COMPREHENSIVE NURSING CARE OF MATERNAL & CHILD WITH FEVER

DENGUE

1) Mrs. Kanimozhi .A , Associate Professor ,Dept of MSN , VMCON, Puducherry . 2) Mrs. Anusha Verghese , Msc Nursing II nd Year , Dept of MSN ,VMCON, Puducherry Introduction Dengue is one of the most common mosquito-borne diseases. It is an acute viral infection characterized by fever. In the past decade, it has become a major health concern, both nationally and globally. The probability of a dengue epidemic is high in India due to the dense urban population, poor sanitation as well as insufficient health awareness. Pregnant women and children are not immune to dengue What is dengue? Flavivirus (type of arbovirus) Transmitted from Aedes aegypti and Aedes albopictus mosquitoes Four Serotypes (Dengue 1-4) However, it is the Aedes aegypti species that is most notorious for transmitting dengue Definition Dengue is a severe viral disease transmitted by the bite of the mosquito and caused by any of 4 dengue virus serotypes. Den-1, Den-2, Den-3, Den-4 Undifferentiated fever Dengue Fever (DF) with the Fever- Myalgia (FM) presentation (classical) Dengue Hemorrhagic Fever (DHF) Dengue Shock Syndrome (DSS) Incidence and prevalence Southern India most hit but dengue deaths in other parts The Government on Friday said southern India was most affected by the dengue, though deaths have been reported in other parts of the country, as well. India has recorded over 37,000 dengue cases, including 227 dengue deaths in 2012 As on November 15, 35,066 cases of dengue with 216 deaths have been reported across the country. The case

Dengue is a flavivirus like malaria and yellow fever. Flaviviruses are part of the larger group of arboviruses, which are viruses transmitted between arthropods and mammals. Dengues vectors are two types of Aedes mosquitoes; 1. Aedes aegypti 2. Aedes albopictus.

fatality rate, however, has remained low at 0.6 per cent. Consequences 20 million cases annually in over 100 countries 24,000 deaths 2.5 billion people at risk No vaccine is available- supportive care only .

water, Assistant Director (Malaria) T. Kalimuthu explained. It takes around eight to 10 days for the mosquito to lay its eggs and the larvae to obtain maturity, he said.( Hindu - November 27, 2012) Causes of dengue fever The dengue virus is spread by the bite of the Aedes aegypti mosquito. These mosquitoes typically bite during the day and remain close to its breeding area. Aedes aegypti

Is dengue a seasonal disease? Dengue is widespread in most parts of the country but is most active after the rains. During the rainy season (June to September), cases of dengue shoot up as the warm humid weather and stagnant water provide perfect breeding ground for the mosquitoes. This trend has been seen ever since the heavy rains experienced as a precursor to Cyclone Nilam. After the rains, it is expected that there will be an increase in dengue cases, since the Aedes mosquito that carries the dengue flavivirus breeds in fresh

Peculiarities of A . aegypti It is a day biting mosquito when normally Coils , repellents, nets etc are not used It breads in fresh water around homes Lays eggs preferentially in water jars, discarded containers, coconut shells, old tires etc. Can transmit trans-ovarially the infection Year round breeding 250 N to 250 S Tropics and sub-tropics are its favorite zones. It is an urban vector
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HOW DENGUE SPREADS 1. Mosquitoes transmit dengue to human dendritic cells 2. Dengue targets areas with high WBC counts (liver, spleen, lymph nodes, bone marrow and glands) 3 Dengue enters WBCs & lymphatic tissue 4 Dengue enters blood circulation

Dengue Illnesses Propagation

Mechanism of Transmission Vector is infected after ingestion of blood meal from a viremic vertebrate Virus multiplies in the system of vector for 2-3 weeks extrinsic incubation period. Virus is injected by the A.aegypti into man After 2-7 days of Incubation Period, man develops Haemmoragic Fever

Pathology Of The Disease 1. Virus transmitted to human in mosquito saliva 2. Virus replicates in target organs. 3. Virus infects wbc and lymphatic tissues 4. Virus released and circulates in blood 5. Second mosquito ingests virus with blood 6. Virus replicates in mosquito midgut and other organs, infects salivary glands. 7. Virus replicates in salivary glands The incubation period is normally 38 days. The virus is detectable 6-18 hrs before the onset of symptoms . Viremia ends as the fever abates.

CLINICAL COURSE: FOUR PHASES Febrile phase Critical phase (leakage phase- DHF) Convalescent phase Recovery phase

-Encephalopathy: Due to cerebral edema, ICH, anoxia, hyponatremia and hepatic injury Complications of second phase- dengue shock syndrome Sweating, Abdominal pain, Persistent vomiting, Restlessness / altered conscious level, Postural dizziness, Decreased UOP(<0.5 ml/kg/hour) Cold extremities, Prolonged capillary refill time >2 seconds, Unexplained tachycardia, Tender hepatomegaly >2 cm, Increasing DBP, Narrow pulse pressure 20 mmHg, Postural drop 20 mmHg of SBP, Hypotension Death in Dengue Hemmoragic Fever -Prolonged shock (organ failure- Liver, Kidney, Respiratory) -Fluid Overload -Massive bleeding -Unusual manifestations: Encephalopathy, Underlying co-morbidity With good clinical care, case fatality rate should be around 0.5 1.0% (otherwise up to 5%) Convalesent phase Watch for clinical features of fluid overload (cough, wheeze, tachypnoea , crepitations , rhonchi ).Urine Output is usually high during this phase. Some patients may develop transient bradycardia

Febrile phase High-grade fever, 27 days facial flushing, skin erythema, body ache, myalgia, arthralgia, headache and N/V Some, sore throat, injected pharynx and conjunctival injection Positive tourniquet test indistinguishable between severe and non-severe dengue cases Monitoring for warning signs Mild hemorrhagic manifestations : petechiae and mucosal membrane bleeding (e.g. nose and gums) Massive vaginal bleeding and GI bleeding may occur Liver often enlarged and tender after a few days of fever The earliest abnormality in CBC : progressive decrease in WBC Critical phase Late febrile phase, after the Day 3 of fever -Selective (Peritoneal & Pleural cavities) and transient. Lasts 24-48 hours. -Generalized or facial oedema (Fluid overload) -Generalised lympadenopathy, Hemorrhagic manifestations, Hepatomegaly -Rare: Cardiomyopathy. Myocarditis, congestive heart failure

IV Phase : Recovery Phase Recovery phase starts after the end of the critical phase. Lasts 2-5 days. Reabsorption of extravasated fluid .Improved general well being and improved appetite, Appearance of convalescent rash, Generalized itching, Haemodynamic stability, Bradycardia, Diuresis Stabilization of HCT, Rise in WBC followed by a rise in Platelets If excessive amounts of IV fluids have been used in the critical phase: signs of fluid overload . EFFECT OF DENGUE IN PREGNANCY Pregnant Mothers immunity levels are suppressed and this can aggravate the effects of dengue. This disease can be very dangerous if left untreated and can cause complications, such as hemorrhage, convulsions, liver failure, and even death. Thats why prevention and early treatment are so important. Most unborn babies remain unharmed even if the mother catches dengue during pregnancy. However, if the infection is virulent, it could lead to complications like pre-term labor and fetal anomalies. Some case studies report that if a pregnant mother is sick with dengue near the time of delivery or during delivery, the child can be born with dengue or may acquire the infection during the delivery process itself.

Vertical Transmission of Dengue in pregnancy With the emergence of dengue epidemic, more number of pregnant women are at risk of dengue infection. Increasing number of cases of perinatal transmission of dengue fever is being reported from various countries. Though secondary infection is more serious, if the mother gets the primary infection in late pregnancy both mother and newborn are at risk of life threatening complications. When mother is acutely ill with dengue at or near the time of delivery. It has been hypothesized that there is an insufficient level of protective maternal antibodies (IgG) transferred to the fetus and the newborn can manifest serious dengue disease.1,2 When mother is affected earlier, the transferred maternal antibodies may initially be protective but as their level wanes they may predispose the infant to severe disease.

Petechiae

Capillary Damage

PURPURA

Ecchymosis Periorbital Edema

Purpura is indicative of more advanced hemorrhaging, as it is a sign of not just single capillary bursting but extensive blood vessel leakage. It is a result of thrombocytopenia (low platelet count) due to the dengue virus and should indicate to the person infected that they must seek medical attention immediately

Large Subcutaneous Bleed

ECCHYMOSIS Clinical manifestations in neonate Baby develops bi-phasic fever with petechiae , hepatomegaly , extreme lethargy and severe thrombocytopenia which developed with the second spike of fever. Baby can have symptom of intracranial bleeding Low birth weight babies were found to have lower levels of transferred antibodies. DHF- Poor Prognostic Signs in children Girl children under 12 with DHF/DSS Severe hypotension and shock Multifocal bleeding abdominal pain CNS encepahlopathy , fits, coma Watch for preorbital edema, proteinuria postural or otherwise hypotension Serotype 2 infection after type 4 Malnutrition is protective Unusual Presentations of Dengue in children Encephalopathy Hepatic damage Cardiomyopathy Severe GI bleeding

This picture illustrates advanced internal bleeding, called ecchymosis. Ecchymosis presents itself as large bruises, indicative of severe internal bleeding (hemorrhaging). Like purpura, it is caused by clotting disorders like thrombocytopenia induced by a second infection of the dengue virus NASAL HEMORRHAGING

This final picture is an example of someone in late stages of DHF, bleeding from their nose. Orifice bleeding is one of the last kinds of bleeding to occur in DHF, and can happen from the ears, anus, and vagina, as well as the nose. Left untreated, this kind of hemorrhaging will inevitably lead to death

Laboratory investigations in Dengue Fever Clinical laboratory tests CBCWBC-- Leucopenia. Rapid fall in platelets Thrombocytopenia Albumin- Hypoalbunemia Liver function testsIncreased SGOT, SGPT Urine--check for microscopic hematuria Thrombocytopenia: up to 50%. Monitor at least every 24 hours Hyponatremia (DHF, DSS), Increased BUN Elevated ALT, AST, Low albumin Full Blood Count: Leukopenia, lymphopenia. Lymphocytosis HCT: Rise of >20%: a sign of haemoconcentration and precedes shock. Monitor HCT every 24 hours. Every 3-4 hours in severe Coagulation: Prolonged PT, APTT, Low fibrinogen, Elevated FDP (DIC) CXR: Right-sided pleural effusion. B/L pleural effusions in DSS Cultures of blood, urine, CSF, and other body fluids: to exclude or confirm other Diagnosis ABG: Severe cases to assess pH, oxygenation, ventilation & acidosis Dengue-specific tests Virus isolation to determine serotype of the infecting virus Serology-IgM ELISA test for serologic diagnosis Rising Ab titre in paired sera Antigen detection ELISA

IgM-capture ELISA within few hours Reverse transcription PCR confirmatory IgG ELISA significant of past infection Immuno Detection Tests

ELISA Plate

ELISA IgM-capture

Pleural Effusion Index

Interpretation of dengue serology IgM Negative Negative Negative Positive IgG Negative Positive( low titre) Positive(high titre ) Negative Positive (low titre) Positive (high titre) Interpertation Early sample/ Not dengue Past dengue infection Secondary dengue Primary dengue infection Current/recent dengue infection Secondary dengue infection

CHEST XRAY Right lateral decubitus x-ray showing a large pleural effusion, typical of DHF the day after defervescence. use pleural effusion index to quantitate the degree of plasma leakage. Tourniquet Test Inflate blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes Positive test: 20 or more petechiae per 1 inch (6.25 cm)

Positive

Positive

PRINCIPLES OF MANAGEMENT BOTH MATERNAL AND CHILD Adequate physical rest Tepid sponging for fever Paracetamol not exceeding 2 tablets six hourly (reduce dose for patients with lower body weights). Warn the patient that the fever may not fully settle with paracetamol, but not to take excess. Antiemetics and H2 receptor blockers if necessary Avoid all NSAIDS and steroids Withhold Aspirin, Clopidogrel & Dipyridamole in patients who take these on long term basis Review daily. A full blood count should be done at least on the third day of
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illness. (A full blood count should be done on the irst day of fever in pregnant patients and in patients with chronic renal failure) In case of severe bleeding, give fresh whole blood 20 ml/kg as a bolus Give platelet rich plasma transfusion exceptionally when platelet counts are below 5,00010,000/ mm3 . After blood transfusion, continue fluid therapy at 10 ml/kg/h and reduce it stepwise to bring it down to 3 ml/kg/h and maintain it for 24-48 hrs. Advise immediate return for review if any of the following occur: Clinical deterioration with settling of fever Inability to tolerate oral luid Severe abdominal pain Cold and clammy extremities Lethargy or irritability/restlessness Bleeding tendency including intermenstrual bleeding or menorrhagia Not passing urine for more than 6 hours HOME REMEDY OF DENGUE FEVER Papaya Juice vs. Dengue ? ( Source: from Indonesia March 2005) Raw papaya leaves, 2 pcs just cleaned and pound and squeeze with filter cloth. You will only get one tablespoon per leaf. So two tablespoon per serving once a day.

Do not boil or cook or rinse with hot water, it will loose its strength. Only the leafy part and no stem or sap. It is very bitter and you have to swallow it. But it works. DENGUE MANAGEMENT IN PREGNANCY Early admission and close follow up with Fetal Beat Count daily is very important Risks: prematurity, IUD, Placental abruption, Hemmorage for both the mother and the newborn If close to term, there is a risk of vertical transmission Baseline parameters should be noted such as Temperature, Pulse, BP, pulse pressure FBC , SGOT/SGPT Risk of bleeding is at its highest during the period of plasma leakage If possible, avoid Cesarean or Induction of labour during critical phase. Procedures/manoeuvres that may provoke or augment labour should be avoided during the critical phase ADJUNCTIVE THERAPY IN THE MANAGEMENT OF DHF IN PREGNANCY Platelet transfusion Prophylactic transfusion of platelets is not recommended. However, platelet transfusions may be required in a patient with thrombocytopenia who is to undergo an urgent surgery, has
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active bleeding which continues in spite of repeated blood transfusions, DIC or in patients with intracranial haemorrhage. Fresh frozen plasma transfusion Prophylactic FFP transfusions do not produce changes in the coagulation status, and therefore, does not change or reduce the bleeding outcome in patients with DHF/DSS. FFP transfusions can also lead to fluid overload. In addition, transfusion of blood products can produce anaphylactic reactions and transmission of blood borne diseases like HIV, Hepatitis B etc. However FFP may be useful in a Dengue patient with hepatic encephalopathy and has active bleeding. Steroids and I.V. immunoglobulin There is no evidence to support the use of intravenous immunoglobulin and steroids in the management of dengue patients.Therefore, use of steroids (hydrocortisone, dexamethasone and methylprednisolone) and/or immunoglobulin is not recommended. Recombinant Factor VII There is no evidence to support the use of recombinant factor VII in DHF patients with bleeding due to prolonged shock, DIC or multi-organ failure. Antibiotics There is no evidence to support prophylactic use of antibiotics in DF or DHF patients with low white blood cell count (WBC). Therefore, there is no place for the use of prophylactic antibiotics during the

First 4-5 days of fever if Dengue is suspected, even in the presence of pleural effusion or ascites. Frusemide Intravenous frusemide (1 mg/kg body weight) could be used in the following circumstances In fluid overloaded patients who are haemodynamically stable In fluid overloaded patients who are haemodynamically unstable in the midway of a colloid infusion or a blood transfusion Tranexamic acid Bleeding per vagina, either menstrual, intermenstrual or premenopausal, can be excessive in DHF. Hence those who have such bleeding may be started on tranexamic acid 1 gram eight hourly MANAGEMENT: THROMBOCYTOPAENIA When platelet count drops below 100,000/mm3 Temperature, pulse, BP, RR, capillary refill time 4 hourly Detailed fluid balance with: 1. Intake with type and route of fluid assess six hourly 2. Output urine/vomitus - assess six hourly Fetal Beat Count daily Hematocrit twice daily The purpose of this monitoring is to detect entry into the critical phase.

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MANAGEMENT: FLUID RESUSCITATION Platelet count >100,000/mm3 -IV if unable to take orally: N. Saline/ Hartmanns . --Total amount of fluid (both I.V. and oral) should be limited to 2.5L x 24 hrs Platelet count <100,000/mm3 - Slow IV Hartmanns/N. Saline: 18 G cannula (1L-2.5L) -Total fluid requirement, (oral+IV x 48 hours) calculation: Maintenance + 5% deficit -Maintenance is calculated: For the 1st 10kg - 100 ml /kg; For the 2nd 10kg - 50 ml/kg; From 20 kg and above up to 50 kg 20 ml/kg; -5% deficit is calculated as 50 ml/kg up to 50 kg E.g. 65kg person (maximum BW for fluid calculation is 50 kg) For the 1st 10 kg - 100 ml/kg = 1000 ml For the 2nd 10 kg - 50 ml/kg = 500 ml From 20 kg and above up to 50 kg 20 ml/kg = 600 ml 5% deficit: 50 ml/kg up to 50 kg = 2500 ml Total fluid requirement for an average adult for the entire phase of critical 48 hours is 4600 ml Management of Shock -IV fluid boluses. If HCT is low or normal the shock is due to significant

concealed Haemmorage in addition to plasma leakage, need urgent blood Transfusion -Adjust the rate of I.V. fluids according to the pulse pressure, capillary refill time, UOP and HCT -colloids should not be used in a dehydrated patient who presents with shock and high HCT, until the hydration is corrected with crystalloid SHOCK Management If the patient is not responding to two boluses of crystalloid, contributory causes for shock other than plasma leakage should be considered. These are, -Acidosis:check blood gas (if present, check liver and renal profiles) -Bleeding: check HCT -S. Calcium and SE -Sugar: check CBS Transfuse blood: HCT not as high as expected for the degree of shock to be explained by plasma leakage alone. (Hypotensive shock with low or normal HCT) A drop in HCT without clinical improvement despite adequate fluid replacement Severe metabolic acidosis and endorgan dysfunction despite adequate fluid replacement. (Hb level may remain normal initially despite significant blood loss)

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Comprehensive nursing care approach Administer drugs Fluid maintenance Watch for signs and symptoms of shock Nutrition Vector control Prevention Health education NURSING MANAGEMENT OF DENGUE FEVER IN PREGNANCY Oxygen therapy Rapid replacement with fluid and electrolyte solution. Plasma should be used for patients with severe cases of shock. Blood transfusion for patients who have severe bleeding. Avoid use of aspirin and ibuprofen because it can increase bleeding and cause stomach pain. If one or more signs of DHF are seen, take the patient to the hospital immediately, give fluids to drink while transferring the patient to the hospital. Blood pressure Evidence of bleeding in skin or other sites Hydration status Evidence of increased vascular permeability-- pleural effusions, ascites Tourniquet test Paediatric Nurses Role in DHF / DSS Record the time of shock or beginning of plasma leakage (high

PCV and/or platelet < 100,000 cells/cumm) Count the hours after shock or leakage - Time after shock, 6 hrs,12 hrs,24 hrs Record amount and type of IV fluid received Record amount of urine output per hour (in severe cases) or per 8 hours shift Urgently notify Dr. for unstable vital signs & abnormal symptoms Family Support & Health Education Intensive Care Oxygen Rehydration Barrier Nursing Mosquito Screen Monitoring of DHF patient 1. 2. 3. 4. 5. 6. Vital Signs Clinical Signs & Symptoms IV infusion PCV & Lab Urine output Good record sheet

Vital Signs Temperature T. 37.6 - 38.30C low grade fever T. 38.4 - 39.00C mild T. 39.1 - 40.00C high T. >40.1 C very high
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Measures every 4 hr. Aims Monitoring Critical Phase Temperature no fever, cold clammy skin notify M.D
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Pulse Rate pulse rhythm & Rate 1. Full 2. Moderate 3. Weak 4. Not palpable Febrile phase q 4-6 hr Critical phase q 2 hr During shock q 15-30 min Convalescent phase q 4-6 hr Blood Pressure Pulse pressure < 20 mmHg e.g. 100/80, 110/90 mmHg. Hypotension e.g. 80/50 mmHg Notify M.D. IV fluid administration as soon as possible CVP monitoring Respiration Respiratory rate if > 30/min. in older children or > 40/min. in infants, notify M.D. (fluid overload or acidosis) Signs & Symptoms to Notify Doctor

Shock / impending shock Cold , clammy skin, cyanosis, mottling skin Rapid and weak pulse Narrow pulse pressure < 20 mm of Hg Hypotension ( Systolic BP< 90 mm of Hg) Notify within 1- 8 hrs. Vomiting / abdominal pain/ poor appetite Dehydration, dry lips ,fair poor skin turgor Dyspnoea , tachypnea Hemoglobinuria/ hematuria No urine output in the past 8 hours < 0.5 ml/kg/hr or > 1 ml / kg/hr Platelet <100,000 or rising Hct > 10 -20 % Puffy eyelids , distended abdomen Anxiety / psychosocial problems.

Care in IV Transfusion Type of IV 5%D/NSS,5%DAR Control flow rate follow Dr.s order Care Position Record total infusion Record time duration Nursing Care every 2-4 hrs. Rapid screening Capillary refill time > 3 second inadequate tissue perfusion (compensated shock) Calculate the IV fluid Body Weight 0-10 kg use 100 cc/kg
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Urgent : Capillary refill time > 2 seconds. O2 sat > 95% Bleeding > 10% TBW 6-8 ml/kg Convulsion Excessive vomiting Severe abdominal pain IV fluid leak in critical period Abnormal lab Change of consciousness

 next 11-20 kg use 50 cc/kg over 20 kg use 20 cc/kg Total Maintenance fluid in 24 hrs. If obese use Ideal Body Weight Age 0-6 year = [age (yr) x2]+8 Over 7 year= age (year) x3 Urine output Record urine output every 8 hrs. ( Febrile phase) Urine 0.5 ml/kg/hr (BW) (Critical phase/Shock) Adequate amount means effective circulatory volume to renal Records For Early Management & Treatment Doctor sheet Dengue sheet IV transfusion sheet Intake/output sheet Discharge of patient when they are, Afebrile for 24 hours without antipyretics Good appetite, clinically improved condition Adequate urine output Stable HCT level(at baseline value or around 38 - 40 % when baseline value is not known) At least 48 hours since recovery from shock Platelet count greater than 50,000 cells/L No distress from pleural effusions or ascites No other complications

NON-BIOLOGICAL MEANS OF DECREASING THE INCIDENCE OF DENGUE PUBLIC HEALTH STRATEGIES Vector Control Surveillance Preparation for outbreaks Research Vector Control of Dengue Mosquito control is expensive impossible Destruction of breeding sites viable Spraying insecticides for adult control- ? Individual measures to avoid vector contact 1. Mosquito screens, repellents (DEET) 2. Permithrin impregnated clothing Non degradable tires, long life plastics-avoid MOSQUITO NETS

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Prevention of Multiplication of Mosquitoes Drain water from coolers, tanks, barrels, drums, buckets, etc. Remove all objects, such as plant saucers, etc. which have water collected in them from house. Cover all water containers at all times. Discard solid waste and objects where water collects: bottles, tins, tires, etc.

Patients with bleeding manifestations Serial hematocrits and platelets at least daily until temperature normal for 1 to 2 days All patients If blood sample taken in first 5 days after onset, need convalescent sample between days 6 - 30 All hospitalized patients need samples on admission and at discharge or death Dengue Vaccine ? No licensed vaccine at present Effective vaccine must be tetravalent Field testing of an attenuated tetravalent vaccine currently underway Effective, safe and affordable vaccine will not be available in the immediate future

Patient Follow-Up Patients treated at home Instruction regarding danger signs Consider repeat clinical evaluation
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Health Education Explain the cause of DHF, warning signs of shock and how to take care. Before go home let them know if people in the same house or around the house are sick with high fever ,they are likely to have dengue infections. To the Parents: Should be educated regarding the proper prevention of dengue. Should be educated on the signs and symptoms of dengue. They should have a regular check up of the patients well-being and immunizations. Mother Should be educated regarding the proper prevention of dengue. Make sure that her children get adequate nutrition to increase resistance from any diseases. To the Family : Rest, drink plenty of fluids and consult a physician Avoid pain relievers that contain aspirin and NSAID such as ibuprofen. Paracetamol may be used. To eliminate mosquito breeding sites and reduce the

risk of dengue by checking around their house and to empty buckets, cans, flower pots and other items that may contain water. Use insect repellents and spray insecticides if there are mosquitoes in the vicinity. To eliminate any containers where mosquito can lay egg by covering them/turning them upside down By installing window and door screens To the Health care personnel Bi-phasic fever has not been previously reported in other case reports. Pediatricians caring for newborns with Dengue fever should carefully observe the baby for a minimum period of two weeks before discharging them. Vigilant monitoring and proper hydration can lead to uneventful recovery from this potentially lethal condition. Clinicians caring for pregnant women should have a high index of suspicion for early diagnosis of Dengue fever and timely referral to a tertiary center for proper management. This can prevent maternal and neonatal deaths. Newborn presenting with skin/mucosal bleed without any maternal history, possibility of dengue has to be considered

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