Introduction: Secondary Hemophagocytic Lymphohistiocytosis (HLH) is a condition seen in severe dengue that can be potentially fatal. Timely management using HLH-directed treatment such as steroids or etoposide have been seen to improve the outcome of patients however there is no protocol on how to manage the disease. Two criteria commonly used to guide the direction of treatment are namely the HLH-2004 criteria and the Hscore; with the latter being used more often. The best cut-off H score is 169 corresponding to a sensitivity of 93%, specificity of 86% and accurate classification of 90% of the patients. We described of five patients diagnosed with severe dengue compli-cated with HLH. Methods: 5 cases that were diagnosed with severe dengue with secondary HLH and received dexa-methasone were reviewed retrospectively and clinical data extracted. Results: All patients had fever beyond critical or leaking phase. Four out of five cases had Hscore higher than 169 and had a mean score of 181 with only one bone marrow performed. Three patients had concurrent leaking and bleeding and three patients had fast progression of se-vere transaminitis during the critical phase. The mean peak ferritin level was 21077 micro/L. The only bone marrow aspiration done revealed increased macrophages and hemophagocytic activity. All patients received a short course of dexamethasone and discharged well. Conclusion: Short course dexamethasone is effective in treatment of HLH in dengue despite the concerns of administration of steroids in bleeding dengue patient. Secondary HLH in dengue remains a clinical diagnosis with no conclusive diagnostic criteria. It should be suspected in a severe dengue patient with hyperferritinemia and persistent fever. Technical difficulty of performing bone marrow during severe dengue makes conclusive diagnosis remains elusive.
Introduction:Increasing number and the complexity of dengue cases pose a great challenge. The dengue outbreak preparedness and contingency plan is a series of collective intervention or polices put into place via collective agreement between administrative, Medical, Emergency Department and Intensive Care Unit (ICU). The aim of this paper is to evaluate the impact implementation of a dengue contingency plan on the clinical outcome of dengue cases. Methods: Implementation of the dengue outbreak preparedness and contingency plan was commenced in 2017. A pre-intervention (2017) and post-intervention (2018) retrospective review of mortality cases and referral to ICU were undertaken. The interventions included mandatory fast review by Emergency Physician, Medical Physi-cian and Anaesthesist in Emergency Department for ill patients (Dengue Care Pathway), cohorting dengue patient to one ward with mandatory monitoring and review system, clinical management adhering to the Clinical Practice Guideline of Management of Dengue Infection in Adults (2015), referring ill patients to ICU, deployment of nurses and experienced doctors to the dengue ward based on ratio of staff to patients, increasing number of doctors on-call at the dengue ward and a dengue bed manager system led by the Matron and Sisters. The plan was activated by mutual agreement between the Head of Medical Department and the Hospital Director. Results: There was a marked increment of admission of dengue cases into intensive care unit by 59% either directly from emergency department or the dengue wards in 2018 compared to 2017. The mortality rates reduced significantly from 5.4 deaths for every 1000 admission in 2017 to 3.3 in 2018. This is a reduction 2.1 death for every 1000 dengue admission. Conclusion:The implementation of the dengue outbreak preparedness and contingency plan aided the team to provide best care and practice in dengue management especially in the severely ill.