KARACHI: “Before I took my ailing father to a private hospital, he had been treated by two doctors at separate health facilities for two weeks. None of them, however, tested him for dengue,” 23-year-old Ahsan, the eldest among his four siblings, narrates how he lost his father, Azeem, whom the government recently declared as the 11th victim of dengue in the city.

A resident of Liaquatabad, Azeem in his late 40s had long been ill with a serious disease but the family was not aware of it. “He hid his illness from us and we discovered only after his death that he had been regularly buying medicines to get relief from migraine, occasional fever and body aches for some six months,” he says.

Around two weeks before his death, Azeem also developed a high-grade fever. The doctors found his white blood cell count low and said he had some blood infection. His condition slightly improved following treatment but it again deteriorated with a further drop in his white blood cells.

“Late in the night on Dec 12, he started having difficulty in breathing and passed blood in urine,” said Ahsan, adding that the family rushed him to a private hospital, where he was diagnosed with a heart problem.

The next morning, Azeem had a paralysis attack. Doctors told the family that Azeem might also have dengue but his heart valves needed to be replaced to save his life. With a 10 per cent chance of successful surgery, the family decided to have the procedure.

But, according to Ahsan, as soon as the surgeon made an incision down the centre of the chest wall, his father passed away as he could not bear the blood loss.

The hospital report states that the patient died of infective endocarditis of aortic and marital valve, cardiogenic shock and severe pulmonary haemorrhage.

Other significant conditions (that contributed to his death) identified in the report included severe left ventricular dysfunction and severe sepsis. There was no mention of dengue, though the dengue prevention and control programme of the provincial government declared Azeem on Dec 14th as an 11th patient who died of dengue.

The family spent about Rs390,000 on the treatment of the patient at the private hospital.

On dengue, the World Health Organisation websites states that the symptoms of the mosquito-borne disease range from mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain and rash. Serious complication can occur which include dengue haemorrhagic fever (DHF).

“Severe dengue (DHF) is characterised by fever, abdominal pain, persistent vomiting, bleeding and breathing difficulty and is a potentially lethal complication, affecting mainly children. Early clinical diagnosis and careful clinical management by trained physicians and nurses increase survival of patients,” it says.

Doctors’ mishandling

With the patient confidentiality rules in place at the hospital in question with government restriction on the public disclosure of the hospital name where a dengue case is treated, it was impossible to get the version of the doctors who had treated Azeem.

Dr Masood Solangi, heading the dengue prevention and control programme, however, said that though Azeem’s case was a bit complicated, doctors at hospitals where he was initially treated seemed to have mishandled his case.

“His platelet blood count seemed to be very low, that’s why he couldn’t survive the blood loss and died (platelets help in clotting the blood and their low count is an important indicator for dengue infection).

“When he initially reported with a high-grade fever and body pains, the doctors should have immediately done specific tests to rule out dengue, malaria and other diseases,” he said, adding that white blood cells could drop in many illnesses, including typhoid.

Dengue diagnostic kits which were available free at tertiary care public sector hospitals, he said, and the results were made available within seconds.

“These rapid diagnostic tests can also be done at home. Unfortunately, Azeem went to a proper health facility quite late. For this delay, I blame the general practitioners and not the patient’s family as they may not be aware of dengue symptoms and its complications,” he said.

Dr Solangi also said that dengue had no specific treatment; patients were advised to rest, drink plenty of fluids and reduce the fever by using paracetamol as other painkillers reduced platelet count. Doctors must be consulted if the condition of the patient deteriorated, he said.

A total of 3,664 cases of dengue fever have been reported in Sindh this year. Of them, Karachi has reported 3,581 cases and 11 deaths, the total figure of dengue fever mortalities in the province. At least half of them were those in which a patient died within a day or two.

In 2014 and 2013, 17 and 32 people died of dengue, respectively, in Sindh.

Director of laboratory services and consultant microbiologist at the Indus Hospital Dr Altaf Ahmed endorsed Dr Solangi’s views and said that the patient’s life could have been saved if he was properly investigated and treated in time.

“It seems to be a misdiagnosed case. In a rare condition, dengue also affects the heart. As for the open heart surgery, I believe the procedure with an extremely low platelet level wasn’t the right decision unless it was a matter of life and death,” he said.

According to him, often hospital doctors mismanage patients by giving unnecessary blood transfusion to dengue patients with a lower count of platelets, which is a burden on their pockets. Until there is any bleeding tendency, blood transfusions should not be provided, he suggests.

The government, he says, should focus on dengue fever prevention as there is no treatment or vaccine available for it.

However, Dr Faisal Mahmood, infectious diseases consultant at the Aga Khan University Hospital, said that delay in a patient’s arrival may or may not be the contributing factor to death in dengue cases.

“There are two possibilities: either the patient did indeed arrive too late or that the dengue infection was so severe that early treatment would not have made a difference. Without reviewing individual cases it is difficult to make an accurate assessment,” he said.

Deaths in dengue cases were owing to a number of different factors. “In general, dengue has an extremely low mortality rate. However, in the cases where other organs are affected or the patient has other underlying illnesses which can complicate treatment, therapy may not work.”

Published in Dawn, December 22nd, 2015