Clinical profile of dengue hemorrhagic fever cases in Mexico.
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Clinical profile of dengue hemorrhagic fever cases in Mexico. Joel Navarrete-Espinosa, MD (1) Héctor Gómez-Dantés, MD (2) Juan Germán Celis-Quintal (2) José Luis Vázquez-Martínez (2) (1) Coordinación de Programas Integrados de Salud, USP, Instituto Mexicano del Seguro Social (IMSS). (2) División Técnica en Estadísticas de Salud, IMSS.
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Objectives: To describe the clinical behavior of Dengue fever (DF) and Dengue hemorrhagic fever (DHF). To determine some of the risk factors associated with the occurrence of hemorrhagic forms and fatal cases in the population attended by the Mexican Institute of Social Security (IMSS).
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Material and Methods Follow-up study Patients were cases diagnosed as DF or DHF confirmed by a serological test (IgM ELISA). Clinical and epidemiological data were obtained from the case report format. Two groups were formed according to their clinical evolution and following the WHO/PAHO established criteria: DF (including dengue fever with hemorrhagic manifestations cases) and DHF (including fatal cases). The information was validated and analyzed to calculate simple frequencies, central tendency and dispersion measures. Cumulative incidence and relative risk were estimated along with their 95% confidence intervals (CI 95%). The statistical analysis to compare groups was performed using the Kruskal-Wallis test and Poisson regression.
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Clinical studies differed in the spectrum of signs and symptoms reported and usually emphasized those that are more prominent in the population studied. Report of dengue hemorrhagic cases (DHF) in the IMSS demonstrated that severe dengue infection is usually accompanied by more than one bleeding site (30%) and that gastrointestinal bleeding as well as petechia and epistaxis were prominent signs. Dengue shock syndrome (DSS) reported higher prevalence of hepatomegaly (16% in adults and 60% in children) than dengue hemorrhagic fever without complications (7% in adults and 22% in children). Abdominal pain, nausea and vomit are among the alarm signs –digestive syndrome- that revealed the imminent evolution towards severity. In the multivariate analysis the risk factors that appeared predictive of severity and indicated a major risk for death were: echymosis, hematomas, ascitis, hematemesis and melena.
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The continuous monitoring of thrombocytopenia and hemoconcentration should be viewed as an obligatory procedure and not only as a diagnostic criterion. Thrombocytopenia was present in 100% of the cases, while hemoconcentration was documented in only 12% of them. An important finding is the proportion in which both events are registered simultaneously and the risk to develop DHF and death from this cause. The frequency of these parameters depends on the form corporal fluids are lost during the infection, hemorrhages or plasma leakage, and time in which laboratory test are requested. Global case fatality rate in the IMSS (2.9%) is smaller than the reported in Cuba (5.8% in 1977), Puerto Rico (5.2% in 1991), the French Guyana (15% in 1991) and India (33% in 1988). Data provided by studies like this should help the physicians and the public health service to improve the dengue surveillance system and the prevention of this emergent infectious disease.
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