title: Dengue deaths in Puerto Rico: lessons learned from the 2007 epidemic.
abstract: BACKGROUND
  The incidence and severity of dengue in Latin America has increased substantially in recent decades and data from Puerto Rico suggests an increase in severe cases. Successful clinical management of severe dengue requires early recognition and supportive care.
  
  
  METHODS
  Fatal cases were identified among suspected dengue cases reported to two disease surveillance systems and from death certificates. To be included, fatal cases had to have specimen submitted for dengue diagnostic testing including nucleic acid amplification for dengue virus (DENV) in serum or tissue, immunohistochemical testing of tissue, and immunoassay detection of anti-DENV IgM from serum. Medical records from laboratory-positive dengue fatal case-patients were reviewed to identify possible determinants for death.
  
  
  RESULTS
  Among 10,576 reported dengue cases, 40 suspect fatal cases were identified, of which 11 were laboratory-positive, 14 were laboratory-negative, and 15 laboratory-indeterminate. The median age of laboratory-positive case-patients was 26 years (range 5 months to 78 years), including five children aged < 15 years; 7 sought medical care at least once prior to hospital admission, 9 were admitted to hospital and 2 died upon arrival. The nine hospitalized case-patients stayed a mean of 15 hours (range: 3-48 hours) in the emergency department (ED) before inpatient admission. Five of the nine case-patients received intravenous methylprednisolone and four received non-isotonic saline while in shock. Eight case-patients died in the hospital; five had their terminal event on the inpatient ward and six died during a weekend. Dengue was listed on the death certificate in only 5 instances.
  
  
  CONCLUSIONS
  During a dengue epidemic in an endemic area, none of the 11 laboratory-positive case-patients who died were managed according to current WHO Guidelines. Management issues identified in this case-series included failure to recognize warning signs for severe dengue and shock, prolonged ED stays, and infrequent patient monitoring.
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases (DVBD), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico. ktomashek@cdc.gov
authors.forename: Kay M
authors.initials: KM
authors.lastname: Tomashek
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Gregory
authors.forename: Aidsa
authors.initials: A
authors.lastname: Rivera Sánchez
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Bartek
authors.forename: Enid J
authors.initials: EJ
authors.lastname: Garcia Rivera
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Hunsperger
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Muñoz-Jordán
authors.forename: Wellington
authors.initials: W
authors.lastname: Sun
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000914:Antibodies, Viral / Q000097:blood; D000956:Antigens, Viral / Q000032:analysis; D002648:Child; D002675:Child, Preschool; D003715:Dengue / Q000453:epidemiology* / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D003716:Dengue Virus / Q000302:isolation & purification; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D007075:Immunoglobulin M / Q000097:blood; D007223:Infant; D008297:Male; D008875:Middle Aged; D011647:Puerto Rico / Q000453:epidemiology; D012367:RNA, Viral / Q000235:genetics / Q000302:isolation & purification; D016019:Survival Analysis; D055815:Young Adult
chemical_list: D000914:Antibodies, Viral; D000956:Antigens, Viral; D007075:Immunoglobulin M; D012367:RNA, Viral