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Table of Contents
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 12-15

Prevalence and characteristics of dengue shock syndrome in an acute care setting

1 Department of Medicine, Leeds Teaching Hospital, Leeds, UK
2 Department of Medicine, Holy Family Hospital, Rawalpindi, Pakistan
3 Independent Researcher, Texas, USA

Date of Submission25-Oct-2021
Date of Decision11-Nov-2021
Date of Acceptance20-Nov-2021
Date of Web Publication28-Jan-2022

Correspondence Address:
Hammad Akram
Independent Collaboration, McKinney, Texas
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_119_21

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Aims and Objectives: Dengue is a mosquito-borne illness caused by Flaviviridae. Although presents with mild symptoms, occasionally deterioration of circulatory parameters results into dengue hemorrhagic fever (DHF) and/or Dengue shock syndrome (DSS) the later presents with plasma leakage and narrow pulse pressure. The objectives of this study are to quantify and characterize dengue shock syndrome among patients with diagnosed dengue fever at the Holy family hospital in Rawalpindi, Pakistan. Methods: A cross-sectional study was conducted between August 2016 and April 2017. Patients with DF were enrolled, and clinical information was abstracted while following the 2011 World Health Organization classifications and guidelines. Results: In our sample (n = 280), we found a higher proportion was of males (71.1%), <30 years old (~64%) and patients with primary type of infection (~71%). 22.1% suffered from DSS. The average duration of illness among patients was 3.6 days. DSS percentage was higher among patients who were aged <30 years (63%), males (64.5%) had a duration of illness <5 days (82.3%) and suffered from primary infection (60%). The odds of DSS were higher among patients with secondary infection (odds ratio [OR] = 2.0, confidence interval [CI] = 1.12–3.62, P = 0.02) and duration of illness <5 days (OR = 15.58, CI = 7.55–32.13, P < 0.0001) compared to the counterpart groups. Conclusion: The identification of complications of dengue is important in preventing the mortality and morbidity of the disease and reducing the burden on the health-care systems as well as on the community.

Keywords: Dengue fever, dengue hemorrhagic fever, dengue shock syndrome, Pakistan, vector-borne illness

How to cite this article:
Mansoor S, Malik A, Akram H. Prevalence and characteristics of dengue shock syndrome in an acute care setting. Apollo Med 2022;19:12-5

How to cite this URL:
Mansoor S, Malik A, Akram H. Prevalence and characteristics of dengue shock syndrome in an acute care setting. Apollo Med [serial online] 2022 [cited 2022 May 21];19:12-5. Available from: https://www.apollomedicine.org/text.asp?2022/19/1/12/336753

  Introduction Top

Dengue is a mosquito-borne viral illness caused by four Flaviviridae family viruses grouped as DENV-1 through DENV-2.[1] Infected Aedes aegypti mosquitoes are known to commonly transmit dengue through their bites and can cause illness after an incubation period of 4–10 days.[1],[2],[3] The illness is usually mild, many times asymptomatic and if symptomatic, the patients can have influenza-like illness symptoms lasting from 2 to 7 days.[1],[2] About 5% of people with dengue can develop severe disease presenting as shock or hemorrhage which can result in mortality.[1] The symptomatic disease can be classified into undifferentiated fever, dengue fever (DF) syndrome, and dengue hemorrhagic fever (DHF). The latter can result in dengue shock syndrome (DSS).[1],[2],[3] The DSS can be presented as spontaneous deterioration after 3–7 days of symptoms onset where patients can develop the signs of circulatory failure leading to shock. This phase can last short usually 12–24 h and can lead to a rapid recovery if appropriately managed or death in <1% of the cases.[1],[2],[3] There is no specific medicine or treatment for dengue except supportive management including fluids and/or fever-reducing medicines.[1],[2] A vaccine is now available for certain eligible populations.[2] Every year close to 400 million individuals become infected with the dengue virus and close to 4 billion people reside in dengue high-risk regions of the world.[2]

Since the identification of the first outbreak of dengue in Pakistan in 1994, close to 150,000 cases of dengue have been identified from 1995 to 2019, and <1% associated deaths.[4],[5] A study carried out at a large hospital in Lahore, Pakistan during the 2011 dengue outbreak revealed a higher morbidity associated with DSS with about one-third of dengue-related deaths were due to the DSS.[6] This urges to examine the DF and DSS characteristic among patient population who sought care at the Dengue unit of the Holy Family Hospital in Rawalpindi, Pakistan. The objectives of the present study are to quantify DSS among patients who were diagnosed with DF and admitted to the above-mentioned facility. Furthermore, the study also examines the profile and demographic characteristics of patients with DF and if any of these factors had any role in the development of DSS.

  Methods Top

A cross-sectional study was carried out for 6 months between October 2016 and April 2017 at the dengue unit of Holy Family Hospital in Rawalpindi, Pakistan. We used the World Health Organization's (WHO) case definition and diagnostic criteria to identify patients with DSS.[7],[8] The criteria define DF, DHF and DSS and described elsewhere.[7],[8] DSS is presented with the evidence of circulatory failure manifestations such as hypotension, narrow pulse pressure < 20 mmHg, rapid and weak pulse, cold, clammy skin, restlessness, and/or altered mental status.[7],[8] Using a consecutive sampling approach, we selected 280 patients after excluding anyone who was younger than 13 or older than 60 years of age, the patients with existing comorbidities such as diabetes, tuberculosis, chronic hepatic or renal diseases, bleeding disorders, chronic obstructive pulmonary disease, and sepsis not related to dengue. Each patient underwent clinical history, physical examination, and initial assessment followed by DSS evaluation as per the case definition and WHO criteria.[7],[8] The routine investigations were sent to the pathology laboratory, ultrasound and X-ray abdomen were carried out at the radiology department. We included all patients diagnosed with DF who were 13–60 years old based on: positive Dengue nonstructural protein 1 (NS1) serology, a <10 days history of fever, thrombocytopenia <100,000, normal total leukocyte count, or leukopenia. Primary infection was considered if NS1 and IgM for dengue were positive with a negative IgG, whereas patients who had NS1, IgM, and IgG positive were considered having a secondary infection. Once the history, examination, and diagnostics were completed, the chart abstraction was carried out and data were maintained electronically.

The data were analyzed using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). The categorical variables were presented as frequencies and percentages. The outcome variables were presented using Fisher exact test or Chi-square test. Continuous variables were presented as geometric mean, standard deviation, and 95% Confidence intervals where applicable. P < 0.05 was considered statistically significant.

The study was approved by the Institutional research forum Rawalpindi Medical College (Research Training and Monitoring Cell allotted registration Number MED-2014-126-9021). Written informed consent was obtained from the patients or their legally authorized representatives. All clinical parameters were entered into a secure electronic database system along with the demographic details of the patients in a password-protected computer.

  Results Top

In our sample (N = 280), a higher proportion was of males (71.1%) compared to females (~29%). Most patients were <30 years old (~64%) and suffered from a primary type of infection (~71%). The mean age of participants was ~27 years. DSS was identified among 22.1% of DF patients. The average duration of illness among patients was 3.6 days. The description of these parameters is shown in [Table 1].
Table 1: Study sample characteristics (n=280)

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DSS percentage was higher among patients who were aged <30 years (63%), males (64.5%), had a duration of illness <5 days (82.3%), and suffered from primary infection (60%) [Table 2].
Table 2: Counts and percentage of patients with dengue (overall sample) and dengue shock syndrome by age, gender, duration of illness, and type of infection

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While examining the role of different patient parameters in the development of DSS, we found that the odds of developing DSS were higher among patients with a shorter duration of disease. Furthermore, the patient with secondary infection had higher odds of having DSS compared to the ones with the primary infection. Both of these relationships were statistically significant [Table 3]. Although odds of DSS were found to be less among the younger age group and males, this relationship was not statistically significant [Table 3].
Table 3: Odds of having dengue shock syndrome by different sample parameters

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  Discussion Top

The present study was an attempt to identify patients with DSS among DF patients who were admitted into a large hospital with close to 900 beds in the Rawalpindi area and serving over 2 million population of the region. We found a higher proportion of males compared to females and a relatively higher younger population in our sample. Furthermore, over two-third of patients were identified with primary infection and about 22% met the DSS criteria as per the WHO guidelines.

We found a higher proportion of dengue (overall) and DSS among patients ages <30 years; however, the odds of having DSS were found to be lower among <30-year-old patients compared with ≥30 groups, but this relationship was not statistically significant. Although this may not be exactly comparable to our sample, the evidence suggests that the incidence of dengue is higher among children in certain regions of Asia.[9] Another study also showed that the highest risk of DSS was among the ones who were younger and as the age decreased mortality increased in the sample.[10] A higher incidence of DSS among children or youth could be associated with the fact that they have increased vascular permeability and microvascular fragility which predispose them to circulatory failure and shock.[11]

For gender, our sample was mainly comprised of men (71.1%) which means that this proportion of males suffered from DF. This has been also observed in another study carried out in Lahore, Pakistan where out of the total sample, about 81% were males.[12] Furthermore, in our study among the patients with DSS, males had a higher proportion of disease versus females, but we observed fewer odds of DSS among males; however, the relationship was not statistically significant. Anker and Arima examines the gender difference in dengue incidence from six Asian countries and they found that the higher number of reported cases were among males ages 15 years or above with a consistent historical trend.[13] The possible reason of this gender difference could be due to the higher male members of society in the labor workforce making them potentially more susceptible to the mosquito bites compared to the women staying mostly inside homes.[13]

Over 82% of patients with DSS had disease duration <5 days this is contrary to the overall sample in which the majority had disease duration ≥5 days (~64%). The odds of DSS were significantly higher among patients with disease duration <5 days. This could be attributed to the evidence that the recovery of DSS is usually rapid after appropriate management is initiated.[2],[3]

Although secondary illness proportion was low for the whole sample (29%) and DSS group (40%), higher odds of DSS were seen among patients with secondary illness with a statistically significant P value. In other studies, a higher proportion of secondary infections has been seen among patients with DHF/DSS. Furthermore, evidence suggests that the secondary infection can potentially be considered as a risk factor for DHF/DSS.[14],[15],[16]

The limitations of our study are the ones that are common with any observational and cross-sectional study, i.e., unable to determine outcome and exposure temporality. Other challenges include recall bias during patient history collection, limitations associated with a sample size and consecutive sampling approach and no opportunity to conduct randomization; hence, the results may not be generalizable at a larger community level. The data is relatively old and corresponds to the regional disease activity at that time; however, still provides valuable results that can be useful locally as well as internationally.

The strengths of the present study are that the data were collected through chart abstraction and contained additional valuable information such as diagnostic reports, patient examination summary, and timeline which provided us with sufficient information to establish our case definitions and helped us fill the potential gaps (e.g., recall bias) that might have occurred during actual patient encounters. Furthermore, we utilized the WHO case definition parameters which provide results that can be comparable to other studies.

  Conclusions Top

Over the past five decades, dengue has emerged as a significant public health problem, especially in countries with rapid urbanization and population explosion.[17],[18] Rapid urbanization and population growth come with an increased burden on waste disposal activities, sanitation, and draining of water, etc.[17] The prevention and control of dengue and other mosquito-borne diseases are dependent on multipronged strategies such as community engagement and education, controlling vectors through reducing breeding sites and use of insecticides, conducting virus and mosquito and other types of enhanced surveillance to detect outbreaks earlier.[2],[19],[20],[21] All this requires collaborative efforts among the community, leaders, and health-care professionals. The present study can provide information that can be useful for healthcare professionals, researchers and community partners and can be used as a baseline to design further studies in the related topic area.


Written informed consent was obtained from the patients or their legally authorized representatives.


The authors thank the patients for allowing us to collect information for this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Centers for Disease Control and Prevention. Dengue, Symptoms and Treatment. Available from: https://www.cdc.gov/dengue/symptoms/index.html. [Last accessed on 2021 Sep 29].  Back to cited text no. 1
World Health Organization. Dengue and Severe Dengue; 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue. [Last accessed on 2021 Oct 01].  Back to cited text no. 2
Gubler DJ, Clark GG. Dengue/dengue hemorrhagic fever: The emergence of a global health problem. Emerg Infect Dis 1995;1:55-7.  Back to cited text no. 3
World Health Organization. Regional Office for the Easter Mediterranean. Pakistan, Dengue Fever. Available from: http://www.emro.who.int/pak/programmes/dengue-fever.html. [Last accessed on 2021 Oct 20].  Back to cited text no. 4
Fatima Z. Dengue infection in Pakistan: Not an isolated problem. Lancet Infect Dis 2019;19:1287-8.  Back to cited text no. 5
Assir MZ, Ahmad HI, Masood MA, Kamran U, Yusuf NW. Deaths due to dengue fever at a tertiary care hospital in Lahore, Pakistan. Scand J Infect Dis 2014;46:303-9.  Back to cited text no. 6
World Health Organization. Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control. 2nd ed. Geneva: World Health Organization; 1997. Available from: http://apps.who.int/iris/bitstream/handle/10665/41988/9241545003_eng.pdf;jsessionid=996708FADB93C1597D102F89D18974AF?sequence=1. [Last accessed on 2021 Oct 11].  Back to cited text no. 7
World Health Organization. Regional Office for South-East Asia. Comprehensive Guideline for Prevention and Control of Dengue and Dengue Haemorrhagic Fever. Revised and Expanded Edition. Geneva:WHO Regional Office for South-East Asia; 2011. Available from: https://apps.who.int/iris/handle/10665/204894. [Last accessed on 2021 Oct 11].  Back to cited text no. 8
Cavalcanti LP, Vilar D, Souza-Santos R, Teixeira MG. Change in age pattern of persons with dengue, northeastern Brazil. Emerg Infect Dis 2011;17:132-4.  Back to cited text no. 9
Anders KL, Nguyet NM, Chau NV, Hung NT, Thuy TT, Lien le B, et al. Epidemiological factors associated with dengue shock syndrome and mortality in hospitalized dengue patients in Ho Chi Minh City, Vietnam. Am J Trop Med Hyg 2011;84:127-34.  Back to cited text no. 10
Gamble J, Bethell D, Day NP, Loc PP, Phu NH, Gartside IB, et al. Age-related changes in microvascular permeability: A significant factor in the susceptibility of children to shock? Clin Sci (Lond) 2000;98:211-6.  Back to cited text no. 11
Aamir M, Masood G, Aamir W. Gender difference in patients with dengue fever admitted in a teaching hospital, Lahore. Cell 2014;92:1.  Back to cited text no. 12
Anker M, Arima Y. Male-female differences in the number of reported incident dengue fever cases in six Asian countries. Western Pac Surveill Response J 2011;2:17-23.  Back to cited text no. 13
Guzman MG, Alvarez M, Halstead SB. Secondary infection as a risk factor for dengue hemorrhagic fever/dengue shock syndrome: An historical perspective and role of antibody-dependent enhancement of infection. Arch Virol 2013;158:1445-59.  Back to cited text no. 14
Burke DS, Nisalak A, Johnson DE, Scott RM. A prospective study of dengue infections in Bangkok. Am J Trop Med Hyg 1988;38:172-80.  Back to cited text no. 15
Halstead SB, Nimmannitya S, Yamarat C, Russell PK. Hemorrhagic fever in Thailand; recent knowledge regarding etiology. Jpn J Med Sci Biol 1967;20 Suppl: 96-103.  Back to cited text no. 16
Kyle JL, Harris E. Global spread and persistence of dengue. Annu Rev Microbiol 2008;62:71-92.  Back to cited text no. 17
Gubler DJ, Meltzer M. Impact of dengue/dengue hemorrhagic fever on the developing world. Adv Virus Res 1999;53:35-70.  Back to cited text no. 18
Aslam F, Akram H. Mixed-methodology in disease surveillance, response, and control. Int J Basic Sci Med 2019;4:43-4.  Back to cited text no. 19
Akram H. West Nile virus: Epidemiological and surveillance approaches. Int J Basic Sci Med 2017;2:111-2.  Back to cited text no. 20
Akram H. Enhancing public health capacity by using epidemiological teams in a public health setting. Cureus 2017;9:e1381.  Back to cited text no. 21


  [Table 1], [Table 2], [Table 3]


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