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Am. J. Trop. Med. Hyg., 77(1), 2007, pp. 151–158 Copyright © 2007 by The American Society of Tropical Medicine and Hygiene

Acute Respiratory Failure in Adult Patients with Dengue Virus Infection
Chin-Chou Wang, Shih-Feng Liu, Shang-Chih Liao, Ing-Kit Lee, Jien-Wei Liu, An-Shen Lin, Chao-Chien Wu, Yu-Hsiu Chung, and Meng-Chih Lin*
Division of Pulmonary and Critical Care Medicine, Departmentof Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China; Department of Respiratory Care, Chang Gung Institute of Technology, Chiayi, Taiwan, Republic of China

Abstract. To investigate clinical course and outcome of dengue with acute respiratory failure (ARF), and to identify related risk factorsfor acquiring ARF in dengue, we retrospectively studied 11 dengue patients with ARF. From June to December 2002, a total of 606 adult patients were diagnosed as having dengue. Eleven (1.8%) of 606 dengue patients had complications of ARF. The main causes of ARF were sepsis (n 6, 54.5%) and upper gastrointestinal (UGI) bleeding (n 3, 27.3%). The mortality rate was 72.7% (n 8). Additionally,univariate analysis showed that age, dyspnea, cough, prothrombin time, activated partial thromboplastin time, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, creatinine, albumin, renal insufficiency, acute renal failure, acute hepatic failure, UGI bleeding, and combination bacterial infection were significantly predictive variables associated with dengue patients with ARF.INTRODUCTION As the most important mosquito-borne viral disease affecting humans worldwide, dengue continues to be a major public health issue in tropical and subtropical areas. Dengue, which is caused by dengue virus infection, is endemic in more than 100 countries and causes an estimated 50 million infections annually worldwide.1–5 Dengue is a febrile illness caused by any one of four serotypesof dengue flavivirus (DEN-1, DEN2, DEN-3, or DEN-4). Most infections are asymptomatic. Symptomatic dengue virus infection can present with a wide range of clinical manifestations, from a mild febrile illness to life-threatening shock syndrome.6–11 Dengue is often classified into two nosologic entities: dengue fever (DF) and dengue hemorrhagic fever (DHF). Dengue hemorrhagic fever is the mostserious manifestation of dengue virus infection. The clinical presentations, laboratory findings, and serologic analysis of dengue virus infection have been widely reported.12–20 However, only one study has investigated dengue patients with acute respiratory failure (ARF) and discussed the effectiveness of oxygen treatment administered by a face mask versus nasal continuous positive airway pressure inpediatric patients with dengue shock syndrome complicated by respiratory failure.17 Otherwise, there is no other published cohort study regarding dengue virus infection with ARF. During dengue virus infection, dengue virus (or viral antigen) has been detected in pulmonary macrophages and pulmonary endothelial cells. In fatal cases of dengue, histopathologic findings include interstitialinflammation and hemorrhage, alveolar fluid and protein (including fibrin), and lung hemorrhage. Hypoxemia with a widened alveolar-arterial oxygen gradient is common in patients with severe dengue. Non-cardiac pulmonary edema is a common complication of fluid replacement in patients with dengue and profound

plasma leakage.15,21–24 Nevertheless, the effects of dengue virus infection on the lung are notcompletely understood and poorly appreciated. There have been many outbreaks of dengue virus infection in Taiwan.25 A major outbreak of dengue occurred in southern Taiwan in 1987–1988, and a small number of clustered cases with dengue virus infection have since been reported in this area. A large epidemic of dengue caused by the DEN-2 virus occurred between June and December 2002 in southern...