International Journal of Perception in Public Health
Volume 2, Issue 1, December 2017 ISSN-2399-8164
Case Study & Review on Dengue Fever: An Emerging Public
Health Issue
Smit Shah1 ,Rachana Tyagi2, Praful Shah3
1
MS-3 Rutgers Robert Wood John-
son Medical School, New Jersey,
USA.
2
FAANS, Department of Neurosur-
gery, Rutgers Robert Wood John-
son University Hospital, New Jer-
sey, USA
3
General Surgeon, Fellow of Mini-
mal Access Surgery, India.
Citation: Shah, S., Tyagi, R., &
Shah, P. 2017. Case study and Re-
view on Dengue Fever: An Emerg-
ing Public Health Issue. Interna-
tional Journal of Perceptions in
Public Health, 2(1):24-30.
DOI: 10.29251/ijpph.2017124
* Corresponding author:
Smit Shah, MS-3, Rutgers Rob-
ert Wood Johnson Medical
School, New Jersey, USA.112-3G
Montgomery Street, Highland
Park, NJ 08904 USA.
Email:
smits@rwjms.rutgers.edu
www.ijpph.org
24
Review
Abstract
Dengue is an emerging public health concern not
only in Asian subcontinent but also in remote are-
as of world secondary to increase in number of
mosquitoes, congested living facilities & lack of
personal hygiene. Annually, morbidity and mor-
tality secondary to dengue has created significant
public health concerns from a socio-economic
standpoint which requires increased awareness to
general public. In this paper, we discuss a case of a
patient who was diagnosed with dengue in urban
India. Here we elaborate upon various systemic
manifestations of dengue fever and also demon-
strate the progression of this patient throughout
the time course in hospital. In addition, we also
elaborate on an interesting public health model
that has been used to risk stratify areas affected
with Dengue.
Keywords: Emerging, Subcontinent, Hygiene,
Dengue, Public health.
Introduction
Dengue fever is a multisystem disorder caused
due to infection by Dengue virus which is a ssRNA
virus belonging to a Flaviviridae family
(Rodenhuis et. al, 2010; WHO 2009). Many diffe-
rent serotypes of this virus have been recognized
of which NS-1 is the most common and lethal
(Rodenhuis et. al, 2010; WHO 2009). Clinical pre-
sentation of Dengue can vary from being asymp-
tomatic to very severe presenting as fever, joint
pain, muscle aches, skin rash characterized by
erythema and warmth, narrow pulse pressure and
delayed capillary refill. Minority of patients end
up progressing to a more severe form of shock or
hemorrhagic fever which includes additional he-
matological manifestations like pancytopenia
 Shah et al., 2017

bleeding and severe hypotension secondary
to septic shock (WHO 2009).
Transmission of virus occurs via vector
(mosquitoes) Aedes Aegypti which are har-
bored in increased number in stagnant wa-
ter. After infection, multiple different im-
munological factors get activated within
the host. Due to increased viral titers there
is endothelial dysfunction, increased mo-
nonuclear cell replication in Langerhans
cells and splenic macrophages, stimulation
of cross reaction of T cells leading to bone
marrow suppression and coaguloapathies
(Martina et. al, 2009).
It is also possible that local vascular beds
can be a target of dengue virus which can
lead to increased endothelial cell retraction
leading to leakage of vascular contents into
interstitial fluid leading to presentation ve-
ry similar toxic shock syndrome which pre-
sents with hypotension, flushing and se-
vere hemodynamic instability which requi-
red aggressive fluid resuscitation (Martina
et. al, 2009).
Case Details (Patient profile, interven-
tions and outcome)
Patient is a 40 year old male who was
brought to ED due to progressive worsen-
ing joint pain, fever and a red-rash on
different parts of his body since 2 weeks
prior to admission along with chills, nausea
and non-bloody, non-bilious vomiting. Pa-
tient denies any other associated symp-
toms like visual changes, dizziness, chest
pain or shortness of breath. No sick con-
tacts in family or any recent travel. Pa-

Figure 1: LISA Model- Helps is assessment of significant risk based on three temporal indices
namely (1) Frequency, (2) Duration and (3) Severity of Dengue Symptoms

Extreme (Both Target and Neigh-

boring areas have high TI)

High LISA Model Moderate

Target area has low (Local Index of Spatial Autocorrelation) Target area has
TI than neighboring higher TI than
areas neighboring areas

Low
Mild
Target and sur-
Target area has rounding area have
same TI than neigh- low TI
boring areas

Source: Nakhapakorn & Jirakajohnkool (2006)

Volume 2 Issue 1, December 2017

25

tient’s past medical and surgical history is
non-significant. No known drug allergies.
No smoking, drinking or illicit drug use.
Denies taking any medications. Patient
works as a project manager in a local con-
struction work site in India. Review of sys-
tems as per history of present illness men-
tioned above. On physical exam, patient
had mild diffuse abdominal tenderness in
all 4 quadrants, without any rebound ten-
derness; (+) Hepatomegaly 2 to 3 cm below
the right costal margin, (+) Splenomegaly,
(+) Ascites. In addition, there is non-
blanching rash with red discoloration in
the periumbilical area and dorsal aspect of
the forearm and lower extremities bilater-
ally. Capillary refill time was 4 to 5 seconds.
In addition, on musculoskeletal exam,
there was pain upon flexion & extension of
PIP, DIP, knee, hip and elbow joints. Con-
sequently, patient was admitted to the hos-
pital and fluid resuscitation was initiated
with 0.9% NS. Basic labs were ordered in-
cluding complete blood count, complete
metabolite panel and liver function tests.
Significant results on blood work demon-
strated pancytopenia with platelet count
16000, Hemoglobin: 9.7 and WBC: 2800.
Chest X-ray demonstrated bilateral pleural
effusion. Abdominal ultrasound confirmed
hepatosplenomegaly. Dengue was suspect-
ed and NS-1 antigen was ordered which
was positive; IgG was positive and IgM was
positive. This confirmed that patient had a
Table 1: Diagnostic differences between Zika, Chikungunya and Dengue
Fever Rash Conjunctivi- Joint Pain
tis
Zika + +
Chikungunya + +
Dengue + +
26
Shah et al., 2017
primary infection with dengue virus. Im-
mediately, patient was placed on complete
bed rest, given 3 packs of standard platelet
rich plasma (PRP) every day to address
thrombocytopenia and placed on IV hydra-
tion 0.9% NS 100ml/hour. In addition,
broad spectrum antibiotics: Cefoperazon +
sulfa-bactam 1.5gm IV twice a day (BID),
Gentamycin 80 mg IV BID and Moxifloxa-
cin 400 mg IV BID, were initiated to pre-
vent bacterial superinfection. After 14 days
of hospitalization patient returned to his
baseline and was discharged.
Discussion
Dengue is a major public health issue glob-
ally. It has been found that that,
“… estimated that about 2.5 billion individ-
uals, a staggering 40% of the world popula-
tion, inhabit areas where there is a risk of
transmission of DF (Dengue Fever) and
that the disease burden has increased at
least fourfold in the last three decades.
Modelling also suggests that approximately
50–100 million human infections occur an-
nually, of which about 500 000 are DHF
(Dengue Hemorrhagic Fever)”. (Guzman et
al, 2010). Prevention is extremely important
via early detection and reducing rate of
transmission. Best prevention can be
achieved by avoiding travel in endemic are-
as during monsoon when Dengue is the
most prevalent. Further reduction of trans-
mission can occur via use of mosquito
Sign of Sepsis
(Arthralgia/ (Haemorrhage/
Myalgia) Shock)
+
Volume 2, Issue 1, December 2017

sprays multiple times a day in house to
prevent harboring, stay in a well ventilated
cold environment and wear mosquito re-
pellant protection on skin with topical
emollients like permethrin.
Two common modes of transmission of
Dengue are epidemic and hyper-endemic
dengue (Tukasan et. al, 2017). In hyperen-
demic dengue, disease and vectors are al-
ways present in local area and viral strain
circulates either seasonally or all year
around in humid environment which leads
to more infections (Tukasan et. al, 2017). In
contrast, epidemic dengue is an introduc-
tion of new strain brought on by an isolat-
Figure 2 and 3 :The resolution of pancytopenia as the hospital stay progresses. Im-
provement in platelet count, hemoglobin and WBC count from HD 1 thru HD 14
Volume 2, Issue 1, December 2017
Shah et al., 2017
ed transmission from area outside of infec-
tion which starts an infectious cycle
amongst hosts (Tukasan et. al, 2017). We
believe this patient to be affected due to
hyperendemic dengue. However, due to
increase global immigration, it is possible
that dengue strains can become a wide-
spread epidemic or even a pandemic. In
terms of diagnosis NS-1 antigen test has
been used extensively to assess the index of
suspicion of Dengue fever. Study by Para-
navitane et. al, demonstrated rapid NS-1
antigen detection test to be extremely effi-
cient in outpatient setting at bedside and
had comparable sensitivity and specificity
27

to NS-1 antigen capture ELISA (Murray et.
al, 2013). In addition, presence of NS-1 anti-
gen is extremely important in predicting
high clinical severity of disease. Recently, it
has been found that NS-1 antigen induces
pathogenesis by induction of interleukin
10. (Adikari et. al, 2016).
In addition, the symptom of “fever” has
been proven to be the most significant pre-
dictor in terms of diagnosis for patients
with Dengue infection and stratifying pa-
tients in low vs high risk. For instance, in a
recent retrospective study “Disease classifi-
cation was found to associate significantly
with both fever and time to treatment
(both P < 0.001). Non-febrile patients were
nearly four-fold more likely to exhibit
“dengue without warning signs” than
“severe dengue” (odds ratio [OR] = 3.74;
95% confidence interval [CI]: 3.20–
4.36)” (Hafeez et. al, 2017). In the same
study interestingly, “Patients who received
treatment within 7 days were twice as like-
ly to have ‘dengue without warning signs’
as opposed to “severe dengue” when com-
pared to those who waited >7 days (OR =
2.23; 95% CI: 1.78–2.80)” (Hafeez et. al,
2017) . So it is important for clinicians to
have a high index of suspicion for Dengue
infection if a patients presents to them
with a recent travel history from a dengue
affected endemic area. Other factors that
determine prognosis should include old
age and low oxygen saturation and other
including septic shock, sepsis and pneumo-
nia.
From a public health standpoint, many
different models have been developed that
help in ensuring better preventative meas-
ure. One of them being LISA (Local Index
of Spatial Autocorrelation) which takes in-
to consideration many demographic factors
for developing a TI (Temporal Index): (1)
Frequency index, (2) duration index to as-
sess severity of epidemics and (3) severity
index (Teparrukkul et al, 2017). This model
has enabled public health researchers to
divide the dengue affected areas into 5 ma-
jor subtypes: demonstrated in Figure 1.
28
Shah et al., 2017
Biggest challenge with this patient was ad-
dressing thrombocytopenia and ensure its
resolution over time with treatment. As we
can see in the figures II and III, it took 14
days of hospital stay for this patient to get
back to baseline hematological status. Res-
olution and improved bone marrow re-
sponse can be monitored by serial physical
examinations to look for elimination of
rash (Figure I), ascites and joint pain. In
addition, it is important to rule out disor-
ders like chikungunya which has similar
presentation but has the hallmark of bone
breaking fever without pancytopenia. With
growing incidence of Zika virus in US
(which is also transmitted by A. Aegypti),
Dengue and Chikungunya should always
be considered in clinical decision making.
Conclusion
In summary, we have presented a case re-
port of a patient who was diagnosed with
Dengue based fever and successfully recov-
ered in 2 weeks secondary to aggressive hy-
dration therapy and preventative measures.
In addition, we have also discussed LISA
model that can be used on a global scale to
stratify areas depending on the level of
risks that can enable public health officials
to prioritize areas of treatment. And finally,
we have also elaborated on how one can
clinically diagnose Dengue based on physi-
cal exam (with a characteristic rash) and
blood work.
Learning Points
 Elaborate on clinical presentation of
patients with Dengue fever.
 Discuss clinical progression and treat-
ment options of a patient with Den-
gue.
 Discuss an interesting clinical model
used to stratify areas affected with
dengue.
Ethical Information
Patient consent was obtained in order to
acquire images for educational purposes
and patient privacy was preserved through
Volume 2, Issue 1, December 2017
 Shah et al., 2017

the case study.

Conflict of Interest
The authors declared no conflicts of inter-
est with respect to the research, authorship
and/or publication of this
Funding
Self funded

Arrows in image above demonstrate a characteristic rash with red discoloration on the
upper & lower extremities along with abdomen. Rash is used clinically to ensure remis-
sion of patient from dengue fever after initiation of treatment.

Volume 2, Issue 1, December 2017

29
 Chowdhury
Shah et
etal.,
al. 2017

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