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Am. J. Trop. Med. Hyg., 78(6), 2008, pp. 990-998
Copyright © 2008 by The American Society of Tropical Medicine and Hygiene

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Influence of the Dengue Serotype, Previous Dengue Infection, and Plasma Viral Load on Clinical Presentation and Outcome During a Dengue-2 and Dengue-4 Co-Epidemic

Laurent Thomas*, Olivier Verlaeten, André Cabié, Stéphane Kaidomar, Victor Moravie, Jenny Martial, Fatiha Najioullah, Yves Plumelle, Christiane Fonteau, Philippe Dussart, AND Raymond Césaire
Centre Hospitalier Universitaire, Fort-de-France, Martinique; Centre d’Investigation Clinique et d’Epidémiologie Clinique, Fort-de-France, Martinique; Centre National de Référence des Arbovirus, Institut Pasteur de la Guyane, Cayenne, French Guyana

Martinique experienced a dengue outbreak with co-circulation of DENV-2 and DENV-4. In an emergency department-based study, we analyzed whether the clinical presentation and outcome of adult patients were related to serotype, immune status, or plasma viral load. Of the 146 adult patients who had confirmed dengue infection, 91 (62.3%) were classified as having classic dengue fever, 11 (7.5%) fulfilled World Health Organization criteria for dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS), 21 other patients (14.4%) presented with at least one typical feature of DHF/DSS [i.e., internal hemorrhage, plasma leakage, marked thrombocytopenia (platelet count ≤ 50,000 platelets/mm3) and/or shock], and 23 further patients (15.8%) had unusual manifestations. Four patients died. Severe illness was more frequent in patients with secondary dengue infection (odds ratio, 7.18; 95% confidence interval, 3.1–16.7; P < 0.001). Multivariate regression analysis showed that gastrointestinal symptoms and other unusual manifestations were independently associated with DENV-2 infection, whereas cough and DHF/DSS features were independently associated with secondary immune response. A high plasma viral load was associated with DENV-2 infection, increased serum liver enzymes, and with DHF/DSS features in patients presenting after the third day of illness. The most severe cases of dengue resulted from the combined effects of DENV-2 and secondary infection.

Received December 14, 2007. Accepted for publication March 6, 2008.

Acknowledgments: We thank the medical and nursing staff of the Emergency and General Medicine Departments and the Intensive Care Units of Fort-de-France University Hospital for their care of the patients; Sylvie Carmès, Jean Robert Longhi, Sarah Schmitt, Paul Henri Chauvin, Robert Vignes, Karine Guitteaud, Claude Ramialison, Ingrid Laudarin, Cedric Fagour, Emily Corp, and Jim Blackburn for help in collecting the data; and Bernard Bucher and Rudy Valentino (CHU de Fort-de-France, Martinique), Mary Warrell (University of Oxford, Oxford, UK), and Bridget Wills (Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam), who reviewed the manuscript.

Financial support: This study was supported by Centre Hospitalier Universitaire de Fort-de-France.

* Address correspondence to Laurent Thomas, Service des Urgences, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique. E-mail: laurent.thomas{at}chu-fortdefrance.fr

Authors’ addresses: Laurent Thomas, Stéphane Kaidomar, and Victor Moravie, Service des Urgences, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, Tel: 596-5965-52150, Fax: 596-5967-50733. Olivier Verlaeten, Jenny Martial, Fatiha Najioullah, and Raymond Césaire, Service de Virologie–Immunologie, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, Tel: 596-5965-52411, Fax: 596-5967-53669. André Cabié, Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, Tel : 596-5965-59613, Fax: 596-5967-52116. Yves Plumelle, Laboratoire Hématologie–Coagulation, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, Tel: 596-5965-52000, Fax: 596-5967-58419. Christiane Fonteau, Laboratoire de Biochimie, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique, Tel: 596-5965-52000, Fax: 596-5967-53189. Philippe Dussart, Centre National de Référence des Arbovirus, Institut Pasteur de la Guyane, 23 Avenue Pasteur, BP 6010, 97306 Cayenne cedex, French Guyana, Tel: 594-5942-92609, Fax: 594-5942-95809.

Reprint requests: Laurent Thomas, Service des Urgences, Centre Hospitalier Universitaire, 97200 Fort-de-France, Martinique. E-mail: laurent.thomas{at}chu-fortdefrance.fr.






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Copyright © 2008 by the American Society of Tropical Medicine and Hygiene.