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Dengue Fever
Plasma leakage :
Hemoconcentration
Hipoproteinemia
Dehydration Pleural effusion
Ascites
Hypovolemia
DIC Shock
Death
WHO case definition of DHF
Classic dengue
positive tourniquet
test with or without
spontaneous bleeding
thrombocytopenia
hemoconcentration Grade I DHF
spontaneous
bleeding Grade II DHF
circulatory failure
pulse pressure < 20 mm Hg
hypotension, cold, clammy skin Grade III DHF
restlessness
DSS
profound shock,
undetectable blood Grade IV DHF
pressure and pulse
Clinical features of DHF
General
High fever, intermittent.
Severe headache (especially retro-orbital).
Flushing.
Myalgia and arthralgia.
Vomiting, anorexia.
Acute abdominal pain.
Bleeding manifestations
Epistaxis.
Bleeding from gums.
Petechiae and ecchymoses.
Hematemesis and melena
Hemoptysis, hematuria
Spotting or menorrhagia in females.
Features of plasma leakage
Circulatory disturbances (low BP, tachycardia, narrow PP)
Periserositis (pleural effusions, ascites sometimes pericarditis).
Complications
Encephalopathy and encephalitis.
Liver failure.
Myocarditis.
Disseminated intravascular coagulation leading to massive bleeding.
Unusual manifestations
- Dengue
Dengue encephalopathy
encephalopathy
- Acute
Acute liver
liver failure
failure
- Myocarditis,
Myocarditis, cardiomyopathy
cardiomyopathy
Symptoms DF (%) DHF (%)
Fever 100 100
Headache 100 96.7
Vomiting 0 47.8
Abdominal pain 0 39.1
Myalgia 27 39.1
Cough 0 39.1
Sore throat 0 21.7
Convulsion 0 17.4
Retro-orbital pain 0 13
Diarrhea 0 4.4
Differential diagnosis of dengue fever and DHF
Dengue fever
Infectious mononucleosis.
Chikungunya viral infections.
Coxsackie and other enteroviral infections.
Rickettsial infections.
Rubella.
Parvovirus B19 infections.
Leptospirosis.
Influenza.
DHF
Leptospirosis.
Chikungunya viral infections.
Kawasaki disease.
Yellow fever.
Hanta viral infections.
Other viral hemorrhagic fevers.
Meningococcal septicemia.
PHYSICAL EXAMINATION
Generalized lymphadenopathy (~ 50 % of cases)
Relative bradycardia
Morbiliform rash on the trunk, spreading to the face
and extremities (3rd 5th day)
Diffuse flushing, mottling, fleeting pinpoint erupsion
Hemorrhagic phenomena
Signs of plasma leakage (ascites, pleural effusion)
Liver enlargement and tenderness
Spleen enlargement
TEMPERATURE CURVE
defervescence phase
Critical convalescent
Fever phase
phase
PERIOD OF DENGUE INFECTION
temp incubation acute phase critical phase recovery
40
39
38
37
0 1 2 3 4 5 6 7 8 day
Warning Signs for Dengue
Shock
AlarmSignals:
Alarm Signals:
Severe
Severeabdominal
abdominalpain
pain
Prolonged
Prolongedvomiting
vomiting
Four
FourCriteria
Criteriafor
forDHF:
DHF: Abrupt
Abruptchange
changefrom
fromfever
fever
Fever
Fever
Hemorrhagic
Hemorrhagicmanifestations
manifestations
Excessive
Excessivecapillary
capillary
permeability
permeability
100,000/mm
100,000/mm3platelets
3
platelets
tohypothermia
to hypothermia
Initial
InitialWarning
WarningSignals:
Signals: Change
Change inlevel
level of
Disappearance When
When in
Patients of
Develop
Patients Develop
Disappearanceof offever
fever consciousness
consciousness (irritability
(irritability
Drop DSS:
DSS:
Dropininplatelets
platelets
Increase
Increaseininhematocrite
hematocrite 33to
to66days
daysafter
afteronset
onsetof of
or somnolence)
LABORATORY EXAMINATION
Early tests
viral isolation
PCR/ RT-PCR
antigen detection
Further tests
serology test - antibody test
LABORATORY EXAMINATIONS
Specific
Viral identification : viral isolation
Serology
detection of dengue antibody in serum
platelet count
hematocrite
Hematocrite
70
60 * *
50 *
40 * *
*
* *
30
20
10
0
1 2 3 4 5 6 7 8 day
WHEN THROMBOCYTE DECREASES ?
Thrombocyte count
200,000
* * *
*
150,000
*
100,000 *
*
50,000
* *
0
1 2 3 4 5 6 7 8 day
Thrombocytopenia
fever phase : decreasing
shock phase : reaches the lowest level
THROMBOCYTOPENIA
SEROLOGIC TESTS
Hemaglutination inhibition test (HI)
Complement fixation test (CF)
Neutralization test (NT)
ELISA and Ig M antibody-capture (MAC) ELISA
sensitivity 80 97 %
Rapid test (rapid dengue
immunochromatographic test for specific Ig M)
ANTIBODY LEVEL
IgG
IgM IgM
IgG
Virus Virus
(day)
5 10 15 2 5
First First
symptoms symptoms
Primary Secondary
infection infection
Keluhan DBD
(Kriteria WHO 1997)
Suspek DBD
Perdarahan Spontan dan Masif ( - )
Syok (-)
- Hb, Ht (n)
- Hb, Ht meningkat 10-20% - Hb, Ht meningkat > 20%
- Tromb < 100.000
- Tromb < 100.000 - Tromb < 100.000
- Infus Kristaloid *
- Infus Kristaloid *
- Hb, Ht, Tromb tiap 24 jam
- Hb, Ht, Tromb tiap 12 jam **
Protokol pemberian Cairan
DBD dengan Ht meningkat
> 20%
5 % defisit cairan
Evaluasi
3-4 jam
PERBAIKAN TIDAK MEMBAIK
Ht dan frekuensi nadi turun, Ht, nadi meningkat
tekanan darah membaik, tekanan darah menurun < 20 mmHg
produksi urin meningkat produksi urin menurun
PERBAIKAN TIDAK
PERBAIKAN MEMBAIK
Kurangi infus
kristaloid Infus kristaloid
3 ml/kg/jam 15 ml/kg/jam
PERBAIKAN
KONDISI MEMBURUK
Tanda syok
Terapi cairan
dihentikan
24-48 jam Tatalaksana sesuai
Protokol syok dan
PERBAIKAN perdarahan
PROTOKOL 4. PENATALAKSANAAN PERDARAHAN SPONTAN
PADA DBD DEWASA
KASUS DBD :
Perdarahan Spontan dan Masif : - Epistaksis tidak terkendali
- Hematemesis melena
- Perdarahan otak
Syok (-)
Kristaloid * Ht Ht
5 ml/kg/jam dalam 1 jam
Koloid*** 10-20 ml/kg/BB Transfusi darah
Perhitungan nutrisi tetes cepat 10-15 menit 10 ml/kg BB dapat diulang
setelah 12 jam
sesuai kebutuhan
(destroxe 5 % bila tidak ada
kontraindikasi) PERBAIKAN****
TETAP SYOK
24-48 jam setelah syok
teratasi, tanda vital/Ht stabil,
diuresis cukup Koloid *** hingga
maksimal 30 ml/kg BB
Pasang kateter
vena sentral *****
TETAP SYOK
- inotropik******
Kombinasi Perbaikan
- vasopresor
koloid kristaloid bertahap vasopresor
- vasodilator
Indication of ICU treatment
Score