Dengue Classiflcation: Current WHO vs.

the Newly
Suggested Classification for Better Clinical Application?
Siripen Kalayanarooj MD*
* Dengue Unit, Queen Sirikit National Institute of Child Health,
College of Medicine, Rangsit University, Bangkok, Thailand

Introduction: There has been confusion regarding the clinical classificaiion of dengue. The current WHO classification used
since the 70s classifies dengue into dengue fever (DF), dengue hemorrhagic fever (DHF), dengue shock syndrome (DSS). In
2009, a new classification of dengue proposed by WHO Tropical Disease Research (TDR) was published in the WHO TDR
2009 dengue guidelines. This new classification classifies dengue into dengue (D), dengue with warning signs (DW) and
severe dengue (SD).
Objective: To compare the effectiveness in clinical management between the current WHO classification and the newly
suggested classification (TDR) and to assess the 4 criteria of the DHF case definition of the current WHO classification for
possible modification.
Material and Method: A prospective study of suspected dengue patients admitted to the Dengue Unit. Queen Sirikit National
Institute of Child Health between June-August 2009 was done. AII cases were managed according to the Thai National Dengue
Guidelines 2008. The final diagnoses were based on the current WHO Classificaiion together with dengue laboratory
confirmation. TDR classification was applied later by the author, using the data from the present study case report forms of
each patient. Statistical analysis comparing clinical and laboratory data between each group ofpatients was done by using
SPSS version 14.
Results: Total 274 confirmed dengue patients and 24 non-dengue febrile illnesses (ND) were used for analysis. There were
180 DF (65.7%), 53 DHF grade I (19.3%), 19 DHF grade II (6.9%). 19 DHF grade III (6.9%>) and 3 DHF grade IV (1.1%)
as classified by the current WHO classification while the suggested TDR classified 85(31%), 160(58.4%) and 29(1.1%) as
D, DWand SD respectively At least one of the warning signs were found in 50,53.3,83, 88.2,100 and 100%> ofND, DF DHF
grade I, DHF grade II, DHF grade III and DHF grade IVpatients. Vomiting and abdominal pain were the 2 most common
warning signs found In both ND and dengue patients. Intensive monitoring and careful medical and IV fluid management
were needed for 94 DHF patients compared to 189 DW and SD patients by the new TDR classification. There were 8 DSS
patients who had AST > 1, OOOU and one patient presented with encephalopathy. These 8 patients cannot be classified properly
in the current WHO classification. One non-dengue patient who presented with gastrointestinal bleeding was classified as
SD. Bleeding and/or positive tourniquet test was found in and 69.7% of DHF patients. Plasma leakage detected using
hemoconcenlration, chest x-ray (CXR) and ultrasonography. Hemoconcentration could detect plasma leakage in 44.7% and
CXR added up evidence ofplasma leakage to 86.3%. Ultrasonography was the most sensitive technique to add evidence of
plasma leakage up to 100%. Platelet < 100,000 cellslmm3 was found in 93.5% of DHF patients.
Conclusion: Current WHO classification is recommended for continuing use because the newly suggested TDR classification
creates about 2 times the workload to health care personnel. In addition, the TDR classification needs dengue confirmatory
tests. More than 90% of DHF defined by WHO case definition are dengue confirmed. However, current WHO classification
needs to be modified for more simple and friendly use. The suggested modification is to address plasma leakage as the major
criteria. Tourniquet test positive or bleeding symptoms can be considered as minor criteria. Unusual dengue Is proposed to
be added to the current WHO classification to cover those patients who do not fit with the current WHO classification
Keywords: Dengue WHO classification, Dengue fever, DF, Dengue hemorrhagic fever, DHF, Dengue shock syndrome, DSS,
Warning signs
J Med Assoc Thai 2011; 94 (Suppl. 3): S74-S84
Full text. e-Journal: http:llwww.mat.or.thljournal

Correspondence to:
Kalayanarooj S, Queen Sirildi National Ittsliliile of Child Healtit, 420/H Rajavithi Road, Bangkok 10400 Thailand.
Phone : 0-2354-8333
E-mail: [email protected]

S74 J Med Assoc Thai Vol 94 Suppl. 3 2011

 Dengue has been increasing worldwide with between June-August 2009 was done. The suspected
50-100 million new cases a year''-^*. Most of the newly
dengue admitted patients were those who presented
dengue outbreak countries and previous endemic with shock or had a history of high fever with bleeding
countries, especially those with high case fatality rate
symptoms (including positive tourniquet test),
(CFR) had reported more severe and unusual leukopenia (WBC < 5,000 cells/mm') and/or platelet
presentations that they have never seen before'"*'. The
count around 100,000 cells/mm\ All cases were
healthcare personnel in those countries with dengue managed according to the Thai National Dengue
problems have limited experience in diagnosis and Guidelines 2008''''. The admitted cases represented
management. The WHO classification'""; dengue fever the more severe cases or cases with more families'
(DF), dengue hemorrhagic fever (DHF) and dengue concern. Patients were classified using the 1997 WHO
shock syndrome (DSS) has been criticized by many Classification and the new TDR classification was
doctors that most of the cases could not fulfill the applied later using the data from the case report form.
requirement for diagnosis of DHF'^'. Most of the Dengue virus infections were determined by
patients they found could not fulfill the DHF case polymerase chain reaction (PCR) and/or by serology.
definition: plasma leakage (rising Hematocrit (Hct) WHO Classification 1997: DF, DHF grade 1,11, III and
> 20%) and thrombocytopenia < 100,000 cells/mm\ In IV. DSS = DHF grade 111 or DHF grade IV.
addition, more patients with multiple organ(s) Probable DF: Fever with 2 of the following:
involvement, e.g. encephalopathy, liver failure, headache, retro-orbital pain, myalgia, arthralgia/bone
renal failure and heart involvement were seen and pain, bleeding manifestations, rash and leukopenia.
cannot be classified according to the current WHO DHF case definition using 4 criteria: Fever,
classification'"'. bleeding manifestation including positive tourniquet
test (> 10 petechiae/sq. inch), plasma leakage
A group of scientists and doctors had set up
a multi-country collaborative dengue study, called (hemoconcentration > 20%, pleural effusion, ascites
DENCO to evaluate the WHO classification including detected by physical examination, chest film-right
lateral decubitus technique or ultrasound) and
the clinical presentations of dengue in order to find the
best solution for the management of suspected dengue thrombocytopenia (platelet count < 100,000 cells/mm\
patients and minimize the CFR. This DENCO project Plasma leakage is determined in most cases
was supported by the European Union and WHO by hemoconcentration (rising Hct > 20%). Some of the
Special Program for Research and Training in Tropical cases, pleural effusion and ascites were detected by
Diseases (TDR) and this clinical part was done during physical examination, chest x-ray (right lateral decubitus
2005-2006. The group has proposed the new technique), ultrasonography, hypoalbuminemia (serum
classification based on the results of the DENCO study.
albumin < 3.5 gm% or change of albumin > 0.5 gm%) or
WHO Tropical Diseases research (TDR) had published hypocholesterolemia (serum cholesterol < 10(1 mg% or
this new suggested classification in the 2009 new change of cholesterol > 20 mg%). Ultrasonography was
guidelines for diagnosis, treatment, prevention and performed in suspected DHF cases without evidence
control'^' for possible replacement of the current WHOof hemoconcentration or pleural effusion by CXR.
classification that has been used effectively in reducing TDR Classification: Dengue (D), Dengue with
CFR, especially in the Southeast Asia and Western warning signs (DW) and severe dengue (SD).
Pacific Regions for more than 3 decades'"'. D: Fever with 2 of the followings: Nausea/
The objectives of the present study were to vomiting, rash, aches and pain, tourniquet test positive,
compare the effectiveness in clinical management leukopenia, any warning sign.
between the current WHO classification to the newly Warning signs: abdominal pain or tenderness,
suggested TDR classification, and to assess the 4 persistent vomiting, clinical fluid accumulation, mucosal
criteria of the DHF case definition of the current WHObleed, lethargy/restlessness, liver enlargement > 2 cms.
classification: fever, tourniquet test and/or bleedingand laboratory: increase in Hct concurrent with rapid
manifestations, plasma leakage and thrombocytopenia. decrease in platelet count.
SD-severe plasma leakage (shock, fluid
Material and Method accumulation with respiratory distress), severe bleeding
A prospective study of the suspected dengue evaluated by clinicians and severe organ involvement
patients who were admitted to the Dengue Unit, Queen (AST or AUT > 1,000 U, CNS-impair consciousness
Sirikit National Institute of Child Health (QSNICH) and heart and other organs involvement).

,/ Med Assoc Thai Vol. 94 Suppl. 3 2011 S75

 SPSS version 14 was used for statistical shown in Table 1. Among 180 DF confirmed cases which
analysis in the present study. were considered to be mild, TDR classified as 105 DW
and 1 SD and among non-dcnguc suspected 19 DF
Results cases TDR classified as 9D and IOD W cases (Table 2).
Diagnoses There was no death in the present study.
There were 356 suspected dengue patients
admitted to the Dengue Unit, QSNICH between June- Demographic data
August 2009 and 298 cases with the complete dengue The mean age of ND, DF DHF were 6.7 ±4.1,
serologic and virological diagnoses were eligible for 8.3 + 3.9 and 9.3 + 4.4 years respectively (p = 0.049).
analysis. There were 274 confirmed dengue patients The male to female ratios were 1.5:1,1.3:1 and 1:1.05
and 24 non-dengue febrile illnesses. There were 180 respectively (p = 0.383).
DF (65.7%%), 53 DHF grade I (19.3%), 19 DHF grade II
(6.9%), 19 DHF grade III (6.9%o) and 3 DHF grade IV Serology
(1.1%.) as classified by the 1997 WHO classification Serologic findings in dengue patients were
while the suggested TDR classified 85 D (31%o), 160 16.1% primary, 77.7% secondary, 1.8% of acute dengue
DW(58.4%) and 29 SD (10.6%)(Fig. 1). Among24 non- infections, 3 % of no serologic diagnosis and 1.7% with
dengue cases (ND), the clinical diagnoses were 19 DF negative dengue serology. Seventy-five, 80.6 and 90.9%
and 4 DHF grade 1 and 1 DHF grade II by the current of DF, DHF and DSS patients had secondary dengue
WHO classification while using TDR classified as 10 infection respectively (p = 0.783) (Fig. 3).
D, 13 DW and 1 SD (Fig. 2). Comparison between the
diagnoses by current WHO and TDR classification is Serotypes
There were 77.4% dengue serotypes identified
from 212 dengue patients as 110 dengue 1 (52.1%), 36
Current WHO Suggested DENCO dengue 2 (17.1 %), 55 dengue 3 (26.1 %) and 10 dengue
1.1
4 (4.7%) (Fig. 3). Dengue 1, 2 and 3 were identified in
one DF patient. Dengue 4 was found in only 10 patients
and 9 of them (90%) was DF while 65.6,55.6 and 67.3%
of dengue 1, 2 and 3 were found in DF patients (p =
0.729). DSS patients were found to be caused by 7.3%
of dengue 1,11.1% of dengue 2,9.1% of dengue 3 and
none of dengue 4 infections.
• DF • DHF I • DHF II
• DHF 111 • DHF IV • m Dengue Criteria for WHO case definition of DHF
• Dengue with warning signs Tourniquet test positive, hemoconcentration
« Severe dengue (rising Hct > 20%), thrombocytopenia (platelet counts
< 100,000 cells/mm') were found in 69.7,44.7 and 93.5%
Fig. 1 Dengue Classification n = 274 (Confirmed dengue) of DHF patients, respectively (Table 3).
Current WHO Suggested DENCO Warning signs
At least one of the warning signs was found
in 50, 53.3, 83, 88.2. 100 and 100% ofND, DF, DHF
grade 1. II, III and IV patients, respectively (p < 0.001)
(Fig. 4,5).
Abdominal pain or tenderness was found in
15,29.5,45.8,72.2 and 73.7%^ ofND, DF, DHF grade I, II.
Ill and IV, respectively (p < 0.001).
Persistent vomiting was found in 40.9, 33.3,
63.3,50,57.9 and 54.4%^ ofND, DF DHF grade 1, II, III
• Dengue with warning signs and IV, respectively (p = 0.008).
~ Severe dengue
Clinical fluid accumulation was found in 0,0.
Fig. 2 Dengue Classificaiion n = 24 (Non-dengue) 8,20,61.5 and 29.4% ofND, DF, DHF grade I, II, III and

S76 J Med Assoc Thai Vol. 94 Suppl. 3 2011

Table 1. Comparison of Dengue Diagnoses between Current WHO Classification with suggested DENCO classification in
confirmed dengue cases
DF DHF 1 DHF II DHF III DHF IV Total Total
(%) (%) (%) (%) (%) DHF (%) (%)
Dengue 74 10 1 0 0 11 85
Dengue with warning signs 105 41 14 0 0 55 160
Severe Dengue 1 2 4 19 3 28 29
Total 180 53 19 19 3 94 274

Table 2. Comparison of Dengue Diagnoses between Current WHO Classification with suggested DENCO classification in
non dengue cases

DF DHF I DHF II DHF III DHF IV Total Total

(%) (%) (%) {%) (Of) DHF (%) (%)
Dengue 9 1 0 0 0 1 10
Dengue with warning signs 10 3 0 0 0 3 13
Severe Dengue 0 0 1 0 0 1 1
Total 19 4 1 0 0 5 24

Table 3. The percentage of each criteria in WHO case definition

Non dengue (%) Dengue p-valuc Note
Tourniquet test 58.3 69.7 0.581
Plasma leakage 16.7 100 0.000
Hemoconcentration 42 44.7 0.000
Platelet < 100.000 cell/mm^ 41.7 93.5 0.000

IV, respectively (p < 0.001). Chest film

Mucosal bleed was found in 4.5,16.6,17,37.5, A chest x-ray was done in 92 patients (30.9%
41.2 and 100% of ND, DF, DHF grade I, II, III and IV, of total study patients) and pleural effusion was
respectively (p = 0.052). documented in 41.6% of DHF patients who did not
Lethargy was found in 9.1, 2.5, 4.4, 67, 33.3 have hemoconcentration > 20%.
and 100% of ND, DF, DHF grade I, II, III and IV,
respectively (p < 0.001). Ultrasonography
Liver enlargement > 2 cms was found in 4.8, Ultrasonography was done in cases of DHF
I. 9,8.9,26.7,18.8 and 66.7% ofND, DF, DHF grade I, II, who had no hemoconcentration, no pleural effusion
III and IV, respectively (p < 0.001). by chest x-ray and pleural effusion and/or ascites were
detected.
Plasma leakage
Hemoconcentration HypoalbuminemialHypocholesterolemia
Rising HCT of > 20% was found in 4.2, 4.5, Mean minimum serum albumin in ND, DF and
37.7,36.8,63.2,1(K) and 44.7% in ND, DF, DHF grade I, DHF grade 1, II, III and IV were 4.53,3.93,3.50,3.04,2.52
II, III, IV and total DHF patients (p < 0.001) while and 2.66 gm% respectively (p < 0.001) Fig. 7.
hemoconcentration > 15-19.9% was found in 12.5, 19.4, Mean minimum serum cholesterol in ND, DF
22.6,36.8,21.1 %Mn ND, DF, DHF grade I, DHF grade II and DHF grade I, II, III and IV were 170.0,168.3,108.9,
and DHF grade 111 (p < 0.001) (Fig. 6). 81.5,82.3 and 33 mg% (p < 0.001) Fig. 7.

./ Med Assoc Thai Vol. 94 Suppl. 3 2011 S77

 Serology Albumin (gm%) Cholesterol [mg%)

160,3

• Primary • Secondary
• Acute • Negative • Dengue 1 • Dengue 2
R No serologic OK • Dengue 3 • Dengue 4 Fig. 7 Mean Minimum Albumin & Cholesterol
Fig. 3 Dengue Serology & Serotypes
Thrombocytopenia
The mean nadir platelet count in ND, DF and
DHF grade I, H, III and IV were 108,174; 96,578; 63,098;
50,474; 46,700 and 51,333 cells/mm^ respectively
(p < 0.001). Platelet count < 100,000 cells/mm' was found
in 41.7, 60.6 and 91.5% ofND, DF and DHF patients.
Platelet count < 50,000 cells/mm'was found in 12.5,15
and 54.4%. of ND, DF and DHF patients Fig. 8.
Leukopenia
The mean nadir WBC in ND, DF and DHF
Fig. 4 Warning signs grade I, II, III and IV were 3,098; 3,032; 3,253; 3,544;
3,523 and 3,890 cells/mm-' respectively (p = 0.551).
Leukopenia was found in 95.7, 92, 88.7, 77.8,84.2 and
100 100% ofND, DF, DHF grade I, II, III and IV respectively
80 (p = 0.632).
— DHF I Tourniquet test
— DHF II
•HFill
Positive tourniquet test was found in 58.3,68,
— DHF IV 75.5,66.7,68.4 and 100%- ofND, DF, DHF grade I, II, III
and IV respectively (p = 0.581).

0^ AST/ALT
The meanAST values were 65,101,153,146,
Fig. 5 Warning signs In DHF 1,178 and 2,832 in ND, DF, DHF grade I, II, III and IV
(p < 0.001) while the mean ALT values were 24,51, 82,
57,427 and 1,131 in ND, DF, DHF grade I, II, HI and IV
respectively (p < 0.001) Fig. 9.
Normal AST values were found in 90.5,56.9,
50,58.8,33.3 and 0 in ND, DF, DHF grade I, II, III and IV
respectively. Elevation of AST in almost all dengue
patients were usually < 200 U. Six DHF grade III and 2
DHF grade IV had AST > l,OOOU.Fig. 10.
Normal ALT values were found in 100, 98.9,
Non DF DHFt DHF II DHF III DHF IV Total 84.6,94.1,50 and 33.3% in ND, DF, DHF grade I, II, III
dengue DHF
and IV respectively. Elevation of ALT in almost all
m>20% • 15-19.9 10-34.9
dengue patients were usually < 200 U. Six DHF grade
III and 2 DHF grade IV had ALT > 1,000 U. Fig. 10.
Fig. 6 Hemoconcenlration

S78 J Med Assoc Thai Vol. 94 Suppl. 3 2011

Management Fig. II general population has made the percentage of DF
IV fluid was given in 68.1% of dengue which is considered to be mild illness admission is very
patients: 28% for DF, 58.5% for DHF grade 1,64.7% for high (65.7%) compared to previously observed at
DHF grade II, 1 ()()% for DSS patients while ND patients QSNICH, 10.7%- in 1982-1986 (80s) and 19%. between
received IV fluid in 33.3%. 1995-1999 (90s). The better dengue case management
Dcxtran-40 was given in 17% of DHF patients; with the updated national dengue guidelines for all
9.4,17.7,36.8 and 33.3% of DHF grade I, II, III and IV, healthcare levels (1999) has made the percentage of
respectively. shock patients decrease to 8% in the present study
Blood was transfused in 8.5% of DHF patients: compared to the percentage of 66.6 and 24.7% shock in
16.2 and 26.3%. of DHF grade II and III. One ND patient the 80s and 90s"". The case fatality rate (CFR) at
received blood transfusion for the upper GI bleeding. QSNICH in the 80s and 90s were 1.36 and 0.2%o
Platelet concentrate was given in 2 DHF respectively while in 2009 the CFR was 0.63%. The
patients: DHF grade II and III who also had blood reason for high CFR is because all the death cases
transfusion. were severe/complicated referred cases. The CFR of
the walk in dengue patients at QSNICH was 0. The
Discussion country CFR were 1.0%, 0.66% and 0.13% in 1980,1990
The percentage of dengue patients in the Ind 2009 respectively"^*.
present study was very high, 92% because the 2 criteria Primary and secondary dengue infections
of positive tourniquet test or bleeding and leukopenia were found in 17.2% of DF and 85 J% of DHF patients
with the better positive predictive value for dengue which is comparable to the 80s and 90s. Alternate
infection''"' + thrombocytopenia was used for the dengue serotypes circulate in Thailand with different
dengue admission instead of using any 2 combinations predominant dengue serotypes every years as in the
of the signs and symptoms of the WHO criteria for present study Dengue 1 (51.9%) was predominated
probable dengue; headache, retro-orbital pain, myalgia, (2009) while dengue 2 (42.1%) and dengue 3 (50.6%)
arthralgia, rash, leukopenia and bleeding manifestations. were predominated in the 80s and 90s''^*.
The increased awareness of dengue illness among the Twenty-four of the suspected dengue cases

AST AIT

0%

m 0-40 • 41-200 • 0-M • <200U

a 201-SOOU • 5 0 M 000U • 201-SOOU • SOl-lOOOU
m lOOl-lOOO • 3001-5000U " 1001-3000 • 3001-SDOOU

• < 50000 •SOOOl-lOOOOO > 100001-150000

Fig. 10 AST and ALT range
Fig. 8 Platelet counts
AST ALT 120 r

• IV a Dedcan •PRC • Platolel

Fig. 9 Mean Maximum AST/ALT Fig. 11IV fluid, Dextran, Blood and Platelet transfusion

J Med Assoc Thai Vol. 94 Suppl. 3 2011 S79

were confirmed not to be dengue. The clinical diagnoses IV fluid by this TDR classification as recommended in
of these 24 confirmed non-dengue cases by the current the new edition 2009 of WHO/ TDR Dengue, guidelines
WHO classification were 19 DF, 4 DHF grade 1 and 1 for diagnosis, treatment, prevention and control. The
DHF grade II; four DHF grade 1,1 DHF grade II were unnecessary observation/ admission will increase the
misdiagnosed because of the thrombocytopenia in all workload in the hospitals in most resource-poor dengue
5 cases; rising HCT > 20% in 4 cases; massive upper GI endemic countries. As a result of the workload, the
bleeding in 1 case. The 19 misdiagnosed as DF cases quality of services, monitoring may be lower and severe
because of the following criteria were met with the cases may be missed if there are not enough personnel
probable dengue cases: 23 cases had leukopenia, 14 to take care of the increase in the number of suspected
positive tourniquet test, 12 cases with rash, 5 cases dengue patients. Besides the inflation of dengue cases,
with headache, 3 cases with thrombocytopenia, 3 cases more complications of fluid overload will also be
with myalgia and 1 case with arthralgia. The current increased in true DHF cases and may lead to death in
WHO classification did not miss any severe DHF cases some cases as fluid overload is one of the major causes
and over-diagnosed 19 DF and 5 DHF (8.1 %). of death in DHF patients in Thailand.
The TDR classified the 24 non-dengue cases If the author defined severity by the need of
as 1 SD, 13 DW, 9 Dengue and 1 ND. SD was diagnosed IV fluid as one criteria for severity in the DENCO study,
because of massive upper GI bleed that needed blood 33.3% ofND, 28% of DF and 68.1%- of all DHF patients
transfusion. TDR classification for severe dengue (all DSS patients received IV fluid resuscitation) had
needed serologic and virological laboratory received IV fluid in the present study. The previous
confirmation or else more patients who required blood observation is more or less the same as the present
transfusion in dengue endemic countries will be study; 15%.of ND, 12%»of DF and 58%. ofDHF patients
diagnosed as SD. For the 13 DW, the above criteria for received IV fluid''^'. This means that DF is not always
probable dengue and additional warning signs were mild and DHF is not ail severe. The severity of dengue
found: 9 cases with persistent vomiting, 4 cases with depends on many factors including management prior
rising Hct and decrease platelet, 3 cases with abdominal to and after hospitalization. The decision to give IV
pain, 2 cases with lethargy and 1 case each had mucosal fluid to the patients varies from place to place so it may
bleeding and enlarged liver > 2 cms. TDR classification not reflex true severity of dengue illness.
made a false alarm for possible more severe disease The suggested TDR classification is claimed
that need intensive monitoring in 13 cases (4.4%), to be simple, user friendly, help in clinical triage and
misdiagnosed 1 severe case and 9 mild cases. accepted by the surveillance personal including the
In the present study, 103 cases satisfied the epidemiologists. But this suggestion is a paradigm shift
DHF/DSS clinical criteria (98 dengue and 5 non-dengue from the previous WHO dengue classification and
cases), i.e. 34.6% of total suspected dengue cases were guidelines that most of the endemic countries have
at risk for severe disease and needed close monitoring. developed their own guidelines and all the relevant
In contrast, the TDR classification identified 217 cases health care personnel are tuned to that. In lieu of
of DW and SD (203 dengue and 14 non-dengue cases, updating the shift put them and the program into
72.8% of suspected dengue patients) which needed jeopardy to attain the program target of control and
close monitoring according to the new guideline. prevention of dengue. In addition it may not be
Warning signs that was emphasized in the consistently affordable. Even though it is simple and
TDR classification for strict observation and medical user friendly, most clinicians found that this won't help
intervention were found in half of the non-dengue cases in the clinical triage of the patients. More suspected
in the present study: 15% abdominal pain, 40.9% dengue patients with warning signs, at least 2 times as
persistent vomiting, 9.1% lethargy and 4.8% of liver in the present study will be found and observed/
enlargement. In the scenario of OPD where many non- admitted to the hospital for close monitoring and
dengue acute febrile illnesses patients arc seen and probably IV fluid administration. Double the workload
non-specific warning signs as above would be of the already hard-working healthcare personnel at
observed in half of these patients and they will be the Dengue Unit of QSNICH is expected with the using
diagnosed as dengue and admitted for strict of the new TDR classification.
observation and medical intervention, most likely IV Rising HCT > 20% as the evidence of
fluid administration. Then an enormous number of plasmaleakage was observed in only 44.7% of DHF
patients diagnosed as dengue will receive unnecessary patients. Chest x-ray, right lateral decubitus technique

SSO J Med Assoc Thai Vol. 94 Suppl. 3 2011

 (which is not routinely done or not available) had added encephalopathy and recovered completely with
the evidence of plasma leakage in DHF patients by supportive and symptomatic treatment.
hemoconcenlration alone up to 86.3%. Low albumin
< 3.5 gm% and low cholesterol < 1 (K) mg% may be used Conclusion
as evidence of plasma leakage in the majority of DHF Current WHO classification is recommended
patients in the present study. Ultrasonography is the for continuing use because the newly suggested TDR
most sensitive investigation to detect plasma leakage classification which emphasizes on warnings signs
(either by detecting pleural effusion or ascites) in cases creates more than 2 times the workload to health care
where the above techniques had failed. The previous personnel, i.e. increase the number of suspected dengue
study confirmed that ultrasound could helped to patients who need close monitoring from 99 DHF
document plasma leakage in 70.6% of DHF patients to 217 DW and SD. In addition this suggested
who had no rising Hct > 20%o''''\ classification included a non-specific warning signs as
Patients who have platelet count < 50,000 cell.s/ the criteria so confirm dengue laboratory is needed
mm' are likely to be cases of DSS as 68.2% of DSS compared to the current WHO case definiti(m with 4
patients in the present study had. The present study criteria that was confirmed in > 90%.
had made the diagnosis of DHF by including those Plasma leakage is the distinct finding in DHF
cases with definite evidence of plasma leakage but their but it is sometimes difficult to document. Extensive
platelet count was low and close to 100,000 cells/mm-', investigation for other evidence of plasma leakage is
as 9L5% of DHF patients had a platelet count < 100,000 highly recommended in suspected DHF patients.
cells/mm\ The authors suggest that the current Patients who have definite evidence of plasma leakage
WHO case definition should be modified to include are likely to be cases of DHF and few of them may or
these cases as had been done. Platelet count might may not necessarily have bleeding manifestations and/
not be done repeatedly in some cases so that real or platelet count < 100,000 cells/mm^ as found in the
thrombocytopenia is missed. present study. Current WHO classification, which
Though leukopenia and a positive tourniquet emphasizes plasma leakage helps in clinical triaging of
test are 2 of the good criteria for suspected dengue the patients, needs to be modified for more simple and
infection'"'but both of them can also be found in some friendly use. The suggested modification is to address
other diseases. Other diseases that have leukopenia plasma leakage as the major criteria. Tourniquet test
include serious bacterial infections, chikungunya, avian positive or bleeding symptoms and thrombocytopenia
influenza and Intluenza A 2009. In the present study can be considered as minor criteria. Unusual dengue is
used these 2 criteria for admission, i.e. why the ND and proposed to be added to cover those patients who do
dengue group had no significant difference in the not fit the current WHO classification.
present finding. In general, a combination of leukopenia
and positive tourniquet test had shown to have high Acknowledgement
positive predictive values (PPV)' The authors wishes to thank all the patients
Liver involvement has been r e p o r t e d ' a n d who were involved in the present study and also to the
the present study had confirmed the findings that only patients' care team at the Dengue Unit, with special
14.8 and 53.4% of total dengue patients had normal appreciation to AFRIMS and their staff for its support
level ofAST and ALT respectively. Degree of liver injury in laboratory-confirmed dengue.
was related to the severity. DSS had higher AST/ALT
than DHF and DHF had higher level AST/ALT than DF Potential conflicts of interest
patients. Elevation of AST may help to rule in dengue
infections as 85.2% of dengue patient had AST None.
elevation while only 9.5% of non-dengue acute febrile References
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S84 J Med Assoc Thai Vol. 94 Suppl. 3 2011