High season for dengue fever

It is currently the rainy season in Cambodia, which brings with it lush greenery and frequent showers, but unfortunately also the peak season for dengue fever. We encounter it daily in the morning report, on the wards, and in its most severe form in the intensive care unit. Since the beginning of this year, 2,554 children have been hospitalized for dengue fever at Kantha Bopha Hospital in Siem Reap, with 15 percent requiring intensive care. For us Swiss medical students, dengue fever was previously a theoretical concept – familiar from textbooks, but hardly tangible, because none of us had ever seen it before. We will now tell you how dengue fever infection occurs, how the disease manifests itself, and how Kantha Bopha Hospital deals with it.

Dengue is a viral infection transmitted by Aedes-mosquitoes that occurs worldwide in tropical and subtropical areas. The dengue virus can occur in four different serotypes, with each serotype causing infection only once. A previous infection only protects against the respective serotype. Subsequent infections with another type increase the risk of a severe course of the disease. The disease can be divided into three phases: the febrile phase, the afebrile phase (also called the critical phase), and the recovery phase. The onset of the disease and the start of the febrile phase occur after about 7 days. The initial symptoms resemble a flu-like infection with high fever, muscle pain, and dizziness, and may also include bleeding gums and small skin hemorrhages.

As soon as the fever begins to subside, the afebrile phase begins, which lasts about 24 to 48 hours. This phase is particularly critical, as it becomes clear whether the course of the disease will be mild or severe. Some children develop hemorrhagic fever, in which fluid leaks from the blood vessels and accumulates in various organs such as the lungs or skin, causing a drop in blood platelets. The accumulation of fluid in the lungs causes breathing difficulties, meaning that many children have to be intubated. In this situation, the children are unresponsive and have to be fed artificially.

In the worst case, the child suffers from shock, also known as dengue shock syndrome, which manifests itself as circulatory failure. In the course of the disease, these children often suffer several episodes of shock, and with each additional episode, their chances of survival decrease. In cases of prolonged shock or multiple episodes of shock, the children may ultimately die of multiple organ failure. If the critical phase is survived, the body replenishes the lost fluid and the recovery phase begins. There is no specific antiviral therapy; only symptomatic treatment is available. Mosquito repellent or mosquito nets are very important for preventing dengue infection.

Now we would like to introduce you to two patients in the intensive care unit who were seriously ill with dengue fever. One of our patients is a ten-year-old girl who was admitted in a state of dengue shock. She suffered a total of three episodes of shock during the critical phase. Day and night, one of her parents sat at their daughter's bedside and was involved in her care. Not knowing whether their child would survive the critical phase, the worry was clearly visible on the parents' faces. Fortunately, she survived the critical phase and can now be transferred to a regular ward. Unfortunately, not every case has a happy ending. At the same time, a six-year-old girl was also in intensive care – also with dengue shock syndrome. She had suffered six episodes of shock during the critical phase. Despite all the intensive medical efforts, instead of improving, she suffered multiple organ failure. She died that night in the presence of her parents.

Such stories are not isolated incidents. After a child dies or is discharged, the bed does not remain empty for long, and within hours a new dengue case is admitted. Thanks to the competent medical care provided by the hospital, most cases have a positive outcome and patients can be discharged. Of the 2,554 dengue cases reported so far this year, 2,225 (87.1%) were classic dengue fever, while 329 cases (12.9%) were accompanied by complications such as dengue hemorrhagic fever or dengue shock syndrome. Unfortunately, seven patients have died from complications since the beginning of the year.

Our time in the intensive care unit had a profound impact on us, and we will always remember the patients who recovered and those who did not. We would like to express our sincere thanks to the intensive care team for sharing their extensive knowledge and for their tireless efforts in the fight against dengue fever.

With best regards from Siem Reap

Rebecca, Elodie, and Lars