluate the mortality rates [26], and
the Disseminate Intravascular Coagulation (DIC) Score to
diagnose DIC and to discriminate DF and DHF from other
febrile illnesses [27].
ISRN Pediatrics
5
nonroutine predictors were not available in many primary
care centers. An investment on such facilities may not be
feasible and may not be cost effective.
Our study developed a scoring system based on clinical risk and routine laboratory parameters and categorized
patients with dengue infection into DF, DHF, or DSS.
DSS
DHF
DF
10
12
14
16
18
20
Probability
0.8
DF
0.6
DHF
0.4
DSS
0.2
0
0
10
12
14
16
18
20
5. Conclusions
The derived dengue infection severity score classified patients
into DF, DHF, or DSS, correctly into their original severity
levels. Validation of the score should be reconfirmed before
application into routine practice.
Conflict of Interests
This investigation was partially supported by the Research
Grant for Basic and Applied Sciences, the Faculty of
Medicine, Chiang Mai University.
Acknowledgments
The authors wish to thank the authorities of the three
hospitals for their support in data collection and wish to
thank the Faculty of Medicine, Chiang Mai University, for the
partial grant support.
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