Dengue

Divya Bappanad Karapitya Hospital Galle, Sri Lanka

Initial Presentation
HPI: 18 yo Sri Lankan male in USOH until developed fever, myalgias and vomiting x 3 days. On basketball team and day prior to fever participated in game with no complaints. PMH: none Medications: none Immunizations: up to date SH: student, lives with mother in nearby community outside Galle, + electricity and running water, no siblings, no recent travel.

Physical Exam
Vitals: T 40C BP 110/80 supine 90/70 standing HR 96 RR 16 SpO2 not available Gen: Alert, Ill appearing HEENT: PERRLA, EOMI, + conjunctival injection, OP clear, MM dry Neck: No LAD CV: RRR, no m/g/r Lungs: CTAB, no w/r/r Ab: +BS, soft, NT, ND, no HSM Ext: No edema Skin: No petechia

Studies
WBC 5.2 86% N, 12% L and 1.2% M, Hgb 14 and Platelets 16,000 Dengue IgM + and IgG + CXR: clear

Continued Clinical Course

Day 2 Coffee ground emesis
Transfused FFP, plts and has transfusion rx

Day 3 Increased work of breathing

Transferred to ICU and intubated Abx, plts and steroids

Day 4 Hypotension, decreased urine output with worsening hypoxia

Started on pressors

Progressive Deterioration
Day 6 Abdominal compartment syndrome
Paracentesis with 1.5 L removed

Day 7 Worsening hypotension, decreased urine output and difficulty ventilating Day 10
Withdrawal of ventilatory support

Dengue Epidemiology
Incidence
2.5 billion people in over 100 endemic countries 50 million people infected annually with 500,000 cases of DHF and approx 20,000 deaths Wide spectrum of illness although most subclinical or asymptomatic Flavivirus: Single Stranded RNA virus Serotypes: DEN-1 to DEN-4 DEN-2 and DEN-3 severe disease with secondary dengue infections

Dengue virus

Epidemiology
Vector
Mosquito Primarily Aedes Aegypti
Aedes albopictus, Aedes polynesiensis and other Aedes species also

Most female Ae. aegypti appear to spend lifetime in or around the houses where they emerge as adults. Suggest people rather than mosquitoes, rapidly move the virus within and between communities

Clinical Progression
Critical phase
3-7 days Temperature defervescence with possible increased capillary permeability and increasing hematocrit If no change in capillary permeability will improve and non-severe dengue If fail to defervesce and develop leakage concerning for development shock

Clinical Progression
Recovery phase
2-3 days Reabsorption of extravascular fluid Bradycardia and ECG changes common Hemodynamics stabilize, auto diuresis begins and patient clinically improves

Severe Dengue( Dengue Hemorrhagic Fever or Dengue Shock Syndrome)

Fever of 27 days plus :
Evidence of plasma leakage, such as:
high or rising hematocrit; pleural effusions or ascites; circulatory compromise or shock

Significant bleeding. Altered level of consciousness (lethargy or restlessness, coma, convulsions). Severe gastrointestinal involvement (persistent vomiting, increasing or intense abdominal pain, jaundice). Severe organ impairment (acute liver failure, acute renal failure, encephalopathy or encephalitis, or other unusual manifestations, cardiomyopathy) or other unusual manifestations.

Diagnosis
Clinical diagnosis
Live and travel in endemic area and fever + 2
Anorexia and nausea Rash Myalgias/arthralgias Leukopenia Tourniquet test + Signs of severe dengue

Serologic Diagnosis
Decreasing wbc
1st serologic abnormality

Dengue IgM and IgG

tests viral specific antibodies 76% sensitive for primary infection and 88% for secondary infection 88%-99% specificity

Treatment
Supportive WHO management algorithm for fluid resuscitation Transfusion Oxygen ICU monitering

Prognosis
Dengue fever < 1% mortality Dengue hemorrhagic fever approx 2.5% mortality
Primarily children

Dengue shock up to 47% mortality

Recurrent infection
Active infection protected from illness from different serotype for 2-3 months, but not long term Infection by one serotype confirms lifelong immunity to that serotype No immunization currently available

Bibliography
Dengue: guidelines for diagnosis, treatment, prevention and control. Second edition. Geneva: World Health Organization. 2009. Accessed at http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf Singhi S, Kissoon N, Bansal A. Dengue and dengue hemorrhagic fever: management issues in an intensive care unit. J Pediatr (Rio J). 2007; 83(2 Suppl):S22-35.