title: Classifying dengue: a review of the difficulties in using the WHO case classification for dengue haemorrhagic fever.
abstract: BACKGROUND
  The current World Health Organisation (WHO) classification of dengue includes two distinct entities: dengue fever (DF) and dengue haemorrhagic fever (DHF)/dengue shock syndrome; it is largely based on pediatric cases in Southeast Asia. Dengue has extended to different tropical areas and older age groups. Variations from the original description of dengue manifestations are being reported.
  
  
  OBJECTIVE
  To analyse the experience of clinicians in using the dengue case classification and identify challenges in applying the criteria in routine clinical practice.
  
  
  METHODS
  Systematic literature review of post-1975 English-language publications on dengue classification.
  
  
  RESULTS
  Thirty-seven papers were reviewed. Several studies had strictly applied all four WHO criteria in DHF cases; however, most clinicians reported difficulties in meeting all four criteria and used a modified classification. The positive tourniquet test representing the minimum requirement of a haemorrhagic manifestation did not distinguish between DHF and DF. In cases of DHF thrombocytopenia was observed in 8.6-96%, plasma leakage in 6-95% and haemorrhagic manifestations in 22-93%. The low sensitivity of classifying DHF could be due to failure to repeat the tests or physical examinations at the appropriate time, early intravenous fluid therapy, and lack of adequate resources in an epidemic situation and perhaps a considerable overlap of clinical manifestations in the different dengue entities.
  
  
  CONCLUSIONS
  A prospective multi-centre study across dengue endemic regions, age groups and the health care system is required which describes the clinical presentation of dengue including simple laboratory parameters in order to review and if necessary modify the current dengue classification.
authors.affiliation: Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Shibani
authors.initials: S
authors.lastname: Bandyopadhyay
authors.forename: Lucy C S
authors.initials: LC
authors.lastname: Lum
authors.forename: Axel
authors.initials: A
authors.lastname: Kroeger
mesh_terms: D002199:Capillary Permeability / Q000502:physiology; D003715:Dengue / Q000145:classification* / Q000150:complications / Q000175:diagnosis; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D012680:Sensitivity and Specificity; D019595:Severe Dengue / Q000145:classification / Q000150:complications / Q000175:diagnosis; D013921:Thrombocytopenia / Q000150:complications; D014111:Tourniquets; D014944:World Health Organization