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CASE REPORT
Year : 2021  |  Volume : 24  |  Issue : 3  |  Page : 140-144

Neonatal dengue as never before - A case series


1 Department of Neonatology, Niloufer Hospital, Osmania Medical College, Telangana, India
2 Department of Pediatrics, Niloufer Hospital, Osmania Medical College, Telangana, India

Date of Submission07-May-2020
Date of Decision21-Jun-2020
Date of Acceptance03-Aug-2020
Date of Web Publication29-Oct-2021

Correspondence Address:
Dr. Rakesh Kotha
Niloufer Hospital, Hyderabad, Telangana
India
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DOI: 10.4103/smj.smj_41_20

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  Abstract 


Dengue is a Flavivirus, affecting about 100 million people annually and mainly in the tropical and subtropical countries. Neonatal dengue is uncommon and usually by vertical transmission or, in the postnatal period, by horizontal transmission. We describe the clinical profile, management and outcome of neonates with dengue infection. Ten patients were prospectively recruited from August to November 2019 during dengue epidemic season at Niloufer Hospital, Hyderabad, India. Four babies had vertical mode of transmission while 6 had horizontal mode of transmission. All babies were positive for Ns1 antigen and IgM dengue serology, confirming dengue infection. Fever, flushing and thrombocytopenia were observed in all the babies while 2 babies had hypotension requiring inotropes. Oxygen supplementation was required in 8 babies. There was no recorded mortality. We conclude that neonatal dengue should be considered as a differential diagnosis in a neonate with sepsis and thrombocytopenia especially in endemic regions. Judicious use of fluids (avoid excessive) and inotropes (dopamine) form the cornerstone of dengue management in neonates.

Keywords: Dengue fever, neonate, management, outcome


How to cite this article:
Madireddi A, Mandala VK, Bapanpally N, Kotha R, Konda KC, Haripriya R. Neonatal dengue as never before - A case series. Sahel Med J 2021;24:140-4

How to cite this URL:
Madireddi A, Mandala VK, Bapanpally N, Kotha R, Konda KC, Haripriya R. Neonatal dengue as never before - A case series. Sahel Med J [serial online] 2021 [cited 2021 Nov 29];24:140-4. Available from: https://www.smjonline.org/text.asp?2021/24/3/140/329516




  Introduction Top


Dengue is the most rapidly spreading mosquito-borne viral disease of humankind.[1] The female Aedes mosquito acquires the infection by feeding on an infected human during the viremia phase. Viral replication occurs in the mosquito over the next 10 days, after which it becomes capable of infecting the humans when feeding on them.[2] Neonatal dengue infection is usually uncommon.[3] Urbanization and overcrowding increase the risk of contracting dengue in both adults and neonates. During the 2019 dengue season, we came across a series of neonatal dengue cases presenting with both vertical and horizontal modes of transmission. Vertical (congenital) transmission occurs in neonates whose mothers have dengue illness (either primary or secondary infection) during the perinatal period. It usually occurs due to the transfer of the virus from the mother to the neonate.[4] Neonates may manifest with symptoms within 2 weeks of life and incubation period may be more prolonged in view of physiologically immature immunity in them. Maternally transmitted antibodies are protective during the initial period of infancy.[5] Moreover, dengue is acquired by horizontal transmission (mosquito bite) in the postnatal period in neonates born to nonimmune mothers, and the absence of protective antibodies in acquired dengue makes neonates vulnerable to severe disease like dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) after primary infection. Although several cases of neonatal dengue with vertical transmission have been reported, there exists a paucity of literature regarding neonatal dengue acquired in the postnatal period by horizontal transmission. To the best of our knowledge, only three such cases have been reported till date.

Objectives

We intend to study the clinical profile, mode of transmission, severity of presentation, response to treatment, and the final outcome of neonates infected with dengue.


  Methods Top


This was a prospective observational descriptive study in neonates presenting with acute febrile illness and thrombocytopenia during the study period (dengue epidemic season) from 2019 August to 2019 November at a tertiary care center – Niloufer Hospital, Hyderabad, India. All the babies were managed symptomatically as per the unit protocol. Vitals were monitored round the clock and inotrope dopamine was added in case of hypotension. In case of respiratory distress, babies were initially started on oxygen through nasal prongs and later upgraded to noninvasive respiratory support when needed. At admission, baseline routine investigations (complete blood picture, renal function tests, liver function tests [LFTs], serum electrolytes, blood culture, bleeding time, and clotting time) were done for all neonates. Arterial blood gas, ultrasonography of the abdomen, and chest X-ray were done based on the requirement as per the unit protocol. Daily weight measurement, urine output, fluid monitoring, hematocrit assessment, and serum electrolytes were done and monitored. Every baby was started on amikacin, empirically suspecting sepsis. The antibiotic was discontinued after documenting a sterile blood culture. Dengue serology and NS1 antigen testing was done for all the mothers of the enrolled neonates.


  Case Series Top


During the study period, 10 cases of neonatal dengue were diagnosed and enrolled. Their clinical attributes are summarized in [Table 1]. Of these 10 cases, four cases were congenital dengue with a vertical mode of transmission. All the mothers of these babies had dengue fever within 1 week prior to delivery with a supporting evidence of positive dengue serology. In the remaining six cases, the transmission was horizontal, as mothers of this group of babies were asymptomic in the perinatal period with a negative dengue serology. All the babies were term gestation (>37 weeks). The mean age of presentation in the congenital dengue group was 11.25 days, while that of the babies with postnatal acquired dengue was 24.3 days.
Table 1: Depicting the clinical attributes of the babies with neonatal dengue

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Fever (in 10 babies) was the most common symptom and flushing (in 10 babies) was the most common sign noticed in all the diagnosed babies [Figure 1]. Two babies had hypotension and required administration of dopamine at 10 mcg/kg/min for its correction. Oxygen supplementation was required in eight babies, and in two of them, the support was upgraded to nasal continuous positive airway pressure (CPAP) therapy. Hepatomegaly was observed in two babies; however, LFTs monitored were only mildly deranged. Complication like acute kidney injury occurred in one case which was prerenal (BUN/Sr creatine <20 and FENa <2) and resolved by conservative treatment. Ascites was also found in one case. Thrombocytopenia was observed in all the babies. However, only two babies had a petechial rash with severe thrombocytopenia requiring platelet transfusion. All the babies were documented of being positive for dengue NS1 antigen and IgM antibodies. All the babies were managed symptomatically with age-appropriate fluid therapy avoiding the administration of excessive fluid. The outcome was good with recovery [Figure 2] of all babies and Zero mortality.
Figure 1: Flushing of the legs, palms, and abdomen

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Figure 2: Baby after recovery

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  Discussion Top


There are few case reports of congenital dengue; however, acquired neonatal dengue remains a relatively gray area.[6],[7],[8] Although our case series had both vertically and horizontally transmitted cases of neonatal dengue, given the paucity of literature, we intend to emphasize more on the cases acquired by horizontal transmission. Horizontally transmitted cases usually tend to present after 2nd week of life (after the usual incubation period of vertical transmission). The mean age of presentation of postnatal dengue in our series was 24.3 days. A similar observation was documented in the available literature where the age of presentation was 26 days.[9],[10] We noted an increased incidence of neonatal dengue in male babies, unlike other pediatric age group studies where they found no sex predilection. This observation could have been by chance as the sample size was very small.[11] In our case series, the most common symptom was fever, and the most common sign was flushing. A similar finding was noticed in a previous study done by Romero-Santacruz et al.[12]

The clinical course of dengue hemorrhagic fever consists of three stages: febrile phase (lasting 2–7 days), critical phase (leaking phase) (24–48 h), and convalescent phase (2–4 days).[13] In our case series, every baby had flushing at the time of admission, lasting for a mean duration of 3.8 days. A mean duration of hospital stay in the pediatric age group was 4 days in an Indian study; however, in our case series, it was 10 days.[14] Although being a vulnerable group of population, the lesser incidence of DSS and DHS in neonates could be explained due to immunological immaturity and decreased production of interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-alpha production in neonates.[15]

The principal complication of dengue illness is vascular permeability, which usually decreases with increasing age. It is probably the explanation why all our babies presented with flushing.[16],[17] Shock, plasma leakage, and marked thrombocytopenia were more pronounced at a younger age, whereas the incidence of internal hemorrhage increased as the age advanced. In our case series, babies with shock responded remarkably to dopamine. Hence, unlike children, early use of dopamine may avoid complications of excessive fluid administration in neonates.[18]

We did not notice any hemorrhagic manifestation in our neonates. The probable explanation is a prerequisite of mature immune response and repeated infections by different serotypes to result in severe manifestations, as evident in children and adults.[19] Hematemesis and melena, on the other hand, were more common in children, followed by infants and then adults.[20] Hemoconcentration is a well-known finding in adults and pediatric age group, but in our babies, we did not find any noticeable difference in packed cell volume during the leaking phase.[21]

French Polynesia suggested that in children, hepatic failure should be considered as a distinct severe form of dengue, particularly type 4. In our study, we did not find any severe hepatic derangement except for the mild elevation of liver enzymes.[19] As evident from literature, age appears to be an important epidemiological risk factor in dengue infection, with a high case fatality rate in children compared to adults.[22] However, in our case series, mortality was zero with all the babies recovering well. The duration of hospital stay varied with a range from 7 to 14 days. Perinatal transmission of dengue through breast milk was reported in one case report, they isolated the virus from breast milk but unable to detect from cord blood; further work is clearly required to evaluate the risk of transmission of dengue infection through breast milk.[23]


  Conclusion Top


Neonatal dengue should be considered as a differential diagnosis while evaluating a case of fever with thrombocytopenia, especially in endemic regions, and if any mother had acquired dengue fever during the perinatal period, the neonate must be followed up for a minimum of 2 weeks before ruling out dengue by vertical transmission. Judicious use of fluids (avoid excessive) and inotropes (dopamine) form the cornerstone of dengue management in neonates. Further research is needed to address the gray areas of neonatal dengue like its pathogenesis and formulation of guidelines for its management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gibbons RV, Vaughn DW. Dengue: an escalating problem. BMJ 2002;324:1563-6.  Back to cited text no. 1
    
2.
Clyde K, Kyle JL, Harris E. Recent advances in deciphering viral and host determinants of dengue virus replication and pathogenesis. J Virol 2006;80:11418-31.  Back to cited text no. 2
    
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Choudhry SP, Gupta RK, Kishan J. Dengue shock syndrome in newborn: a case series. Indian Pediatr 2004;41:397-9.  Back to cited text no. 3
    
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Carroll ID, Toovey S, Van Gompel A. Dengue fever and pregnancy – A review and comment. Travel Med Infect Dis 2007;5:183-8.  Back to cited text no. 4
    
5.
Halstead SB, Lan NT, Myint TT, Shwe TN, Nisalak A, Kalyanarooj S, et al. Dengue hemorrhagicfever in infants: Research opportunities ignored. Emerg Infect Dis 2002;8:1474-9.  Back to cited text no. 5
    
6.
Thaithumyanon P, Thisyakorn U, Deerojnawong J, Innis BL. Dengue infection complicated by severe hemorrhage and vertical transmission in a parturient woman. Clin Infect Dis 1994;18:248-9.  Back to cited text no. 6
    
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Chye JK, Lim CT, Ng KB, Lim JM, George R, Lam SK. Vertical transmission of dengue. Clin Infect Dis 1997;25:1374-7.  Back to cited text no. 7
    
8.
Kerdpanich A, Watanaveeradej V, Samakoses R, Chumnanyanakii S, Chulyamitporn T, Sumeksri P, et al. Perinatal dengue infection. Southeast Asian J Trop Med Public Health 2001;32:488-93.  Back to cited text no. 8
    
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Chopra KK, Singh V, Arora A. Postnatally acquired dengue in a neonate – A case report. J. Commun Dis 2013;45:101-3.  Back to cited text no. 9
    
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Kanwaljeet KC, Varun S, Anita A. Postnatally acquired dengue in a neonate – A case report. J Commun Dis. 2013;45:101-3.  Back to cited text no. 10
    
11.
Morgue B, Deparis X, Chungue E, Cassar O, Roche C. Dengue: an evaluation of dengue severity in French Polynesia based on an analysis of 403 laboratory-confirmed cases. Trop Med Int Health 1999;4:763-73.  Back to cited text no. 11
    
12.
Romero-Santacruz E, Lira-Canul JJ, Pacheco-Tugores F, Palma-Chan AG. Neonatal dengue. Presentation of clinical cases. Ginecol Obstet Mex 2015;83:308-15.  Back to cited text no. 12
    
13.
Vaughn DW, Green S, Kalayanarooj S, Innis BL, Nimmannitya S, Suntayakorn S, et al. Dengue viremia titer, antibodyresponse pattern, and virus serotype correlate with disease severity. J Infect Dis 2000;181:2-9.  Back to cited text no. 13
    
14.
Mishra S, Ramanathan R, Agarwalla S. Clinical Profile of Dengue Fever in Children: A Study from Southern Odisha, India. Scientifica, 2016;2016;1-6.  Back to cited text no. 14
    
15.
Gamble J, Bethell D, Day NP, Loc PP, Phu NH, Gartside IB, et al. Age-related changes in microvascular permeability: A significant factor in the susceptibility of children to shock? Clin Sci 2000;98:211-6.  Back to cited text no. 15
    
16.
Hottz ED, Lopes JF, Freitas C, Valls-de-Souza R, Oliveira MF, Bozza MT, et al. Platelets mediate increased endothelium permeability in dengue through NLRP3-inflammasome activation. Blood 2013;122:3405-14.  Back to cited text no. 16
    
17.
Bethell DB, Gamble J, Pham PL, Nguye MD, Tran TH, Ha TH, et al. Noninvasive measurement of microvascular leakage in patients with dengue hemorrhagic fever. Clin Infect Dis 2001;32:243-53.  Back to cited text no. 17
    
18.
Ghosh A, Roy S, Uttam KG. Two cases of severe neonatal dengue fever during an outbreak in Kolkata city. Indian J Case Rep 2017;3:119-21.  Back to cited text no. 18
    
19.
Wang C, Lee I, Su M, Lin H, Huang Y, Liu S, et al. Differences in clinical and laboratory characteristics and disease severity between children and adults with dengue virus infection in Taiwan, 2002. Trans R Soc Trop Med Hyg 2009;103:871-7.  Back to cited text no. 19
    
20.
Lam PK, Van Ngoc T, Thu Thuy TT, Van Hong NT, Nhu Thuy TT, Hoai Tam DT, et al. The value of daily platelet counts for predicting dengue shock syndrome: results from a prospective observational study of 2301 Vietnamese children with dengue. PLoS Negl Trop Dis 2017;11:1-20.  Back to cited text no. 20
    
21.
Kularatne SA, Weerakoon KG, Munasinghe R, Ralapanawa UK, Pathirage M. Trends of fluid requirement in dengue fever and dengue haemorrhagic fever: a single centre experience in Sri Lanka. BMC Res Notes 2015;8:130.  Back to cited text no. 21
    
22.
Burke DS, Nisalak A, Johnson DE, Scott RM. A prospective study of dengue infections in Bangkok. Am J Trop Med Hyg 1988;38:172-80.  Back to cited text no. 22
    
23.
Barthel A, Gourinat AC, Cazorla C, Joubert C, Dupont-Rouzeyrol M, Descloux E. Breast milk as a possible route of vertical transmission of dengue virus? CID 2013:57:415-7.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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