Factors Associated With Intensive Care Attention of Dengue Patients A Retrospective Cohort Study From a Single Center Jin Yu Chieng, FRCP,*† Logaruban Aravan, MRCP,† Durga A. Arimuthu, MRCP,† Wendy Ai Ying Tan, MRCP,† Tharani Naidu, MBBS,† and Yan Pan, PhD‡ Background: Dengue is caused by dengue virus infection, and it is wide- spread globally. This study aimed to identify indicative markers for inten- sive care unit admission. Methods: A retrospective study was conducted via recruiting dengue pa- tients (≥15 years) admitted to Hospital Serdang, Malaysia, from January to April 2017. Results: In total, 455 patients were included in this study. Among the fac- tors considered, older age (P = 0.0226), Chinese (P = 0.0297), dengue with comorbidity (P = 0.0039), severe dengue (P < 0.0001), acute kidney injury (P < 0.0001), lower platelet level (P < 0.0001), higher bilirubin level (at ad- mission, P = 0.0089; at highest concentrations, P = 0.0479), and prolonged activated partial thromboplastin time (P = 0.0144) were associated with in- tensive care unit admission. Conclusions: Demographic characteristics (older and Chinese), clinical presentations (dengue with comorbidity, severe dengue, acute kidney in- jury), and laboratory findings (lower platelet, higher bilirubin, and pro- longed activated partial thromboplastin time) could be used as suggestive indicators for dengue patients requiring intensive care to minimize mortal- ity and to improve prognosis. Key Words: dengue, factor, ICU, intensive care (Infect Dis Clin Pract 2019;28: 27–33) D engue is derived from infection of dengue viruses, which be- longs to the genus Flavivirus, within the family Flaviviridae. Dengue virus is primarily transmitted by female mosquitoes of the species Aedes aegypti and, to a lesser degree, Aedes albopictus. Dengue is seen widespread throughout the tropical climates. 1 His- torically, it was reported in tropical and subtropical regions, where the vectors A. aegypti and A. albopictus were thought to have orig- inated from African continent and Asian countries, respectively. However, because of globalization and traveling, dengue has spread widely all around the world. Although the exact number of dengue cases is underreported, the incidence of dengue has grown rapidly in the past few years. The number of cases reported to the World Health Organization (WHO) has continued to in- crease from 2.2 million in 2010 to 3.2 million in 2015. 2 Dengue is a flulike illness with a wide spectrum of clinical manifestations. Based on the WHO 1997 guidelines, dengue is classified into undifferentiated fever, dengue fever, and dengue hemorrhagic fever (DHF). The DHF has been further classified as grades 1 to 4 according to severity. Grades 3 and 4 are catego- rized as dengue shock syndrome, which is the most dangerous condition of dengue. 3 It has been a challenge for physicians to identify those in whom the dengue will develop to the severe form. The WHO has released a revised dengue guidelines in 2009, which divides dengue into probable dengue, dengue with warning signs (abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing hemato- crit with decreasing platelets), and severe dengue. 4 Of note, muco- sal bleeding has been proposed as one of the indicators of severe dengue. 4 Hemorrhage in dengue infection often involves gastroin- testinal (GI) bleeding. The GI bleeding was reported to be associ- ated with poor prognosis among patients with dengue. 5–8 On the other hand, dengue associated with liver injuries has been re- ported. 9,10 Possible immune mechanisms were proposed but yet to be verified. 11 In Malaysia, the first dengue case was reported at 1902 in Penang. 12 Similar to the global situation, the incidence rate of dengue in Malaysia has raised several folds in the last decades. According to the latest dengue situation update provided by WHO, the cumulative number of dengue cases in Malaysia was 46,607 including 74 deaths, as of May 11, 2019. This number was more than double of that reported during the same period in 2018. 13 Few articles have discussed dengue in Malaysia with regard to baseline properties and also predictive factors for severe dengue. 14,15 This study aimed to investigate the potential effects of dengue infections on GI and liver functions. It was initiated by the determination of the baseline characteristics of dengue pa- tients admitted to Hospital Serdang, Malaysia, and ascertaining GI as well as liver factors that contributed to a diagnosis of severe dengue or intensive care unit (ICU) admission. Subsequently, it was to identify GI clinical presentations and laboratory findings in dengue patients associated with a complicated clinical course and requirement of intensive care, which in turn might be able to lower morbidity and mortality. METHODS A retrospective study was conducted via recruiting dengue patients admitted to Hospital Serdang, Malaysia, from January to April 2017. Ethics approval had been received from Medical Review and Ethics Committee of the Ministry of Health Malaysia prior to the study (NMRR-18-358-40140). Inclusion criteria were patients older than 15 years, who fulfill the WHO criteria for symptomatic dengue accompanied by a positive labo- ratory test on dengue antibody immunoglobulin M detected by enzyme-linked immunosorbent assay. 16 Previous patient records were retrieved via the electronic health information system. The data were then analyzed using GraphPad Prism version 7.00 for Windows, GraphPad Software, La Jolla, Calif, www.graphpad. com. Fisher exact test was employed for the analysis of categorical variables, and paired or unpaired t test was performed for From the *Pantai Hospital Ampang, Kuala Lumpur; †Department of Medicine, Serdang Hospital, Selangor; and ‡Division of Biomedical Science, School of Pharmacy, Faculty of Science and Engineering, University of Nottingham Malaysia, Selangor Darul Ehsan, Malaysia. Correspondence to: Pan Yan, PhD, Division of Biomedical Science, School of Pharmacy, University of Nottingham Malaysia, Jalan Broga, 43500 Semenyih, Selangor Darul Ehsan, Malaysia. E‐mail: panyan1980@hotmail.com. The authors have no funding or conflicts of interest to disclose. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1056-9103 ORIGINAL ARTICLE Infectious Diseases in Clinical Practice • Volume 28, Number 1, January 2020 www.infectdis.com 27 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.