title: Vascular leakage in dengue--clinical spectrum and influence of parenteral fluid therapy.
abstract: OBJECTIVE
  Clinical management of dengue relies on careful monitoring of fluid balance combined with judicious intravenous (IV) fluid therapy. However, in patients with significant vascular leakage, IV fluids may aggravate serosal fluid accumulation and result in respiratory distress.
  
  
  METHODS
  Trained physicians followed suspected dengue cases prospectively at seven hospitals across Asia and Latin America, using a comprehensive case report form that included daily clinical assessment and detailed documentation of parenteral fluid therapy. Applying Cox regression, we evaluated risk factors for the development of shock or respiratory distress with fluid accumulation.
  
  
  RESULTS
  Most confirmed dengue patients (1524/1734, 88%) never experienced dengue shock syndrome (DSS). Among those with DSS, 176/210 (84%) had fluid accumulation, and in the majority (83%), this was detectable clinically. Among all cases with clinically detectable fluid accumulation, 179/447 (40%) were diagnosed with shock or respiratory distress. The risk for respiratory distress with fluid accumulation increased significantly as the infused volume over the preceding 24 h increased (hazard ratio 1.18 per 10 ml/kg increase; P < 0.001). Longer duration of IV therapy, use of a fluid bolus in the preceding 24 h, female gender and poor nutrition also constituted independent risk factors.
  
  
  CONCLUSIONS
  Shock and respiratory distress are relatively rare manifestations of dengue, but some evidence of fluid accumulation is seen in around 50% of cases. IV fluids play a crucial role in management, but they must be administered with caution. Clinically and/or radiologically detectable fluid accumulations have potential as intermediate severity endpoints for therapeutic intervention trials and/or pathogenesis studies.
authors.affiliation: Section Clinical Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Kerstin D
authors.initials: KD
authors.lastname: Rosenberger
authors.affiliation: Department of Pediatrics, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Lucy
authors.initials: L
authors.lastname: Lum
authors.affiliation: MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Neal
authors.initials: N
authors.lastname: Alexander
authors.affiliation: Section Clinical Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Junghanss
authors.affiliation: Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.
authors.forename: Bridget
authors.initials: B
authors.lastname: Wills
authors.affiliation: Section Clinical Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Jaenisch
mesh_terms: D000293:Adolescent; D000328:Adult; D001808:Blood Vessels / Q000503:physiopathology; D002648:Child; D002675:Child, Preschool; D003715:Dengue / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D018450:Disease Progression; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012769:Shock / Q000209:etiology / Q000821:virology; D055815:Young Adult
keywords: IV fluid therapy; clinical spectrum; dengue; espectro clínico; fluidothérapie IV; fuga vascular; fuite vasculaire; prospectif; prospective; prospectivo; spectre clinique; terapia IV de fluidos; vascular leakage