DENGUE HEMORRHAGIC

FEVER

Prof. CHHOUR Y MENG

MD, MPH
Director National Pediatric Hospital
 The key components are
represented by 4 W’s:

• WHAT ?
• WHO ?
• WHEN ?
• WHERE ?
 1) WHAT IS DENGUE ?

• Dengue is a vector borne disease

• Serious public health problem in
Cambodia
• Constitutes as one of the ten leading
causes of hospitalization and death of
childhood.
 2) WHO AFFECTED BY
THE DENGUE ?

All people ( Male / Female ), especially:

• Children < 15 years old,

• The most affected, children 4–6 y
• High mortality, children from 1 – 4 y.
3)WHERE DOES THE DENGUE OCCUR ?

• Rural: along the river, bamboo,

coconut shells, earthen jars…
• Urban: slum areas,
overcrowded places,
containers, water jars, ant-
traps, unused-containers…
 Indoor Outdoor
Larvae Water containers Water containers

Water jars Water jars

Pots of flowers Unused containers
Ant-traps Tires, cans, coconut
shells
Plastic bags, broken
earthen jars
Bamboos
Adult Clothes Holes in tree
mosquito
Curtains
4) WHEN DOES THE DENGUE HAPPEN?

• Rainy seasons(May–October, November)

- Poor sanitation + lifestyle
- A lot of breeding sites
- Increase the mosquito density.
• But the transmission is happen all long
year
• Epidemic occurs every 2 to 3 years.
 T H E 3 P R E D O M IN A N T D IS E A S E S i n N P H 2 0 0
250

200

150

100

50

0
J an F eb M ar A pr M ay J un J ul A ug S ep O c t N o v D ec
D iarrhea A R I D HF
HOW DOES THE DENGUE TRANSMIT?
 Etiology
• 4 sertypes of dengue viruses:
– Serotypes 1, 2, 3, 4
– Members of the family Flaviviridae

The infection in human by anyone of theses

serotypes can produce life-long immunity against
reinfection of the same serotype, but only temporary
and partial protection against the others.
CLINICAL MANIFESTATIONS
INCUBATION PERIOD
5 – 8 DAYS
 CLINICAL
MANIFESTATIONS IN
TYPICAL CASE OF DHF

1. High, continuous fever

2. Hemorrhagic manifestation
3. Hepatomegaly
4. Circulatory disturbance / shock.
 LABORATORY CRITERIA

1. Haemoconcentration
( ≥ 20% increase in HCT level ).
2.Thrombocytopenia
( ≤ 100,000/mm3).
Clinical Manifestations Contd.
• Incubation: 1-7 days
• Acute Febrile Phase (2- 7 days):
– Typically, sudden on set of fever,
Temperature: 39.5 – 41ºc
– Facial flushing, skin erythema, headache and
muscle pain
– Convulsion may be present in infants
– Mild conjunctival injection
– Injected Pharynx, anorexia, vomiting and
abdominal pain are common
Acute Febrile Phase (cont.):
– Hemorrhagic manifestations:
• Skin petechia (invariable)
• Positive Tourniquet test ( more than 10 per 2.5cm²)
• Easy bruising
• Epistaxis, gum bleeding, gastrointestinal bleeding
are less common, but may be severe. Massive
gastrointestinal hemorrhage may be present in
association with prolonged shock. Hematuria is
extremely rare.
– Soft and tender Hepatomegaly is often found
– Generalized lymphadenopathy occurs in
some cases
Tourniquet test positive
• Critical Phase (24-48 hours) occurs at the
end of febrile phase.
– Rapid drop of temperature (subnormal temp.)
– Circulatory disturbances
– Sweating, restless, cold extremities.

In mild DHF cases, the changes of vital

signs are minimal and transient. Patients
will recover shortly after an appropriate
treatment.
In more DHF severe cases, the disease
develops rapidly a stage of shock.
DHF/DSS:
– Acute onset
– Acute abdominal pain
– Restless
– Subnormal temperature
– Cold and clammy skin
– Weak and rapid pulses
– Narrow blood pressure (≤20mmHg)
– Respiration rapid and labored.
SEVERITY OF DHF
 GRADE I

Fever accompanied by
non-specific symptoms with
a positive tourniquet test.
 GRADE II

Spontaneous bleeding-skin
and/or other haemorrhage
are in additional to those of
Grade I
 GRADE III

Circulatory failure
 GRADE IV

Profound shock with

undetectable BP and Pulse
 MANAGEMENT
Symptomatic and Supportive
 Type of solutions
• Crystalloid solutions:
- 5%D/NSS
- 5%DLR*
- 5%D/AR
• Colloid solution:
- Dextran 40
- FWB

• Lactate Ringer solutions are contra-indicated

in case of acidosis.
• NSS or Acetate Ringer should be instead of LR
in case of shock
WARNING SIGNS OF SHOCK

1. Sudden drop of temperature-

subnormal level.
2. Restless.
3. Acute abdominal pain.
4. Cold at extremities.
5. Oliguria.
Causes of death in DHF
• Prolonged shock
• Fluid overload
• Massive bleeding
• Unusual manifestations:
– Encephalopathy/ Encephalitis
– Hepatic failure
– Dual Infections
Drowsiness, shock. Platelet count only 1000/mm3
DHF/DSS + restlessness
DHF/DSS with profound shock + respiratory
failure
Shock, very severe dyspnea and massive ascites
DHF/DSS with respiratory failure + renal failure
DHF/DSS + very severe respiratory distress +
massive ascites
PREVENTION AND CONTROL