Facing dengue in pediatrics: studies in a highly endemic region: Dengue in pediatrics

An overview of dengue epidemiology in Indonesia over 45 years showed an increase in dengue infections in the adolescent age group since 1999. Clinical and laboratory manifestations in children were mostly fever, petechiae, epistaxis, hepatomegaly, and thrombocytopenia. Encephalopathy and gastrointestinal bleeding were found only in dengue shock syndrome (DSS). Subsequent study demonstrated that in our tertiary care hospital, one third of hospitalized children with dengue fever progressed to DSS, and of dengue hemorrhagic fever (DHF) cases, 6% progressed to DSS. Only fever duration was significantly associated with clinical progression, suggesting that the disease course of dengue in children is predictable and stressing the importance of close clinical monitoring of patients. Further study of the profile and clinical signs in infants with confirmed dengue in a 10-year period showed that two strong indicators of DSS in infants were liver enlargement and fluid accumulation. Diarrhea and cough as atypical clinical presentations were found in one third of dengue in infants. The diagnostic value of warning signs in different age groups of children was also explored, to help clinicians facing dengue in endemic countries. Infants with the warning signs of liver enlargement and clinical fluid accumulation are more likely to progress to severe dengue, while in younger children and adolescents, the warning signs are firstly an increase in hematocrit with concurrent rapid decrease in platelet count, followed by abdominal pain, vomiting, or fluid accumulation. A long-term follow-up study of pediatric DHF patients assessed Carotid intima-media thickness (cIMT) and arterial stiffness to detect preclinical atherosclerosis, comparing a post-DHF group and a control group. The result showed no differences in arterial stiffness; longer follow-up studies are warranted.