Clinical profile and outcome of hospitalized patients during first outbreak of dengue in Makkah, Saudi Arabia

Abstract

Objective

To describe clinical profile of patients with dengue virus infection hospitalized at a single center during the first outbreak of dengue in Makkah, Saudi Arabia from April to July 2004.

Methods

Clinical information and laboratory abnormalities of patients with suspected dengue infection were collected by a standardized data collection sheet and review of medical records. Dengue virus infection was confirmed by a positive IgM capture ELISA or RT-PCR.

Results

Of the 160 clinically suspected patients, 91 were confirmed (64 by IgM ELISA, 14 by RT-PCR and 13 by both) to have dengue virus infection. Dengue serotypes 2 and 3 were identified in 19 and 4 patients respectively. Most patients were young adults with median age of 26 (range = 6–94) years and male:female ratio of 1.5:1. The common symptoms were fever (100%), malaise (83%), musculoskeletal pain (81%), headache (75%), nausea (69%), vomiting (65%) and abdominal pain (48%). According to World Health Organization (WHO) classification (10 patients were excluded due to lack of serial hematocrits), 75 (93%) had dengue fever (DF) and 6 (7%) had dengue hemorrhagic fever (DHF). Only one patient with DHF was in pediatric age group. Twenty-one patients (5 with DHF and 16 with DF) developed one or more clinical complications that included bleeding (14), shock (4), seizures (3), acute renal failure (2), meningo-encephalitis (1), and secondary bacterial infection (1). Only one patient with shock had dengue shock syndrome (DSS) by WHO classification. Development of clinical complications was significantly associated with absence of musculoskeletal pain (p-value = 0.03), lower platelet counts (p-value = 0.03) and higher serum aspartate aminotransferase levels (p-value = 0.04). The median duration of symptoms and hospitalization was 8 days (range = 3–18) and 4 days (range = 1–10) respectively. No mortality was noted.

Conclusion

Occurrence of dengue virus infection in Makkah, Saudi Arabia is documented. Continued surveillance and effective vector control programs are warranted due to unique population dynamics of Makkah that receives millions of pilgrims annually from all over the world.

Introduction

Dengue virus is the most important arbovirus that causes human disease. It belongs to Flaviridiae family, and is transmitted by mosquitoes Aedes aegypti and Aedes albopictus. There are four related but antigenically distinct serotypes of dengue virus designated as DEN-1, DEN-2, DEN-3, and DEN-4. Most individuals with dengue virus infection are asymptomatic, or develop dengue fever (DF) characterized by fever and non-specific constitutional symptoms. A minority of patients develop severe disease in the form of dengue hemorrhagic fever and dengue shock syndrome (DHF/DSS) that begins like DF but is characterized by abrupt development of severe vascular leakage which may rapidly lead to shock or death (Gibbons and Vaughn, 2002). Dengue has become a global disease being reported from more than 100 countries, with 2.5–3 billion people living in areas at potential risk of dengue transmission. It is estimated that 50–100 million patients of dengue infection occur annually of which 250,000 progress to DHF/DSS resulting in 24,000 deaths (WHO, 1997).

Dengue like disease was observed in the Arabian Peninsula in the late 19th century (1870–1873). The disease appeared in Zanzibar, in Dar el Salam, on the East African coast, in Arabia (Aden, Mecca, Madina and Jeddah) (Gubler, 1997). In Saudi Arabia, dengue virus (DEN-2 serotype) was first isolated from a fatal case of DHF in Jeddah, a port city on the Red Sea, in 1994 (Fakeeh and Zaki, 2001). Surveillance from 1994 to 2002 at a referral laboratory in Jeddah reported 319 confirmed patients of dengue viral infection, most of whom (91%) were detected during 1994 epidemic. DEN-2, DEN-1 and DEN-3 serotypes were identified in that order of frequency (Fakeeh and Zaki, 2003).

Makkah is a city in Western Saudi Arabia located 75 km inland from Jeddah. It is considered the holiest city in Islam visited by more than four million pilgrims from all parts of the world to perform Hajj and Umrah (minor pilgrimage). It has a resident population of 650,000. The city is served by six major hospitals. In this paper, we describe clinical features and outcome of patients with dengue infection that were hospitalized at Al Noor Specialist Hospital, a 550-bed teaching hospital managed by the Ministry of Health, during 2004 epidemic in Makkah.