Final Diagnosis for a Patient with Severe Dengue and Pleural Effusion Who Died
The final diagnosis should be Dengue Hemorrhagic Fever (DHF) with Dengue Shock Syndrome (DSS), or more specifically, severe dengue with plasma leakage and shock leading to death.
Diagnostic Classification
The presence of pleural effusion in a fatal severe dengue case is a hallmark manifestation of plasma leakage, which is the defining pathophysiologic feature of DHF/DSS 1. According to CDC case definitions, dengue hemorrhagic fever is defined as an acute febrile illness with minor or major bleeding phenomena, thrombocytopenia (≤100,000/mm³), and evidence of plasma leakage documented by hemoconcentration (hematocrit increased by ≥20%) or other objective evidence of increased capillary permeability, including pleural effusion 1.
Clinical Context and Pathophysiology
Pleural effusion is a common and expected finding in severe dengue, occurring as a direct result of acute capillary permeability increase that causes plasma to leak into interstitial spaces and serous cavities 2.
The presence of pleural effusion indicates progression to severe disease with significant plasma leakage, which is associated with higher mortality risk 2, 3.
In fatal dengue cases, pleural effusion is frequently bilateral and may be accompanied by other manifestations of plasma leakage including ascites and pericardial effusion 4.
Important Clinical Considerations
Dengue Shock Syndrome (DSS) should be included in the final diagnosis if shock was present, defined as hypotension or narrow pulse pressure (≤20 mm Hg) in addition to the criteria for DHF 1. The classification would then be:
DHF Grade 3 or 4 (DSS) if shock occurred with or without profound shock 2.
Severe dengue with multi-organ involvement if there was evidence of organ dysfunction beyond plasma leakage 2.
Critical Diagnostic Nuances
Not all fatal dengue cases present with classic hemoconcentration and pleural effusion. Research from Jakarta found that 30% of virologically confirmed fatal dengue cases had massive gastrointestinal hemorrhage without evidence of hemoconcentration or pleural effusion 5. However, since your patient had pleural effusion, this represents the more typical presentation of severe dengue with plasma leakage.
The presence of pleural effusion alone is sufficient evidence of plasma leakage for DHF diagnosis, even without documented hemoconcentration ≥20% 1, 6.
Dengue-associated Adult Respiratory Distress Syndrome (ARDS) should be considered as a complicating diagnosis if there was severe respiratory compromise requiring mechanical ventilation, as pleural effusion in severe dengue can progress to ARDS 2.
Final Diagnostic Statement
The most accurate final diagnosis is: Dengue Hemorrhagic Fever (DHF) with Dengue Shock Syndrome (DSS) or using current WHO terminology: Severe Dengue with plasma leakage (evidenced by pleural effusion), shock, and fatal outcome 1, 2.
If encephalitis signs were present (convulsions, somnolence, altered consciousness), add: with neurological complications 5.
If severe bleeding occurred: with hemorrhagic manifestations 5.
If respiratory failure developed: complicated by ARDS 2.