Volume 97, Issue 1
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



The increase in severe dengue (SD) cases has caused great impact on public health and has concerned authorities of countries where the disease is endemic and epidemics reach high proportions. The recognition of progression signs of this severe disease during the initial febrile phase can be difficult, since the symptoms are often indistinguishable from other febrile diseases. The aim of this study was to evaluate the clinical manifestations and laboratory findings in patients from two dengue outbreaks and their association with the disease. The study was conducted in patients ( = 153) with signs and symptoms consistent with dengue occurred during two distinct epidemics, 2010 and 2013, in the city of Campos dos Goytacazes, Rio de Janeiro, Brazil. According to the 2009 World Health Organization criteria, patients were classified as dengue without warning signs ([DwoWS] 60.6%, 57/94), dengue with warning signs ([DwWS] 30.9%, 29/94), and SD (4.25%, 4/94). Patients with DwWS/SD presented lower platelet and leukocyte counts and higher transaminase levels when compared with the DwoWS ones. Interestingly, patients from the epidemic of 2010 caused by dengue virus 2 (DENV-2) had lower platelet counts than patients of the 2013 epidemic caused by DENV-4. Furthermore, plasma leakage, gastrointestinal bleeding, and pleural effusion, hallmarks for a more severe disease, were also more frequently observed in those cases. Although previous studies may have extensively reported the wide range of the clinical aspects of dengue, the characterization of DENV-4 is desirable considering the burden of the disease during epidemics, especially for the health units and hospitals performing patient's management.


Article metrics loading...

Loading full text...

Full text loading...



  1. Brady OJ, Gething PW, Bhatt S, Messina JP, Brownstein JS, Hoen AG, Moyes CL, Farlow AW, Scott TW, Hay SI, , 2012. Refining the global spatial limits of dengue virus transmission by evidence-based consensus. PLoS Negl Trop Dis 6: e1760.[Crossref]
  2. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, Drake JM, Brownstein JS, Hoen AG, Sankoh O, Myers MF, George DB, Jaenisch T, Wint GR, Simmons CP, Scott TW, Farrar JJ, Hay SI, , 2013. The global distribution and burden of dengue. Nature 496: 504507.[Crossref]
  3. Guzman MG, Halstead SB, Artsob H, Buchy P, Farrar J, Gubler DJ, Hunsperger E, Kroeger A, Margolis HS, Martinez E, Nathan MB, Pelegrino JL, Simmons C, Yoksan S, Peeling RW, , 2010. Dengue: a continuing global threat. Nat Rev Microbiol 8 (Suppl) : S7S16.[Crossref]
  4. Pan American Health Organization (PAHO), 2016. Number of Reported Cases of Dengue and Severe Dengue (SD) in the Americas, by Country: Epidemiological Week/EW 5 February 3, 2016. Washington, DC: PAHO.
  5. Osanai CH, Travassos da Rosa AP, Tang AT, do Amaral RS, Passos AD, Tauil PL, , 1983. Dengue outbreak in Boa Vista, Roraima. Preliminary report [in Portuguese]. Rev Inst Med Trop Sao Paulo 25: 5354.
  6. Schatzmayr HG, Nogueira RM, Travassos da Rosa AP, , 1986. An outbreak of dengue virus at Rio de Janeiro: 1986. Mem Inst Oswaldo Cruz 81: 245246.[Crossref]
  7. Teixeira MG, Costa Mda C, Barreto F, Barreto ML, , 2009. Dengue: twenty-five years since reemergence in Brazil. Cad Saude Publica 25 (Suppl 1) : S7S18.[Crossref]
  8. Nogueira RM, Eppinghaus AL, , 2011. Dengue virus type 4 arrives in the state of Rio de Janeiro: a challenge for epidemiological surveillance and control. Mem Inst Oswaldo Cruz 106: 255256.[Crossref]
  9. Heringer M, Nogueira RM, de Filippis AM, Lima MR, Faria NR, Nunes PC, Nogueira FB, dos Santos FB, , 2015. Impact of the emergence and re-emergence of different dengue viruses' serotypes in Rio de Janeiro, Brazil, 2010 to 2012. Trans R Soc Trop Med Hyg 109: 268274.[Crossref]
  10. Secretaria de Vigilância em Saúde/Ministério da Saúde (SVS/MS), 2014. Casos de Dengue. Brasil, Grandes Regiões e Unidades Federadas, 1990 a 2014. Brasília, Brazil: SVS/MS
  11. Secretaria de Vigilância em Saúde/Ministério da Saúde (SVS/MS), 2011. Dengue: diagnóstico e manejo clínico—adulto e criança, 4th edition. Brasília, Brazil: Secretaria de Vigilância em Saúde, Diretoria Técnica de Gestão/Ministério da Saúde.
  12. Rothman AL, , 2004. Dengue: defining protective versus pathologic immunity. J Clin Invest 113: 946951.[Crossref]
  13. World Health Organization (WHO), 2009. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. New edition. Geneva, Switzerland: WHO.
  14. Teixeira MG, Barreto ML, , 2009. Diagnosis and management of dengue. BMJ 339: b4338.[Crossref]
  15. Faria NRC, Solorzano VEF, Nogueira RMR, Chouin-Carneiro T, Nunes PCG, Simoes JBS, Nogueira FB, Lima MRQ, Pinto LMO, Kubelka CF, da Cunha RV, de Azeredo EL, dos Santos FB, , 2016. Dengue epidemics in two distinct periods reveal distinct epidemiological, laboratorial and clinical aspects in a same scenario: analysis of the 2010 and 2013 epidemics in Mato Grosso do Sul, Brazil. Trans R Soc Trop Med Hyg 110: 228236.[Crossref]
  16. Miagostovich MP, Nogueira RM, dos Santos FB, Schatzmayr HG, Araujo ES, Vorndam V, , 1999. Evaluation of an IgG enzyme-linked immunosorbent assay for dengue diagnosis. J Clin Virol 14: 183189.[Crossref]
  17. Lima MRQ, Nogueira RMR, de Filippis AMB, Nunes PCG, de Sousa CS, da Silva MH, dos Santos FB, , 2014. A simple heat dissociation method increases significantly the ELISA detection sensitivity of the nonstructural-1 glycoprotein in patients infected with DENV type-4. J Virol Methods 204: 105108.[Crossref]
  18. Lanciotti RS, Calisher CH, Gubler DJ, Chang GJ, Vorndam AV, , 1992. Rapid detection and typing of dengue viruses from clinical samples by using reverse transcriptase-polymerase chain reaction. J Clin Microbiol 30: 545551.
  19. de Morais Bronzoni RV, Baleotti FG, Ribeiro Nogueira RM, Nunes M, Moraes Figueiredo LT, , 2005. Duplex reverse transcription-PCR followed by nested PCR assays for detection and identification of Brazilian alphaviruses and flaviviruses. J Clin Microbiol 43: 696702.[Crossref]
  20. Alexander N, Balmaseda A, Coelho IC, Dimaano E, Hien TT, Hung NT, Janisch T, Kroeger A, Lum LC, Martinez E, Siqueira JB, Thuy TT, Villalobos I, Villegas E, Wills B, European Union, World Health Organization (WHO‐TDR) supported DENCO Study Group, 2011. Multicentre prospective study on dengue classification in four south-east Asian and three Latin American countries. Trop Med Int Health 16: 936948.[Crossref]
  21. Fried JR, Gibbons RV, Kalayanarooj S, Thomas SJ, Srikiatkhachorn A, Yoon IK, Jarman RG, Green S, Rothman AL, Cummings DA, , 2010. Serotype-specific differences in the risk of dengue hemorrhagic fever: an analysis of data collected in Bangkok, Thailand from 1994 to 2006. PLoS Negl Trop Dis 4: e617.[Crossref]
  22. Nogueira RM, Schatzmayr HG, de Filippis AM, dos Santos FB, da Cunha RV, Coelho JO, de Souza LJ, Guimaraes FR, de Araujo ES, De Simone TS, Baran M, Teixeira G, Miagostovich MP, , 2005. Dengue virus type 3, Brazil, 2002. Emerg Infect Dis 11: 13761381.[Crossref]
  23. Guilarde AO, Turchi MD, Siqueira JB, Feres VC, Rocha B, Levi JE, Souza VA, Boas LS, Pannuti CS, Martelli CM, , 2008. Dengue and dengue hemorrhagic fever among adults: clinical outcomes related to viremia, serotypes, and antibody response. J Infect Dis 197: 817824.[Crossref]
  24. Honorio NA, Nogueira RMR, Codeco CT, Carvalho MS, Cruz OG, Magalhaes Mde A, de Araujo JM, de Araujo ES, Gomes MQ, Pinheiro LS, da Silva Pinel C, Lourenco-de-Oliveira R, , 2009. Spatial evaluation and modeling of dengue seroprevalence and vector density in Rio de Janeiro, Brazil. PLoS Negl Trop Dis 3: e545.[Crossref]
  25. Thomas L, Verlaeten O, Cabié A, Kaidomar S, Moravie V, Martial J, Najioullah F, Plumelle Y, Fonteau C, Dussart P, Césaire R, , 2008. 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. Am J Trop Med Hyg 78: 990998.
  26. Murgue B, Cassar O, Guigon M, Chungue E, , 1997. Dengue virus inhibits human hematopoietic progenitor growth in vitro. J Infect Dis 175: 14971501.[Crossref]
  27. Basu A, Jain P, Gangodkar SV, Shetty S, Ghosh K, , 2008. Dengue 2 virus inhibits in vitro megakaryocytic colony formation and induces apoptosis in thrombopoietin-inducible megakaryocytic differentiation from cord blood CD34+ cells. FEMS Immunol Med Microbiol 53: 4651.[Crossref]
  28. Tsai JJ, Jen YH, Chang JS, Hsiao HM, Noisakran S, Perng GC, , 2011. Frequency alterations in key innate immune cell components in the peripheral blood of dengue patients detected by FACS analysis. J Innate Immun 3: 530540.[Crossref]
  29. Nakao S, Lai CJ, Young NS, , 1989. Dengue virus, a flavivirus, propagates in human bone marrow progenitors and hematopoietic cell lines. Blood 74: 12351240.
  30. Lin CF, Wan SW, Cheng HJ, Lei HY, Lin YS, , 2006. Autoimmune pathogenesis in dengue virus infection. Viral Immunol 19: 127132.[Crossref]
  31. Hottz ED, Oliveira MF, Nunes PC, Nogueira RM, Valls-de-Souza R, Da Poian AT, Weyrich AS, Zimmerman GA, Bozza PT, Bozza FA, , 2013. Dengue induces platelet activation, mitochondrial dysfunction and cell death through mechanisms that involve DC-SIGN and caspases. J Thromb Haemost 11: 951962.[Crossref]
  32. Jameel T, Mehmood K, Mujtaba G, Choudhry N, Afzal N, Paul RF, , 2012. Changing haematological parameters in dengue viral infections. J Ayub Med Coll Abbottabad 24: 36.
  33. Nguyen TL, Nguyen TH, Tieu NT, , 1997. The impact of dengue haemorrhagic fever on liver function. Res Virol 148: 273277.[Crossref]
  34. Trung DT, Thao LTT, Hien TT, Hung NT, Vinh NN, Hien PT, Chinh NT, Simmons C, Wills B, , 2010. Liver involvement associated with dengue infection in adults in Vietnam. Am J Trop Med Hyg 83: 774780.[Crossref]
  35. Lee LK, Gan VC, Lee VJ, Tan AS, Leo YS, Lye DC, , 2012. Clinical relevance and discriminatory value of elevated liver aminotransferase levels for dengue severity. PLoS Negl Trop Dis 6: e1676.[Crossref]
  36. Roy A, Sarkar D, Chakraborty S, Chaudhuri J, Ghosh P, Chakraborty S, , 2013. Profile of hepatic involvement by dengue virus in dengue infected children. N Am J Med Sci 5: 480485.[Crossref]
  37. Itha S, Kashyap R, Krishnani N, Saraswat VA, Choudhuri G, Aggarwal R, , 2005. Profile of liver involvement in dengue virus infection. Natl Med J India 18: 127130.
  38. Tanner L, Schreiber M, Low JG, Ong A, Tolfvenstam T, Lai YL, Ng LC, Leo YS, Thi Puong L, Vasudevan SG, Simmons CP, Hibberd ML, Ooi EE, , 2008. Decision tree algorithms predict the diagnosis and outcome of dengue fever in the early phase of illness. PLoS Negl Trop Dis 2: e196.[Crossref]

Data & Media loading...

  • Received : 21 Mar 2016
  • Accepted : 27 Sep 2016

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error