National Institutes of Health (NIH), World Health ... · DHF Dengue hemorrhagic fever DIRF Dengue illness report form DSS Dengue shock syndrome DVI Dengue Vaccine Initiative ECG Electrocardiogram

Version 0.11, 7 July 2015 Confidential NIH-WHO-PDC, Washington DC, April 2015

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National Institutes of Health (NIH), World

Health Organization (WHO), Partnership

for Dengue Control (PDC)

Workshop on Dengue Clinical Case

Classification for Clinical Research

Washington DC, USA

27-28 April 2015


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EXECUTIVE SUMMARY


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Table of Contents

EXECUTIVE SUMMARY ....................................................................................................... 2

1 Introduction ...................................................................................................................... 10

2 Objectives ........................................................................................................................ 13

3 Framing the issue: the challenges of measuring dengue disease severity in pathogenesis

studies and interventional research .......................................................................................... 14

3.1 Observational/pathogenesis studies in international clinical settings (Dr. Thomas

JÄNISCH; Clinical Tropical Medicine, Department for Infectious Diseases, Heidelberg

University Hospital, Germany) ............................................................................................ 14

3.2 Sanofi’s experience on disease classification from Phase II/Phase III vaccine trials

(Dr. Fernando NORIEGA; Head Global Clinical Dengue Program & Clinical Development

Latin America, Sanofi Pasteur) ............................................................................................ 15

3.3 Takeda’s experience on disease classification from Phase II vaccine trials (Dr.

Dereck WALLACE; Clinical Program Lead for Dengue, Takeda Vaccines, Singapore) ... 17

3.4 Oxford University’s experience from Phase II therapeutic trials (Prof. Bridget

WILLS, Centre for Tropical medicine and Global Health, Oxford University) .................. 17

3.5 Utility of rapid dengue diagnostics for use in interventional trials (Dr. Elisabeth

HUNSPERGER; Head, Immunodiagnostics, Development and Research Laboratory CDC

Dengue Branch, San Juan, Puerto Rico) .............................................................................. 17

4 Defining dengue severity markers: acute febrile illness (AFI) ........................................ 19

4.1 Scientific Working Group deliberation summary ..................................................... 19

4.2 Discussion and conclusions ....................................................................................... 20

5 Defining dengue severity markers: severe bleeding ........................................................ 21


5.2 Bleeding in dengue: thrombin time as point of care (Dr. Norma de BOSCH,

Venezuela) ........................................................................................................................... 25

5.3 Discussion and conclusion ........................................................................................ 26

5.3.1 Severity of bleeding ........................................................................................... 26

5.3.2 Severity of hemophagocytic lymphohistiocytosis (HLH) ................................. 27

6 Defining dengue severity markers: plasma leakage......................................................... 28


6.1.1 Hemoconcentration ............................................................................................ 28

6.1.2 Imaging .............................................................................................................. 30

6.1.3 Assessment of plasma protein changes .............................................................. 33


7 Defining dengue severity markers: organ involvement ................................................... 36


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7.1 Liver and gastrointestinal tract .................................................................................. 36

7.1.1 Scientific Working Group deliberation summary .............................................. 36

7.1.2 Discussion and conclusions ............................................................................... 39

7.2 Central nervous system ............................................................................................. 42



7.3 Lungs ......................................................................................................................... 49



7.4 Muscle ....................................................................................................................... 55



7.5 Heart .......................................................................................................................... 59



7.6 Kidney ....................................................................................................................... 65



8 Plans to evaluate a refined dengue clinical case classification ........................................ 70



9 Summary and next steps .................................................................................................. 76

10 References ........................................................................................................................ 78


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List of Tables and Figures

Table 1-1 WHO 1997 classification of dengue hemorrhagic fever ......................................... 10

Table 3-1 Intermediate reference standard: grading severity by intervention ......................... 14

Table 5-1 Definitions for bleeding in dengue patients by country based on literature review 22

Table 5-2 Definitions for HLH in dengue patients based on literature review ........................ 24

Table 5-3 Proposed classification by Working Group of bleeding severity according to the

type of intervention .................................................................................................................. 26

Table 5-4 Proposed classification by Working Group of bleeding severity according to

location: skin bleeding ............................................................................................................. 26


location: mucosal bleeding ...................................................................................................... 26

Table 5-6 Proposed classification by Working Group of HLH severity based on intervention

.................................................................................................................................................. 27

Table 6-1 Definitions for hemoconcentration by country........................................................ 29

Table 6-2 Imaging definitions for plasma leakage .................................................................. 31

Table 6-3 Definitions for hypoproteinemia ............................................................................. 34

Table 7-1 Frequency of acute hepatitis in dengue ................................................................... 37

Table 7-2 Frequency of acute liver failure in dengue .............................................................. 38

Table 7-3 Proposed definitions for liver involvement in dengue patients ............................... 41

Table 7-4 Definitions for encephalitis, encephalopathy, and other neurological manifestations

in dengue .................................................................................................................................. 43

Table 7-5 Proposed definitions for neurological involvement in dengue ................................ 48

Table 7-6 Pathology and pathogenesis for lung involvement in dengue ................................. 50

Table 7-7 Exacerbation of asthma in dengue ........................................................................... 51

Table 7-8 Pleural effusion in dengue ....................................................................................... 51

Table 7-9 Acute respiratory failure (ARF)/acute respiratory distress syndrome (ARDS) in

dengue ...................................................................................................................................... 52

Table 7-10 Proposed case defining criteria and grading for ARF in dengue........................... 54

Table 7-11 Definitions for muscle involvement in dengue ..................................................... 56

Table 7-12 Proposed definitions for muscle involvement in dengue ...................................... 58

Table 7-13 Definitions for heart involvement in dengue ......................................................... 60

Table 7-14 Proposed definitions for cardiac involvement in dengue ...................................... 64

Table 7-15 Definitions for kidney involvement in dengue ...................................................... 66

Table 7-16 Proposed definitions for renal involvement in dengue .......................................... 69


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Table 8-1 Summary of proposed definitions for dengue severity markers (table provided by

the scientific committee after the workshop) ........................................................................... 72

Figure 1-2 WHO 2009 classification of dengue ...................................................................... 11

Figure 3-2 ROC curve for severe versus mild and moderate cases ......................................... 15

Figure 3-3 Process for the evaluation of dengue severity used by Sanofi Pasteur for clinical

trials.......................................................................................................................................... 16

Figure 5-2 Platelet and thrombin time among patients with dengue or other febrile illness ... 25

Figure 5-3 Platelet and thrombin time among dengue patients with or without bleeding ....... 25

Figure 9-1 Simplified schematic for identification of moderate or severe cases of dengue .... 76

List of Appendices

Appendix 1: Abbreviated meeting agenda ............................................................................... 87

Appendix 2: List of participants .............................................................................................. 89


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List of abbreviations

Abbreviation Definition

AASLD American Association for the Study of Liver Diseases

AFI Acute febrile illness

AKI Acute kidney disease

ALP Alkaline phosphatase

ALT Alanine aminotransferase

ARDS Acute respiratory distress syndrome

ARF Acute renal failure/acute respiratory failure

AST Aspartate aminotransferase

CLD Chronic lung disease

CNS Central nervous system

CPK Creatine phosphokinase

CRF Case report form

CSF Cerebrospinal fluid

DENCO Dengue control

DHF Dengue hemorrhagic fever

DIRF Dengue illness report form

DSS Dengue shock syndrome

DVI Dengue Vaccine Initiative

ECG Electrocardiogram

EEG Electroencephalogram

(cont.)


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GBS Guillan-Barré syndrome

GBW Gall bladder wall

H&P History and physical examination

HAV Hepatitis A virus

Hb Hemoglobin

HBV Hepatitis B virus

HCT Hematocrit

HCV Hepatitis C virus

HE Hepatic encephalopathy

IDMC Independent Data Monitoring Committee

IgM Immunoglobulin M

IgG Immunoglobulin G

INR International normalized ratio

LATV Live attenuated tetravalent vaccine

LVEF Left ventricular ejection fraction

NIH National Institutes for Health

NP Not performed

NS1 Non-structural protein 1

NT pro-BNP N-terminal pro-brain natriuretic protein

OFI Other febrile illness

PDC Partnership for Dengue Control

(cont.)


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PDVI Pediatric Dengue Vaccine Initiative

POC Point of care

RDT Rapid diagnostic test

SCLS Systemic capillary leak syndrome

SD Standard deviation

SOP Standard operating procedure

TDR Tropical Diseases Research

ULN Upper limit of normal

WHO World Health Organization


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1 Introduction

Case definitions for dengue were first developed using clinical experiences from dengue

outbreaks involving children in Southeast Asia (1-4). The case definitions were published in

the World Health Organization (WHO) technical guide in 1975 and updated in 1997 (1-6).

The WHO 1997 classification offers the possibility of grading of the severity of dengue cases

(6).

Table 1-1 WHO 1997 classification of dengue hemorrhagic fever

Grade Signs & symptoms Laboratory

I Fever & hemorrhagic manifestation (positive

tourniquet test (TT)) & evidence of plasma

leakage

Thrombocytopenia ≤ platelet count

<100,000 platelets/mm3

Plasma leakage as shown by pleural

effusion, ascites or >20%

hemoconcentration

II As for Grade I plus spontaneous bleeding

III As for Grade I or II plus circulatory failure

IV As for Grade III plus profound shock with

undetectable blood pressure & pulse

In 2008, the World Health Organization (WHO) released guidelines for the clinical

evaluation of dengue vaccines in endemic areas (7, 8). These guidelines were developed over

the course of nearly two years by an invited group of technical experts. In these guidelines,

primary efficacy endpoints were defined as the detection of dengue virus (DENV) in a study

subject with at least two days of fever irrespective of dengue severity. The guidelines

specified that laboratory confirmation be defined by either isolating DENV from the subject’s

serum, or by detecting DENV genome by reverse transcription polymerase chain reaction

(RT-PCR) assay or DENV nonstructural protein 1 (NSI) by a NS1 antigen assay. The

guideline further suggested that secondary endpoints be further developed but that they may

include: 1.) effect of vaccine on disease severity; 2.) effect of vaccine on clinical presentation

including atypical cases; and 3.) effect of vaccine by age group, sex, geographical location

and different management settings. Recently, there have been renewed calls for the dengue

research community to develop international standards for detailed discrimination of clinical

phenotypes to be used for clinical trials and pathogenesis studies (9, 10).

In November 2009, a new dengue case classification using a set of clinical and/or laboratory

parameters was released by WHO (Figure 1-1) to improve clinical management and

surveillance across the globe in all settings, regardless of resources. These new case

definitions were developed to address issues with DHF definition including: 1.) sensitivity of

the definition (i.e., DHF too restrictive); 2.) feasibility of DHF case definition (i.e., difficult

to apply in primary care setting, e.g. hemoconcentration); 3.) ability to identify cases with

atypical manifestations (e.g., liver failure, encephalitis); and 4.) applicability to adult

populations since developed from pediatric experience.


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Figure 1-1 WHO 2009 classification of dengue

This model split dengue cases into two large subgroups of patients:

i) dengue ± warning signs.

ii) severe dengue (patient has to meet at least one of three criteria including: severe

plasma leakage, severe bleeding, and severe organ impairment).

The 2009 WHO dengue case definitions are widely used in endemic countries for case

detection, patient triage and clinical management. However, these definitions are of limited

use in clinical research because criteria for severe disease are not adequately defined for that

purpose (11). This could affect reproducibility of data or results between trial sites even

within same country. Further refinement of these case definitions is needed to develop

international standards for the detailed discrimination of clinical phenotypes for use in

pathogenesis studies and/or therapeutic intervention trials (9) and to ensure complete,

accurate, and harmonized classification of cases in the context of monitoring long-term safety

and effectiveness of dengue vaccines and/or therapeutics (10). A new case classification

system for clinical trial endpoints should be reproducible, easy to implement and enable

standard, quantifiable endpoints that are comparable between clinical trials.

A 2-day workshop was organized by the National Health Institute (NIH), WHO and

Partnership for Dengue Control (PDC), and held in Rockville, Maryland on April 27-28 2015

to develop a refined Dengue Clinical Case Classification System for Clinical Research

(DCCC) for moderate and severe dengue to be used in pathogenesis research studies and

interventional trials. In preparation for the April meeting, 56 dengue scientists, clinicians, and

clinical trial experts from 16 countries were invited to participate in five sub-working groups

(SWG) including: severe bleeding; severe plasma leakage; organ involvement; acute febrile

illness; and evaluation of case classification system. The sub working groups were charged

with the following activities:

Review the literature to determine how dengue disease severity is measured and

defined in different clinical settings.

Identify standard definitions used by international medical organizations for severe

and moderate disease endpoints for plasma leakage, bleeding, and specific organ

involvement (e.g. acute liver failure and hepatitis).


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Identify issues in how case definitions may be operationalized to discuss at the April

meeting.

Propose definitions for each of the severity markers and acute febrile illness

Propose a plan for how the DCCC can be evaluated.

This document reports on the findings of each SWG, and presents the proposed DCCC

definitions.


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2 Objectives

The main objectives of the workshop were to reach a consensus on DCCC to be used in

pathogenesis studies and/or therapeutic intervention trials (9) and to ensure complete,

accurate, and harmonized classification of cases in the context of monitoring long-term safety

and effectiveness of dengue vaccines and to develop a plan to evaluate the classification

systems in the field to:

Facilitate clinical trials and pathogenesis studies by providing standard, quantifiable

clinical endpoints that can be measured in different studies and clinical settings.

Provide tools to ensure that implementation of this classification system is

consistently reproducible and results are comparable between different studies,

products and clinical settings.

Provide standardized means to evaluate programs and interventions that aim to

improve patient management.

The new clinical case classification systems are not intended to

Replace existing guidelines for patient management.

Replace existing guidelines to conduct surveillance or epidemiologic studies.

Replace existing primary endpoints for vaccine trials. (e.g., immunogenicity or

prevention of infection with dengue). The DCCC, developed as a part of this

workshop, will be used to classify study subjects with laboratory confirmed DENV

infections who are being monitored as part of an interventional trial or pathogenesis

study.


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3 Framing the issue: the challenges of measuring dengue disease severity in

pathogenesis studies and interventional research

The challenges in measuring the severity of dengue disease in pathogenesis studies and

interventional research with the use of existing WHO dengue classification was discussed

during the workshop using examples presented by academics and vaccine manufacturers.

3.1 Observational/pathogenesis studies in international clinical settings (Dr. Thomas

JÄNISCH; Clinical Tropical Medicine, Department for Infectious Diseases, Heidelberg University

Hospital, Germany)

The dengue control (DENCO) consortium has conducted a prospective, hospital-based,

multicenter observational study (EC, FP6, 2005-2009) that was set-up to evaluate the 1997

WHO dengue classification across all age groups in seven countries in South-East Asia and

Latin America and to develop a revised evidence-based classification that would better reflect

clinical severity (12). Overall, 1734 confirmed cases of dengue were enrolled and followed

daily. An intermediate reference method was used as the ‘gold standard’ to grade the severity

by intervention Table 3-1. Each patient was classified according to the level of intervention

for that day. All clinical signs were used to look at differences between the three groups of

dengue patients (severe, intermediate and mild).

Table 3-1 Intermediate reference standard: grading severity by intervention

Category 1 Standard Protocol

Category 2 Intermediate Protocol

Category 3 Major intervention

Nursing

care* Level 1

and no

intervention

Level 2 or 3 and

no intervention

Fluid

therapy None IV fluids (any) for

maintenance or

rehydration

Shock resuscitation, or IV

fluids (any) for rehydration

with nursing care level 3

Blood

products None Platelets, fresh

frozen plasma or

cryoprecipitate**

with nursing care

level 1 or 2

Platelets, fresh frozen

plasma or cryoprecipitate

with nursing care level 3

Whole blood, packed red

cells, or any combination of

blood products

Other

interventions None Oxygen therapy

Diuretics without

other specific

intervention

Oxygen therapy with

nursing care level 3

Respiratory support

Inotropic support

Specific treatment for liver,

renal or other organ failure

*Nursing care levels, individualised according to local practice:

1 - in- or out-patient, free to walk around, standard observation protocol – e.g. 6 hourly

2 - hospitalized, more stringent observation protocol – e.g. 2-4 hourly

3 - bed rest, ICU level observation protocol – e.g. hourly

** At some sites certain blood products were given in response to abnormal laboratory findings rather than for

clinical reasons. Such interventions are classified in the intermediate category (Category 2).


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The platelet curve (Figure 3-1) shows that despite using three categories, only two could be

distinguished because of the overlap between mild and moderate cases. These results

highlight the importance of using a reference method, active follow-up and documentation of

absence of abnormalities. Time stamps (i.e. the date and time that a certain event occurred)

are also important to provide better accuracy, rather than using simply the date (which is

inherently ±12 hours).

Figure 3-1 ROC curve for severe versus mild and moderate cases

0.00

0.25

0.50

0.75

1.00

Sens

itivity

0.00 0.25 0.50 0.75 1.001 - Specificity

Area under ROC curve = 0.7435

ROC platelets severe vs mod. & mild, all centres

The International Research Consortium on Dengue, Risk assessment, Management and

Surveillance (IDAMS) is another collaborative project, funded by the European Commission.

To be carried out in Vietnam, Cambodia, Malaysia, Indonesia, Brazil, Venezuela and El

Salvador. The objectives of this consortium are organized into six work packages under two

main areas: 1) improving clinical management and diagnosis and 2) assessing the risk of

dengue spread (13). Work package 1 is a prospective multicenter observational study

targeting 8000-10,000 patients aged >5 years with undifferentiated fever. Study endpoints

are: a combined endpoint of hospitalization or IV fluid therapy (1st level) and severe dengue

as per the WHO 2009 classification (2nd

level), and the objectives are to identify factors that

differentiate between dengue and non-dengue illness during the early febrile phase and

factors among dengue infected patients that predict likely progression to a more severe

disease course. This would allow an evaluation of the practical application of the previous

(DHF/DSS) and the current WHO criteria for dengue +/- warning signs classification scheme

(WHO 2009) across a series of clinical sites and to update the guidelines for ‘Integrated

Management of Childhood Illness’ used in dengue-endemic countries. The results are

expected to be available in 2016-2017.

3.2 Sanofi’s experience on disease classification from Phase II/Phase III vaccine

trials (Dr. Fernando NORIEGA; Head Global Clinical Dengue Program & Clinical Development Latin

America, Sanofi Pasteur)

The live attenuated tetravalent dengue vaccine (CYD-DTV) developed by Sanofi Pasteur is

currently under evaluation in Phase III clinical trials to assess its safety and efficacy after

three doses each given 6 months apart in 2-14 and 9-16 year-old children (7).


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The primary endpoint was symptomatic virologically confirmed cases that occur 28 days

following a vaccine dose. Dengue severity assessment was based on the WHO 2009

classification (14) and followed the process shown in Figure 3-2. Cases were first classified

by severity at the study site. Sanofi Pasteur and an Independent Data Monitoring Committee

(IDMC) subsequently re-classified each case. A mismatch between classifications was found

for 18 (54.5%) virologically confirmed cases. As an example, 4 of those 18 cases were

classified as severe by the investigator and the IDMC although they did not fully comply with

the WHO 1997 classification for DHF. These results provide evidence that just a small

difference in the definition used could lead to different classifications, with severe cases not

being correctly identified. Therefore, methodological and operational training of study site

personnel should be verified and validated before starting any large scale Phase III efficacy

study. However, Principal Investigators are frequently not same as the physician making the

assessment, and training hospital personnel has operational difficulties. The use of a simple

‘severe case’ definition would allow the number of cases that are wrongly classified to be

reduced. Finally, an IDMC composed of both dengue clinical experts and experienced

vaccine clinical/statistical scientists is important to properly safeguard the safety of study

participants by assessing 1) severity of virologically-confirmed dengue cases within and

across studies, 2) possible presence of trends, clustering and signals and 3) futility analysis

(i.e. the inability of a clinical trial to achieve its objectives).

Figure 3-2 Process for the evaluation of dengue severity used by Sanofi Pasteur for clinical

trials


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3.3 Takeda’s experience on disease classification from Phase II vaccine trials (Dr.

Dereck WALLACE; Clinical Program Lead for Dengue, Takeda Vaccines, Singapore)

The live attenuated tetravalent vaccine developed by Takeda is currently being evaluated in

Phase II safety and immunogenicity clinical trials in 1800 children aged 2-18 years. To

capture all dengue cases, all children with fever on any two of three consecutive days,

regardless of their clinical presentation, are enrolled at the study sites. A virologically

confirmed dengue case is subsequently defined as febrile illness or illness suspected clinically

to be dengue by the Investigator with a positive serotype-specific RT-PCR. The trial protocols

rely on local standards of care, which can vary substantially by site/country, patient’s age,

season and the treating physician. Any investigations/observations made by the treating

physician as part of routine clinical care are recorded in the case report form to enable an

accurate assessment of severity.

A Phase III efficacy study is planned in 20,000 children at the end of 2015.

3.4 Oxford University’s experience from Phase II therapeutic trials (Prof. Bridget

WILLS, Centre for Tropical medicine and Global Health, Oxford University)

Oxford University has initiated a series of therapeutic interventional trials and observational

studies in Vietnam to investigate the antiviral efficacy of some marketed drugs on the course

of dengue infection and disease.

The first double-blind, randomized, placebo-controlled trial using chloroquine in adults with

suspected dengue provided evidence of a significant reduction in fever clearance time in

intention-to-treat population (Hazard ratio=1.37; 95%CI: 1.08-1.74) and a trend towards a

lower incidence of DHF in patients receiving chloroquine in the per protocol population

(Odds ratio=0.60; 95% CI: 0.34-1.04). However, chloroquine treatment did not reduce the

duration of viremia and NS1 antigenemia (15). The use oral corticoid therapy (prednisolone)

at the early acute phase of infection was not associated with reduction in the incidence of

dengue related complications (16). In another double-blind, randomized, placebo-controlled

study, the kinetics of viremia, NS1 antigenemia, fever clearance, plasma cytokine

concentration and the whole blood transcriptional profile were also not attenuated by

balapiravir treatment (17). There are clear distinctions between children and adults regarding

the pattern of dengue complications (18) and comparison of these studies is not easy because

of difference in treatment groups. A formal schedule of clinical and laboratory assessment is

essential to identify differences between treatment groups. Harmonization of the CCC would

allow comparisons between different studies, but the focus should be on common events,

rather than rare manifestations.

3.5 Utility of rapid dengue diagnostics for use in interventional trials (Dr. Elisabeth

HUNSPERGER; Head, Immunodiagnostics, Development and Research Laboratory CDC Dengue

Branch, San Juan, Puerto Rico)

Accurate and timely diagnosis of dengue is essential for appropriate clinical management of

patients. Traditional tests such as virus isolation are time consuming and not practical in the

context of point of care (POC). A number of Rapid Diagnostic Tests (RDTs) have been

developed during the last decade to be used for POC. The analytic performance and


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reproducibility of these tests, evaluated by a network of laboratories established by

WHO/TDR (Tropical Diseases Research) and the Pediatric Dengue Vaccine Initiative (PDVI)

showed that diagnostic tests for both IgM anti-DENV and NS1 had variable sensitivity (19).

Sensitivity was in general lower in convalescence/secondary infection than in acute/primary

infection. Factors that related to the observed differences in sensitivity were cross-reactivity

with other flavivirus or chronic autoimmune conditions (for IgM), the type of sample

(primary/secondary/convalescence), and the serotype. To increase sensitivity, a new RDT, the

standard Bioline dengue duo containing two devices (left side - Dengue NS1 Ag test, right

side-Dengue IgG/IgM test) has been developed. This test was first evaluated in prospective

studies during dengue outbreaks. Detection of NS1 was most sensitive at Day 3 while for

DENV-IgM Day 5 was the most sensitive. The results provide evidence that the combination

of two tests had moderate added value to detect a dengue case. More recent prospective

studies confirmed the absence of added value of RDT in the clinical management of patients

or in the final diagnosis (20-22).

Variation in results by study could be explained by, among others, differences in reference

tests, serotypes, age groups, or inclusion criteria. Moreover, reader-to-reader variability could

also explain in part the observation of RDTs being very subjective (23). The best reference to

evaluate a test is to:

i) Compare the same analytes.

ii) Compare a ‘gold standard’ test with a new test.

iii) Compare a clinical diagnosis with a laboratory test.

iv) Combine clinical symptoms of dengue with a laboratory reference test.

Future evaluation of NS1 RDTs should continue to consider sensitivity and specificity

compared to a reference test and clinical defined cases but also by accuracy. It is also

important to investigate the impact of such RTDs on patient management and treatment.

There is consensus on the need for an accurate POC test. For the RDT test to be used as a

POC, the best practice needs to be defined.


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4 Defining dengue severity markers: acute febrile illness (AFI)

4.1 Scientific Working Group deliberation summary

Fever comprises a range of values that fluctuate from time to time and place to place in

different individuals. As such it can be a somewhat arbitrary value, based on the consensus of

clinicians, investigators and the public (Brighton fever working group (24)). Fever by itself

has no impact on functional impairment, disability-adjusted life year or public health, but

signs and symptoms associated with fever, defined as acute febrile illness (AFI) syndrome,

can impact public health.

The main objectives of the working group were:

i) Define and characterize the AFI.

ii) Develop a Dengue Severity Index (DSI) that could be used in clinical trials by vaccine

developers and regulatory and public health agencies.

iii) Utilize the DSI to inform vaccine developers and regulatory and public health

agencies of a vaccine candidate’s efficacy and effectiveness beyond the currently used

case definitions of non-severe and severe dengue.

iv) Use the DSI to compare in a standardized way, the impact of vaccines and drugs on

dengue illness at various global testing sites.

The working group proposed that AFI should be composed of at least one or more of the

following signs and symptoms:

Signs: rash, conjunctivitis, vomiting.

Symptoms: feeling feverish, chills, irritability/fussiness, malaise/fatigue, headache,

anorexia, nausea, abdominal pain, myalgia/body pain, arthralgia, itching, eye

symptoms (photophobia or painful movement)

Any one or a combination of these individual signs and symptoms can cause functional

impairment (disruption of daily activities) and such impairment can be stratified by severity

as mild, moderate or severe.

AFI can be characterized using a dengue illness report form (DIRF) - a diary card designed to

capture the daily occurrence of signs and symptoms associated with dengue illness - and the

daily and overall severity (intensity) of the illness measured by the impact on daily activities

(functional activity). The daily DIRF diary cards have already been pre-qualified or validated

and are easily incorporated into existing vaccine trial study designs. The DIRF could be

evaluated using existing data sets from prospective cohort studies or vaccine trials, which

have already collected data in this manner (e.g. PCR proven, daily recording of symptoms,

and known clinical outcomes).

Characterization of AFI by DIRF can subsequently be used to calculate a DSI score for each

illness episode capturing: the total number and duration of all signs and symptoms (days),


20

and daily and overall functional impairment associated with the episode. Functional activity

can be measured on a scale of 1 to 3:

1. Mild: does not affect normal activity; no medication required.

2. Moderate: some impact on daily activities and/or non-prescription/medication

required to treat signs and symptoms.

3. Severe: prevents daily activities and/or prescription/medications required to treat

symptoms, visit to health care provider.

Such a DSI would provide a low-tech tool for vaccine developers to assess if different

vaccine candidates reduce dengue severity compared to controls when trial cohorts are

naturally infected in the field. It would also allow more effective comparison of vaccine

effectiveness/efficacy than the current case definitions of non-severe and severe dengue. The

DSI may also be able to capture and integrate data collected for other disease severity

working groups focused on plasma leakage, bleeding and organ impairment (see

Section 5 and Section 6).

A greater understanding of dengue disease severity and the personal, economic, and societal

burden of disease associated with dengue infections should provide an additional important

measure of a vaccine candidate’s efficacy related to incidence of more severe disease in

additional to its reduction of overall dengue incidence and hospital admissions. The DIRF

and DSI obtained during vaccine trials will provide another way to obtain such information.

4.2 Discussion and conclusions

The concept of a severity index is not new. It has already been used by Merck in Rotateq

vaccine trials and in early clinical dengue trials. The accuracy of DSI is function of data

collected by the DIRF and a recognized limit of such tool is the problem of recall bias if

patients do not fill the DIRF daily. This emphasizes the importance of pre-qualifying a DIRF

by previously existing, good quality data.

The next suggested steps are:

Agreement on the concept of a DSI.

Agreement on the signs and symptoms to be recorded, how to rate severity, how to

collect this data, and how to complete computations (e.g. geometric vs arithmetic

mean scores).

Identification of gaps in the DSI proposal.

Identification of existing data sets to pre-qualify the DSI.

Encouragement of vaccine developers to incorporate DSI into upcoming trials for

qualification and validation.


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5 Defining dengue severity markers: severe bleeding


Various definitions have been used for bleeding and are summarized based on a review of the

available literature in Table 5-1.

The definition of hemophagocytic lymphohistiocytosis (HLH) among dengue patients has

also been subject of a literature review, summarized in Table 5-2.


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Table 5-1 Definitions for bleeding in dengue patients by country based on literature review

Definition Study type

Study population

and number Number with bleeding (dengue) Reference Spontaneous bleeding,

Internal Bleeding – Daily macroscopic

examination of vomitus, stool and urine

PT <70%

Hospital-

based,

prospective

Adults 15-55 years

151 lab-confirmed

(RT-PCR or virus

isolation)

Spontaneous bleeding 127/151, 84.1%;

Internal bleeding 37/151, 24.5%

PT<70% 51/151, 34.9%

Types of mucosal bleeds:

Epistaxis 21%

Malaena 6%

Gingivorrhagia 29%

Menorrhagia 24%

Haemetemsis 10%

Hematuria 3%

(25)

Mild, moderate or severe shock.

Bleeding categories:

Mild: Spontaneous petechiae or bruising at

venepuncture

Moderate: Mucosal bleed, did not affect

hematocrit

Severe: mucosal bleed sufficient to cause

detectable decrease in hematocrit or warrant

transfusion

Hospital-

based,

prospective

Children 1-15 years

with DSS

167 confirmed

dengue shock

4 died with severe GI bleeding

PT/PTT significantly increased at admission compared to follow-up values, but

within acceptable normal range.

Fibrinogen was moderately low. Median PT slightly more prolonged in moderately

severe shock group compared to mild shock.

Protein C, protein S and Antithrombin III levels significantly reduced at admission,

more so in those with severe shock.

Significant increases in levels of tissue factor, thrombomodulin and plasminogen

activator inhibitor-1, even after correction for hemoconcentration.

Day 2: Protein S and AT-III were significantly lower in patients with more severe

shock, these had higher levels of thrombomodulin.

Higher levels of PAI-1 and lower levels of protein S were associated with greater

severity of bleeding.

Low levels of proteins C & S and AT-III could be due to plasma leakage and

correlate with shock. High levels of TF, thrombomodulin, PAI-1 reflect activation

of platelets and endothelial cell lines, secondary to direct activation of fibrinolysis

by dengue virus.

(26)


23

4 Vascular leak categories:

Percentage hemoconcentration:

A < 10%

B 10-12%

C >20%

D Clinical shock

Bleeding manifestations:

1.No clinical bleeding

2.Petechiae/bruising at venepuncture sites only

3.Minor mucosal bleed

4.Significant mucosal bleeding necessitating

interventions such as PICU admission, nasal

packing, blood transfusion

Hospital-

based,

prospective

Children 2-15 years

375 lab-confirmed

dengue, compared to

40 OFI

Bleeding in dengue patients (67%), in OFI group (10%); mainly minor skin

bleeding, p<0.001.

Bleeding in dengue shock (78%) those without shock (66%), p<0.001.

One child with significant bleeding: melaena and a drop in haematocrit after shock

resus.

Hemorrhagic manifestations similar across the three vascular leak categories

without shock, mucosal bleed relatively infrequent; most were minor epistaxis or

gum bleeding.

(27)

Bleeding severity : - Categories

1. No clinical bleeding throughout observation

2. Minor skin bleeding only (petechiae or

bruising at venepuncture sites)

3. Mild/moderate mucosal bleeding (no

intervention required)

4. Severe bleeding - bleeding requiring

intervention (eg transfusion, nasal packing), or

bleeding into a vital organ (e.g. intracranial

bleeding)

Hospital-

based,

prospective

738 adults, 947

children with

suspected dengue

647 adults, 881

children with

confirmed dengue

Among DSS patients:

All adults had bleeding, 33% of children had no bleeding at all.

Severe bleeding 2% in children and 12.8% in adults, p<0.001

Lower nadir platelet counts in adults, 18 vs 32 x 109/L

Uncomplicated dengue: None with Grade 4, Grades 2/3, 85% of adults, 56% of children , p<0.001

Nadir platelet counts: 80 (adults) vs 42 x 109/L (children)

Significant correlation between platelet counts and severity of bleeding

(18)

- Prospective,

Observational

and RCT

1810 DSS children

1719 with confirmed

dengue; median age

10 years

29% of patients with no bleeding;

Grade 2: 67%

Graded 3: 4%

2% with severe bleeding

(28)

Haemorrhagic tendencies included positive TT,

skin bleeding (petechiae, ecchymosis or

purpura), bleeding from mucosa (epistaxis,

gum bleeding), haemetemesis or melena.

Clinical bleeding – spontaneous bleeding

includes all hemorrhage except positive TT.

Hospital-

based,

retrospective

906 admitted with

suspected DHF

347 serological

confirmed 4m to 66

years

Clinical bleeding in 124 patients (24 DF, 100 DHF) (124/347=35.7%) Petechiae

(77% vs 52%) and gum bleeding (26% vs 1%) more common in adults; while

children more epistaxis (41% vs 13%).

(29)

Significant haemorrhage:

Haemorrhage accompanied by a drop in

hematocrit and hemodynamic instability

Hospital-

based,

prospective

and

retrospective

114 children

Age: 7 days to 12

years, mean 6 years

110 DSS, 4 severe DF (30)

Bleeding – any bleeding that did not contribute

to haemodynamic instability and did not

require blood transfusion

Hospital-

based

retrospective

110 children with

DSS.

56/110 = 50.9% (31)


24

Table 5-2 Definitions for HLH in dengue patients based on literature review

Definition Study type

Study population and

number

No. with dengue (%

frequency) Reference

Diagnostic criteria developed by Histiocytic Society (HLH-2004): (5 of the

following criteria)

Fever; duration >7 days with peaks >38.0 C

Splenomegaly; >3cm below costal arch

Cytopenias affecting at least 2 of 3lineages in the peripheral blood:

Haemoglobin <90 g/L, Platelets <100 x 10^9/L, Neutrophil <1.0 x10^9/L

Hypertriglycerdemia and/or hyperfibrinogenamia (Fasting triglycerides

>3.0 mmol/L)

Haemophagocytosis in bone marrow, spleen, or lymph nodes

Low or absent NK-cell activity

Ferritin > 500 microgram/L

Soluble CD25 >2400 U/L

Hospital

based

prospective

13 Children with HLH

0 (0/13=0%) (32)

Same as above Hospital-

based

retrospective

(India)

10 Children with HEH (7

acquired HEH)

1 (1/7=14.2%)

(33)

Genetic defect consistent with HLH AND >5 out of 8 clinical and laboratory

criteria fulfilled

Hospital-

based,

retrospective

(India)

43 Children with HEH 5 (5/43=11.6%) (34)

Patients who fulfilled at least five signs or laboratory parameters were

enrolled

Hospital-

based,

prospective

33 Children with HEH

Median age 3 years 2 (2/33=6.06%)

(35)

Diagnostic guidelines of The Histiocytic Society

Hospital-

based,

prospective

(India)

Children

212 with dengue

23 with BM evidence

(23/212=11%)

(36)


25

5.2 Bleeding in dengue: thrombin time as point of care (Dr. Norma de BOSCH, Venezuela)

The possibility of using thrombin time as a POC test has been investigated in a group of 133

confirmed dengue cases and 38 patients with other febrile illness (OFI). The results showed

that compared to OFI, dengue cases had sensitively lower levels of platelets and prolonged

thrombin time (Figure 5-1).

Figure 5-1 Platelet and thrombin time among patients with dengue or other febrile illness

Red bar: Dengue patients; Blue bar: Patients with OFI

Similar results have been found when comparing dengue patients with or without bleeding

(Figure 5-2).

Figure 5-2 Platelet and thrombin time among dengue patients with or without bleeding

Grey bar: dengue patients with no bleeding; Yellow bar: dengue patients with bleeding

These results suggest that:

There is a diagnostic and prognostic value utilizing the measurement of thrombin time

in the laboratory, the critical time being 4±0.96 seconds over the control sample.

There is a continuous trend of increased thrombin time through the course of disease,

and there is a prognostic value for a prothrombin time >2.04±0.72 to distinguish

dengue from other febrile illnesses.


26

5.3 Discussion and conclusion

5.3.1 Severity of bleeding

The working group proposed to classify bleeding severity into three grades (non-severe,

intermediate and severe) according to the site of bleeding (skin or mucosal bleeding), the type

of intervention, and bleeding severity (Table 5-3, Table 5-4, Table 5-5), and also concluded

that intracranial bleeding should be considered as severe.

Table 5-3 Proposed classification by Working Group of bleeding severity according to the

type of intervention

Classification Intervention

Non-severe Outpatient review or standard inpatient monitoring (4-6 hourly depending on the regular

hospital practice) only, no other medical intervention required to stop bleeding.

Intermediate More intensive observation on a regular ward, or transfer to HDU or ITU depending on

facilities available.

Cross matching in case blood needed.

Getting an expert opinion, e.g. ophthalmologist if concerned about eye bleeding, gynecologist

if concerned about vaginal bleeding etc.

Local Intervention such as nasal or gum packing.

Hematocrit/Hb check

Severe Use of blood products, or volume resuscitation with crystalloid if not available. Any bleeding

into a critical organ


location: skin bleeding

Bleeding type Intervention

required

Classification* Comments

Unprovoked skin bleeding No Non-severe

Skin bleeding at injection sites No Non-severe

Skin bleeding at injection sites Yes intermediate Pressure bandage

Skin bleeding at injection sites Yes Severe Blood transfusion

required

Bruising No Non-severe

Petechiae No Non-severe

Echymosis No Non-severe

Purpura No Non-severe

* All bleeding leading to hemodynamic instability is classified as severe, regardless of bleeding location


location: mucosal bleeding


27

Bleeding type Intervention

required

Classification* Comments

Eye bleeding No Intermediate Requires ophthalmology consult

Eye bleeding Yes Severe Vision endangered

Nose bleeding No Non-severe

Nose bleeding** Yes Intermediate Need for nasal packing

Nose bleeding Yes Severe Need for packing and blood

transfusion or volume resuscitation

GI bleeding Yes Intermediate H-2 blockers or Proton pump

inhibitor

GI bleeding Yes Severe Need for blood transfusion or

volume resuscitation

Vaginal bleeding Yes Intermediate Need for hormonal treatment

Vaginal bleeding Yes Severe Need for blood transfusion or


Urine stick positive 1-3+ No Non-severe Microscopic

Macroscopic haematuria No Intermediate No need to transfuse but requires

close monitoring

Macroscopic haematuria No Severe Need for blood transfusion or


* All bleeding leading to hemodynamic instability is classified as severe, regardless of bleeding location

** Bleeding in upper respiratory tract may manifest as hemetemesis

5.3.2 Severity of hemophagocytic lymphohistiocytosis (HLH)

The proposed severity of HLH is presented in Table 5-6.

Table 5-6 Proposed classification by Working Group of HLH severity based on intervention

Classification Intervention

Non-severe There is no non-severe HLH in dengue. Any evidence of HLH should lead to classification as

Intermediate or Severe

Intermediate More intensive observation on a regular ward, or transfer to HDU or ITU depending on

facilities available.

Cross matching in case blood needed.

Getting an expert opinion

Severe Standard treatment based on treatment protocol for HLH


28

6 Defining dengue severity markers: plasma leakage


Plasma leakage in dengue can be absent, present and rated as mild or moderate, or present

and rated as severe (which can result in dengue shock syndrome [DSS]). There are three

potential methods that could be used to assess plasma leakage – hemoconcentration, imaging,

and plasma protein changes: each is considered separately in the following sub-sections.

6.1.1 Hemoconcentration

Various definitions have been used for hemoconcentration largely depending on the

geographical area, and are summarized based on a review of the available literature for

Thailand, Vietnam, Nicaragua, Puerto Rico, in Table 6-1.

Ideally repeated hematocrit (HCT) or hemoglobin (Hb) measurements should be taken

although in practice, and especially in vaccine clinical trials, this can be difficult, particularly

in infants who may be febrile and unable to provide repeated blood samples. Either HCT or

Hb can be used for the assessment of hemoconcentration, as long as the chosen parameter is

used consistently; similarly, either capillary or venous samples can be used but should be

consistent.

The baseline value should be obtained either early in the febrile period (Day ≤3, provided no

IV fluids have been given as these can obscure the overall severity of hemoconcentration), in

the 1 month prior to the febrile period, or during convalescence (Day 14 or later, provided no

significant bleeding, transfusion, or hemolysis). The peak value should ideally be identified

by repeated sampling from Day 4 to Day 10, although in practice, as described above, this

can be difficult. If no HCT/Hb values are available at the relevant time point(s) then the

patient cannot be identified for hemoconcentration.


29

Table 6-1 Definitions for hemoconcentration by country

Country Definition Study type Study population and number Number with

hemoconcentration

Reference

Thailand >20% above the value on Day 8-10 Hospital-based,

prospective

Children 6 months-14 years with fever <72 h without

obvious cause

60 lab-confirmed (of total 89)

28/60 (40%) (37)

≥20%a (≤15%: no evidence; 15-20%: intermediate Hospital-based,

prospective


obvious cause

381 lab-confirmed

29 DHF (54%)

13 DF/DHF (24%)

12 DF (22%)

(38)

≥20%b (expert clinician reviewed each case in

terms of difficulties in using HCT, but no formal

rules described)

Hospital-based,

prospective


obvious cause

414 lab-confirmed (of total 1013)

150/414 (36%) (39)

Vietnam ≥20% (baselinec 37% for 5-10 year-olds; cut-off

>44%)

Hospital-based,

prospective

Children with suspected dengue, with all severities

712/1136 lab-confirmed

319/712 (45%) (40)

≥20% (≤10%: normal variation, 10-20%: mild

hemoconcentration)d

Hospital-based,

prospective

Children with suspected dengue, with all severities


110 (plus

33DSS)/367 (39%)

(27)

≥20d Hospital-based,

prospective

Children or young adults with suspected dengue

a) 644, b) 647, c) 225 lab-confirmed

NP a) (41)

b) (18)

c) (16)

Nicaragua ≥20% above the stabilized HCT at discharge, or

above normal HCT by age & sexe

Cut-offs:

>42% in children ≤18 years

>45% (females) and >50% (males) >18 years

Hospital and health

center-based,

prospective

Both children and adults with suspected dengue


60/614 (10%) (42-44)

Puerto Rico ≥20% above the baseline or a drop ≥20% after

intravenous fluid treatment = significant

hemoconcentrationf

Surveillance study Hospitalized suspected dengue patients


NP (45)

≥20% above the baseline or a drop ≥20% after

intravenous fluid treatment = significant

hemoconcentrationf

Surveillance study Fatal dengue patients

23/31

16/23 (70%) (46)

aPeak HCT: Maximum HCT around defervescence. Baseline HCT: Minimum HCT during acute illness / early convalescence DHF: >=20% or > 1cm fluid accumulation, DF: <=15% and no detectable fluid

accumulation, Intermediate DF/DHF: > 15-20% or <= 1cm fluid accumulation bPeak HCT: Maximum HCT during hospitalization, Baseline HCT: HCT at convalescence (discharge) cBaseline HCT: The lowest value documented before day 3 of illness provided the platelet count is at least 100,000 mm3 on the same sample or at the follow-up visit (day 14 of illness or more) provided that no severe

bleeding has occurred; if neither is available the local population mean for age and sex is used (from a reference database for > 1000 healthy Vietnamese children and 850 healthy Vietnamese adults, unpublished data) dMaximum HCT: Peak HCT between days 3-8, at least 3 days of serial HCT data including at least 2 days around defervescence eNormal HCT by age and sex was not available for the Nicaraguan population at that time, so the mean values for the United States were used instead fDifference between maximum and minimum recorded HCT (or hemoglobin) values, divided by the minimum value. Other criteria were also suggested such as HCT >= 50% and accepting haemoconcentration >=10%

NP=not provided


30

6.1.2 Imaging

Various definitions have been used for imaging and are summarized based on a review of the

available literature in Table 6-2.

Most of these studies have been limited by being small, retrospective, and focusing on high-

risk groups, which can lead to bias towards finding abnormalities. Other limitations include

inter-operator error and lack of standardization, unclear definitions for the gall bladder wall

(GBW) thickening abnormalities, and the difficulty of making repeated measurements

(especially for vaccine clinical trials, as described in Section 6.1.1).

Imaging can be used to support the identification of vascular leakage and isolated

abnormality. Multiple scans that showed evidence of increasing effusions or ascites would be

strong evidence of the progression of leakage (although it should be noted that repeated scans

could be difficult in practice and should not be a requirement).

Lateral decubitus X-rays (taken at an appropriate time) using the standard cut-off of 1 cm

would be acceptable.

Standardization of interpretation of chest X-rays for the diagnosis of pneumonia in children

has been already investigated and is difficult.


31

Table 6-2 Imaging definitions for plasma leakage

Definition Study type Study population and number Number with evidence of

plasma leakage

Reference

Splenomegaly: splenic index greater than 20 cm2.

Thickened gallbladder wall: thicker than 3.5 mm.

Ascites not defined.

Pleural effusion not defined.

Cross sectional study during

outbreak in Taiwan

Adults: mean age 49 (range 18-76)

Mean +SD duration of fever 3.7+ 2.0 days

65 patients (36 female)

59% thickened gallbladder wall

(0.6 + 0.4 cm)

Ascites 24%

Splenomegaly 34%

Pleural effusion 32%

(47)

Pleural effusion and ascites detected by Xray and

USS. Methodology NOT defined.

(Lateral decubitus films were not carried out)

Prospective study in referral

pediatric hospital at Chennai

Daily clinical exam and

complementary chest Xray and

USS. Xray taken at admission and

when clinically indicated

Children >= 1 month to 18 years of age

65 cases.

DF 30, (46%)

DHF 35, (54%)

(DSS=6, 9%)

(48)

USS Protocol:

Pleural effusion: vertical dimension of the fluid

collection by measuring distance between the top of

the dome of the diaphragm and the base of lung.

Ascites: hepatorenal pounch and retrovesicular

area in a supine position.

Quantitative measurement of the fluid behind the

urinary bladder (anteroposterior and transverse

diameter).

X ray: Pleural effusion index in a right lateral

decubitus chest Xray.

Serial ultrasonographic study.

Daily evaluation from admission

till one day after defervescence or

according to clinical course

Thai children < 15 years of age with <72 hours

of fever without obvious focus of infection.

82 patients.

DHF 21

DF 61.

DF: 1.6% pleural effusion, 4.9%

gall bladder wall (>2mm), 6.5%

retrovesicular fluid, 1.6%

hepatorenal pouch fluid

DHF: 9.5% pleural effusion,

4.2% gall bladder wall (>2mm),

5.2% retrovesicular fluid, 4.8%

hepatorenal pouch fluid

Positive predictive value to

diagnose DHF (more than 1 day

of fever): X ray: 61%, US

upright: 93%, gall bladder more

than 2 mm: 54%, hepatorenal

pouch: 100%, retrovesicular fluid

55%.

(49)

Method: Siemans ultrasound with tissue harmonic

imagin

Evaluation of costophrenic angles, pericardium and

pelvis. Second review in those with questionable

findings

Abdominal sonographic findings

during a trial of challenge with

attenuated monovalent virus.

Blinded observer.

USS performed after fever onset: 1,

3, 5 and 7 days.

Those with no fever 9,11 and 13

days after inoculation.

All adult men, 12 challenged with virus and 3

with placebo

15

Effusion or ascites were seen in 7

of 12. None had clinical evidence

of plasma leakage.

All findings appeared after

defervescence. 9-14 days after

challenge. All serotypes

manifested as sonographic

findings

(50)


32

Definition Study type Study population and number Number with evidence of

plasma leakage

Reference

Examination during fasting state by one radiologist.

Ten parameters.

Thoracic scanning was done in supine posture.

Pericardial space was evaluated using subcostal

approach.

Retrospective analysis of 10

ultrasonographic features of

patients presenting with probable

dengue during outbreak in 2006 in

India. They were classified

according to serologic findings

Children and adults.

169 subjects.

Mean age 27.9 + 13.

Min 3-Max 75 years.

GBW thickening: 72%

Ascites: 74%

Pleural effusion bilateral 11%

Unilateral 28%

Hepatomegaly 46%

Pericardial effusion 4.1%

Splenomegaly 39%

Pericholecystic collection 14%

(51)

Capillary leakage was considered in case of ascites,

pleural effusion or thickened edematous gallblader.

There is no explanation about the criteria used to

define it.

Israeli travelers returning from

endemic dengue areas, between

2002-2009.

All confirmed by serology.

Adult hospitalized cases, mean age 30 yrs.

Sonography was performed around 6.9 + 1 days

after fever onset.

35 cases

2 cases fulfilled WHO DHF

definition. None had significant

hemoconcentration measured as

increase 20% of hematocrit

value. 34% showed evidence of

capillary leakage. 10 ascites,

concomitant gall bladder edema

in 3 cases, concomitant pleural

effusion in 5 cases, and 2 cases

isolated pleural effusion.

(52)

Handheld ultrasound and conventional US by

radiology physicians trained during four weeks,

after 6 hours of fasting. Gall bladder thickened was

defined by 3 mm. Pleural effusion was established

by observation of bilateral costophrenic angles in

supine position.

Prospective observational study, of

cohort. Daily bedside ultrasounds

till 48 hours after fever

deffervescence.

Patients with dengue infections 14 years and

above, admitted to referral hospital in Java, -

Indonesia. 2011-2012.

66 cases

11 developed severe dengue by

WHO 2009 criteria. Presence of

subclinical plasma leakage at

enrollment had positive

predictive value of 35% and

negative predictive value of 90%

for severe dengue. Gall bladder

edema usually preceded ascites

and effusions.

(53)

Single measurement, done by radiologist with more

than 5 years of experience. Gall bladder wall

thickening was measured as well as thoracic

scanning in either sitting or supine posture.

Spleen longer than 12 cm was enlarged. Liver

measuring more than 15 cm was taken as

hepatomegaly.

Retrospective analysis of

confirmed dengue cases referred

for ultrasound scanning / X ray

imaging.

Tertiary care center in Bangalore India during

outbreak 2012.

Ages between 0 and more than 40 years. Mean

age not indicated, but 43 cases belonged to age

group 20 to 39 years.

96 cases.

GB wall thickening 66%, ascites

65%, bilateral pleural effusion

26%, hepatomegaly 17%,

splenomegaly 17%.

(54)


33

6.1.3 Assessment of plasma protein changes

Various definitions have been used for imaging and are summarized based on a review of the

literature in Table 6-3.

These studies are even more limited than those for hemoconcentration and imaging to

identify plasma leakage. Most do not provide sufficient detail to quantify hypoproteinemia,

and other conditions – such as nephrotic syndrome or systemic capillary leak syndrome

(SCLS) – are not defined using low protein levels in isolation. Caution should be therefore

used if defining severity of plasma leakage based on abnormal values; the scale used for

assessing SCLS severity could be adapted for use in dengue. Also, hemoconcentration may

affect changes in plasma proteins, and low levels are typically not apparent until after IV

fluids have been given for plasma volume loss. Additionally, as for hemoconcentration and

imaging, the correct time in the disease evolution needs to be accurately identified but again

repeated measurements can be problematic.

Overall, at this stage it is recommended not to use albumin levels to define plasma leakage.


34

Table 6-3 Definitions for hypoproteinemia

Definition Study type Study population Other information Reference

Decrease in serum albumin from patients own

baseline used (in addition to other criteria) to

diagnose an attack

Hospital based retrospective

cohort

25 patients admitted to Mayo Clinic 1981-

2008 with well documented SCLS.

For this population, median

reduction in albumin 1.9g/dL;

IQR 1.0-2.2G/dL during an

attack

(55)

Serum albumin below lower limit of normal

range defined by laboratory.

Case series report 6 Children, aged 5-11yrs, from USA,

Canada, Australia and Italy with SCLS

During attacks, albumin

values ranged from 1.1g/dl –

2.3g/dl

Hsu,

2015a


range defined by laboratory

Case series report

European multicenter

28 patients referred to European

multicenter SCLS register 1997-2010

13 M, 15F (Age?)

Established diagnostic criteria

for SCLS, including

‘hypoalbuminemia’ but cut-

off not defined.

During attacks (median):

Protein 4.3g/dl range, 2.7- 6.6

Albumin 2.1 g/dl, range, 1.1-

3.8

(56)


range defined by laboratory.

Case series report 8 patients with SCLS

Aged 28-66yrs at presentation

‘Hypoalbuminemia’ reported

in all cases. Values reported

for one severe case resulting

in death. Serum albumin

0.8g/dl

(57)


defined by laboratory

Case series report 44 cases published in case reports and case

series 1990 - 2006

Serum protein & albumin low

in 37 cases, actual values not

always reported

Albumin (mean ± SD) of

1.67±0.66 g/dl.

(58)

Not defined Systematic Review

Diagnosis and clinical

management

- Recommend measuring serum

albumin to confirm protein

leakage.

(59)

aReference not found


35


Severe plasma leakage leading to dengue shock syndrome (DSS) can be defined by the

presence of the three following criteria:

Either pulse pressure ≤20 mmHg or hypotension (systolic pressure <80 mmHg for those

aged <5 years or 80 to 90 mmHg for older children and adults).

Tachycardia, cool extremities, delayed capillary refill, weak pulse, lethargy or

restlessness.

Evidence of plasma leakage.

Severe plasma leakage leading to respiratory distress can be defined by the presence of the

two following criteria:

Tachypnea with evidence of increased work of breathing.

Evidence of plasma leakage.

While severe plasma leakage leading to DSS and leading to respiratory distress can be

defined in this way, it is difficult to provide similar definitions for moderate plasma leakage

or for its absence. However, it may not be necessary to distinguish between moderate and

severe leakage, and in any case this is not practically feasible in vaccine clinical trials with

pre-defined visits, which may not coincide with the relevant time points to detect peak

leakage. Additionally, measuring plasma leakage itself is problematic as described in

Section 6.1.


36

7 Defining dengue severity markers: organ involvement

7.1 Liver

7.1.1 Scientific Working Group deliberation summary

A number of definitions exist for acute hepatitis in the infectious disease and dengue

literature (60-63). However, all definitions describe an acute illness with discrete onset of

signs and symptoms plus either the presence of jaundice and/or an elevated serum alanine

aminotransferase (ALT), or an elevated ALT or serum aspartate aminotransferase (AST)

level. Most definitions specify that the ALT or AST level should be greater than 10 times the

upper limit of normal (ULN). Even though there are these consistencies among acute

hepatitis definitions used in the literature, issues arise in how they are operationalized

because AST/ALT cut-off values may vary by laboratory and by patient gender of the patient.

Similarly, there are a number of definitions used for acute liver failure (ALF) in the infectious

disease and dengue literature. However, the most commonly used ALF definitions describe

an acute clinical syndrome consistent with hepatitis that is followed by the development of

acute liver dysfunction as evidenced by new onset coagulopathy (i.e., an international

normalized ratio greater or equal to 1.5) and mental status changes or hepatic

encephalopathy. Most ALF definitions specify that cases should not have pre-existing liver

disease or at least no pre-existing symptomatic liver disease. Most of the variability among

ALF definitions is in how cases are classified. Case classification, which is done for

prognostic purposes, is determined by the duration of the interval between onset of liver

injury (i.e., defined by onset of jaundice or onset of hepatitis) and development of mental

status changes or encephalopathy. For example, some definitions specify that cases with an

interval of 0-4 weeks should be classified as acute while other definitions specify that cases

with an interval of <7 days are hyperacute while those with an interval of 8 to 28 days are

acute (64-69).

The frequency of acute hepatitis and ALF in dengue are summarized based on a review of the

literature in Table 7-1 and Table 7-2.

Serum aminotransferases are elevated in most (82-97%) hospitalized dengue patients (41,

70), with higher levels generally found among more severe cases. AST levels are typically 2

to 3 times higher than ALT levels in dengue patients. AST levels increase before ALT, and

both reach peak levels 7 to 10 days after the onset of fever (41, 70). Several studies have

found that increased AST and ALT levels may be associated with more severe vascular

leakage and bleeding (41, 70-73). In prospective studies, acute hepatitis defined by an ALT

>10 ULN occurs in about 2-6% of dengue patients; 3-17% of dengue patients have hepatitis

when defined by an AST >10 times ULN (73-75). ALF, which typically occurs during the

second week of illness (41, 70, 76-79), is less common among dengue patients. ALF occurs

in about 0.5-1% of hospitalized adult patients and 3-6% of hospitalized pediatric dengue

patients.


37

Table 7-1 Frequency of acute hepatitis in dengue

Definition Study type Study population and number Total number with hepatitis Reference

>10-fold upper limit of normal (ULN) ALT or

ASTa

Prospective study at Referral

Center

Suspected dengue pts. at referral center all

ages; 91% DF

1,585 lab confirmed

28 (1.8%) ALT

54 (3.4%) AST

(73)

>10-fold ULN ALT or AST Prospective AFI Study in ED AFI pts. >13 yrs. present to ED; 195/506

hospitalized

560 lab confirmed

42 (7.5%) ALT or AST (79)

>400 U/L; Neg. HAV, HBV, malaria/typhoid Hospital-based prospective Suspected hospitalized dengue pts. <15

yrs.; 54% DF, 4.5% jaundice

110 lab confirmed

6 (5.5%) ALT

19 (17.3%) AST

(74)

>10-fold ULN ALT or AST. Neg. malaria Hospital-based prospective Suspected hospitalized dengue pts. >18

yrs.; 4.8% jaundice

327 lab confirmed

34 (10.3%) ALT or AST

(80)

>400 U/L; Neg. HAV, HBV, HDV

Hospital-based, retrospective

Dengue fever pts. >14 yrs.; 254

hospitalized

270 lab confirmed

20 (7.4%) ALT

30 (11.1%) AST

(70)

>10-fold ULN ALT or AST Hospital-based, retrospective Febrile serologic confirmed dengue in pts.

>14 yrs.; 83% DF

127 lab confirmed

12 (9.5%) ALT

13 (10.2%) AST

(81)

>300 U/L or >10 ULN ALT; Neg. chronic

liver disease (CLD), malaria

Hospital-based, retrospective

Febrile serologic confirmed dengue in pts.

>13 yrs. with ALT done; 86% DF

699 lab confirmed

103 (14.7%) ALT (82)

aALT > 720 U/L males and ALT >520 U/L for females, and AST >590 U/L for males and AST >360 U/L for females; neg. HAV, HBV, HCV


38

Table 7-2 Frequency of acute liver failure in dengue

Definition Study type Study population and number Total number with acute liver

failure

Reference

American Association for the Study of Liver

Diseases (AASLD) Definition

Hospital-based, prospective Admitted suspected dengue pts. >14 yrs.

old; 1.7% jaundice

644 lab confirmed

5 (0.8%) (1 died) (41)

Fulminant hepatitis not defined ED prospective AFI Study AFI pts. >13 yrs. old present to ED;

195/506 hospitalized

560 lab confirmed

2 (0.4%) (all died) (79)

Fulminant hepatitis not defined; Neg. CLD Hospital-based, prospective Acute IgM confirmed in pts. <15 yrs.; 60%

jaundice

120 lab confirmed

7 (5.8%) (all died)

(77)

Severe encephalopathy, coagulopathy, liver

dysfx

Hospital-based, retrospective IgM pos., JE neg. hospitalized pts. <12

yrs.; 1.4% jaundice

215 lab confirmed

8 (3.7%) (1 died)

(76)

Neg. HAV, HBV, HCV, HDV. Elevated

bilirubin

Hospital-based, retrospective Dengue fever pts. >14 yrs.; 254

hospitalized

270 lab confirmed

3 (1.1%) (all died) (70)

Liver failure with HE + increase in ALT/AST Hospital-based, retrospective DHF/DSS in pts. at pediatric hospital

334 lab confirmed

18 (5.4%) (5 died) (78)


39

7.1.2 Discussion and conclusions

Case definitions, developed as a part of this workshop, will be used to classify study subjects

who are being monitored as part of a vaccine trial and who meet the primary efficacy

endpoint (i.e., two days of fever plus laboratory-confirmed DENV infection), and those who

are in therapeutic trials and pathogenesis studies. Taking this into consideration, we choose to

use case definitions that are commonly described in the infectious disease and dengue

literature, and that could be readily operationalized in a diversity of field sites. Table 7-3

presents the proposed definitions for liver involvement in dengue patients.

Acute liver failure (severe liver impairment – liver dysfunction):

Proposed case definition for acute liver failure does not include jaundice, which

generally represents a plasma bilirubin level of >3mg/dL, as a case defining criteria

because jaundice is not always present and it can be difficult to assess in some

populations and therefore limits the reproducibility of the definition.

Proposed case definition for acute liver failure includes new onset coagulopathy as

demonstrated by an INR of greater or equal to 1.5 and new onset mental status changes

or encephalopathy as a case defining criteria. However, in infants and young children

with no obvious mental status changes a higher INR cut-off of greater than or equal to

2.0 may be used as case defining. This is consistent with criteria used by the multi-site,

international study, the Pediatric Acute Liver Failure Study Group (83).

Proposed that all PCR-confirmed dengue study subjects who meet case definition for

acute liver failure be evaluated for pre-existing liver disease, co-infections and toxicities

as part of the work-up in order to better define cases that develop acute liver failure.

Acute hepatitis (non-severe liver impairment – liver injury):

Proposed definition for acute hepatitis does not include AST as it is a less specific

endpoint than ALT which is present in highest concentration in the liver. In addition,

dengue patients typically have AST levels that are 2 to 3 times higher than ALT. As AST

is found in several tissues including skeletal muscle, an elevated AST may also reflect

muscle inflammation in patients with dengue. We propose using the cut-off of ALT >10

ULN for acute hepatitis as this value corresponds to a grade 4 adverse reaction on the US

Food and Drug Administration (FDA) toxicity grading tables for healthy volunteers

enrolled in clinical trials (84).

Proposed that the presence of jaundice not be used to define acute hepatitis. We did this

because we wanted to capture cases with moderate liver involvement, and jaundice is a

sign of hepatic dysfunction and therefore, more severe disease. In addition, jaundice is

typically a late finding in cases with acute hepatitis and may be difficult to access in

some populations. It was acknowledged that not all cases with acute hepatitis will

necessitate hospitalization or an intervention outside of monitoring their serum ALT

level.


40

Proposed that all PCR-confirmed dengue study subjects who meet case definition for

acute hepatitis be evaluated for pre-existing liver disease, co-infections and toxicities as

part of the work-up in order to better define cases that develop acute hepatitis.


41

Table 7-3 Proposed definitions for liver involvement in dengue patients

Case defining criteria

Grade Acute illness Elevated serum ALTa

Hepatic

encephalopathy (HE)

Coagulopathy (defined

by an international

normalized ratio [INR]) Other information

Acute Hepatitis

(Moderate Liver Involvement)

Acute illness with discrete onset

of signs and symptoms consistent

with acute viral hepatitis (e.g.,

fatigue, abdominal pain, loss of

appetite, intermittent nausea,

vomiting, dark urine, clay colored

or light stools).

ALT >10 times ULN

consistent with grade

4 toxicity in the FDA

2007 toxicity tables*

No mental status

changes

Normal INR

-

Acute Liver Failure

(Severe Liver Involvement)

Acute illness that meets case

definition for acute hepatitis (as

above).

ALT greater than 10

times ULNb

Hepatic

encephalopathy of

any grade that occurs

following signs and

symptoms of hepatitis

INR ≥1.5

If infant/young child,

INR 1.5-1.9 with HE or

INR ≥2.0 if no HE

Patient may have

jaundice, hepatomegaly,

and right upper quadrant

tenderness but these are

not case defining.

aALT preferred to AST as the former is more specific for liver disease. See

http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Vaccines/ucm091977.pdf bALT level may decrease due to massive destruction of viable hepatocytes, so ALT may no longer be >10 times ULN at the time of diagnosis of acute liver failure


42

7.2 Central nervous system


Neurological involvement in dengue based on a review of the literature is summarized in

Table 7-4.

Studies provided evidence of neurological involvement in every setting across all endemic

areas (South and South East Asia, Central and South America) and also across age groups,

but case definitions varied (for example seizure, encephalitis, encephalopathy, meningitis)

and myelitis, Guillaine-Barré syndrome (GBS), motor weakness, and ischemic stroke are also

reported.

Due to these differences in population and case definition, as well as the research method, the

overall frequency of CNS involvement in dengue is difficult to determine, although

neurological manifestations among dengue patients were reported with an incidence of 1-3%,

and dengue encephalopathy/encephalitis among patients who presented with CNS infection

were reported in 2.3-26.5% of cases.

Neurological involvement usually occurs simultaneously with dengue symptoms.

Laboratory diagnosis can be problematic (e.g. due to technical problems of CSF collection,

imaging, etc) and sensitivity can be low.


43

Table 7-4 Definitions for encephalitis, encephalopathy, and other neurological manifestations in dengue

Definition Study type Study population and number Number with

encephalitis/encephalopathy

Reference

Reduced consciousness (GCS <15)

PLUS abnormal CSF findings

1. Febrile encephalopathy (FE) (fever with

altered sensorium)

2. Acute pure motor weakness (F with muscle

weakness)

No mention of virus presence in CSF

Hospital-based,

prospective (neuro

ward)

174 patients hospitalized with neurological

disorders of viral etiology

17 lab confirmed dengue

(5-56y)

(24 lab confirmed dengue, but 7 excluded

due to coexistent Malaria (1), JE(2),

hepatic failure (2), Intracerebral

hemorrhage (2)

11 FE:

8 with lymphocytic

pleocytosis

8: EEG – theta to delta

slowing

(Other 3 with altered

sensorium but normal CSF,

6 with pure motor weakness)

Frequency 11/174 = 6.3%

(85)

1.Encephalitis: Focal involvement of CNS: motor,

sensory, cranial nerve, visual, speech, ataxia or seizures

+/- CSF abnormalities

2. Encephalopathy: Non-localizing neuro S&S and

non-focal CNS features: confusion, reduced

consciousness, behavior without CSF abnormalities

3. Meningitis: meningeal irritation and pleocytosis

Hospital-based,

prospective

101 patients hospitalized with suspected

dengue virus infection


(14-72Y)

18 with neuro S&S.

12 with encephalitis.

(6 others with altered

sensorium without neuro-

deficit and normal CSF)

Frequency of encephalitis

12/85 = 14.1%

(86)

Encephalitis: CNS involvement

PLUS positive CSF viral isolation/ PCR/ NS1/ IgM/

IgG

Population-based

cross-sectional

150 FATAL patients died from suspected

infectious diseases


(2M-86Y)

41/84

Frequency 48%

(87)

Encephalitis: Reduced consciousness without metabolic

cause, PLUS 1 of

Abn. CSF >5 white cell,

focal neuro sign,

convulsion

Encephalopathy if none of above

Hospital-based

Prospective;

ICU and all with

suspected CNS

infections

1675 patients hospitalized with clinically

DHF PLUS 378 patients with suspected

CNS infections (228 adults + 150 child)

Total dengue patients:1691 (1675 + 16

suspected CNS infection)

(1412 children)

Neuro diagnosis:

16/1691

9 with encephalitis

PCR/IgG/IgM in CSF,

4 acute encephalopathy,

2 were transverse myelitis, 1

meningismus

Frequency 0.9%

(88)


44



Reference

Encephalitis: Dengue Encephalopathy plus evidence of

virus in CSF

Hospital prospective

study, acute febrile

encephalopathy

(AFE), excluded bact

and TB meningitis

and hepatic

encephalopathy

265 patients with AFE; compared dengue

with non-dengue

44 JE; 130 definitely not dengue, 96 not

sure whether negative, thus excluded.

15 dengue positive by HI, 47 dengue IgM

positive

Compared 130 definite not dengue with

39 definite dengue

39 with PCR positive or HI

positive for dengue

PCR positive in CSF in 21/29

cases

Frequency 23.1% (39/169)

(89)

1. Encephalitis-like illness: Fever, headache, altered

mental state

2. Aseptic Meningitis: Fever, headache, neck stiffness,

no change in mental state

3. Motor disorder: weakness, paralysis with no change

in mental state

A lab-positive dengue with neuro manifestations :with

positive virologic or serologic tests on serum or CSF

Enhanced

surveillance system

for encephalitis and

aseptic meningitis,

Puerto Rico

86 patients reported,

16 excluded bact. identifiable cause,

34 with encephalitic-like illness,

25 aseptic meningitis,

11 motor disorder


(9M-82Y)

34 encephalitic-like illness –

9 confirmed dengue incl 1

positive IgM CSF plus

2 confirmed dengue with

motor disorders

None with aseptic meningitis

Frequency 9/34 = 26.5%

(90)

Encephalitis: reduced conscious level, focal neuro

signs, focal or generalized seizures.

GBS: acute rising paraparesis with demyelinating

polyneuropathy on EMG

Myelitis: Evolving paraperesis with sensory level or

sphincteric involvement

Hospital based,

retrospective case

series

Summer of 2002 in Rio de J City: 106,721

cases of dengue; 1304 cases had

neurological diseases during the study

period

13 dengue IgM positive with neurological

signs,

(1.3% of cases with neuro signs during

dengue outbreak)

Age 11-79 Yrs. median 52 Yrs.

7 with encephalitis (2 had

IgM in CSF)

4 GBS (2 positive IgM in

CSF)

2 Myelitis (2 positve IgM in

CSF)

GBS and myelitis: present 7

to 14 days after fever onset.

5 patients had >5 cells/mm3 in

CSF

(long time frame between

illness and sampling of CSF,

range 7 days to 1 year)

(91)


45



Reference

“Neurological dengue”

(Clinical diagnosed viral CNS infection)

Dept of Microbiology

based, retrospective

401 specimens of suspected viral CNS

infections; age range 8 months to 49 years,

mean 9.6 years

54 of 401 lab confirmed dengue (13.5%)

28/54 (50%) encephalitis

18/54 (33%) meningitis

6/54 (11%) seizures

2/54 (3.7%) GBS/Acute

flaccid paralysis (all clinical)

Lab evidence of neuro

infection 12/54 (22%)

(92)

Alteration of consciousness, seizure, nuchal rigidity,

neuro deficit

Hospital-based

Prospective

2975 children hospitalized with dengue

infection

2975 lab confirmed

(3M-14Y)

30

6/28 CSF pleocytosis

2/22 positive IgM in CSF

1/2 histopathology diagnosed

as viral encephalitis

Frequency 1%

(93)

GCS <13 with or S neurologic manifestation

(seizure, CN palsy, meningism, papilledema)

Hospital-based

prospective

44 children hospitalized with viral

encephalitis


(7-12Y)

1 patient, PCR positive

None had cells in CSF

Frequency 2.3% (1/44)

(94)

1. Encephalitis: Reduced consciousness to the level

stupor or lower

(however, 45% had seizure, nuchal rigidity, spasticity,

hemiplegia)

2. Seizure: Seizure without reduced consciousness to the

level of stupor or lower

3. Miscellaneous: (meningism)

Hospital-based

retrospective

1493 children hospitalized with dengue

infection

1493 lab confirmed (0-15Y)

80 (5.4%) with neurological

manifestation:

42 Encephalitis

35 seizure

3 miscellaneous

0/16, CSF PCR/IgM positive

7/31, CSF cells > 5/mm3

Frequency of encephalitis:

2.8% (42/1493)

(95)

Fever with decreased conscious levels plus evidence of

dengue virus in CSF

Case report 6 cases, aged 5 months to 11 years 4 patients, CSF virus

isolation,

2 patients, PCR positive

1 patient, IgM positive

(96)


46



Reference

Did not mention (dengue patients with neurological

manifestations)

Case report

(same pop. as in

Soares, 2006 (ref (91)

– see above)

10 dengue patients with neurological

manifestations

10 cases (22-74Y)

5 GBS, 3 myelitis,

1 encephalitis and

1 optic neuromyelitis

9 patients, CSF IgM IgG

positive

(1 negative in GBS group)

4 patients, CSF cells > 5/mm3

3 patients, CSF AI IgG

positivea

(Note: AI asso. with CSF

cells)

(97)

Immunohistochemical studies Case report 5 fatal cases of dengue associated with

neurological disorders

3/5 had positive staining in

brain tissues

(98)

CNS involvement and positive IgM and abnormal MRI Case report 1 lab confirmed (13Y) (99)

Dengue virus 2 in CSF and blood Case report, Fr

Guiana

1 case (fatal)

(100)

Altered sensorium, seizure,

CSF pleocytosis CSF +ve IgM

Case report 1 lab confirmed (4 Y) (101)

Severe headache, nuchal rigidity, CSF pleocytosis Case report 1 lab confirmed

(24 Y)

Soares,

2010b

Guillain-Barre Syndrome, Nerve conduction tests

of demyelinating polyneuropathy – sensory and motor

nerves and muscle action potential

Case report – 44 year

old female

IgM positive but CSF completely normal,

taken at 7 days.

(102)

Case report Right hemiparesis, and dysarthria

59 years old, diabetes mellitus

Blood PCR positive

CT scan hypodensity over R

thalamus, ischemic stroke

(103)

aAI IgG is an index of IgG produced in nervous system rather than coming from sera

bReference not found


47


It is important to bear in mind that one of the limitations of this literature review is the use of

serology that is not specific for the assessment of dengue.

Based on the literature review, the proposed definitions for neurological involvement in

dengue cases defined by confirmed dengue infection, onset <30 days after onset of fever, and

exclusion of other CNS infections (TB, cerebral malaria, Japanese encephalitis, and West

Nile disease) are presented in Table 7-5.

Additionally the following definitions for moderate and severe are proposed:

Moderate:

All encephalopathy/encephalitis lasting less than 24h

Neurological manifestations requiring intervention.

Severe:

any sign and symptom of encephalopathy/encephalitis lasting 24 hours or more

regardless of final outcome


48

Table 7-5 Proposed definitions for neurological involvement in dengue

Definite encephalitis Clinical encephalitis Encephalopathy Nervous system involvement without

encephalopathy

Altered level of consciousness

AND

1 or more of the following:

• Demonstration of acute

inflammation of central nervous

system parenchyma by

histopathology

• Demonstration of Dengue virus

from the brain tissue (PCR, viral

isolation)

Altered level of consciousness for 24 h

without metabolic explanation

AND


• Decreased or absent response to

environment or external stimuli

• Seizure associated with loss of

consciousness

• Focal or multifocal findings

referable to the central nervous

system

AND


• CSF pleocytosis

• Evidence of Dengue virus

infection in the CNS (Positive

PCR, viral isolation, IgM, IgG

in CSF)

• EEG findings consistent with

encephalitis

• Neuroimaging consistent with

encephalitis

Altered level of consciousness for 24 h

without metabolic explanation

and does not meet the criteria for

encephalitis

No change in level of consciousness

AND


• Motor weakness (grade 0-4

MRC scale)

• Spinal cord involvement signs

& symptoms (i.e. limb paresis,

limb paresthesia, hypo or

hyperreflexia, and urine

incontinence

• Convulsion other than simple

febrile convulsion

• Meningeal irritation signs (i.e.

nuchal rigidity) and CSF

pleocytosis


49

7.3 Lungs


Lung involvement in dengue based on a review of the literature is summarized in Table 7-6

(pathology and pathogenesis), Table 7-7 (asthma exacerbation), Table 7-8 (pleural effusion),

and Table 7-9 (acute respiratory failure [ARF] and acute respiratory distress syndrome

[ARDC]).

In summary for lung involvement:

Asthma exacerbation due to dengue has never been reported.

Pleural effusion has been correlated to plasma leakage, severity of illness, and DHF (49,

53, 54, 104, 105). For accurate assessment, serial evaluations are needed, ideally using

ultrasonography (to avoid excessive irradiation).

Dengue infection may compromise gas exchange:

o ARF may result from large pleural effusion, pulmonary edema, ARDS, or extensive

neuromuscular illness involving respiratory muscles.

o Pulmonary edema may result from plasma leakage, congestive heart failure, and/or

iatrogenic fluid overload; the most common presentation of pulmonary edema occurs

after fluid resuscitation in patients with DSS (106).

o ARDS may be observed as part of multi-organ failure in decompensated DSS (107),

and the need for mechanical ventilation may result in 67% fatality (108).

In summary for ARF, clinical presentation includes:

An acute illness with overt onset of symptoms (eg., chest pain, cough, hemoptysis,

shortness of breath),

Physical examination findings (eg., tachypnea, cyanosis, use of accessory respiratory

muscles, decreased audibility of breath sounds on auscultation or crepitations, dullness to

percussion)

Laboratory findings (eg., decreased SaO2 and PaO2 and/or increased PaCO2, decreased

PaO2:FiO2 ratio)

Clinical imagery findings (eg., pleural effusion, pulmonary infiltrates)


50

Table 7-6 Pathology and pathogenesis for lung involvement in dengue

Definition Study type Study population and number Number with lung involvement Reference

Pathology findings (macro and microscopy)

Retrospective, autopsy cases

1957-1963

Age <15 years, probable DSS

N=100

Petechiae

pleural 27

lungs 10

Pleural effusion 72

Alveolar hemorrhage 24

Alveolar septa

edema 100

cellular infiltration 85

No necrosis of epithelial cells

No hyaline membrane

Additional information

general vascular damage

haem-diapedesis

plasma leakage

no visible micro angiopathy

phagocytosis of lymphocytes

(109)


51

Table 7-7 Exacerbation of asthma in dengue

Definition Study type Study population and number Number (%) with asthma Reference

History of bronchial asthma Observational DHF patients

N=76

14 (18.4)

0 acute asthma

(110)

History of bronchial asthma Case-control study DF/DHF patients

170 DHF

1175 control

10 (5.9)

62 (5.3)

0 acute asthma

(111)

Table 7-8 Pleural effusion in dengue

Definition Study type Study population and number Number (%) with pleural effusion Reference

Daily (bedside) US examination; 1997 WHO

classification

prospective observational PCR or serology confirmed

DF 61

DHF 21

1 (1.6)

2 (9.5)

(49)

daily (bedside) US examination; 2009 WHO

classification

prospective, observational

PCR or serology confirmed

66 adults, hospitalized

27 (41) (53)

US examination (radiology department) retrospective NS1 or serology confirmed

96 children and adults, hospitalized

48 (50)

(25 bilateral)

(54)

CT-scan (radiology department); 2009 WHO

classification

retrospective serology confirmed; patients with

respiratory symptoms

29 adults, hospitalized

16 (55)

(13 bilateral)

(104)

CxR examined by pneumologists retrospective DHF (WHO 1997) aged 1-87

N= 363

111 (30.6)

small (23.7)

moderate (5.5)

massive (1.4)

(105)

Documented pleural effusion in medical

records

retrospective Hospital database, according to ICD-

10 classification

777 consecutive files

DF 391

DHF 296

DSS 90

0 (0)

20 (6.8)

34 (37.8)

(112)


52

Table 7-9 Acute respiratory failure (ARF)/acute respiratory distress syndrome (ARDS) in dengue

Definition Study type Study population and number Number (%) with ARS/ARDS Reference

Failure to respond to 40% oxygen by a nasal

cannula as evidenced by cyanosis, SaO2 <

93% or PaO2<70 mmHg, RR>50 breaths/min,

or severe chest retraction and nasal flaring

prospective children<15 years

DSS with ARF (non intubated)

N=48

48 (100) (106)

PaO2<60 mmHg despite FiO2:0.4 via nasal

canula or PaCO2>50 mmHg or RR>35/min,

or RR≤10/min

retrospective serology confirmed

606 adults

11 (1.8%) (113)

Analysis of deaths among DHF retrospective DHF (WHO 1997)

130 adults (7 deaths)

4 (3%) (died)

(107)

ARF not defined prospective, observational Dengue patients admitted in the ICU

198 adults

Mechan. Ventil.

Died

26 (13.1)

18/26 [69]

12/18 (67)

(108)

Need for mechanical ventilation

prospective observational

DSS (WHO 1997)

238 children

208 survived

30 died

44 (18.5)

14/44 [32]

30/44 [68]

(114)


53


Case definitions should only be used for PCR- or NS1-confirmed cases, and the proposed

definition/grading for ARF in dengue is presented in Table 7-10.

A consensus was reached on the fact that respiratory distress results mainly from plasma

leakage and the group decided not to keep lung involvement as an isolated syndrome.

Moreover, comorbidities are an important factor in lung function and further complicate the

classification. Respiratory rate (RR) and Sp02 (pulse oxymetry) should be monitored in

dengue patients; before any therapeutic intervention, increasing RR is suggestive of

metabolic acidosis; after fluid therapy, tachypnea and decreased Sp02 indicate fluid overload

and plasma leakage at the pulmonary level.


54

Table 7-10 Proposed case defining criteria and grading for ARF in dengue

Case defining criteria

Grade Symptoms Signs Blood gases (room air) Other information

Severe Shortness of breath at rest;

marked limitation in activity

due to symptomsa; agitated,

drowsy or confused; sits

upright, can’t talk

RRc>25/min; cyanosis; use

of accessory muscles;

foam/blood coughed-up;

diffuse decreased audibility

of breath sounds; diffuse

crackles/crepitations on

auscultation

SpO2<90%;

PaO2 <63 mmHg;

PaCO2≥45 mmHg

PaO2/FiO2<300

Under high flow O2 mask,

SpO2 <92% and RR> 25/min

indicate severe illness

Moderate Mild shortness of breath and

slight limitation during

ordinary activityb; alert, can

talk

RRc20-25/min; no use of

accessory muscles; no

dullness to percussion; good

air entry, limited crackles /

crepitations on auscultation

SpO2 90–95 %;

PaO2 63-84 mmHg

PaCO2 40-45 mmHg

PaO2/FiO2 300-400 mmHg

Rapid reversal of airflow

obstruction with

bronchodilator indicates

moderate illness

aNYHA class III or IV or FDA toxicity tables grade 3

bNYHA class II or FDA toxicity tables grade 2

cAge >8 years (<8 years, defined as follows:<2 months <60 /minute; 2–12 months <50 /minute; 1–5 years <40 /minute; 6–8 years <30 /minute)


55

7.4 Muscle


Muscle involvement in dengue based on a review of the literature is summarized in Table

7-11, there being a range of academic definitions and case-defining criteria for

rhabdomyolysis (115-118). Limitations of the definitions include that 50% of cases with

serum creatine phosphokinase (sCPK) >5000 may not complain of muscle pain or weakness,

that myoglobin is rapidly cleared from plasma and so myoglobinuria may be transient and

difficult to observe (119), and that elevated sCPK may be observed 3-5 days after the end of

rhabdomyolysis.

In summary:

Myalgias and discrete muscle weakness are commonly observed in dengue patients

during the early prodromic/acute febrile phase of illness and reported as acute benign

myositis (120).

Myositis present with myalgias, tenderness, swelling and muscle weakness of varying

intensity ranging from limited muscle weakness affecting most commonly the proximal

muscles of lower limbs to extensive quadriplegia involving respiratory muscles (121).

Rhabdomyolysis is believed to be the most severe form of dengue myositis. Most severe

forms include anuria and hyperkalemia requiring emergency hemodialysis (122).

Acute neuromuscular weakness may be associated with hypokalemia (123).

Kalemia and sCPK should be measured in dengue patients who develop symptoms of

intense muscle pain and/or muscle weakness.


56

Table 7-11 Definitions for muscle involvement in dengue

Definition Study type Study population and number Number (%) with ‘elevated’

CPK

Reference

DF with severe myalgias prospective muscle biopsies Serology-confirmed, aged 14-47 yrs

N=15

3 (20) (120)

sCPK > x3 UNL prospective Lab confirmed, recovered (N=110

• Myalgias (N=64)

• severe myalgias (N=12)

• muscle weakness (N=3)

110 (100) (124)

Myositis (pain and weakness) retrospective Dengue aged 3-40 (N=7)

• quadriplegia/respiratory (N=2) (died)

• para / quadriparesis (N=5)

7 (100)

• >100 x ULN

• >5 x ULN

(121)

Motor weakness defined with MSGS retrospective Lab confirmed, recovered (N=88)

• Hypokalemia (N=10)

• Myositis (N=1)

• GBS (N=1)

10/88 (11.4)

• 8/10 (80)

• 1 (100)

• 1 (100)

(123)

Elevated sCPK, myoglobinuria case reports Dengue Rhabdomyolysis

17-66 years (N=11)

11 (100)

(4000-750,000 IU/L)

-

Aged >12 years, with signs of myositis

observational, retrospective

DF patients with atypical presentation

N=300

2 (0.7) diagnosed with

rhabdomyolysis

(125)

sCPK > 20xULN observational, prospective dengue RT-PCR+, aged >13 years, in the ED

N=714

11 (1.5) (126)

sCPK> 5xULN observational, retrospective hospital, laboratory confirmed dengue

N=1076

9 (0.8)

(7DHF, 6AKF, 1 died)

(127)


57


Based on the literature review, the proposed definitions for the grading of muscle

involvement in dengue are presented in Table 7-12.


58

Table 7-12 Proposed definitions for muscle involvement in dengue

Case-defining criteria (except myoglobinuria)

Grade Acute illness

Myoglobinuriab

(not case-defining)

Elevated serum creatine

phosphokinase (sCPK)b Other information

Severe Diffuse myalgias consistent with

grade 3 FDA toxicity grading

scale*; muscle strength ≤3/5;

dark urine suggesting intense

myoglobinuria and

rhabdomyolysis.

May have oligoanuria, acute

respiratory failure and/or

myocarditis.

Urine dipstick test positive for

red cells

Urine sediment microscopic

examination negative for red

cells

Limitations: hematuria may be

frequently observed in dengue;

myoglobinuria may be only

transiently observed

sCPK > 10xULN (> 2500

UI/L), consistent with FDA

toxicity tablesa

• Kalemia <3.3 or >5.4 mEq/L

indicate severe illness

• The degree of sCPK elevation is

proportional to the muscle injury,

leading to myoglobinuria

• Some patients with sCPK 10 to 20

fold ULN may have little / no

muscle symptoms

• sCPK>5000 increase the risk of

acute kidney failure

• dark urine may miss at late

presentation, due to rapid serum

clearance of myoglobin

Moderate Acute onset of muscle pain

consistent with grade 2 FDA

toxicity grading scalea and

muscle strength ≥4/5 suggesting

acute benign myositis.

sCPK ≤10xULN, consistent

with FDA toxicity tablesa

aFDA Toxicity Grading Scale for Health Adult and Adolescent Volunteers Enrolled in Preventive Vaccine and Clinical Trials

(http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Vaccines/ucm091977.pdf) bBeetham, 2000 (115)

http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Vaccines/ucm091977.pdf


59

7.5 Heart


Cardiac involvement in dengue based on a review of the literature is summarized in Table

7-13.

In summary:

Asymptomatic myocarditis may be found in dengue (128).

ECHO: external jugular <50% generally reported as abnormal. Depressed cardiac

function found most commonly in DHF/DSS patients (129-131).

Cardiac dysfunction may be preload dependent and this should be taken into account

when performing ECHO [myocardial tissue doppler is relatively preload independent as

is rate corrected velocity of circumferential fiber shortening adjusted to left ventricular

wall stress (VCFC/ESS)] (129, 131).

ECG abnormalities: bradycardia not infrequent in convalescent phase. Conduction

abnormalities (heart block) seen in acute illness (129, 132).

Cardiac enzymes; not elevated commonly even in suspected myocarditis (128, 131).

Depressed ejection fraction is transient and returns to normal during convalescence(128).

Summary of cardiac findings in dengue live attenuated tetravalent vaccine (LATV) trials in

flavi-naïve and flavi-exposed subjects:

No lesions of cardiac origin have been associated with experimental LATV dengue

vaccination in a highly naïve (US) and dengue primed (Thai) population.

Following dengue challenge of healthy volunteers with under attenuated monovalent live

virus dengue vaccine candidates subclinical pericardial effusions were noted.


60

Table 7-13 Definitions for heart involvement in dengue

Definition Study type Study population and number Number with cardiac involvement Reference

ECHO Ejection fraction <50%

Tc pyrophosphate imaging (4 patients,

ECG 17 (patients)

Hospital-based,

retrospective

Studied 17 consecutive patients with

DHF/DSS (14 – 58 years)

8/17 DSS

New Delhi, India

17 (12 male, 5 female) 14

seropositive

14/17 seropositive for DENV

infection

LVEF by ECHO < 50% (Mean 47.1%)

Global hypokinesia detected in 12 patients

(70.59%)

Mean LVEF in DSS 39.3%)

ECG showed ST & T wave changes in 17

(130)

ECHO including Doppler(17 patients)

ECG (51 patient): Troponin (17 patients)

Hospital Hospitalized adults and children (8 –

46 years)

Vietnam

22 dengue, 42 dengue with warning

signs, 15 severe dengue NEW

1 DF, 43 DHF Gr. 2, 12 DHF Gr 3, 1

DHF Gr. 4 (OLD classification)

18/51 ECG abnormality (1° heart block,

sinus bradycardia, T wave & ST changes

LV systolic function impaired in 45% of

patients

Troponin borderline elevated in 1 patient,

normal in 16 others

(131)

ECHO (10 patients)

Troponin I and NT-proBNP were

determined for all

Hospital Hospitalized children and adults (4

months – 81 years)

Brazil

81 (54 DF, 26 DHF, 1 DSS)

12/81 had increased levels of ≥1 biomarker

and 4 had both

10/12 had ECHO: 2 had abnormal wall

motion with preserved LVEF, 1 had

decreased LVEF (<50%), 1 had pericardial

effusion

2 died prior to ECHO

Miranda, 2013a

Troponin

ECG

ECHO

Case report 65 year-old woman

Southern Taiwan

1 (DHF/DSS) (DENV-3)

Elevated troponin

LVEF <62% (defined as suboptimal LVEF)

ECG ST depression >1mm V3-V6

Lee, 2010a

ECHO

ECG

CPK, CPK-MB

Hospital Hospitalized children and adults

Sri Lanka

217 met minimum criteria for DF

(fever 2 – 7 days + Plt < 100K) IgM

confirmed in 95%

85% had 2D ECHO

If had abnormal ECHO, presumed to have

myocarditis (24%)

None had clinically overt myocarditis

All had relative bradycardia despite 2-D

ECHO suggestive of myocarditis

RV dilation with assoc. tricuspid regur in

35/61 (57%), LV dilation in 13/61 (16%)

(128)


61


Clinical evaluation

ECHO (7 patients)

ECG (11 patients)

Hospital Hospitalized children (13 months to

10 years)

102 (23 DF, 79 DHF)

Myocarditis clinically in 13.9% of 79

patients

ECG bradycardia in 81.8% of 11 patients,

tachycardia in 18.2% of 11 patients and T

wave inversion in 7/11ECHO showed

pericardial effusions in 71.4% of 7 patients

and diastolic dysfunction in 28.3% of 7

patients

(132)

ECHO Hospital Hospitalized children <12

New Delhi

54 (79.6% DHF)

20.4% DF with bleeding

EF < 60% was found in in 19/54

Of the 19, EF reduced to < 50% by

modified Simpsons in 9/54 (16.7%);

reduction was mild (35 – 50%) in 7 and

significant (<35%) in 2

Kabra, 1998a

CVP, arterial monitoring Hospital Hospitalized children with DSS (age

6 – 14)

Thailand

5 (4 DSS, 1 DHF)

Reduced cardiac index with increase in

peripheral vascular resistance

Stroke volume low in 4/5

CVPs low or normal (not CHF)

Pongpanich, 1978a

No specific definition Case report 25-year-old man

1 case

DEN serotype unknown

Global hypokinesia with an ejection

fraction of 20%

(died)

Lee, 2008a

No specific definition

Case report

44-year-old male

Taking medication for hypertension

Seropositive for DEN3

1 case

ECHO: ejection fraction of 10% and left

ventricle

dilation without focal wall motion defect

and or focal thinning

(died)

Tahir, 2015a

No specific definition. Used ECHO Hospital 24 children with DHF Grades I-III.

Mean age 10.8

Thailand

24 cases DHF: Grade 1 = 4; Grade 2

= 10; Grade 3 = 10

ECHO performed within 12 hours of DHF

diagnosis and at convalescence and weeks

later. Found myocardial contractility was

impaired during the toxic stage to a mild

degree (EF >45% in most patients.

Bradycardia during convalescence.

(129)

No specific definition Literature

review

2 case reports from Thailand

Literature from Index Medicus,

Science Citation Index, and 256 local

Found only 2 case reports of dengue

myocarditis. Review of autopsy reports

from 51 Thai fatal DHF cases, none had

cardiac manifestations. Two myocarditis

Wiwanitkit, 2010a


62


Thai Journals cases had bradycardia with junctional

rhythm

T wave inversion, ST depression 1mm in

> 3 leads; bundle branch block

Hospital Dengue fever patients presented to

hospital during an outbreak

120 serologically-confirmed dengue

cases

75/120 (62.5%) had ECG change. 80% of

patients who had 12 lead ECG changes

showed a cardiac dysfunction (mostly tachy

& bradycardias). 5 patients had LVEF <

55%

Kularatne, 2007a

No specific definition – used ECHO

Hospital based

Children admitted to hospital in

Thailand and was seropos. Or PCR +

for dengue ECHO feasible

N=91 children 5 – 15years of age;

DF=30, DHF=36, DSS = 25.

E.F. <50% in 6.7% DF; 13.8% DHF; and

36% DSS. Troponin not elevated (11/91

evaluated)

Khongphattanayothin,

2007a



63


Due to the lack of major findings in the literature for the assessment of vaccine reactogenicity

in clinical trials it is probably not worthwhile performing prospective and sequential cardiac

evaluations (other than history and physical examination [H&P]). For dengue disease

surveillance (Phase IV of an evaluation) it is reasonable to be prepared to conduct H&P

directed cardiac evaluations (not on a schedule) with the understanding any suspected cardiac

lesion may be a pre-load issue easily corrected by proper management of intravascular

volume.

Cardiac involvement would require expert evaluation by a cardiologist and it is accepted that

this may not be available in many research settings.

Based on the literature review, the proposed definitions for the grading of cardiac



64

Table 7-14 Proposed definitions for cardiac involvement in dengue

Case-defining criteria

Grade Cardiac dysfunction Bradycardiaa Tachycardia

a Hypotension

a

Severe EF ≤ 35% by ECHO

or other hemodynamic monitoring <45 bpm

>130 bpm <80 mmHg systolic

Moderate EF 36 – 49% by ECHO

or other hemodynamic monitoring

45-49 bpm 116-130 bpm 80-84 mmHg systolic

aFDA Toxicity Grading Scale for Health Adult and Adolescent Volunteers Enrolled in Preventive Vaccine and Clinical Trials for adults (use standards for pediatric patients)


65

7.6 Kidney


Renal involvement in dengue based on a review of the literature is summarized in Table 7-15.

Summary:

Acute kidney injury (AKI) or acute renal failure (ARF) is a potential complication of

severe dengue infection and is typically associated with hypotension/shock,

rhabdomyolysis, or hemolysis (122, 133, 134).

AKI1 or ARF generally are generally defined by a rapid rise in serum creatinine (135-

137).

Proteinuria & hematuria can be present (138).

1 The AKI Network definition of AKI is a sudden decrease (in 48 hours) of renal function, defined by an

increase in absolute SCr of at least 0.3 mg/dL or by a percentage increase in SCr of ≥ 50% (1.5x baseline).


66

Table 7-15 Definitions for kidney involvement in dengue

Definition Study type Study population and number Number with kidney involvement Reference

AKI: abrupt (within 48°) reduction in kidney function

defined as an absolute increase in Cr of ≥0.3 mg/dL or a %

increase of ≥ 50% (1.5 fold from baseline).Mild: Cr

≥0.3mg/dL or an increase to ≥ 150 – 200%

Moderate AKI (an increase in serum creatinine to ≥ 200-

300%)

Severe AKI ( increase in serum creatinine to > 300% or

≥4.0 mg/dL)

Retrospective Hospitalized patients with dengue

223 with dengue illness

24 developed AKI (10.8%)

54 (24%) were diagnosed with DHF. 12

(5.4%) had mild AKI; 7 (3.1%) had

moderate AKI; 5 (2.2%) had severe AKI

Concluded that higher SGPT and ALP

and lower albumin and serum HCO3 are

risk factors for AKI which is suggestive

of hypoxia and metabolic acidosis

(136)

AKI: AKI was defined by a sudden increase in serum

creatinine (Cr) levels > 2mg/dL or a serum creatinine

concentration that was > 2 times previous or subsequent

values and that was also higher than the upper limit of

normal values for the patient’s age.

Urine output lower than 0.5 mL/kg/h was classified as

oliguric AKI.

Retrospective Hospitalized at tertiary care

center, Thailand.

All children (<15 yrs) diagnosed

with AKI caused by DVI from

1/89-12/07

2,893 patients hospitalized with

DVI.

25 (0.9%) had or later developed AKI

16/25 died

24/25 had diagnosis of DSS, 1/25 DHF

Gr II

Significant risk factors associated with

AKI in DHF were Grade IV DHF and

obesity

Of the 9 surviving patients, only 3 needed

renal replacement therapy (RRT)

AKI itself does not increase the risk of

fatality in DVI patients who must have

RRT, but profound shock subsequently

causing respiratory failure and massive

bleeding are the major causes of fatal DVI

(133)

ARF: rapid elevation of serum Cr that was Hospital Patients > 18 admitted to hospital

with dengue

714 dengue patients; 304 DHF

10/304 (3.3%) developed ARF

DSS was found in 8/10

Active GI bleeding in 8/10

Elevated LFTs in 6/9

3/8 had elevated BUN

Multivariate analysis showed DSS was an

independent risk factor for ARF in DHF

(135)

Laboratory normals

Retrospective,

hospital

100 hospitalized cases of dengue

from Cairns Australia outbreak

1997

100 hospitalized dengue patients:

7 <17, 13 >66 yrs

U/A recorded for 87%;blood was detected

in 31%, protein in 74%

(138)


67

Definition Study type Study population and number Number with kidney involvement Reference

ARF Lit. Review Fatal DHF cases in Thailand

6,154 DHF cases

51 Fatal DHF cases, 17 had ARF (33.3%)

0.3% among all DHF cases

Wiwanitkit,

2005a

AKI Lit. review

AKI is an unusual complication of

dengue, usually associated with

hypotension, rhabdomyolysis, or

hemolysis

(134)



68


Based on the literature review, the proposed definitions for the grading of kidney



69

Table 7-16 Proposed definitions for renal involvement in dengue

Case-defining criteria (AKINa)

Grade Serum creatinine Urine output

Severe AKIN Stage 3: Increase in serum creatinine to >300% or ≥4.0 mg <0.3 mL/kg/h for ≥24 hours or anuria for ≥12 hours

Moderate AKIN Stage 2: Increase in serum creatinine to >200 – ≤300% <0.5mL/kg/h for >12 hours

aLopes and Jorge, 2013 (137)


70

8 Plans to evaluate a refined dengue clinical case classification


This section summarizes discussions regarding the development of a consistent methodology

and endpoints for intervention trials regardless of variables such as location, trial design, and

trial population to harmonize methodologies and improve comparability.

The key areas discussed were:

Accuracy:

Which parameters to record and how to document them, including how to standardize

self-assessment by outpatients as well as by health professionals during hospitalization.

Repeatability:

The implementation of an independent assessment of the same patient by a separate

health professional as well

The implementation of an independent review of medical notes/source documents/CRF

by a separate health professional at the same and at a different location, and possibly

using a computer algorithm (although the latter would require precise definitions).

Intermediate severity endpoints:

The importance of recording the presence as well as the absence of clinical

abnormalities.

The importance of recording medical interventions.

Datasets for validation:

Minimal (e.g. data as a time stamp) and maximal/optimal requirements (e.g. date, hour,

and minute as a time stamp).

Comparison of existing datasets versus those for future trials, lists of variable and

standard operating procedures (SOPs).

Two options for validation analysis – either develop data analysis guidelines (which

would require highly detailed SOPs) or

Develop data extraction guidelines.


The aspect of comorbidities was discussed and it was considered that these could be

accounted for in the data analysis rather than excluding such patients/subjects from clinical

trials.


71

Plasma leakage is a fundamental part of dengue – could this be quantified/clarified

independently to severe dengue classification, or could the severity of dengue be classified as

a function of plasma leakage, i.e. could plasma leakage be used as a proxy of dengue

severity? As discussed elsewhere in this document, this becomes problematic when serial

measurements are required, especially in children or outpatients. Some events are very rare

and their analysis should not be systematic for interventions. In Phase IV trials, clinical

presentation of dengue could change and some complications will become more apparent.

The suggestion is to take the WHO 2009 guidelines (14) and add more granularity and detail,

and to then have this extra detail validated by a group of dengue physician experts. It is

important to emphasize that the toxicity of medications is important, and so granularity will

be higher in clinical trials for drug development.

A proposition of ranking between mild, moderate and severe was proposed during the

workshop. An initial proposition for each severity marker is presented in Table 8-1. A follow-

up meeting will be organized in October 2015 during the ASTMH meeting with the objective

of reaching a consensus.

.


72

Table 8-1 Summary of proposed definitions for dengue severity markers (table provided by the scientific committee after the workshop)

Severity marker Moderate Severe Issues to consider Best time for

measurement

Bleeding Local Intervention such as

nasal or gum packing

Platelets <10,000

Level of bruising – can it be

quantified?

Any bleeding into an end organ (e.g.

cerebral bleed)

Need for packed RBCs or whole blood

Plasma leakage No evidence of shock, plus:

Evidence of plasma leakage

defined by

hemoconcentration 10<20%

change in hematocrit or hgb

NOT DISCUSSED: imaging

Evidence of Shock as defined by either:

1) pulse pressure ≤20 mmHg or 2)

hypotension by age, defined as systolic

pressure <80 mmHg for those aged <5 years

or 80 to 90 mmHg for older children and

adults, PLUS tachycardia, cool extremities,

delayed capillary refill, weak pulse, lethargy

or restlessness Plus:

Evidence of plasma leakage defined by

haemoconcentration >/= 20% change in

hematocrit or hgb, OR positive findings of

effusion on imaging (CXR with pleural

effusion on lateral decubitus of >1 cm, OR

serial U/S findings of pleural effusion,

ascites or other effusion)

IV fluids may obscure overall

severity of hemoconcentration and

outcome of shock or respiratory

distress.

Need HCT or

Hgb at baseline

defined as <3

days or >14

days post onset

OR population

based level if

baseline not

available. Also

need critical

phase HCT or

Hgb value.


73


measurement

Liver involvement Acute illness with discrete

onset of signs and symptoms

consistent with acute viral

hepatitis

ALT >10 times upper limit

of normal (ULN) or (>400

IU/L), whichever is greater

Patient with clinical or laboratory evidence

of acute hepatitis plus:

New onset coagulopathy as defined by INR

≥ 1.5 (Note: in infants and young children

may use INR ≥ 2.0 without mental status

changes)

New onset change in mental status

Note: Patient may have jaundice,

hepatomegaly, and right upper quadrant

pain/tenderness but these are not case

defining.

History of pre-existing liver disease

Chronic infectious disease (HIV-1,

HIV-2, HBV, HCV)

Medication use including herbal

remedies, acetaminophen, etc.

Co-infections including malaria,

typhoid, leptospirosis, JE, etc.

CNS involvement Peripheral neurologic

involvement with muscle

strength scale of at least 4/5

Altered levels of

consciousness lasting less

than 24 hours

Any neurological manifestation requiring

interventions (e.g. mechanical ventilation,

IVIG for GBS)

Peripheral neurological illness: No change in

level of consciousness

AND 1 or more of the followings:

Motor weakness (grade 0-4 MRC scale)

Spinal cord involvement signs & symptoms

(i.e. limb paresis, limb paresthesia, hypo or

hyperreflexia, and urine incontinence

Convulsion other than simple febrile

convulsion

Meningeal irritation signs (i.e. nuchal

rigidity

Central neurological involvement: Altered

level of consciousness for >24 hrs. without

Consult with neurologists to better

define this definitions


74


measurement

metabolic explanation

AND 1 or more of the following:

• Decreased or absent response to

environment or external stimuli

• Seizure associated with loss of

consciousness

• Focal or multifocal findings

referable to the central nervous

system

EEG findings consistent with encephalitis

Neuroimaging consistent with encephalitis

Muscle involvement Acute onset of muscle pain

and weakness consisting of a

grade 3 FDA toxicity tables

sCPK </=10xULN

Kalemia 3.3-5.4 Eq/L

Tenderness to palpation or

movement

Muscle strength >/=4/5

Deep tendon reflexes normal

Acute onset of muscle pain and weakness

consisting of a grade 4 FDA toxicity tables

sCPK >/=10xULN

Kalemia <3.3 or > 5.4 Eq/L

Myoglobinuria (dark urine, Haem positive

dipstick and no hematonuria)

Edema (limbs)

Deep tendon reflexes decreased or abolished

Muscle strength <4/5

Weak peripheral lower limb pulse

Maybe observed during the

prodromic phase and in 50-80% of

dengue patients during the early

febrile phase

Important to differentiate the

limitation of activity due to pain and

exhaustion from overt decrease of

muscle strength

Search for other organ failure

(respiratory, renal, cardiac)

sCPK >20 times ULN (>5000 U/L)

are at risk for AKF

50% of sCPK<5000 have no

significant pain

Myoglobinuria is found in 70% of

adults and only 4% of children

Serial examination needed to rule out


75


measurement

compartment syndrome

Renal involvement UO <0.5mL/kg/h for >12

hours

Increase in serum creatinine

to > 200 – ≤ 300%

UO <0.3 mL/kg/h for ≥24 hours or anuria

for ≥ 12 hours

Increase in serum creatinine to > 300% or ≥

4.0 mg or need for renal replacement therapy

(RRT)

Pre-existing kidney disease

Cardiac involvement Ejection Fraction 36 – 49%

by ECHO or other

hemodynamic monitoring

(adjusted for preload)

Ejection Fraction ≤ 35% by ECHO or other

hemodynamic monitoring (adjusted for

preload)

Consult with cardiologist to better

define this definition.

Also, cardiac manifestation is rare

and it’s hard to measure in most

endemic countries. Perhaps best to

table this for now and refine these

definitions at a later stage.

Volume status

(preload status

makes a

difference

Pre-existing

heart disease

(adults)

Other diseases

(e.g. Chagas)


76

9 Summary and next steps

This NIH-WHO-PDC April and October 2015 meeting successfully brought together a

diverse range of dengue experts from governmental and non-governmental organizations as

well as from industry and academia. Over two days, the clinical case classification of dengue

for clinical trials was discussed in depth.

The overall goal was to develop a refined clinical case classification for moderate and severe

dengue to be used in interventional trials and pathogenesis studies as secondary endpoints.

By this we mean, that the case definitions, developed as a part of this working group, will be

used to classify study subjects who are being monitored as part of an interventional trial or

pathogenesis study and who meet the primary efficacy endpoint (i.e., two days of fever plus

laboratory-confirmed DENV infection). We developed the case definitions by identifying

clinical and laboratory parameters that contribute to the characterization of dengue disease

and help identify clear differences between moderate and severe disease states. We plan to

work on the proposed case definitions over the next 6 months leading up to the American

Society of Tropical Medicine and Hygiene (ASTMH) annual meeting in October, at which

time we will meet to finalize our work. Our second goal was to develop a plan to evaluate the

standardized classification in the field. In order to accomplish this second goal, we will first

need to determine how we will operationalize the case definitions so that these parameters

will be applied in a consistent and standardized manner irrespective of the trial location, or

study population. In the end, we would like the DCCC be quantifiable and reproducible so

that we can improve the comparability of the data obtained from interventional trials and

pathogenesis studies.

Such standardization is needed to account for differences in clinical care and hospitalization

practices, to account for variations in study design, and to fully assess the clinical benefit of a

vaccine or drug that may not prevent all clinical disease manifestations but which may still be

of benefit to the individual and/or to public health.

It is vital to bear in mind that these recommendations must remain practical, not subjective,

and that these are intended for primarily clinical research rather than clinical care. A

simplified option to delineate moderate from severe cases is presented in Figure 9-1, below.

Figure 9-1 Simplified schematic for identification of moderate or severe cases of dengue


77

Although the final identification of a proposed clinical case classification of dengue for

clinical trials was not reached, progress was made in the identification of parameters for

moderate and severe dengue. Discussions and literature reviews included relevant laboratory

and clinical parameters, optimal (and practical) time points, febrile illness, disparities in

clinical case and hospital admission practices, and age specificities.

The next steps include a follow-up meeting, including representatives from a Regulatory

Authority, which is to be planned to coincide with the 64th

Annual Meeting of the American

Society of Tropical Medicine and Hygiene, 25-29 October 2015. It is important to re-iterate

that the endpoint is not to re-write the existing guideline (14) but to add more granularity and

detail for use in clinical trials.


78

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87

Appendix 1: Abbreviated meeting agenda


88

Day 1

08h00-10h00 Concomitant Scientific Working Group Meetings

10h00-10h30 Welcome and Introduction

10h30-12h00 Session I: Framing the issue: the challenges of measuring dengue disease severity

in pathogenesis studies and interventional research

Observational/pathogenesis studies in international clinical settings

(Thomas Jänisch)

Sanofi’s experience on disease classification from Phase II/Phase III

vaccine trials (Fernando Noriega)

Takeda’s experience on disease classification from Phase II vaccine trials

(Derek Wallace)

Oxford University’s experience from Phase II therapeutic trials (Bridget

Wills)

Status of rapid dengue diagnostics for use in interventional trials

(Elizabeth Hunsperger)

13h00-13h50 Session II: Defining dengue severity markers: acute febrile illness (Bob Edelman

and Stephen Thomas)

13h50-15h00 Session III: Defining dengue severity markers: severe bleeding Lucy Lum and

Norma de Bosch)

15h30-17h30 Session IV: Defining dengue severity markers: plasma leakage (Bridget Wills and

Elsa Rojas)

Day 2

08h00-12h00 Session V: Defining dengue severity markers: organ involvement

Liver and gastrointestinal tract (Kay Tomashek)

Central nervous system and lung (Lucy Lum and Laurent Thomas)

Muscle, heart, and kidney (Laurent Thomas and Anna Durbin)

13h00-14h00 Session VI: Plans to evaluate a refined dengue clinical case definition (Thomas

Jänisch and João Bosco Siqueira)

14h30-16h30 Session VII: Summary and next steps (Walla Dempsey and Stephen Thomas)


89

Appendix 2: List of participants

Name Organization email

ABEYGUNAWARDANA,

Chitrananda

Merck & Co., USA [email protected]

AGULTO, Liane NIAID/NIH, USA [email protected]

BOSCH, Irene MIT, USA [email protected]

CARVALHO, Ana Sabin Vaccine Institute, USA [email protected]

CASIMIRO, Danilo Merck & Co., USA [email protected]

CASSETTI, Cristina NIAID, USA [email protected]

COLLER, Beth-Ann Merck & Co., USA [email protected]

de BOSCH, Norma Universidad de Venezuela,

Venezuala

[email protected]

DEMPSEY, Walla NIAID/NIH, USA [email protected]

D’HONT, Benjamin ALCIMED, France [email protected]

DURBIN, Anna Johns Hopkins Bloomberg,

USA

[email protected]

DUTEL, Catherine Fondation Mérieux, France [email protected]

EDELMAN, Robert University of Maryland, USA [email protected]

FAY, Michael NIAID/NIH, USA [email protected]

GUBLER, Duane Duke-NUS Graduate Medical

School, Singapore

[email protected]

GUIGNARD, Adrienne GSK, Belgium [email protected]

HALSTEAD, Scott Uniformed Services University,

USA

[email protected]

HARRIS, Eva University of California,

Berkeley, USA

[email protected]

mailto:[email protected]



90


HARTMANN, Katharina Takeda Vaccines Inc.,

Switzerland

[email protected]

HOMBACH, Joachim WHO, USA [email protected]

HUNSPERGER, Elizabeth CDC, USA [email protected]

JÄNISCH, Thomas Heidelberg University Hospital,

Germany

[email protected]

KIM, Denny Takeda Vaccines Inc., USA [email protected]

LANE, Andrew Lane Medical Writing, France [email protected]

LAUGHLIN, Catherine NIAID/NIH, USA [email protected]

L’AZOU, Maïna Sanofi Pasteur, France [email protected]

LUM, Lucy University Malaya, Malaysia [email protected]

MARGOLIS, Harold CDC, USA [email protected]

MARKS, Morgan Merck & Co. USA [email protected]

NARVAEZ, Federico Nicaraguan Ministry of Health,

Nicaragua

[email protected]

NGUYEN, Van Vinh Chau Hospital for Tropical Diseases,

Vietnam

[email protected]

NORIEGA, Fernando Sanofi Pasteur, USA [email protected]

PRECIOSO, Alexander Butantan Institute, Brazil [email protected]

ROJAS, Elsa Universidad Industrial de

Santander, Colombia

[email protected]

ROTHMAN, Alan University of Rhode Island,

USA

[email protected]

SAADATIAN, Mitra Fondation Mérieux, France [email protected]

SCHMIDT, Alexander GSK, Belgium [email protected]








91


SCOTT, Thomas W. University of California Davis,

USA

[email protected]

BOSCO SIQUEIRA, João Federal University of Golas,

Brazil

[email protected]

STOUGHTON, Daniel NIAID/NIH, USA [email protected]

SUNTARATTIWONG,

Piyarat

Queen Sirikit National Institute

of Child Health, Thailand

[email protected]

TEYSSOU, Rémy Partnership for Dengue Control,

France

[email protected]

THOMAS, Stephen Walter Reed Army Institute of

Research, USA

[email protected]

THOMAS, Laurent University Hospital Martinique,

France

[email protected]

TISSERA, Hasitha Ministry of Health, Sri Lanka [email protected]

TOMASHEK, Kay NIAID/NIH, USA [email protected]

TURNER, Harshini Takeda Vaccines Inc., USA [email protected]

VANNICE, Kirsten WHO, Switzerland [email protected]

VON SONNENBURG, Frank University of Munich, Germany [email protected]

WALLACE, Derek Takeda Vaccines Inc.,

Singapore

[email protected]

WHITEHEAD, Stephen NIAID/NIH, USA [email protected]

WILDER-SMITH, Annelies Partnership for Dengue Control,

Singapore

[email protected]

WILLS, Bridget Oxford University Clinical

Research Unit, UK

[email protected]

YANCEY, Dana Emmes Corporation, USA [email protected]

SIN, Leo Yee Tan Tock Seng Hospital,

Singapore

[email protected]











92


YOON, In-Kyu AFRIMS, Thailand [email protected]

Documents

National Institutes of Health (NIH), World Health ... · DHF Dengue hemorrhagic fever DIRF Dengue illness report form DSS Dengue shock syndrome DVI Dengue Vaccine Initiative ECG Electrocardiogram