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DENGUE FEVER AND ALIKE

PGI Deepak Ghimire


SHH - Department of Medicine

Sources: WHO Dengue guidelines for diagnosis, treatment, prevention and control,2009
Dengue Fever
Most rapidly spreading mosquito-borne viral disease
In the last 50 years, incidence has increased 30-fold
Increasing geographic expansion
New countries
From urban to rural settings
DOH - 41% increase in cases of dengue fever
January 2016 to June 2016 compared with the same( period in 2015
Average: 220 dengue cases (2010-2015)
Peak : July - November (few month after rainy season)

https://www.interhealthworldwide.org
DOH records
DOH records
DENGUE
Definition:

DENGUE VIRUS

Aedes aegypti

Mosquito-borne tropical disease


caused by Dengue Virus
RNA-Virus of the family
Flaviviridae; genus Flavivirus
Dengue Virus: 3 structural proteins
Dengue Virus

3 7
How many serotypes of
Dengue virus are known ?
Previously recognized: 4 serotypes
Serotypes
DEN-1
DEN-2
DEN-3
DEN -4

The fifth variant DENV-5 has been isolated in October 2013.


DENV-5 follows the sylvatic cycle unlike the other 4 serotypes
Has potential for human infection (few incidence; Malaysia, Singapore)

Which serotypes of most dangerous ? Den-2


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4297835/
Vector of Dengue Fever
Principal vector: Aedes aegypti
Tropical & subtropical species
Relatively uncommon above 1000 metres
May spend their lifetime in or around the houses
Immature stages are found in water-filled habitats

several species: outbreak


Aedes albopictus
Aedes polynesiensis
AGE DISTRIBUTION
2000-2010 (DOH)
1-4 y0: (15-31%)
5-14 yo (28-50%)--- Highest proportion :
15-49yo: (21-37%)

Visayas (2015,DOH) : wider distribution in >21 y.o


DENGUE VIRUS PATHWAY
PROBABLE DENGUE

Lives in or travel to dengue-endemic area, with fever lasting 2-7 days,


PLUS any TWO (2) of the following:

Headache Anorexia
Body Malaise Nausea
Myalgia Vomiting
Arthralgia Diarrhea
Retro-orbital pain Flushed skin
Rash (Petechial,
Hermanns sign)

And LABORATORY TESTS LABORATORY CONFIRMED DENGUE


CBC (leukopenia with or without Viral culture Isolation
thrombocytopenia) and/or
Dengue NS1 Antigen test or
PCR
Dengue IgM antibody test (optional) Dengue serology
TOURNIQUET TEST

(+) TT increases the


probability of dengue

(+) hemorrhagic
manifestations
HOW TO DO A TORNIQUET TEST
Take the patients blood pressure and record it
For example, 100/70mmHG
Inflate the cuff to a point MIDWAY between SBP and DBP,
and maintain for 5 minutes, (100+70)/2= 85mmHg
Reduce and wait 2minutes
Count petechial below antecubital fossa
POSITIVE TEST : 10 or more petechiae /square inch
CLINICAL DIAGNOSIS OF DENGUE
THINGS TO CONSIDER:
Exposure Hx.
S/sx. consistent with Dengue
R/O other diseases exposure
R/O other Acute febrile illnesses

Clinical laboratory findings consistent with dengue


DENGUE SIGNS AND CLINICAL
SYMPTOMS
Incubation Period: 4-10 days (usually 4-7 days)
Sudden onset of high fever

Three Phases Febrile Phase


1. Febrile phase Critical Phase
2. Critical Phase
3. Recovery phase Recovery Phase
PHASES OF DENGUE FEVER
FEBRILE PHASE
Usually lasts 2-7 days CLINICAL SIGNS AND LABORATORY TESTS
Monitoring warning
SYMPTOMS
signs: recognize Headache CBC
progression to Critical Body Malaise
Myalgia
Leukopenia
Phase Arthralgia with or without
Mild hemorrhagic Retro-orbital pain thrombocytopenia)
manifestations: Anorexia and/or
Petechiae and mucosal Nausea Tourniquet test
Vomiting
bleeding may be seen Diarrhea Dengue NS1 Antigen
Earliest Abnormality in Flushed skin test or
CBC: total WBC Rash (Petechial, Hermanns
sign) Dengue IgM antibody
test (optional)

COMPLICATIONS : DEHYDRATION
Mimics of Dengue fever

, Zika virus
Disease transmitted by Aedes aegypti

Thrombocytopenia Small joints pain


stooped posture
Laboratory test for Dengue Fever
Laboratory test for Dengue Fever
Primary and secondary Dengue infection
Other Laboratory test for Dengue Fever

Liver enzymes
Creatinine
Cardiac enzymes *
Diagnosis of Chikungunya

Illness <5 days : RT-PCR


Illness 5-7 days : RT-PCR + serology (IgM ELISA)
Illness >7 days : serology (4 x rise is titer)
PHASES OF DENGUE FEVER
CRITICAL PHASE
DEFERVESCENCE: DAY 3-7 of WARNING SIGNS
illness; when Temp. drops to Abdominal pain or tenderness
37.5-38C or less, and
remains below this level Persistent Vomiting
Mucosal Bleeding
Pt. can either IMPROVE or Clinical signs of Fluid accumulation
DETERIORATE
IMPROVE: Dengue without Lethargy, restlessness
Warning signs Liver enlargement
DETERIORATE: Laboratory:
Dengue With Warning signs
Severe Dengue INCREASE in Hct (20%)
and/or
DECREASE Platelet count <100,000/ul

COMPLICATIONS: SHOCK, BLEEDING / ORGAN IMPAIRMENT


Mimics of Dengue fever
PHASES OF DENGUE FEVER
RECOVERY PHASE
In the next 48-72hrs: Gradual Appearance of Classical rash:
re-absorption of extravasated isles of white in the sea of red
fluid from intravascular to Hct stablize/ lower due to dilution
effect of reabsorbed fluids
extravascular space thru
WBC- rises soon after
Lymphatics. defervescence (1st), then Platelet
Improvement of well-being Count normalizes
Stable hemodynamic status
Diuresis

COMPLICATIONS : HYPERVOLEMIA
RECOVERY PHASE

isles of white in the sea of red


DENGUE CLASSIFICATION
WHO 1997
classification Revised WHO classification (2009)
1. Undifferentiated
Fever 1.Dengue WITHOUT
2.
3.
Dengue Fever (DF)
Dengue
warning signs
Hemorrhagic Fever
(DHF)- Grade 2.Dengue WITH
I,II,III,IV(DSS)
warnings signs
3.SEVERE Dengue
DENGUE
DENGUE WITH
WITHOUT
WARNING WARNING SIGNS SEVERE DENGUE
SIGNS

Lives in or travel to dengue-endemic area, with fever lasting 2-7 days,


PLUS any TWO (2) of the
following: PLUS any ONE (1) of the Dengue with or without warning signs,
following: PLUS any of the following:
Headache
Body Malaise Abdominal pain or
Myalgia tenderness Severe Plasma Leakage, leading to:
Arthralgia Persistent vomiting -shock
Retro-orbital pain
Clinical signs of fluid -fluid accumulation with respiratory distress
Anorexia
Nausea accumulation Severe Bleeding
Vomiting Mucosal bleeding Severe Organ Impairment
Diarrhea Lethargy, restlessness - Liver: AST or ALT 1000
Flushed skin Liver enlargement -CNS: seizure, impaired consciousness
Rash (Petechial, Laboratory: INCREASE in Hct -Heart: Myocarditis
Hermanns sign)
and/or DECREASE Platelet -Kidneys: renal failure
And LABORATORY TESTS count <100,000/ul
CBC (leukopenia with or
without thrombocytopenia) CONFIRMED DENGUE
and/or
Dengue NS1 Antigen test or Viral culture Isolation
Dengue IgM antibody test PCR, dengue serology
(optional)
DENGUE
WITH/WITHOUT
WARNING SIGNS

Lives in or travel to dengue-endemic area, with fever lasting 2-7 days,


PLUS any ONE (1) of the following:

Abdominal pain or tenderness


Persistent vomiting
Clinical signs of fluid accumulation
Mucosal bleeding
Lethargy, restlessness
Liver enlargement
Laboratory: INCREASE in Hct and/or DECREASE
Platelet count <100,000/ul
SEVERE DENGUE

Lives in or travel to dengue-endemic area, with fever lasting 2-7 days,


and any of the above clinical manifestations for dengue with or without warning signs, PLUS
any of the following:

Severe Plasma Leakage, leading to:


-shock
-fluid accumulation with respiratory distress
Severe Bleeding
Severe Organ Impairment
- Liver: AST or ALT 1000
-CNS: seizure, impaired consciousness
-Heart: Myocarditis
-Kidneys: renal failure
TREATMENT
Treatment of uncomplicated dengue fever is
supportive
Bed rest is advised during the febrile period.
Antipyretics should be used to keep body
temperature < 40 C (104 F)
Analgesics or mild sedation may be required to
control pain
Aspirin is contraindicated
Fluid and electrolyte replacement - required for
deficits caused by sweating, fasting, thirsting,
vomiting, and diarrhea
DENGUE CASE MANAGEMENT: GROUP A ( OPD/home care)

GROUP CRITERIA : Px. With out warning signs AND who are able:
To tolerate adequate volumes of oral fluids
To pass urine at least once every 6 hours
LABORATORY TESTS
Complete blood count (CBC)
Haematocrit (HCT) px. With stable HCT can be sent home
TREATMENT
Adequate bed rest
Adequate fluid intake
Paracetamol, 4 gram maximum per day in adults and accordingly in children.

MONITORING : Daily review for disease progression:


Decreasing white blood cell count
Defervescence
warning signs (until out of critical period)
INSTRUCTIONS:
Advice for immediate return to hospital if development of any warning signs, and
written advice for management (e.g. home care card for dengue).
DENGUE CASE MANAGEMENT: GROUP B (In-hospital care)
GROUP CRITERIA : Px. With WARNING SIGNS OR
co-existing conditions :pregnancy,infancy, old age,diabetes mellitus,renal failure
social circumstances : living alone, living far
TREATMENT: Obtain reference HCT before fluid therapy
Give isotonic solutions such as 0.9 % saline, ringers lactate.
Start with 57 ml/kg/hr for 12 hours then
Reduce to 35 ml/kg/hr for 24 hr, and then
Reduce to 23 ml/kg/hr or less according to clinical response
REASSESS CLINICAL STATUS AND REPEAT HCT:
if HCT remains STABLE continue with 23 ml/kg/ hr for another 24 hours;
if vital signs Worsens & HCT rises rapidly increase rate to 510 ml/kg/hr for 12 hours
REASSEMENT IVF RATE: reduce intravenous fluids gradually when the rate of plasma leakage
decreases towards the end of the critical phase
Adequate urine output and/or fluid intake
HCT deceases below the baseline value in a stable patient.
MONITOR:
vital signs and peripheral perfusion (14 hourly until patient is out of critical phase
urine output (46 hourly)
HCT (before and after fluid replacement, then 612 hourly)
blood glucose
other organ functions (renal profile, liver profile, coagulation profile, as indicated).
DENGUE CASE MANAGEMENT: GROUP C (Needs Emergency care)
GROUP CRITERIA : Px. With WARNING SIGNS & any of the following features:
severe plasma leakage with shock and/or fluid accumulation with respiratory distress
severe bleeding
severe organ impairment

Severe dengue

Compensated Hypotensive Severe


shock shock bleeding

signs of Compensation Signs of shock Drop in Hct (20% or >)


Signs of poor perfusion Narrowed pulse pressure Or frank hemorrhage
Normal B.P Hypotension GI bleed
Met. Acidosis Epistaxis
DENGUE CASE MANAGEMENT: GROUP C (Needs Emergency care)

COMPENSATED SHOCK
COMPENSATED SHOCK : Fluid challenge for 24-48 hours
Start isotonic crystalloids at 510 ml/kg/hr over 1 hour.
Reassess condition.

IF PATIENT IMPROVES:
IV fluids should be reduced gradually
57 ml/kg/hr for 12 hours
35 ml/kg/hr for 24 hours
2-3 ml/kg/hr for 24 hours
Reduced further depending on haemodynamic status;

IF PATIENT IS STILL UNSTABLE: check HCT after first bolus;


If HCT increases/still high (>50%), repeat a 2nd bolus of crystalloids (10-20 ml/kg/hr for 1 hr)
If (+) improvement after 2nd bolus reduce rate to 710 ml/kg/hr for 1-2 hrs
continue to reduce as above;

IF HCT DECREASES, this indicates bleeding


need to cross-match and transfuse blood as soon as possible.
DENGUE CASE MANAGEMENT: GROUP C (Needs Emergency care)
HYPOTENSIVE SHOCK:
TREATMENT OF HYPOTENSIVE SHOCK :
Initiate IV fluid resuscitation with crystalloids or colloids at 20 ml/kg as a bolus for 15 min
IF PATIENT IMPROVES:
give a crystalloid/colloid solution of 10 ml/kg/hr for 1 hour, then reduce gradually as above.
IF PATIENT IS STILL UNSTABLE: Review the HCT taken before the fi rst bolus
IF HCT WAS LOW (<40% in children and adult females, <45% in adult males)
Indicates bleeding cross-match and transfuse
IF HCT WAS HIGH COMPARED TO BASELINE VALUE
Change to IV colloids at 1020 ml/kg as a second bolus over 30 minutes to 1 hour
Reassess after second bolus.
IF PATIENT IS IMPROVING reduce the rate to 710ml/kg/hr for 12 hours, then back to
IV cystalloids and reduce rates as above;
IF PATIENTS CONDITION IS STILL UNSTABLErepeat HCT after second bolus.
If HCT decreases, this indicates bleeding

IF HCT INCREASES/REMAINS HIGH (>50%)


continue colloid infusion at 1020 ml/kg as a third bolus over 1 hour, then reduce to 710
ml/kg/h 12 hours, then change back to crystalloid solution and reduce rate as above.
DENGUE CASE MANAGEENT: GROUP C (Needs Emergency care)

SEVERE BLEEDING:

TREATMENT OF HAEMORRHAGIC COMPLICATIONS:

Give 510 ml/kg of fresh packed red cells

OR
1020 ml/kg of fresh whole blood.

Haematocrit of <30% as a trigger for blood transfusion, as recommended in the Surviving


Sepsis Campaign Guideline (15), is not applicable to severe dengue.
ALGORITHM FOR FLUID MANAGEMENT IN HYPOTENSIVE SHOCK
INFANTS. CHILDREN AND ADULTS
TREATEMENT OF HEMORRHAGIC
COMPLICATIONS
Mucosal bleed
If stable with fluid resuscitation; consider it minor
Profound thrombocytopenia
Strict bedrest and protection from trauma
Do NOT give IM injections
avoid hematoma
Watch out for BLACK STOOL:
GI Bleed or Internal bleed
Complications in Dengue
Dehydration
Bleeding
hyperglycaemia or hypoglycaemia
Bradyarrythmia
Electrolyte and acid-base imbalances
co-infections (URTI, Iv site, FBC ?)
Hypervolemia most frequent cause of death
DEATH IN DENGUE: HYPERVOLEMIA
Early clinical features of fluid overload:
Respiratory distress, difficulty in breathing;
Rapid breathing;
Chest wall in-drawing;
Wheezing (rather than crepitations);
Large pleural effusions;
Tense ascites;
Increased jugular venous pressure (JVP).
Late clinical features:
pulmonary edema
irreversible shock (heart failure)
Disease notification
In dengue-endemic countries, cases of suspected,
probable and confirmed dengue should be notified
as soon as possible so that appropriate public health
measures can be initiated.
Laboratory confirmation is not necessary before
notification but should be obtained.

In non-endemic countries, usually only confirmed


cases will be notified.
DISCHARGE CRITERIA
Prevention
Sanitation
Vector control
Dengue Vaccine
GOOD MORNING !