DEMAM DENGUE

dan
DEMAM BERDARAH DENGUE

Dr. Khomimah, SpPD

Rumah Sakit Islam Pondok Kopi, Jakarta Timur.
FKK UMJ Jakarta
Chapter 2 Clinical management and delivery of clinical services

Pedoman diagnosis,
terapi, pencegahan
dan pengendalian
dengue – edisi BARU
2009
PENDAHULUAN
Virus Dengue
• Demam dengue dan Demam Berdarah Dengue adalah
penyakit infeksi yg disebabkan virus dengue.
• Arbovirus termasuk dalam genus flavivirus
• Ditularkan melalui gigitan nyamuk
• Virus Dengue merupakan virus RNA yang tersusun
rantai positif tunggal
• Terdapat 4 serotipe virus (DEN-1, 2, 3, 4)
Distribusi Dengue

1.8 Billion or >70% of the population at risk for dengue worldwide live in the Southeast Asia and Western Pacific Region

Dengue: Guideline for diagnosis, treatment, prevention and control – new edition. WHO 2009
Patogenesis Dengue
DIAGNOSIS dan PENATALAKSANAAN DENGUE
Kriteria Demam Berdarah Dengue WHO 1997 vs 2009

1997 2009

DF DBD tanpa tanda bahaya

DBD I
DBD dengan tanda bahaya

DBD II
DBD berat
DBD III

DBD IV
“Dengue is one disease entity with
different clinical presentations
and often with unpredictable clinical
evolution and outcome”
 Kalsifikasi dan Derajat Dengue

with warning 1.Severe plasma leakage

without signs 2.Severe haemorrhage
3.Severe organ impairment

Kriteria Dengue + Tanda Bahaya Kriteria Dengue Berat

Kemungkinan Dengue Tanda Bahaya Kriteria Dengue Berat

Tinggal/dari daerah endemik dengue. • Nyeri perut Kebocoran Plasma Berat
Demam dan 2 dari kriteria berikut :
• Muntah persisten • Shock (DSS)
• Mual, muntah
• Akumulasi cairan • Akumulasi cairan dg distres
• Ruam
pernafasan.
• Perdarahan mukosa
• Nyeri otot
Perdarahan Hebat
• Letargi, gelisah
• Tourniquet (+)
• Sesuai pemeriksaan
• Pembesaran hati > 2 cm
• Lekopeni
Perburukan Organ yg Terlibat
• Lab: peningkatan HT disertai
• Tanda bahaya
penurunan trombosis yang drastis • Liver : AST atau ALT > 1000
• CNS : penurunan kesadaran
• Jantung dan organ lain

Dengue: Guideline for diagnosis, treatment, prevention and control – new edition. WHO 2009
Perjalanan Penyakit Demam Dengue
Course of dengue infection and timings of diagnosis

Published with permission of Scott B Halstead, Lancet 2007; 370: 1644–52

Dengue infections (Majority = Asymptomatic)

DHF &
DSS
Dengue Fever <1%
Febrile illness of < 10 days.
No consequence 3rd-7th day
90 % = children
Bleeding
Asymptomatic diathesis
50-90 % leading to
shock
Leaves behind Immunity only
20-30 % of DHF
go into shock
 Gejala dan Tanda dari Demam Dengue

● Demam

● Nyeri kepala

● Nyeri otot dan sendi

● Mual/muntah
C : Capsid
M : Membrane
● Rash
E : Envelope
RNA : Ribo Nucleic Acid
● Manifestasi perdarahan
Manifestasi Klinis dari Demam Dengue
 Pemeriksaan laboratorium penunjang

Isolasi virus, deteksi antigen/PCR dan uji serologis

(diperlukan pemahaman perjalanan penyakit)

 Isolasi virus terbaik saat viremia (3-5 hari)

 IgM terdeteksi hari ke 5, meningkat sampai minggu
III, menghilang setelah 60-90 hari
 IgG pada infeksi primer mulai terdeteksi pada hari 14,
pada infeksi sekunder mulai hari 2.
 Uji HI, Dengue Blot ( single / Rapid / Duo )
DENGUE IgM and IgG RESPONSES
INTERPRESTASI HASIL IgM DAN IgG DENGUE

IgM IgG Interprestasi

+ - Infeksi primer

+ + Infeksi sekunder

Tersangka infeksi
- + sekunder

- - Tidak ada infeksi

 Problem Klinis pada Fase Dengue

Dehidrasi; demam tinggi mungkin karena

1 Fase Demam kelainan neurologi dan kejang demam pada
anak-2

Syok karena kebocoran plasma; Perdarahan

2 Fase Kritis
berat; gannguan organ

3 Fase Penyembuhan Hipervolumia (terapi cairan IV berlebihan)

Fase demam
 Demam tinggi mendadak 2-7 hari.
 Demam sering disertai wajah kemerahan, eritema kulit, nyeri seluruh
tubuh, mialgia, atralgia dan nyeri kepala. Beberapa pasien bisa nyeri
tenggorokan dan injeksi konjungtiva. Anoreksia dan mual muntah biasa
ditemukan.
 Tourniquet (+) pada fase ini meningkatkan kemungkinan bahwa ini
merupakan demam dengue.
 Manifestasi perdarahan ringan (petechiae dan perdarahan mukosa bisa
ditemukan.
 Perdarahan hebat vaginal dan gastrointestinal bisa terjadi pada fase ini
tapi jarang.
 Hati sering membesar beberapa hari setelah demam.
 Penurunan progresif dari sel darah putih merupakan kemungkinan besar
tanda demam dengue
 Diferensial Diagnosis Demam Dengue

Kondisi yang menyerupai infeksi dengue pada fase demam

Flu-like syndromes Influenza, measles, Chikungunya,

infectious mononucleosis , HIV
seroconversion illness

Illnesses with a rash Rubella, measles, scarlet fever,

meningococcal infection,
Chikungunya, drug reactions

Diarrhoeal diseases Rotavirus, other enteric infections

Illnesses with neurological Meningo/encephalitis febrile seizures

manifestations
 Problem Klinis pada Fase Dengue

Dehidrasi; demam tinggi mungkin karena

1 Fase Demam kelainan neurologi dan kejang demam pada
anak-2

Syok karena kebocoran plasma; Perdarahan

2 Fase Kritis
berat; gannguan organ

3 Fase Penyembuhan Hipervolumia (terapi cairan IV berlebihan)

Fase Kritis
 Suhu menurun sampai 37,5-38℃ atau lebih rendah lagi antara hari
ke-3 sampai hari ke-7 penyakit.
 Peningkatan hematokrit bisa terjadi. Ini merupakan tanda
dimulainya fase kritis
 Kebocoran plasma yang signifikan berlangsung selama 24-48 jam.
 Progresif leukopenia diikuti penurunan drastis platelet mengawali
kebocoran plasma.
 Efusi pleura dan ascites bisa muncul (indikasi rontgen dan USG
abdomen)
 Kebocoran plasma hebat menyebabkan hipoperfusi organ lain
sementara perdarahan semakin hebat diikuti hematokrit yang
semakin menurun.
 Gangguan organ bisa terjadi seperti hepatitis, ensefalitis atau
miokarditis
 Pasien yang membaik dalam fase ini disebut sebagai non-severe
dengue
 Pasien yang memburuk akan menunjukkan *tanda bahaya*. Pasien
ini bisa membaik dengan rehidrasi intravena atau tetap memburuk
yang kemudian disebut severe dengue.
 Diferensial Diagnosis Demam Dengue

Kondisi yang menyerupai infeksi dengue pada fase kritis

Infeksi Acute gastroenteritis, malaria, leptospirosis,
typhoid, viral hepatitis, acute HIV seroconversion
illness, bacterial sepsis, septic shock

Keganasan Acute leukemia and other malignancies

Other clinical pictures Acute abdomen

– acute appendicitis, cholecystitis, perforated viscus
Diabetic ketoacidosis
Lactic acidosis
Leukopenia and thrombocytopaenia ± bleeding
Platelet disorders
Renal failure Respiratory distress (Kussmaul’s
breathing)
Systemic Lupus Erythematosus
 Problem Klinis pada Fase Dengue

Dehidrasi; demam tinggi mungkin karena

1 Fase Demam kelainan neurologi dan kejang demam pada
anak-2

Syok karena kebocoran plasma; Perdarahan

2 Fase Kritis
berat; gannguan organ

3 Fase Penyembuhan Hipervolumia (terapi cairan IV berlebihan)

Fase penyembuhan
 Jika pasien bertahan selama 24-48 jam fase kritis, maka reabsorbsi
cairan ekstravaskular akan terjadi selama 48-72 jam berikutnya.
 Keadaan umum membaik, hemodinamik stabil dan diuresis.
Beberapa mengalami ruam, gatal, bradikardi dan perubahan EKG
biasa ditemukan.
 Hematokrit stabil atau menurun akibat reabsorbsi cairan. Leukosit
mulai meningkat diikutip peningkatan platelet beberapa lama
kemudian.
 Distres pernapasan dan ascites bisa terjadi akibat terapi cairan yang
berlebihan, dihubungkan dengan edema pulmonal dan gagal
jantung kontestif.
Ruam Penyembuhan

isles of white in the sea of red

atau
isles of red in the sea of white
Kriteria Perawatan Pasien Dengue
Penatalaksanaan
 GRUP A
– Pasien boleh pulang.
– Mampu mengkonsumsi cairan oral dan BAK minimal setiap 6
jam.
– Tidak ditemukan tanda bahaya
 GRUP B
– Pasien yang harus dirawat inap.
– Ditemukan tanda bahaya atau kondisi pasien yang beresiko
– Kondisi yang beresiko: kehamilan, bayi, usia tua, obesitas, DM,
gagal ginjal, penyakit hemolitik kronis dan pasien yang tinngal
sendiri atau tempat tinggal jauh dari fasilitas kesehatan
 GRUP C
– Pasien yang membutuhkan tindakan gawat darurat
– Ditemukan hal-hal berikut: Kebocoran plasma hebat, perdarahan
hebat, gangguan berat organ
 A Stepwise Approach to the Management of
Dengue
Langkah I. Overall assessment
I.1 History, including information on symptoms, riwayat penyakit dahulu dan
keluarga
I.2 Pemeriksaan fisik, including full physical and mental assessment
I.3 Investigation, including routine laboratory and dengue-specific laboratory

Langkah II. Diagnosis, assessment of disease phase and severity

Langkah III. Manajemen

III.1 Disease notification
III.2 Management decisions. Depending on the clinical manifestations and
other circumstances, patients may:
– be sent home (Group A);
– be referred for in-hospital management (Group B);
– require emergency treatment and urgent referral (Group C).
 A Stepwise Approach to the Management of Dengue

Langkah I - Asesmen
Riwayat penyakit
Riwayat penyakit termasuk :
– tanggal mulai demam/sakit;
– quantity of oral intake;
– asesmen tanda bahaya;
– diare;
– perubahan status mental/kejang/letargi;
– urin output (frequency, volume and time of last voiding);
– other important relevant histories, such as family or neighbourhood
dengue, travel to dengue endemic areas, co-existing conditions,
jungle trekking and swimming in waterfall, recent unprotected sex or
drug abuse (consider acute HIV seroconversion illness).
Step I - Overall assessment
Physical Examination
– assessment of mental state;
– assessment of hydration status;
– assessment of haemodynamic status
– checking for tachypnoea/acidotic breathing/pleural effusion;
– checking for abdominal tenderness/hepatomegaly/ascites;
– examination for rash and bleeding manifestations;
– tourniquet test (repeat if previously negative or if there is no bleeding
manifestation).
Investigation
A full blood count should be done at the first visit. A hct test in the early febrile
phase establishes the patient’s own baseline hct. A decreasing white blood cell
count makes dengue very likely. A rapid decrease in platelet count in parallel
with a rising hct is
suggestive of progress to the plasma leakage/critical phase. In the absence of
the patient’s baseline, age-specific population hct levels could be used as a
surrogate during the critical phase
Step II - Diagnosis, assessment of disease
phase and severity
Step III - Management
Disease notification
In dengue-endemic countries, cases of suspected, probable and
confirmed dengue should be notified for appropriate public health
measures. Suggested criteria for early notification of suspected cases are
that the patient lives in or has travelled to a dengue-endemic area, has
fever for three days or more, has low or decreasing white cell counts,
and/or has thrombocytopaenia ± positive tourniquet test. In dengue-
endemic countries, the later the notification, the more difficult it is to
prevent dengue transmission.
Management decisions
Patient may be sent home (Group A), be referred for in-hospital
management (Group B), or
require emergency treatment and urgent referral (Group C).
Calculations for normal maintenance of intravenous
fluid infusion
Algorithm for fluid management in compensated shock
Algorithm for fluid management in hypotensive shock
Algorithm for fluid management in hypotensive shock
Calculations for normal maintenance
of intravenous fluid infusion
Choice of intravenous fluids for resuscitation
Haemodynamic assessment: continuum of haemodynamic
changes
Perlu diingat bahwa trombositopenia pada penderita DBD tidak
diobati.
Saat ini, pemberian transfusi trombosit dilakukan secara luas,
padahal belum ada bukti sah mengenai efektivitasnya.
 Indikasi Transfusi Darah

● Whole blood, komponen darah (PRC, FFP, suspensi

trombosit)
● Indikasi pemberian trombosit
- klinis terdapat perdarahan masif
- jumlah trombosit rendah bukan indikasi
- suspensi trombosit tidak pernah diberikan sebagai
profilaksis
 Treatment of complications and other areas of treatment

Fluid overload
Large pleural effusions and ascites is a common cause of acute
respiratory distress and failure in severe dengue
Causes of fluid overload are:
– excessive and/or too rapid intravenous fluids;
– incorrect use of hypotonic rather than isotonic crystalloid solutions;
– inappropriate use of large volumes of intravenous fluids in patients with
unrecognized severe bleeding;
– inappropriate transfusion of fresh-frozen plasma, platelet concentrates
and cryoprecipitates;
– continuation of intravenous fluids after plasma leakage has resolved (24–
48 hours from defervescence);
– co-morbid conditions such as congenital or ischaemic heart disease,
chronic lung and renal diseases.
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 oedema (cough with pink or frothy sputum ±
crepitations, cyanosis);
– irreversible shock (heart failure, often in combination with ongoing
hypovolaemia).
Additional Investigations
– Chest x-ray shows cardiomegaly, pleural effusion, upward
displacement of the diaphragm by the ascites and varying degrees of
“bat’s wings” appearance ± Kerley B lines suggestive of fluid overload
and pulmonary oedema;
– ECG to exclude ischaemic changes and arrhythmia;
– ABG;
– Echocardiogram for assessment of left ventricular function,
– Cardiac enzymes.
The management of fluid overload varies according to the phase of the diseaseand
the patient’s haemodynamic status.

• Stable haemodynamic status and is out of the critical phase (more than 24–48
hours of defervescence), stop IVF but continue close monitoring. If necessary,
give oral or IV furosemide 0.1–0.5 mg/kg/dose once or twice daily, or a
continuous infusion of furosemide 0.1 mg/kg/hour.
- Monitor serum potassium and correct the ensuing hypokalaemia.
• Stable haemodynamic status but is still within the critical phase, reduce the
intravenous fluid accordingly.
- Avoid diuretics during the plasma leakage phase because they may lead to
intravascular volume depletion.
• In shock with low or normal haematocrit levels but show signs of fluid overload,
consider occult haemorrhage.
- Fresh whole blood transfusion should be initiated as soon as possible.
- If the patient remains in shock and the haematocrit is elevated, repeated
small boluses of a colloid solution may help.
Treatment of Fluid Overload
 Oxygen therapy should be given immediately.
 Stop IVF therapy during the recovery phase will allow fluid in the
pleural and peritoneal cavities to return to the intravascular
compartment.
 IVF should be discontinued or reduced to the minimum rate when the
following signs are present:
– signs of cessation of plasma leakage;
– stable blood pressure, pulse and peripheral perfusion;
– HCT decreases in the presence of a good pulse volume;
– afebrile for more than 24–48 days (without the use of antipyretics);
– resolving bowel/abdominal symptoms;
– improving urine output.

Recognizing when to decrease or stop IVF is key to preventing fluid

overload.
Other complications of dengue
• Hyperglycaemia and hypoglycaemia, even in the absence of diabetes
mellitus and/or hypoglycaemic agents.
• Electrolyte and acid-base imbalances are probably related to
gastrointestinal losses. Hyponatraemia, hypokalaemia, hyperkalaemia,
serum calcium imbalances and metabolic acidosis (sodium bicarbonate
for metabolic acidosis is not recommended for pH 7.15) can occur.
• Co-infections and nosocomial infections.
 Kriteria pemulangan pasien DBD
(semua kriteria harus tepenuhi)

• Tidak demam selama 48 jam

Klinis • Perbaikan kondisi klinis (status klinis membaik,

nafsu makan membaik, status hemodinamik
stabil, tidak dijumpai distres pernafasan)

• Hematokrit stabil tanpa intervensi cairan iv

Laboratorium
• Peningkatan jumlah trombosit
 Pandangan Keliru tentang DHF

✘ DHF merupakan penyakit anak-2

✔ Segala usia dapat terserang Dengue
✘ DHF merupakan problem pada keluarga kurang mampu
✔ Semua kelompok sosioekonomi dapat terkena DBD
✘ Dengue + Perdarahan = DBD
✔ Sesuai kriteria WHO, permeabilitas kapiler (kebocoran plasma)
✘ Kematian pada DBD disebabkan oleh Perdarahan
✔ Pasien meninggal akibat syok yang tidak teratasi
✘ Infeksi dengue yang tdk obati dg baik akan menjadi DBD
✔ Infeksi dengue bila tidak diobati dengan baik akan menjadi berat,
tapi DBD merupakan spektrum klinis yang berbeda, tetap terjadi
walaupun diobati dengan baik
✘ Tes tourniquet positif = DBD
✔ Tes Tourniquet tidak spesifik sbg indikator fragilitas kapiler
 Kesimpulan
● Seorang dokter harus memahami patogenesis Demam
Berdarah Dengue untuk bisa menatalaksana kasus DBD
dengan baik dan optimal

● Ketrampilan untuk menegakkan diagnosis secara dini

dan pengambilan keputusan yang tepat akan
menentukan keberhasilan pengobatan DBD serta
program penanggulangannya
TERIMA KASIH