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Indian Pediatr 2013;50: 528-529 |
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The Real Need of the Hour
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Mani Ram Krishna and Singaravelu Manickavasagam
Dr RK Nursing home, Thanjavur, Tamil Nadu, India.
Email: [email protected]
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During a recent surge in the number of dengue cases in
central and southern Tamil Nadu, we handled a number of
referrals from the surrounding rural areas in our nursing
home. While analyzing a total of 50 children with a
diagnosis of dengue during the month of December 2012, we
came across results which probably merit serious rethinking
about our approach to early diagnosis and appropriate
management of infectious diseases.
Of the 50 patients, 12% were below 1 year
of age and 64% were above 5 years with a slight male
predominance (60:40). Warning symptoms were present in 40%
of cases and was usually vomiting or epigastric pain. Two
children had petechial and purpuric spots and no child had
significant mucosal or systemic bleeds. Only one child (2%)
has evidence of significant plasma leakage and compensated
shock requiring fluid resuscitation. 4 children (8%) showed
evidence of fluid overload (2 children had ascites and 2
children had ascites with pleural effusion) but this did not
cause respiratory embarrassment or warrant diuretic therapy
in any case. 44 children (88%) were referred because of
positive NS1 antigen and 6 children due to positive IgM
antibodies to dengue. Significant pruritus was present in 16
cases (32%) and was noticed to herald recovery from the
illness in these children. Thrombocytopenia (platelet count
< 100,000/ mm 3)
was present in 22 cases (44%). None of the patients required
blood component therapy. Regression analysis showed that
thrombocytopenia was a poor indicator of bleeding tendency
and positive NS 1 did not show co-relation to
thrombocytopenia, presence of warning signs or fluid
overload.
While none of the findings are new or
suggest any change in the existing management of the
illness, we feel that many of the patients and the treating
pediatricians were unnecessarily traumatized because of a
positive antigen test. This made us recall a perspective on
early diagnosis of febrile illness in the journal [1]. In
that article, it was argued that as infectious diseases are
a major cause of mortality in children and also placed
tremendous economic burden on the country, early diagnosis
of infectious disease is the need of the hour [1], and the
case for NS 1 antigen in dengue was well made out. NS1
assays are very useful in the diagnosis of dengue with high
sensitivity and specificity [2]. In our case, we noticed a
reverse of the predictions with an increase in economic and
health care burden due to a rapid diagnostic test for dengue
resulting in stress for parents and unnecessary paranoia. It
should be remembered that the natural history of dengue and
the pointers towards children who can develop severe dengue
have been characterized [3]. The symptoms are easily
recognizable by parents and they can be taught to identify
the symptoms and bring the child to medical attention should
the need arise. Hence, the real need of the hour in a
country like ours, where there is a serious lacunae in high-
quality primary care and referral services, is to improve
the skills of the pediatricians in not just recognizing the
symptoms and signs of specific illness but also to counsel
and coach the parents about the appropriate management of
their wards [4]. The role of rapid diagnostic tests,
especially in dengue, should be probably be limited to serve
epidemiological purposes.
References
1. Dhingra B, Mishra D. Early diagnosis
of febrile illness: The need of the hour. Indian
Pediatr. 2011;48: 845-9.
2. Kumarasamy V, Abdul Wahab AH, Chua SK,
Hassan Z, Chem YK, Mohamad M, et al. Evaluation of a
commercial dengue NS1 antigen-capture ELISA for laboratory
diagnosis of acute dengue virus infection. J Virol Method.
2007;140:75-9.
3. Handbook for Clinical Management of
Dengue 2012. Available from:
www.who.int/denguecontrol/9789241504713/en/index.html.
Accessed on 29 March, 2013.
4. Ranebennur V. Role of medical doctors and paramedics
in counselling services. J Fam Welfare. 2004;50:
38-41.
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