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

Dengue virus

Flavivirus: Single Stranded RNA virus

Serotypes: DEN-1 to DEN-4
DEN-2 and DEN-3 severe disease with secondary
dengue infections

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.