V Dengue feverȂlike illnesses were described in

Chinese medical writings dating back to 265 AD.

V In 1789, Benjamin Rush, MD, published an account
of a probable dengue fever epidemic that had
occurred in Philadelphia in 1780.
V Rush coined the term break-bone fever to describe
the intense symptoms reported by one of his patients.
V The socioeconomic disruptions caused by World
War II resulted in increased worldwide spread of
dengue viruses.
V The first epidemic of dengue hemorrhagic fever was
described in Manila in 1953
V In the 1950s, 9 countries reported dengue
outbreaks; today, the geographic distribution includes
more than 100 countries worldwide
V An estimated 2.5-3 billion people in approximately
110 countries worldwide are at risk for dengue
infection.
V Yearly, approximately 100 million people are
infected with dengue and 250,000 individuals develop
dengue hemorrhagic fever
V Annually, approximately 24,000 deaths are
attributed to dengue worldwide
VThe most common arboviral illness transmitted
worldwide
VCaused by infection with 1 of the 4 serotypes of
dengue virus.
VDengue is transmitted by mosquitoes of the genus

 which are widely distributed in subtropical and
tropical areas of the world
VClassified as a major global health threat by the World
Health Organization (WHO).
V MAY PRESENT AS
NON SPECIFIC FEBRILE ILLNESS
DENGUE HAEMORRHAGIC FEVER (DHF)
DENGUE SHOCK SYNDROME (DSS)
V GEOGRAPHICAL PATTERNS
Epidemic dengue : into a region as an isolated event that involves a
single viral strain and is the current pattern of transmission in parts
of Africa and South America, areas of Asia.
Hyperendemic dengue: characterized by the continuous circulation
of multiple viral serotypes in an area where a large pool of
susceptible hosts and a competent vector and reported in Vietnam,
Thailand, Indonesia, Pakistan, India, Malaysia, and the Philippines.
V Currently, dengue hemorrhagic fever is one of the
leading causes of hospitalization and death in children
in many Southeast Asian countries.
V 
 
is present in a large portion of the
Middle East and sub-Saharan Africa.
V In recent decades, reports of dengue infections in
long-term expatriates, aid workers, military personnel,
immigrants, and travelers returning from the tropics
and subtropics have been increasing
V Caused by 1 of 4 related, but antigenically distinct,
viral serotypes
V Dengue viruses are small, spherical, single-stranded
enveloped RNA viruses of the family Flaviviridae,
genus Flavivirus
V Infection with one dengue serotype confers lifelong
homotypic immunity and a very brief period of partial
heterotypic immunity, but each individual can
eventually be infected by all 4 serotypes. Several
serotypes can be in circulation during an epidemic
V Transmitted by the bite of an infected 

mosquito
V Female 
 mosquitoes are daytime feeders
V One can develop infection within a 24- to 36-hour
period after mosquito bite
V Humans serve as the primary reservoir for dengue
V Vertical transmission of dengue virus in mosquitoes
has been documented
V Incubation period of 3-14 days (average 4-7 d)
V Infection of target cells, primarily those of the
reticuloendothelial system, such as dendritic cells,
hepatocytes, and endothelial cells, result in the
production of immune mediators that serve to shape
the quantity, type, and duration of cellular and
humoral immune response to both the initial and
subsequent virus infections.
V Following incubation, a 5- to 7-day acute febrile
illness ensues. Recovery is usually complete by 7-10
days
V Dengue hemorrhagic fever or dengue shock
syndrome usually develops around the third to
seventh day of illness
V DHF and DSS include plasma leakage and bleeding
V Plasma leakage is caused by increased capillary
permeability and may manifest as hemoconcentration
(changes in haematocrit values), as well as pleural
effusion and ascites
V Bleeding is caused by capillary fragility and
thrombocytopenia and may manifest in various forms,
ranging from petechial skin hemorrhages to life-
threatening gastrointestinal bleeding
V Recovery from dengue infection is usually complete
V The fatality rate associated with dengue shock
syndrome varies by country from 12-44%
V Data from the 1997 Cuban epidemic suggests that,
for every clinically apparent case of dengue fever, 13.9
cases of dengue infection went unrecognized because
of absent or minimal symptoms.
V Fever be as high as 41°C
V often preceded by chills, erythematous mottling of
the skin, and facial flushing
V Headache is usually generalized.
V Retroorbital pain is common and is often described
as severe.
V Patients may report nausea and vomiting.
V Patients typically describe a maculopapular or
macular confluent rash over the face, thorax, and
flexor surfaces, with islands of skin sparing. The rash
typically begins on day 3 and persists 2-3 days.
V Myalgias, particularly of the lower back, arms, and
legs, and arthralgias, especially of the knees and
shoulders
V Hemorrhagic manifestations may range from small
amounts of bleeding from the nose or gums to
melena, menorrhagia, or hematemesis.
V Abdominal pain is reported; often, abdominal pain in
conjunction with restlessness, change in mental
status, hypothermia, and a drop in the platelet count
presages the development of dengue hemorrhagic
fever.
V may report conjunctival injection, sore throat, and
cough.
V Cardiomyopathy is reported, with tachycardia
during the febrile period and bradycardia and
conduction defect. Myocarditis and congestive heart
failure are rare.
 In nutshell the clinical description of dengue fever is
an acute febrile illness of 2-7 days duration associated
with 2 or more of the following:
Severe headache
Retroorbital pain
Severe myalgias
Arthralgia
Characteristic rash
Hemorrhagic manifestations
Leukopenia
 Isolation of the dengue virus from serum, plasma, leukocytes, or
autopsy samples
Demonstration of a 4-fold or greater change in reciprocal
immunoglobulin G (IgG) or immunoglobulin M (IgM) antibody titers
to one or more dengue virus antigens in paired serum samples
Demonstration of dengue virus antigen in autopsy tissue via
immunohistochemistry or immunofluorescence or in serum
samples via enzyme immunoassay (EIA)
Detection of viral genomic sequences in autopsy tissue, serum, or
cerebral spinal fluid (CSF) samples via polymerase chain reaction
(PCR)
 Criteria includes a probable or confirmed case of dengue
infection and hemorrhagic tendencies as evidenced by one or
more of the following:
A positive result from the tourniquet test
Petechiae, ecchymoses, or purpura
Bleeding from the mucosa, gastrointestinal tract, injection sites, or
other sites
Hematemesis or melena and thrombocytopenia (<100,000 cells/ɊL)
and evidence of plasma leakage due to increased vascular
permeability that manifests as one or more of the following: greater
than 20% rise in average hematocrit level for age and sex, greater than
20% drop in hematocrit level following volume replacement compared
to baseline, or signs of plasma leakage (eg, pleural effusion, ascites,
hypoproteinemia)
 Dengue shock syndrome is diagnosed in cases
meeting all of the criteria for DHF plus
evidence of circulatory failure, such as the
following:
Rapid, weak pulse
Narrow pulse pressure (<20 mm Hg)
Hypotension
Cool, clammy skin
Altered mental status
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V Complete blood cell count for Leukopenia,
lymphopenia, hematocrit level, Thrombocytopenia
V Basic metabolic panel findings include
Hyponatremia, Metabolic acidosis (associated with
shock), Elevated BUN levels
V Liver function test: Transaminase levels may be mildly
elevated. Low albumin levels are a sign of
hemoconcentration.
V Coagulation studies: Prothrombin time is prolonged,
activated partial thromboplastin time is prolonged, low
fibrinogen and elevated fibrin degradation product levels are
signs of disseminated intravascular coagulation.
V Serum specimens should be evlauated for
serodiagnosis, PCR, and viral isolation (rise in antibody
titer in paired IgG or IgM)
V Cultures of blood, urine, CSF, and other body fluids
should be performed as necessary to exclude or
confirm other potential causes of the patients'
condition.
V Chest radiography: Right-sided pleural effusion is
typical
V Ultrasonography findings include fluid in the chest
and abdominal cavities, pericardial effusion, and a
thickened gallbladder wall
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V Factors believed to be responsible for dengue's spread
include explosive population growth, unplanned urban
overpopulation with inadequate public health systems,
poor standing water and vector control, climate change
V Factors that affect disease severity include patient
age, nutritional status, ethnicity, the sequence of
infection with different dengue serotypes, virus
genotype, and the quality and extent of available
medical care
V Mosquito control:
Antilarval measures: environment control, chemical control,
biological control.
Antiadult measures: residual sprays, space sprays, genetic
control.
Protection against mosquito bite.
 A presentation by
Dr Saurav Arora
dr.saurav.arora@gmail.com
http://audesapere.in