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What and How much we know about

Dengue fever?
- Sajeeb Sarker

Dengue, again, is the issue; we suffer a lot and we forget about then. This
happens just every single time. But, if we just try to know something about this –
in as much details as possible, we can have a lot more chance to prevent it. And by
knowing a little more about its types and diagnosis systems, we can increase the
chance of preventing being misdiagnosed. Here are some information about
Dengue that can be a lot helpful for both purposes, and for all people:

Dengue fever is a disease caused by a family of viruses that are transmitted


by mosquitoes. It is an acute illness of sudden onset that usually follows a benign
course with headache, fever, exhaustion, severe joint and muscle pain, swollen
glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever,
rash, and headache (and other pains) are particularly characteristics of dengue.

Dengue fever and dengue hemorrhagic fever (DHF) are acute febrile
diseases caused by four closely related virus serotypes of the genus Flavivirus,
family Flaviviridae. The geographical spread is similar to malaria. Each serotype
is sufficiently different that there is no cross-protection and epidemics caused by
multiple serotypes (hyperendemicity) can occur. Dengue is transmitted to humans
by the Aedes aegypti (rarely Aedes albopictus) mosquito, which feeds during the
day.

Virus Classification
Group: Group IV {(+) ssRNA}
Family: Flaviviridae
Genus: Flavivirus
Species: Dengue Virus

Dengue (pronounced DENG-gay) strikes people with low levels of


immunity. Because it is caused by one of four serotypes of virus, it is possible to
get dengue fever multiple times. However, an attack of dengue produces immunity
for a lifetime to that particular serotype to which the patient was exposed.

Dengue goes by other names, including "breakbone" or "dandy fever."


Victims of dengue often have contortions due to the intense joint and muscle pain,
hence the name breakbone fever. Slaves in the West Indies who contracted dengue
were said to have dandy fever because of their postures and gait.

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Dengue hemorrhagic fever is a more severe form of the viral illness.
Manifestations include headache, fever, rash, and evidence of hemorrhage in the
body. Petechiae (small red or purple blisters under the skin), bleeding in the nose
or gums, black stools, or easy bruising are all possible signs of hemorrhage. This
form of dengue fever can be life-threatening or even fatal.

Dengue haemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is


a potentially lethal complication, affecting mainly children. Early clinical
diagnosis and careful clinical management by experienced physicians and nurses
increase survival of patients. Well, we’ll discuss it later.

How is dengue contracted?

The virus is contracted from the bite of a striped Aedes aegypti mosquito
that has previously bitten an infected person. The mosquito flourishes during rainy
seasons but can breed in water-filled flower pots, plastic bags, and cans year-
round. One mosquito bite can inflict the disease.

Again, dengue is transmitted by the bite of an Aedes mosquito infected with


any one of the four dengue viruses. It occurs in tropical and sub-tropical areas of
the world. Symptoms appear 3—14 days after the infective bite. Dengue fever is a
febrile illness that affects infants, young children and adults.

The virus is not contagious and cannot be spread directly from person to
person. There must be a person-to-mosquito-to-another-person pathway.

What are the signs and symptoms of dengue?

After being bitten by a mosquito carrying the virus, the incubation period
ranges from three to 15 (usually five to eight) days before the signs and symptoms
of dengue appear. Dengue starts with chills, headache, pain upon moving the eyes,
and low backache. Painful aching in the legs and joints occurs during the first
hours of illness. The temperature rises quickly as high as 104° F (40° C), with
relative low heart rate (bradycardia) and low blood pressure (hypotension). The
eyes become reddened. A flushing or pale pink rash comes over the face and then
disappears. The glands (lymph nodes) in the neck and groin are often swollen.

Fever and other signs of dengue last for two to four days, followed by rapid
drop in temperature (defervescence) with profuse sweating. This precedes a period
with normal temperature and a sense of well-being that lasts about a day. A second
rapid rise in temperature follows. A characteristic rash appears along with the

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fever and spreads from the extremities to cover the entire body except the face.
The palms and soles may be bright red and swollen.

Symptoms range from a mild fever, to incapacitating high fever, with


severe headache, pain behind the eyes, muscle and joint pain, and rash. There are
no specific antiviral medicines for dengue. It is important to maintain hydration.
Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs
(e.g. Ibuprofen) is not recommended.

Yet, we can have another look over the signs and symptoms of dengue for a
little more information:

This infectious disease is manifested by a sudden onset of fever, with


severe headache, muscle and joint pains (myalgias and arthralgias—severe pain
gives it the name break-bone fever or bonecrusher disease) and rashes. The
dengue rash is characteristically bright red petechiae and usually appears first on
the lower limbs and the chest; in some patients, it spreads to cover most of the
body. There may also be gastritis with some combination of associated
abdominal pain, nausea, vomiting or diarrhea.

Other symptoms include:

• fever;
• chills;
• constant headaches;
• bleeding from nose, mouth or gums;
• severe dizziness; and,
• loss of appetite.

Some cases develop much milder symptoms which can, when no rash is
present, be misdiagnosed as influenza or other viral infection. Thus travelers from
tropical areas may inadvertently pass on dengue in their home countries, having
not been properly diagnosed at the height of their illness. Patients with dengue can
pass on the infection only through mosquitoes or blood products and only while
they are still febrile.

The classic dengue fever lasts about six to seven days, with a smaller peak of
fever at the trailing end of the disease (the so-called "biphasic pattern"). Clinically,
the platelet count will drop until the patient's temperature is normal.

Cases of DHF also show higher fever, haemorrhagic phenomena,


thrombocytopenia, and haemoconcentration. A small proportion of cases lead
to dengue shock syndrome (DSS) which has a high mortality rate.

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Dengue shock syndrome is defined as dengue hemorrhagic fever plus:

• Weak rapid pulse,


• Narrow pulse pressure (less than 20 mm Hg) or,
• Cold, clammy skin and restlessness.

What is dengue hemorrhagic fever?

Here, we’ve spoken of dengue hemorrhagic fever several times; let’s take a
little close look at this:

The WHO definition of dengue haemorrhagic fever has been in use since
1975; all four criteria must be fulfilled:

1. Fever, bladder problem, constant headaches, severe dizziness and loss of


appetite.
2. Hemorrhagic tendency (positive tourniquet test, spontaneous bruising,
bleeding from mucosa, gingiva, injection sites, etc.; vomiting blood, or
bloody diarrhea)
3. Thrombocytopenia (<100,000 platelets per mm³ or estimated as less than
3 platelets per high power field)
4. Evidence of plasma leakage (hematocrit more than 20% higher than
expected, or drop in haematocrit of 20% or more from baseline following
IV fluid, pleural effusion, ascites, hypoproteinemia)

In other words, dengue hemorrhagic fever (DHF) is a specific syndrome


that tends to affect children under 10. It causes abdominal pain,
hemorrhage (bleeding), and circulatory collapse (shock). DHF is also called
Philippine, Thai, or Southeast Asian hemorrhagic fever and dengue shock
syndrome.

DHF starts abruptly with high continuous fever and headache. There are
respiratory and intestinal symptoms with sore throat, cough, nausea, vomiting, and
abdominal pain. Shock occurs two to six days after the start of symptoms with
sudden collapse, cool, clammy extremities (the trunk is often warm), weak pulse,
and blueness around the mouth (circumoral cyanosis).

In DHF, there is bleeding with easy bruising, blood spots in the skin
(petechiae), spitting up blood (hematemesis), blood in the stool (melena), bleeding
gums, and nosebleeds (epistaxis). Pneumonia is common, and inflammation of the
heart (myocarditis) may be present.

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Patients with DHF must be monitored closely for the first few days since shock
may occur or recur precipitously. Cyanotic (bluish) patients are given oxygen.
Vascular collapse (shock) requires immediate fluid replacement. Blood
transfusions may be needed to control bleeding.

The mortality, or death rate, with DHF is significant. It ranges from 6%-30%.
Most deaths occur in children. Infants under a year of age are especially at risk of
dying from DHF.

Diagnosis

The diagnosis of dengue is usually made clinically. The classic picture is


high fever with no localising source of infection, a petechial rash with
thrombocytopenia and relative leukopenia.

Serology and polymerase chain reaction (PCR) studies are available to


confirm the diagnosis of dengue if clinically indicated.

How is dengue fever treated?

Because dengue is caused by a virus, there is no specific medicine or


antibiotic to treat it. For typical dengue, the treatment is purely concerned with
relief of the symptoms (symptomatic). Rest and fluid intake for adequate hydration
is important. Aspirin and nonsteroidal anti-inflammatory drugs should be
avoided. Acetaminophen (Tylenol) and codeine may be given for severe
headache and for the joint and muscle pain (myalgia).

The mainstay of treatment is supportive therapy. Increased oral fluid intake


is recommended to prevent dehydration. Supplementation with intravenous
fluids may be necessary to prevent dehydration and significant concentration of
the blood if the patient is unable to maintain oral intake. A platelet transfusion is
indicated in rare cases if the platelet level drops significantly (below 20,000) or if
there is significant bleeding.

The presence of melena may indicate internal gastrointestinal bleeding


requiring platelet and/or red blood cell transfusion.

Aspirin and non-steroidal anti-inflammatory drugs should be avoided as


these drugs may worsen the bleeding tendency associated with some of these
infections. Patients may receive paracetamol preparations to deal with these
symptoms if dengue is suspected.

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Emerging treatments

Emerging evidence suggests that mycophenolic acid and ribavirin inhibit dengue
replication. Initial experiments showed a fivefold increase in defective viral RNA
production by cells treated with each drug. In vivo studies, however, have not yet
been done.

How can dengue fever be prevented?

Vaccine development

There is no commercially available vaccine for the dengue flavivirus. However,


one of the many ongoing vaccine development programs is the Pediatric Dengue
Vaccine Initiative which was set up in 2003 with the aim of accelerating the
development and introduction of dengue vaccine(s) that are affordable and
accessible to poor children in endemic countries. Thai researchers are testing a
dengue fever vaccine on 3,000–5,000 human volunteers after having successfully
conducted tests on animals and a small group of human volunteers. And, a number
of other vaccine candidates are entering phase I or II testing.

Mosquito control

A field technician looking for larvae in standing water containers during


the 1965 Aedes aegypti eradication program in Miami, Florida. In the 1960s, a
major effort was made to eradicate the principal urban vector mosquito of dengue
and yellow fever viruses, Aedes aegypti, from southeast United States.

Primary prevention of dengue mainly resides in mosquito control. There


are two primary methods: larval control and adult mosquito control. In urban
areas, Aedes mosquitos breed on water collections in artificial containers such as
plastic cups, used tires, broken bottles, flower pots, etc. Continued and sustained
artificial container reduction or periodic draining of artificial containers is the
most effective way of reducing the larva and thereby the aedes mosquito load in
the community. Larvicide treatment is another effective way of control the vector
larvae but the larvicide chosen should be long lasting and preferably have World
Health Organization clearance for use in drinking water. There are some very
effective insect growth regulators (IGR`s) available which are both safe and long
alasting e.g. pyriproxyfen. For reducing the adult mosquito load, fogging with
insecticide is somewhat effective.

Prevention of mosquito bites is another way of preventing disease. This can


be achieved either by personal protection or by using mosquito nets. In 1998,
scientists from the Queensland Institute of Research in Australia and Vietnam's

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Ministry of Health introduced a scheme that encouraged children to place a water
bug, the crustacean Mesocyclops, in water tanks and discarded containers where
the Aedes aegypti mosquito was known to thrive. This method is viewed as being
more cost-effective and more environmentally friendly than pesticides, though not
as effective, and requires the ongoing participation of the community.

Personal protection

Personal prevention consists of the use of mosquito nets, repellents


containing NNDB or DEET, covering exposed skin, use of DEET-impregnated
bednets, and avoiding endemic areas.

Potential antiviral approaches

In cell culture experiments and mice Morpholino antisense oligos have


shown specific activity against Dengue virus.

The yellow fever vaccine (YF-17D) is a vaccine for a related Flavivirus,


thus the chimeric replacement of yellow fever vaccine with dengue has been often
suggested but no full scale studies have been conducted to date.

In 2006, a group of Argentine scientists discovered the molecular


replication mechanism of the virus, which could be attacked by disruption of the
polymerase's work.

We can think of prevention in different words as:

The transmission of the virus to mosquitoes must be interrupted to prevent


the illness. To this end, patients are kept under mosquito netting until the second
bout of fever is over and they are no longer contagious.

The prevention of dengue requires control or eradication of the mosquitoes


carrying the virus that causes dengue. In nations plagued by dengue fever, people
are urged to empty stagnant water from old tires, trash cans, and flower pots.
Governmental initiatives to decrease mosquitoes also help to keep the disease in
check but have been poorly effective.

Wear long pants and long sleeves. For personal protection, use mosquito
repellant sprays that contain DEET when visiting places where dengue is endemic.
Limiting exposure to mosquitoes by avoiding standing water and staying indoors
two hours after sunrise and before sunset will help. The Aedes aegypti mosquito is
a daytime biter with peak periods of biting around sunrise and sunset. It may bite

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at any time of the day and is often hidden inside homes or other dwellings,
especially in urban areas.

There is currently no vaccine available for dengue fever. There is a vaccine


undergoing clinical trials, but it is too early to tell if it will be safe or effective.

What is the outcome with typical dengue?

Typical dengue does not result in death. It is fatal in less than 1% of cases.
The acute phase of the illness with fever and myalgias lasts about one to two
weeks. Convalescence is accompanied by a feeling of weakness (asthenia), and
full recovery often takes several weeks.

Dengue : The ‘Evil Spirit’...

The origins of the word dengue are not clear, but one theory is that it is
derived from the Swahili phrase "Ka-dinga pepo", which describes the disease as
being caused by an evil spirit. The Swahili word "dinga" may possibly have its
origin in the Spanish word "dengue" (fastidious or careful), describing the gait of a
person suffering dengue fever or, alternatively, the Spanish word may derive from
the Swahili. It may also be attributed to the phrase meaning "Break bone fever",
referencing the fact that pain in the bones is a common symptom.

Outbreaks resembling dengue fever have been reported throughout history.


The first definitive case report dates from 1789 and is attributed to Benjamin
Rush, who coined the term "breakbone fever" (because of the symptoms of
myalgia and arthralgia). The viral etiology and the transmission by mosquitoes
were deciphered only in the 20th century. Population movements during World
War II spread the disease globally.

In 2007 replication mechanism of the virus was interrupted by interception


of the viral protease, and currently a project to identify new protease interception
mechanisms of the whole familly of the virus has been launched (Dengue virus
belong to the familly Flaviviridae, which includes among others HCV, West Nile
and Yellow fever viruses). The software and information about the project can be
found at the World Community Grid web site.

What areas are at high risk for contracting dengue fever?

Dengue is prevalent throughout the tropics and subtropics. Outbreaks have


occurred in the Caribbean, including Puerto Rico, the U.S. Virgin Islands, Cuba,
and Central America. Cases have also been imported via tourists returning from

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areas with widespread dengue, including Tahiti, the South Pacific, Southeast Asia,
the West Indies, India, and the Middle East.

Dengue fever is common and may be increasing in Southeast Asia.


Thailand, Vietnam, Singapore, and Malaysia have all reported an increase in
cases. According to the World Health Organization, there are an estimated 50
million cases of dengue fever with 500,000 cases of dengue hemorrhagic fever
requiring hospitalization each year. Nearly 40% of the world's population lives in
an area endemic with dengue.

Though not that much epidemic as other places, yet, Bangladesh is not even
a fresher for dengue. A lot people have suffered and have been suffering, and a
considerable number of people have already died. In this circumstance, we should
treat the issue of dengue as a highly priorative, and knowing about dengue as
much as possible is a must to make prevention against it.

Sources:

1. http://www.medicinenet.com/dengue_fever/page4.htm
2. http://www.phac-aspc.gc.ca/tmp-pmv/2007/dengue070823_e.html
3. http://www.who.int/tdr/publications/publications/pdf/planning_dengue.pdf
4. http://www.cdc.gov/ncidod/dvbid/dengue/
5. http:/www.who.int/topics/dengue/en/
6. http:www.en.wikipedia.org
7. Acosta, Dalia (2006-09-12). "War on Mosquitoes Continues During Global Summit", Inter Press Service.
8. Manson's Tropical Diseases
9. Mandell's Principles and Practices of Infection Diseases
10. Cecil Textbook of Medicine
11. The Oxford Textbook of Medicine
12. Harrison's Principles of Internal Medicine
13. Theiler, Max and Downs, W. G. 1973. The Arthropod-Borne Viruses of Vertebrates: An Account
of The Rockefeller Foundation Virus Program 1951-1970. Yale University Press.
14. Downs, Wilbur H., et al. 1965. Virus diseases in the West Indies. Special edition of the Caribbean
Medical Journal, Vol. XXVI, Nos. 1-4, 1965.
15. Earle, k. Vigors. 1965. "Notes on the Dengue epidemic at Point Fortin." The Caribbean Medical
Journal, Vol. XXVI, Nos. 1-4, pp. 157-164.
16. Hill, A. Edward. 1965. "Isolation of Dengue Virus from a Human Being in Trinidad." Virus
diseases in the West Indies. The Caribbean Medical Journal, Vol. XXVI, Nos. 1-4, pp. 83-84;
"Dengue and Related Fevers in Trinidad and Tobago." Ibid, pp. 91-96.
• Courtesy: Centers for Disease Control and Prevention, Public Health Image Library.

- SAJEEB SARKER
e-mail: sajib.0205@yahoo.com

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