The Predictive Diagnostic Value of Serial Daily Bedside Ultrasonography for Severe Dengue in Indonesian Adults.

Background: Identification of dengue patients at risk for progressing to severe disease is difficult. Significant plasma leakage is a hallmark of severe dengue infection which can suddenly lead to hypovolemic shock around the time of defervescence. We hypothesized that the detection of subclinical plasma leakage may identify those at risk for severe dengue. The aim of the study was to determine the predictive diagnostic value of serial ultrasonography for severe dengue. Methodology/Principal Findings: Daily bedside ultrasounds were performed with a handheld ultrasound device in a prospective cohort of adult Indonesians with dengue. Timing, localization and relation to dengue severity of the ultrasonography findings were determined, as well as the relation with serial hematocrit and albumin values. The severity of dengue was retrospectively determined by WHO 2009 criteria. A total of 66 patients with proven dengue infection were included in the study of whom 11 developed severe dengue. Presence of subclinical plasma leakage at enrollment had a positive predictive value of 35% and a negative predictive value of 90% for severe dengue. At enrollment, 55% of severe dengue cases already had subclinical plasma leakage, which increased to 91% during the subsequent days. Gallbladder wall edema was more pronounced in severe than in non-severe dengue patients and often preceded ascites/pleural effusion. Serial hematocrit and albumin measurements failed to identify plasma leakage and patients at risk for severe dengue. Conclusions/Significance: Serial ultrasonography, in contrast to existing markers such as hematocrit, may better identify patients at risk for development of severe dengue. Patients with evidence of subclinical plasma leakage and/or an edematous gallbladder wall by ultrasonography merit intensive monitoring for development of complications. Author Summary: Dengue virus infection ranges from a mild febrile illness to severe illness. Severe dengue is mainly characterized by transient plasma leakage, which may lead to a sudden onset of shock around the time of defervescence. Severe bleeding and organ impairment are less common features of severe dengue. In clinical practice it is difficult to predict which dengue patient will develop severe complications. Commonly used laboratory markers indicating plasma leakage—such as hematocrit—are rarely of clinical benefit. In contrast, ultrasonography can directly visualize plasma leakage. Because ultrasonography is not routinely used due to financial and logistical limitations, we used a more affordable handheld ultrasound device for daily bedside follow up, which had similar results as conventional ultrasonography. This study shows that a substantial proportion of mildly ill patients already had small amounts of plasma leakage before severe complications developed and—most importantly—that these patients had an increased risk for progression to shock compared to patients without plasma leakage. We conclude that ultrasonography can help to identify dengue patients at risk for shock and that patients with ultrasonographic evidence of plasma leakage should be monitored more carefully for circulatory status to timely recognize and possibly prevent shock. [ABSTRACT FROM AUTHOR]