Population and study design

A retrospective study was conducted to review the medical records of patients who died of dengue in the Piura region up to epidemiological week 42 of 2017, which includes a dengue outbreak. The Epidemiology Area of the Regional Health Directorate of Piura (DIRESA-Piura), provided 32 medical records, eight of which were excluded (duplicate records, no medical death certificate, illegible information and incomplete information), therefore 24 were finally included.

Dengue case definition

Dengue was diagnosed according to the clinical and epidemiological criteria established by the technical guideline of the Peruvian Ministry of Health (MINSA) ⁷. All cases had positive results in one or more of the diagnostic tests, either the enzyme-linked immunosorbent assay (ELISA) for the nonstructural glycoprotein NS1, or the detection of IgM or IgG antibodies with the Peruvian TARIKI-DENGUE kit and Standard Diagnostics BIOLINE Dengue Duo, respectively.

Data collection

All cases were from the Piura region. The physicians in charge filled the MINSA forms and the registry. A data collection instrument was used to obtain information from the medical records. We obtained epidemiological data such as age, sex, pathological history, history of dengue, time of illness, place of care, characteristics of the time of care between admissions to healthcare facilities; signs and symptoms such as fever (axillary temperature higher than 38°C), headache, retroorbital pain, myalgia, arthralgia, malaise, others; vital functions; fluid management; life and hematological support; laboratory tests (automated equipment was used to assess blood gases) and use of antipyretic drugs and antibiotics.

Statistical analysis

Continuous variables were reported with mean and standard deviation (SD) or median and interquartile range (IQR), depending on their normal distribution. Categorical variables were reported with frequencies and percentages. All statistical analyses were performed with the SPSS 21 statistical program.

Ethical aspects

This study was approved by the Research Ethics Committee of the Universidad Peruana Unión (UPeU) (code: 2022-CEUPeU-001).

Diagnosis and care of dengue cases

Of the 24 cases, 62.5%, 70.8% and 41.7% were positive by NS1 (ELISA), IgM (ELISA) and IgG (ELISA), respectively. According to medical records, 8 (33.3%) deaths occurred at MINSA’s Santa Rosa II-2 Hospital, 6 (25.0%) at EsSalud’s Cayetano Heredia III Hospital, 5 (20.8%) at other EsSalud hospitals, 1 (4.2%) at the Armed Forces health facility, and 4 (16.7%) occurred at a primary care center.

Clinical and epidemiological characteristics of dengue deaths

The epidemiological characteristics of the patients who died from dengue are described in Table 1. Mortality in female patients was higher; 3 (12.5%) of the deceased were pregnant. Comorbidities such as diabetes mellitus and arterial hypertension were reported in 12.5% and 16.7%, respectively; corticosteroids were not used prior to admission in any case. Four participants (16.7%) were identified as having possible previous contact with a patient with dengue fever (1 case with febrile syndrome and 3 cases with a previous history of dengue fever). According to the clinical diagnoses at admission, 6 (25%) had dengue with warning signs and 10 (42%) had severe dengue. The mean time elapsed between the first admission to a healthcare facility and death was 4.10 (SD 5.34) days (Table 1).

The clinical characteristics on admission are described in Table 2. The most frequent clinical manifestations were related to the febrile phase of dengue fever: fever (87.5%) and systemic symptoms such as headache (33.3%), nausea/vomiting (58.3%), abdominal pain (45.8%), arthralgia (33.3%) among others. In addition, vital signs on admission revealed tachycardia (mean heart rate of 108 beats per min), and polypnea (mean respiratory rate of 25).

Laboratory results are described in Table 3. The hemogram was performed within 48 hours of admission and showed wide variability, this may have been due to the fact that the data from peripheral healthcare facilities were obtained manually and data from greater complexity facilities were obtained using systematized methods. The results showed a decreasing trend of the platelet count. Lactate levels were found to be high. Results showed that transaminase enzymes (AST and ALT) were high, suggesting hepatic alterations; INR levels were also high. Half of the patients had thrombocytopenia.

Management of dengue cases

Patient management at the onset of signs and symptoms included mainly crystalloid fluids, sodium chloride solution 9°/00 (91.7%); the use of vasoactive drugs and mechanical ventilation was frequent (70.8%), analgesics (58.3%) and doses <300mg/24h of intravenous corticosteroids (45.8%) were also reported. Transfusion of blood derivatives or more than one blood product at the same time was reported in 46% of patients (Table 4).

The use of analgesics such as paracetamol was reported in 25% and metamizole in 17% of patients who died of dengue. Physical means were not used in any case. Antibiotics were widely used, 71% of patients received more than two classes of antibiotics (Table 4). Regarding transfusion, 45.8% of the patients received blood and 25% fresh frozen plasma. Platelet units and cryoprecipitate were also transfused in 16.8% of cases.

Aspects related to the causes of death

PaO₂/FiO₂ values of 220 indicate pulmonary involvement; the pH was 7.22 which suggests severe acidosis. High lactate levels were reported with a median of 11.1 mmol/L (Table 3). Finally, 100% of the deaths presented neurological, respiratory and cardiovascular disorders. Hematologic disorders were reported in 58.3% and gastrointestinal and renal dysfunction in 50% of the cases.