Dengue

Approach Considerations
Because the signs and symptoms of dengue fever are nonspecific, attempting laboratory confirmation of dengue infection is important. Laboratory
criteria for diagnosis include one or more of the following:

Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy samples
Demonstration of a fourfold or greater change in reciprocal immunoglobulin G (IgG) or immunoglobulin M (IgM) antibody titers to one or
more dengue virus antigens in paired serum samples
Demonstration of dengue virus antigen in autopsy tissue via immunohistochemistry or immunofluorescence or in serum samples via
enzyme immunoassay (EIA)
Detection of viral genomic sequences in autopsy tissue, serum, or cerebral spinal fluid (CSF) samples via polymerase chain reaction (PCR)
A reverse-transcriptase PCR test has demonstrated promise, yielding a serotype-specific diagnosis very rapidly. [49, 50] However, this test is currently
available only in research laboratories.
The following laboratory tests should also be performed:

Complete blood count (CBC)

Metabolic panel
Serum protein and albumin levels
Liver panel
Disseminated intravascular coagulation (DIC) panel
Characteristic findings in dengue fever are thrombocytopenia (platelet count < 100 x 10 9/L), leukopenia, and mild-to-moderate elevation of aspartate
aminotransferase and alanine aminotransferase values. Jaundice and acute liver failure are uncommon. Peak liver enzyme levels occur later than
other complications in adults studied prospectively in Vietnam. Enzyme levels begin to rise during the early stage and peak during the second week.
Clinically severe involvement was found to be idiosyncratic and infrequent but did contribute to severe bleeding. [51]
A hematocrit level increase greater than 20% is a sign of hemoconcentration and precedes shock. The hematocrit level should be monitored at least
every 24 hours to facilitate early recognition of dengue hemorrhagic fever and every 3-4 hours in severe cases of dengue hemorrhagic fever or dengue
shock syndrome.
In patients with dengue hemorrhagic fever, the following may be present:

Increased hematocrit level secondary to plasma extravasation and/or third-space fluid loss
Hypoproteinemia
Prolonged prothrombin time
Prolonged activated partial thromboplastin time
Decreased fibrinogen
Increased amount of fibrin split products
Signs of early coagulopathy may be as subtle as a guaiac test that is positive for occult blood in the stool. Guaiac testing should be performed on all
patients in whom dengue virus infection is suspected.
Typing and crossmatching of blood should be performed in cases of severe dengue hemorrhagic fever or dengue shock syndrome because blood
products may be required.
Urinalysis identifies hematuria. Cultures of blood, urine, CSF, and other body fluids should be performed as necessary to exclude or confirm other
potential causes of the patient's condition.
Arterial blood gas should be assessed in patients with severe cases to assess pH, oxygenation, and ventilation.
Electrocardiography may demonstrate nonspecific changes as a result of fever, electrolyte disturbances, tachycardia, or medications. The usefulness
of these changes as a marker of cardiac involvement is unclear.
Biopsy of the skin lesions in patients with nonfatal, uncomplicated dengue fever reveals an abnormality of the small blood vessels. Endothelial swelling,
perivascular edema, and mononuclear cell infiltration are the primary histologic findings.
Perform chest radiography to look for pleural effusions and bronchopneumonia. Right-sided pleural effusion is typical. Bilateral pleural effusions are
common in patients with dengue shock syndrome. Head computed tomography without contrast may be indicated in patients with altered level of
consciousness, to detect intracranial bleeding or cerebral edema from dengue hemorrhagic fever.
Since January 2010, dengue has been a reportable illness in the United States. Report known or suspected cases of dengue fever, dengue
hemorrhagic fever, or dengue shock syndrome to public health authorities. Such reports should include the following:

Patient demographics and recent travel history

Case classification
Date of onset of illness

Whether hospitalization was necessary

Outcome
When multiple patients are involved, reports should include the number of cases of dengue fever and dengue hemorrhagic fever/dengue shock
syndrome stratified by age, number of confirmed cases and serotypes, and number of hospitalizations and deaths.

Complete Blood Cell Count

Leukopenia, often with lymphopenia, is observed near the end of the febrile phase of illness. Lymphocytosis, with atypical lymphocytes, commonly
develops before defervescence or shock. A systematic review found that patients with dengue had significantly lower total WBC, neutrophil, and
platelet counts than patients with other febrile illnesses in dengue-endemic populations. [52]
A hematocrit level increase greater than 20% is a sign of hemoconcentration and precedes shock. The hematocrit level should be monitored at least
every 24 hours to facilitate early recognition of dengue hemorrhagic fever and every 3-4 hours in severe cases of dengue hemorrhagic fever or dengue
shock syndrome.
Thrombocytopenia has been demonstrated in up to 50% of dengue fever cases. Platelet counts less than 100,000 cells/L are seen in dengue
hemorrhagic fever or dengue shock syndrome and occur before defervescence and the onset of shock. The platelet count should be monitored at least
every 24 hours to facilitate early recognition of dengue hemorrhagic fever.

Metabolic Panel and Liver Enzymes

Hyponatremia is the most common electrolyte abnormality in patients with dengue hemorrhagic fever or dengue shock syndrome. Metabolic acidosis is
observed in those with shock and must be corrected rapidly. Elevated blood urea nitrogen (BUN) levels are observed in those with shock. Acute kidney
injury is uncommon.[53, 54]
Transaminase levels may be mildly elevated into the several thousands in patients with dengue hemorrhagic fever who have acute hepatitis. Low
albumin levels are a sign of hemoconcentration.

Coagulation Studies
Coagulation studies may help to guide therapy in patients with severe hemorrhagic manifestations. Findings are as follows:

Prothrombin time is prolonged

Activated partial thromboplastin time is prolonged
Low fibrinogen and elevated fibrin degradation product levels are signs of disseminated intravascular coagulation

Serum Studies
Serum specimens should be sent to the laboratory for serodiagnosis, PCR, and viral isolation. Because the signs and symptoms of dengue fever are
nonspecific, attempting laboratory confirmation of dengue infection is important. Serodiagnosis is made based on a rise in antibody titer in paired
specimens obtained during the acute stage and during convalescence. Results vary depending on whether the infection is primary or secondary.
The IgM capture enzyme-linked immunosorbent assay (MAC-ELISA) has become the most widely used serologic assay for dengue. Other tests are
also used, however, including the following:

Complement fixation (CF)

Neutralization test (NT)
Hemagglutination inhibition (HI)
IgG ELISA
NS1 strip test[55]
Draw serum specimens for diagnosis as soon as possible after the onset of illness or hospitalization and at the time of death or discharge from the
hospital. Immediately place specimens on wet ice and send to the laboratory. Obtain a second (ie, convalescent) blood sample for convalescent-phase
serologic testing 7-21 days after the acute-phase serum specimen was drawn. Ideally, draw the convalescent-phase serum specimen 10 days after the
acute-phase specimen.
A European study found that if only a single serum sample is available, a single positive result on enzyme-linked ELISA (PanBio IgM or IgG) has a high
rate of false positivity and should be confirmed using a second, more specific diagnostic technique. In the absence of further testing, platelet and white
blood cell counts can be diagnostically helpful, because the combination of thrombocytopenia and leukopenia is present in 40.4% of confirmed cases
but in only 6.1% of false-positive cases. [56, 57]

Ultrasonography
Ultrasonography is a potentially timely, cost-effective, and easily used modality in the evaluation of potential dengue hemorrhagic fever. Positive and
reliable ultrasonographic findings include fluid in the chest and abdominal cavities, pericardial effusion, and a thickened gallbladder wall. Thickening of
the gallbladder wall may presage clinically significant vascular permeability. [2, 58]
The utility of previous studies was limited because patients underwent only a single scan. However, in a study by Srikiatkhachorn et al, daily serial
ultrasonographic examinations of the thorax and abdomen proved useful in the evaluation of patients with suspected dengue hemorrhagic fever. [58]
Plasma leakage was detected in some patients within 3 days of fever onset. Pleural effusion was the most common sign. Based on ultrasonographic
findings, dengue hemorrhagic fever was predicted in 12 patients before hemoconcentration criteria had been met.

Case Definitions

Cases are classified as suspected dengue if they are compatible with the clinical description. They are classified as probable dengue if they are
compatible with the clinical definition and satisfy one or more of the following criteria:

Supportive serology (reciprocal hemagglutination-inhibition antibody titer greater than 1280, comparable IgG EIA titers, or positive IgM
antibody test in late acute or convalescent-phase serum specimen)
Occurrence at the same location and time as other confirmed cases of dengue fever
A confirmed case of dengue is one that is compatible with the clinical definition and is confirmed by the laboratory.
Criteria for the diagnosis of dengue hemorrhagic fever include a probable or confirmed case of dengue infection and hemorrhagic tendencies as
evidenced by one or more of the following:

A positive result from the tourniquet test

Petechiae, ecchymoses, or purpura
Bleeding from the mucosa, gastrointestinal tract, injection sites, or other sites
Hematemesis or melena and thrombocytopenia (< 100,000 cells/L)
Evidence of plasma leakage due to increased vascular permeability
Plasma leakage may manifest as one or more of the following:
Greater than 20% rise in average hematocrit level for age and sex
Greater than 20% drop in hematocrit level following volume replacement compared with baseline
Signs of plasma leakage (eg, pleural effusion, ascites, hypoproteinemia)
Dengue shock syndrome is diagnosed in cases meeting all of the above criteria plus evidence of circulatory failure, such as the following:
Rapid, weak pulse
Narrow pulse pressure (< 20 mm Hg), with increased peripheral vascular resistance (PVR) and elevated diastolic pressure
Hypotension
Cool, clammy skin
Altered mental status, although the patient may initially remain alert
The onset of shock may be subtle, indicated by raised diastolic pressure and increased PVR in an alert patient.
WHO classification
The accuracy of the World Health Organization (WHO) classification system for dengue has been called into question. [59] A study in Indonesian children
found that the WHO classification system was in only modest agreement with the intuitive classification by treating physicians, whereas several
modified classification systems were in good agreement. [60]
The WHO classification system was found to have a sensitivity of 86% for the detection of dengue shock syndrome. [16] Modified systems that added the
above early predictors of compensated shock and considered models using varying combinations of evidence of hemorrhagic tendencies,
thrombocytopenia, and hemoconcentration were found to yield higher sensitivities (88-99%).
Proceed to Treatment & Management

Typhoid
Laboratory Studies
The diagnosis of typhoid fever (enteric fever) is primarily clinical.
Importantly, the reported sensitivities of tests for S typhi vary greatly in the literature, even among the most recent articles and respected journals.

Culture
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o

The criterion standard for diagnosis of typhoid fever has long been culture isolation of the organism. Cultures are widely
considered 100% specific.
Culture of bone marrow aspirate is 90% sensitive until at least 5 days after commencement of antibiotics. However, this
technique is extremely painful, which may outweigh its benefit. [31]
Blood, intestinal secretions (vomitus or duodenal aspirate), and stool culture results are positive for S typhi in approximately
85%-90% of patients with typhoid fever who present within the first week of onset. They decline to 20%-30% later in the disease course. In
particular, stool culture may be positive for S typhi several days after ingestion of the bacteria secondary to inflammation of the intraluminal
dendritic cells. Later in the illness, stool culture results are positive because of bacteria shed through the gallbladder.
Multiple blood cultures (>3) yield a sensitivity of 73%-97%. Large-volume (10-30 mL) blood culture and clot culture may
increase the likelihood of detection.[32]
Stool culture alone yields a sensitivity of less than 50%, and urine culture alone is even less sensitive. Cultures of punch-biopsy
samples of rose spots reportedly yield a sensitivity of 63% and may show positive results even after administration of antibiotics. A single rectal
swab culture upon hospital admission can be expected to detect S typhi in 30%-40% of patients. S typhi has also been isolated from the
cerebrospinal fluid, peritoneal fluid, mesenteric lymph nodes, resected intestine, pharynx, tonsils, abscess, and bone, among others.
Bone marrow aspiration and blood are cultured in a selective medium (eg, 10% aqueous oxgall) or a nutritious medium (eg,
tryptic soy broth) and are incubated at 37C for at least 7 days. Subcultures are made daily to one selective medium (eg, MacConkey agar) and

one inhibitory medium (eg, Salmonella-Shigella agar). Identification of the organism with these conventional culture techniques usually takes 4872 hours from acquisition.
Table 2. Sensitivities of Cultures[2, 32, 33, 34] (Open Table in a new window)
Incubation
Bone marrow aspirate (0.5-1 mL)
Blood (10-30 mL), stool, or duodenal aspirate culture
Urine

Week 1

Week 2

Week 3

Week 4

90% (may decrease after 5 d of antibiotics)

40%-80%

~20%

Variable (20%-60%)

25%-30%, timing unpredictable

Polymerase chain reaction (PCR):[35, 36] PCR has been used for the diagnosis of typhoid fever with varying success. Nested PCR, which
involves two rounds of PCR using two primers with different sequences within the H1-d flagellin gene of S typhi, offers the best sensitivity and
specificity. Combining assays of blood and urine, this technique has achieved a sensitivity of 82.7% and reported specificity of 100%. However, no
type of PCR is widely available for the clinical diagnosis of typhoid fever.

Specific serologic tests

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Assays that identify Salmonella antibodies or antigens support the diagnosis of typhoid fever, but these results should be
confirmed with cultures or DNA evidence.
The Widal test was the mainstay of typhoid fever diagnosis for decades. It is used to measure agglutinating antibodies against
H and O antigens of S typhi. Neither sensitive nor specific, the Widal test is no longer an acceptable clinical method.
Indirect hemagglutination, indirect fluorescent Vi antibody, and indirect enzyme-linked immunosorbent assay (ELISA) for
immunoglobulin M (IgM) and IgG antibodies to S typhipolysaccharide, as well as monoclonal antibodies against S typhi flagellin,[37] are promising,
but the success rates of these assays vary greatly in the literature.

Other nonspecific laboratory studies

o
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Most patients with typhoid fever are moderately anemic, have an elevated erythrocyte sedimentation rate (ESR),
thrombocytopenia, and relative lymphopenia.
Most also have a slightly elevated prothrombin time (PT) and activated partial thromboplastin time (aPTT) and decreased
fibrinogen levels.
Circulating fibrin degradation products commonly rise to levels seen in subclinical disseminated intravascular coagulation (DIC).

Liver transaminase and serum bilirubin values usually rise to twice the reference range.

Mild hyponatremia and hypokalemia are common.

A serum alanine amino transferase (ALT)tolactate dehydrogenase (LDH) ratio of more than 9:1 appears to be helpful in
distinguishing typhoid from viral hepatitis. A ratio of greater than 9:1 supports a diagnosis of acute viral hepatitis, while ratio of less than 9:1
supports typhoid hepatitis.[38]

Imaging Studies

Radiography: Radiography of the kidneys, ureters, and bladder (KUB) is useful if bowel perforation (symptomatic or asymptomatic) is
suspected.

CT scanning and MRI: These studies may be warranted to investigate for abscesses in the liver or bones, among other sites.

Procedures

Bone marrow aspiration: The most sensitive method of isolating S typhi is BMA culture (see Lab Studies).

Histologic Findings
The hallmark histologic finding in typhoid fever is infiltration of tissues by macrophages (typhoid cells) that contain bacteria, erythrocytes, and
degenerated lymphocytes. Aggregates of these macrophages are called typhoid nodules, which are found most commonly in the intestine, mesenteric
lymph nodes, spleen, liver, and bone marrow but may be found in the kidneys, testes, and parotid glands. In the intestines, 4 classic pathologic stages
occur in the course of infection: (1) hyperplastic changes, (2) necrosis of the intestinal mucosa, (3) sloughing of the mucosa, and (4) the development
of ulcers. The ulcers may perforate into the peritoneal cavity.
In the mesenteric lymph nodes, the sinusoids are enlarged and distended by large collections of macrophages and reticuloendothelial cells. The spleen
is enlarged, red, soft, and congested; its serosal surface may have a fibrinous exudate. Microscopically, the red pulp is congested and contains typhoid
nodules. The gallbladder is hyperemic and may show evidence of cholecystitis. Liver biopsy specimens from patients with typhoid fever often show
cloudy swelling, balloon degeneration with vacuolation of hepatocytes, moderate fatty change, and focal typhoid nodules. Intact typhoid bacilli can be
observed at these sites.[2, 6]

Staging
The proper treatment approach to typhoid fever depends on whether the illness is complicated or uncomplicated. Complicated typhoid fever is
characterized by melena (3% of all hospitalized patients with typhoid fever), serious abdominal discomfort, intestinal perforation, marked
neuropsychiatric symptoms, or other severe manifestations. Depending on the adequacy of diagnosis and treatment, complicated disease may develop
in up to 10% of treated patients. Delirium, obtundation, stupor, coma, or shock demands a particularly aggressive approach (see Treatment). [29]
Proceed to Treatment & Management