Dengue fever Viruses

Patient infected with this virus may present with Dengue fever or Dengue hemorrhagic
fever (DHF).
It is endemic in Asia; South America; East and West Africa; and Northern Australia.
There are 4 serotypes. They all cause similar clinical problems; however some serotypes
are associated with severe illness; and others like serotype 4 is associated with mild
illness.
More than one serotype can circulate at one time.
Vector- a female Aedes aegypti (domestic mosquito) feeds on humans in day time and it
is found mostly in urban area.
-Aedes albopictus also play an important role in South America outbreak
As human is the primary host, it is common in urban area.

Transmission
Occur throughout the year in tropical countries.
Outbreak occurs in rainy season or just after rainy season.
Transmission is from person to person by insect bite.
Vertical transmission can also occur, however transmission after needle stick injuries is
rare.

Pathology
The rash is immune mediated.
DHF/DSS is cause by re-infection with different serotypes.
There is no carrier state.

Incubation period from mosquito’s bite ranges between 3 and 14 days.

Clinical Presentations

1. Asymptomatic and mild infection

It is very common.

2. Dengue Fever (primary infection)

There is no plasma leakage.
Patient presents with Influenza like illness-fever-arthralgia- rash syndrome.
DF is characterized by high fever; sever frontal headache; retro-ocular pain; muscle
(break bone fever) and joint pain; and generalized maculopapular rash. Conjunctiva may
be injected (become red).
Nausea, vomiting diarrhea, abdominal pain are other common problems.
Photophobia, sore throat, lymphadenopathy and bleeding tendencies are not uncommon.
Unlike DHF, tourniquet test is positive in only one-third of the patients.
The illness lasts 5 to 7 days.
Immunity is life long. On the contrary immunity or prior exposure increases the risk of
Dengue Hemorrhagic Fever or Dengue Shock syndrome.
Some patients would experience depression (heart break fever) and fatigue for several
months after recovery.

3. Dengue Hemorrhagic fever

The prominent feature is bleeding.
It is caused by either re-infection by a different dengue virus serotypes or rarely by
primary infection (virulent serotypes or strains).
It is common in children in Under 15 years of Age in Asia whereas in South America it is
observed in all ages.
It is characterized by sudden rise in temperature and other manifestations of Dengue
fever.
Tourniquet test is positive in half of the patients.
Petechiae, easy bruising, gingival bleeding and epistaxis are common.
Gastrointestinal bleeding observed in patients with severe illness..
Hepatomegaly and splenomegaly are common in children.
4. Dengue Shock Syndrome
The prominent feature is hypotension (hypovolumic shock)
It is uncommon after 15 years of age.
The clinical features include weak pulse with narrow blood pressure (<20 mm of Hg),
cold and clammy skin.
Pleural effusion, ascites and intense abdominal pain may predict eminent Dengue shock
syndrome.

Sign of impending DSS

 Persistent increase in haematocrit
 Decrease in platelets count
 Abdominal pain
 Persistent vomiting
 Neurological problems (restlessness, lethargy, prostration)

Complications
 Cardiomyopathy
 Hepatitis
 Neurological problems- altered state of consciousness, convulsions, coma
 Neonatal Dengue fever, Dengue hemorrhagic fever or spontaneous
abortion

Investigation

Laboratory results
CBC- Leukopenia, neutropenia, lymphocytosis
- Thromocytopenia – moderate in Dengue fever and < 100,000/ml in
DHF/DSS
LFT- increase in transaminase level is common

Radiology
Chest x-ray shows pleural effusion and occasionally pericardial effusion
Ultrasound
To detect pericardial effusion and ascites

Tests
Specimen- Serum should be send to virology laboratory to detect the virus or for
serology.
Virus isolation has a sensitivity of 50 %. Culture is done in cell line derived from A.
albopictus cell. Immunoflurescent techniques are used to detect viral replications. The
virus can be isolated in patients with fever.
Serology
IgM is detectable in 90 % of patients by the 6th days of illness. Serum collected early may
give false negative result. The IgM may remain detectable for 2-3 months. It is not
possible to identify serotype with serological tests.
The antibody produced against yellow fever or other Flavivirus may cross react with
Dengue Virus antigen and as a result it is difficult to interpret the result.
IgM Positive result may suggest recent infection with Dengue fever. However definitive
diagnosis can only be made if the virus is isolated or the virus genome is detected by
PCR.
Once the IgG is detected, it will remain positive for years. Seroconversion or increase in
titer may indicate recent infection.
The appropriate samples for PCR test include plasma and serum. Molecular test is highly
sensitive but it can be used in patients only with viraemia.

Management

There is no specific treatment.

1. Dengue Fever
Oral fluid, analgesics and antipyretics (paracetamol) are the main stay of therapy.

Avoid Aspirin it may

aggravate bleeding or it
may cause Reye
syndrome.
2. Dengue Hemorrhagic fever/ Dengue Shock
Syndrome
Patient with these problems require admission as the
mortality can be as high as 40% without intervention.
Close monitoring of vital sign is central in the
management of these patients. In addition level of
consciousness, Haematocrit level and platelets count
should be monitored.
 Monitoring of fluid input and output is important.

Intravenous fluid -Crystalloid (Ringer lactate) followed by colloid (Dextran 40%) fluids
are essential to maintain adequate perfusion to major organs.
Steroids are not helpful.
Consideration before discharge
1 Observation for at least 3 days after recovery from shock
2 No respiratory distress from pleural effusion or ascites
3 Platelet count >50,000
4 Absence of fever for more than 24 hours
5 Return of appetite

Prevention

No vaccine at present. The vaccine should be against all four serotypes.

At community level
 Control the vector
 Using insecticide and vector surveillance

Individual level
 Mosquito repellant
 Protective clothing
 Impregnated bed net

Dengue & Dengue haemorrhagic fever. Seminar. Rigall-Pewrez, J et al. The Lancet
(1998) 352;971-7