Pearls and Pitfalls

in Diagnosis & Management of

Dengue Cases
Eggi Arguni
UKK Infeksi dan Penyakit Tropis
Topics
Dengue
Dengue course of
classification
infection
WHO 2009

Pearls and pitfalls

Take home
of diagnosis and
messages
management
Course of Illness in Dengue Infection
 Dengue Case Classification
1997 2009 2011
Dengue fever Dengue without Dengue fever (no
(no plasma leakage) warning signs plasma leakage)
DHF grade I (no shock) DHF grade I (no shock)
DHF grade II (no shock, Dengue with warning DHF grade II (no shock,
spontaneous bleeding) signs spontaneous bleeding)
DHF grade III/DSS DHF grade III /DSS
(dengue shock (dengue shock
syndrome) Severe dengue syndrome)
DHF grade IV (DSS (severe plasma DHF grade IV
with profound shock) leakage, hemorrhage,
organ involvement) Expanded dengue
syndrome (unusual
manifestation, organ
involvement, co-
morbidity
4/4/19 4
Adult management Adult management
Pitfalls: many disease resembling dengue
• Especially in febrile phase
• Be aware of DAY OF FEVER!
• Knowing the exact hours of fever onset is crucial
• Re-anamnesis…… re-anamnesis
• Parents may not aware
• Parents usually did not use any thermometer --> not sure about the fever onset and pattern

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Conditions that mimic the febrile phase of dengue
Pearls and pitfalls: abdominal pain
Pearls:
• Abdominal pain should be considered a warning sign when it becomes the chief complaint
• Could be as severe as in a surgical abdomen
• If in doubt, check the CBC for leukopenia, thrombocytopenia and/or raised HCT

Pitfalls:
• vigorous intravenous fluid therapy, patients with increased capillary permeability  ascites.
• Tense abdomen due to ascites + liver congestion can cause abdominal pain;
• Consider fluid overload instead!
• If IV fluid therapy increases, this can cause acute pulmonary oedema
Pearls: Persistent vomiting
• Vomiting is a common symptom in viral illnesses and in the early febrile phase of dengue.
• What is persistent vomiting?
• Persistent vomiting > 3 times / day
• Patient is not able to tolerate oral fluid.
• What does persistent vomiting signify?
• Important sign of plasma leakage
• May cause dehydration  even worsen the condition of plasma leakage
Pearls: lethargy
• When is lethargy is more than usual?
• Patient is confined to bed for most of the day.
• Patient sleeps most of the time.
• Patient is uninterested in food or television.
• Patient is too weak to walk to toilet.

Remember !
restlessness = severe shock + cerebral hypoperfusion
Pearls: laboratory warning signs
Leukopenia
• Occurs 24 hours before rapid decrease in platelet count
• Not predictive of plasma leakage
• Good indicator that patient could have dengue

Rapid decrease in platelet count + rising trend in haematocrit

• Occur shortly before or at defervescence
• May precede changes in blood pressure and pulse pressure
• Indicate an increase in vascular permeability

NOTE: Changes in haematocrit may be masked by IV fluid therapy

Pearls and pitfalls: laboratory
dengue biological markers
• False negative may lead to wrong diagnosis and
management
• NS1 for dengue antigen  NOT MORE than day 3th of fever
• IgG IgM anti dengue  NOT LESS than day 5th of fever
Pitfalls: platelet transfusion
• Children are at a higher risk of mucosal bleeding and severe dengue
• Blood transfusion should be given only in cases with suspected/severe bleeding
• Inappropriate transfusion of fresh-frozen plasma, platelet concentrates may cause volume
overload
• Mucosal bleeding (e.g. epistaxis) should be considered as minor.
• In patients with profound thrombocytopaenia, ensure strict bed rest and protect from trauma to
reduce the risk of bleeding
• Prophylactic platelet transfusions for severe thrombocytopaenia in otherwise haemodynamically
stable patients have not been shown to be effective and are not necessary
Fig 1. Platelet trend between treatment groups.
 Pearls and pitfalls: dengue shock
Dengue shock presents as a physiologic-time continuum

Decompensated shock In the late stages

Compensated shock in the early stage
(hypotension & unrecordable blood
(normal or elevated blood pressure)
pressure)

Compensated Hypotensive Cardiac

Stable Warning signs
shock shock arrest

• Delayed treatment leads to a clinical course complicated by severe bleeding and organ impairment.
• Severe bleeding will exacerbate the shock state and if unrecognized will cause refractory and irreversible shock
with a very poor outcome
Pitfall: Why is it easy to miss dengue shock?
• Even in the severe shock state, the patient appears deceptively normal or “stable” with a lucid
conscious level.
• A careful physical examination is critical to recognizing a patient in shock before the stage of
cardiovascular collapse.
Pearls: clinical examination in dengue patient

Hold the patient’s hand to evaluate peripheral perfusion

Save life in 30 seconds by recognizing shock
Take home massage
• Pay attention to pearls that will make us more accurate in determining diagnosis
and treatment
• Avoid pitfalls by understanding the pathophysiology of the course of dengue
infection

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