Dengue Diagnosis

Ratna Setia Asih

 Dengue Guidelines

1997 2009 2011 2014

WHO WHO WHO-SEARO IDAI
2
Manifestation of Dengue Virus Infection
Dengue case classification (2009)
Manifestation of dengue virus infection

5
WHO Classification of Dengue Infection and Grading of Severity
WHO-SEARO 2011
DF/D Grade Signs & Symptoms Laboratory
HF
DF Fever with 2 following signs Leucopenia (WBC ≤5000 cells/mm3)
• Headache Thrombocytopenia (≤150.000
• Retro-orbital pain cells/mm3)
• Myalgia Rising hematocrit (5%-10%)
• Arthralgia/bone pain No evidence of plasma loss
• Rash
• Hemorrhage manifestations
• No evidence of plasma leakage
DHF I Fever & hemorrhagic manifestation Thrombocytopenia <100.000 cells/mm3
(positive tourniquete test) and Hematocrit rising ≥20%
evidence of plasma leakage
DHF II As grade I plus spontaneous Thrombocytopenia <100.000 cells/mm3
bleeding Hematocrit rising ≥20%
DHF* III As grade I or II plus circulatory Thrombocytopenia <100.000 cells/mm3
failure (weak pulse, narrow pulse Hematocrit rising ≥20%
pressure (≤20 mmHg) hypotensive,
restless
DHF* IV As grade III plus profound shock Thrombocytopenia <100.000 cells/mm3
with undetectable BP & pulse Hematocrit rising ≥20%
Dengue mimics many clinical syndrome
Clinical course of dengue
Febrile phase:
Symptoms

Headache
Bleeding gums and nose
•Sudden-onset fever
Skin erythaema

•Dehydration
Vomiting

Diarrhoea • progressive leucopenia

Muscle pain • Progressive

thrombocytopenia
Joint pain
Condition that mimics the febrile phase of dengue
Critical phase
Some patients

Acute febrile phase Critical phase Recovery phase

Warning signs1
Abdominal pain or tenderness – persistent vomiting –
Clinical Clinical fluid accumulation – mucosal bleed – Lethargy;
restlessness – liver enlargement > 2 cm

Increase i n haematocrit concurrent with rapid dcrease

Laboratory in platelet count, folllowed by blood pressure and pulse
changes
 Warning signs 2009 & 2011
Dengue Guideline
Abdominal pain
Persistent vomiting,
Clinical fluid accumulaton
Bleeding
Lethargy and/or restlessness
Liver enlargement > 2 cm
Increase in Hct concurrent with
rapid decrease in platelet count
No clinical improvement or
worsening of the situation
Giddiness
Pale,cold, a clammy hands and feet
Less/no urine output for 4–6 hours
2009 2011
+ severe + or tenderness
+ + , lack of water intake
+ -
Mucosal Epistaxis, black stool, haematemesis, excessive
bleed menstrual bleeding, dark-coloured
urine (haemoglobinuria) or haematuria.
+ + , sudden behavioural changes
+ -
+ -
- +
- +
- +
- +
 Critical phase:
Evolution of the disease
Days of illness

Temperature

Potential clinical issues

Laboratory changes

Serology and virology

Course of dengue illness

Critical phase:
Symptoms
• Defervescene

• Increase in haematocrit

• Plasma leakage

•Hypotention

•Progressive leucopenia
• Progressive
thrombocytopenia

Severe dengue
Severe plasma leakage
Severe bleeding
Severe organ impairment
Condition that mimics the critical phase of dengue
Recovery Phase
• Most patients progress to recovery within 7 days (after fever
onset) without developing any signs of severity1,2
– Improvement of general well-being
– Return of appetite
– Abatement of gastrointestinal symptoms
– Stabilization of haemodynamic status
• Body temperature is normal after 2 days
• During recovery, a second rash may occur, resolving over 1-2
weeks3
• Adults may experience extreme fatigue for several weeks
following recovery
Clinical presentation of dengue disease:
Overview
Influenza-like
Platelets
UNCOMPLICATED DENGUE FEVER
illness

Gastro-intestinal Fatigue
symptoms Exhaustion syndrome
Asthenia, Deshydratation
Hyponatremia Rash, purpura
Encephalopathy Postural hypotention Pruritus,
Leucopenia bradycardia
Rhabdomyolysis
Hepatitis
Cholecystitis DHF/DSS
Encephalitis Hemococentration Myocarditis
SEVERE Pleural efusion, ascites Ocular, neurological
DENGUE Hemorrhage, Shock manifestations
 Laboratory Diagnostic Options in a Patient with
Suspected
Laboratory Diagnostic Options Dengue
in a Patient Infection
with Suspected Dengue
. Infection.

Simmons CP et al. N Engl J Med 2012;366:1423-1432

Diagnosis
Dengue infection confirmation

Suspected case

< Day 5 Day 5 > Day 5

Diagnostic

Virus isolation NS1 detection

NS1 detection RT – PCR IgM
RT - PCR ± IgM

Serotype Serotype
Surveillance

identification identification

Sequencing and Epidemiology

Primary DENV Infection Secondary DENV Infection

• Primary infection
IgM detected earlier than IgG or in the beginning of infection no IgG was
detected
• Secondary infection
IgG detected at the beginning of infection; IgM titer sec infection <IgM
primary infection
 Interpretation of dengue diagnostic test

• Handbook mangement of dengue, TRD-WHO,2012

 Prevention and Treatment
• Mosquito surveillance and control – the only preventive measure
– Mixed results
– Expensive and unsustainable
• However, there is no spesific treatment available
– Symptomatic treatment only
• Oral/IV fluid replacement
• antipyretics
• Vaccination is the best way forward

WHO NTD group (WHA, Geneva – May 2012)

Targets and milestones for control of negleted tropical diseases, 2015-2020
• To reduce dengue deaths by 50% by 2020
• To reduce dengue morbidity by at least 25 % by 2020
Thank you