Dengue trends puzzle physicians

"In 2019, a patient's condition wouldn't deteriorate before five days. This time within three to four days the patient's blood pressure falls, water accumulates in the chest and abdomen, the patient goes into shock and there is haemorrhaging. Previously we couldn't think of anything critical before four days," said physician of Old Dhaka's Sir Salimullah Medical College and Mitford Hospital, Mohammad Mizanur Rahman, talking about dengue patients.

Physicians of other government hospitals in Dhaka have echoed his observation about the dengue outbreak this time. They say that the severity of this viral attack is much worse this time. Previously 5 to 10 per cent of the children who went into shock, would face brain and heart complications. This time that rate has reached 30 to 35 per cent.

A recent study of Bangladesh Council of Scientific and Industrial Research (BCSIR) also indicated that this time dengue is much more severe than previous times. The blood platelet count drops rapidly and the patient has to be rushed to hospital.

Scientists say that so far four types of dengue have been identified. Most people have been affected by the Denvi-3 variety. This variety dominated in 2019 too. That year saw the highest number of dengue deaths in Bangladesh. It also saw the highest number of dengue cases.

This year, according to the Directorate General of Health Services (DGHS), 10,651 dengue patients were admitted to hospital. Of them, 7,698 patients were admitted last month, August. This year 45 persons died of dengue, according to official records.

Specialist physicians say there were a much higher number of dengue patients detected in 2019, but critical cases were less. This time while the number of detected cases is less, the complications are more.

Among the government hospitals in Dhaka, the most dengue patients were admitted to Mitford Hospital and Dhaka Shishu Hospital. Last month, in August, a four-month-old infant Ahmed died while undergoing treatment for dengue at Shishu Hospital. The child had been transferred from the general ward to ICU and then placed on life support, but still couldn't be saved.

The child's father Nasir Uddin told Prothom Alo, Ahmed contracted fever on 5 August. The fever abated after he was given Napa syrup. Then his body grew cold. After four days he developed convulsions and was rushed to hospital. He was given platelets but could not be saved.

The child was under the care of Dhaka Shishu Hospital critical care paediatrics department's professor Mohammad Monir Hossain.

Speaking to Prothom Alo, he said when the child was brought to the hospital, his brain had been affected. This was called expanded dengue syndrome. He also developed convulsions, fever, pneumonia and blood infection. He had so many complications that he could not be saved.

So far physicians would be alert about possible complications, taking the different stages of dengue into consideration.

According to the National Guideline for Clinical Management of Dengue Syndrome 2018, in the four stages of dengue infection, first the patient develops fever which is difficult to differentiate from other viral fevers. In the second phase there is dengue fever and in this stage there may or may not be bleeding from the nose, stomach and oesophagus.

According to the guideline, in the third phase there could be plasma leakage along with the bleeding. This causes a drop in platelets and white blood cells and an increase in haemoglobin. This can send the patient into shock, with their limbs turning cold and blood pressure falling. Not everyone goes into shock. Going into shock is known as dengue shock syndrome.

The fourth and alarming state is expanded dengue syndrome. According to the guideline, in this state complications may develop in the liver, kidney, brain and heart. This stage is rare.

The guideline says that dengue fever normally recedes on the fourth day. Once the fever is in recession, the patient begins to recover. Even if the patient doesn't recover then, the fever begins to subside. The fifth day to the seventh day is a critical time. That is when plasma leakage sets in and the other complications begin to develop.

But physicians say this time dengue is not following these stages. While the guideline says that expanded dengue syndrome is very rare, this time it is appearing much more, particularly in the case of children.

Professor Mohammad Monir Hossain is in charge of children's treatment at Dhaka Shishu Hospital's Neonatal Intensive Care Unit (NICU) and PICU (Paediatric Intensive Care Unit).

Speaking to Prothom Alo he said, "This time the patients are coming more with heart and brain problems along with the symptoms like before. Water accumulating in the heart and heart blockages are taking on alarming proportions.

He observed that this time 30 per cent of dengue shock syndrome patients are developing expanded dengue syndrome. Last time this was 5 to 10 per cent.

Professor Mohammad Monir Hossain said, "This year, as compared to previous years, the patients are going into shock while suffering from fever. The trend is alarming."

Also, he said, this time obese children were more prone to risk. "Suddenly they have no blood pressure," he said.

According to the records of the health emergency operations centre and control room of DGHS on Monday, this year 424 children have been admitted to hospitals with dengue and 6 have died.

Monday's reports of DGHS also said that this year 1,609 dengue patients have been admitted to Sir Salimullah Medical College and Mitford Hospital. Seven of them died. This is the highest number of patients admitted with dengue to any hospital. Children and adults are being treated separately in this hospital.

Assistant professor of the hospital's paediatric department, Md Ibrahim Khalil said, "This year more patients are going into shock than haemorrhaging. Such patients may die at any time if not treated in time."

The physician said that these children are being brought to hospital only when their situation deteriorates considerably. He said almost half the patients have gone into shock. In 2019 this was around 10 to 20 per cent.

This time many of the children in hospital are falling unconscious within three or four days, said Md Ibrahim Khalil. "This has become common now," he said.

Adults are being treated separately outside of the children's unit. The focal person there, Mohammad Mizanur Rahman, said that this time expanded dengue syndrome is appearing within three days of the fever developing. Previously it would take six to seven days for this state to appear.

Mitford Hospital is observing a rapid drop in platelets among dengue patients. General speaking, a normal person has 150,000 to 400,000 platelet count. All these days it took at least a week for this count to fall to 20,000, but this time it is falling to that level within just two or three days, said Mohammad Mizanur Rahman.

Dhaka Medical College's principal and medicine specialist Md Tito Miah was asked why the condition of the dengue patients is turning critical so soon this time. In reply, he told Prothom Alo that towards the end of 2019 they noted patients rapidly going into shock and that has recurred now.

He said, the changes in complications are due to the type of dengue. And if anyone is affected for the second time, the complications are more. Also, when the body's immune system fights the virus, there are some reactions. These can cause complications too.

DGHS's disease control director and spokesperson of the directorate, Nazmul Islam, told Prothom Alo, "This time the number of patients is less than in 2019. However, patients are coming to hospital in a more critical condition. If they do not come to hospital very quickly and instead simply follow the treatment of others, then their condition deteriorates."

He said, one of the reasons that more complications have emerged is many come very late for treatment. Everyone first tests for coronavirus and is relieved when the results are negative. Only much later do they test for dengue.

Nazmul Islam went on to say that risks heighten if a patient is affected with dengue for the second time. That is why it is important to check if the patient had dengue previously. DGHS had contacted many physicians in this regard and will work in accordance to their feedback.