Clinical Scorecard: Determinants of Mortality in Severe Dengue: A Retrospective Cohort Analysis from Espírito Santo, Brazil, 2020-2024

At a Glance

Key Highlights

• Among 251 patients with laboratory-confirmed severe dengue, 117 (46.6%) died.

• Fatal cases were significantly older than survivors.

• Weak or undetectable pulse, late-stage arterial hypotension, progressive hematocrit increase, and altered consciousness were associated with higher mortality in the overall multivariable model.

• Weak or undetectable pulse and late-stage hypotension remained associated with higher mortality in both exploratory age groups.

• Fever and sudden platelet decline were associated with lower mortality, but these findings do not establish protective effects.

Guideline-Based Recommendations

The source is a retrospective cohort study, not a clinical guideline. The following points reflect its methods and the authors’ interpretation.

Diagnosis

• Study inclusion required laboratory confirmation by NS1 antigen detection, viral isolation, reverse-transcription polymerase chain reaction, or IgM enzyme-linked immunosorbent assay.

• Severe disease was defined by severe plasma leakage causing shock or respiratory distress, severe bleeding, or severe organ involvement. These were study eligibility criteria, not a requirement that all manifestations occur together.

Management

• The authors identify advanced hemodynamic instability as the predominant pattern associated with mortality among patients who already have severe dengue.

• Altered consciousness is described as a marker of systemic decompensation requiring immediate intensive monitoring and management.

Monitoring & Follow-up

• The authors call for prospective studies with precisely timed clinical data and longitudinal follow-up.

• The study does not establish a monitoring schedule or validate its findings as early predictors of death.

Risks

• Older adults may have less typical presentations, complicating clinical recognition.

• The absence of fever or a sudden platelet decline should not be interpreted as reassuring.

• Age-stratified findings are exploratory and do not establish statistical effect modification by age.

Patient & Prescribing Data

The analysis included 251 laboratory-confirmed severe dengue cases reported between 2020 and 2024. Patients were classified according to recorded dengue-related death.

Data on time to care, fluid management, medication use, and socioeconomic factors were unavailable. The study does not compare prescribing or treatment strategies.

Clinical Best Practices

• Recognize weak or undetectable pulse, late-stage hypotension, and altered consciousness as manifestations associated with poor outcomes in this cohort.

• Interpret classical warning signs cautiously in older adults.

• Avoid treating associations with lower mortality as evidence of protection.

• Consider the uncertain timing of manifestations, potential surveillance-data misclassification, and residual confounding when interpreting the findings.

Related Resources & Content

• Dengue: diagnóstico e manejo clínico: adulto e criança, sixth edition — Ministério da Saúde do Brasil — Ministério da Saúde, 2024.

• Risk predictors of progression to severe disease during the febrile phase of dengue: a systematic review and meta-analysis — Sangkaew S, Ming D, Boonyasiri A, et al. — The Lancet Infectious Diseases, 2021;21:1014–1026.

• Challenges in dengue fever in the elderly: atypical presentation and risk of severe dengue and hospital-acquired infection — Rowe EK, Leo YS, Wong JG, et al. — PLOS Neglected Tropical Diseases, 2014;8:e2777.

• Clinical manifestations, laboratory profile and outcomes of dengue virus infection in hospitalised older patients — Ng WY, Ngim CF, Chow KY, Goh SXM, Zaid M, Dhanoa A — Transactions of the Royal Society of Tropical Medicine and Hygiene, 2022;116:545–554.

• Prognosis and mortality risk in elderly patients with dengue virus infection: excess fatality and the urgent need for revising current WHO criteria for elderly patients — Jeng MJ, Lee NY, Lee IK, et al. — Travel Medicine and Infectious Disease, 2025;65:102855.