1

Introduction
• Dengue is a febrile illness caused by a flavivirus transmitted by mosquitoes

• It is endemic in Asia, the Pacific, Africa and the Americas

D • The principal vector is the mosquito Aedes aegypti
E
• Aedes albopictus is a vector in some South-east Asian countries
N
G • There are four serotypes of dengue virus, all producing a similar clinical syndrome

U (DENV-1,DENV-2,DENV-3,DENV-4)
E

2
 Pathogenesis
• Dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) occur in
individuals who are immune to one dengue virus serotype and are then infected

D with another.

E • Prior immunity results in increased uptake of virus by cells expressing the antibody
N Fc receptor and increased T-cell activation with resultant cytokine release, causing
G capillary leak and disseminated intravascular coagulation
U
E

3
 Pathogenesis

D
E
N
G
U
E

4
 Clinical Features
Three phases:

1. Febrile phase (2 – 7 days)

D 2. Critical phase (day 3 – day 7)
E
3. Convalescent phase
N
G
U
E

5
 Clinical features
Incubation period

• 2–7 days
D Prodrome
E • 2 days of malaise and headache
N
Acute onset
G
U • Fever, backache, arthralgias, headache, generalised pains (‘break-bone fever’),

E pain on eye movement, lacrimation, scleral injection, anorexia, nausea, vomiting,

pharyngitis, upper respiratory tract symptoms, relative bradycardia, prostration,
depression, hyperaesthesia, dysgeusia, lymphadenopathy
6
 Clinical Features
Fever

• Continuous or ‘saddle-back’, with break on 4th or 5th day and then

D recrudescence; usually lasts 7–8 days
E Rash
N
• Initial flushing faint macular rash in first 1–2 days.
G
• Maculopapular, scarlet morbilliform blanching rash from days 3–5 on trunk,
U
spreading centrifugally and sparing palms and soles; onset often with fever
E
defervescence.

• May desquamate on resolution or give rise to petechiae on extensor surfaces

7
 Clinical Features

D
E
N
G
U
E

8
 Clinical Features
• Convalescence

• Slow and may be associated with prolonged fatigue syndrome, arthralgia or

D depression
E
N
G
U
E

9
 Complications
• Dengue haemorrhagic fever and disseminated intravascular coagulation

• Dengue shock syndrome

D • Severe organ involvement
E
• Vertical transmission if infection within 5 weeks of delivery
N
G
U
E

10
Probable dengue fever Dengue with warning signs Severe dengue
• Exposure in an endemic area • Probable dengue plus one of : 1. Severe plasma leakage leading to:
• Fever Shock (dengue shock syndrome)
• Two of: » Abdominal pain or tenderness Fluid accumulation with respiratory distress
Nausea/vomiting » Persistent vomiting 2. Severe haemorrhagic manifestations, e.g.
Rash » Signs of fluid accumulation, e.g. gastrointestinal haemorrhage

D
Aches/pains pleural effusion or ascites 3. Severe organ involvement (atypical features):
Positive tourniquet test » Mucosal bleed » Liver AST or ALT ≥ 1000 U/L
E
Leucopenia » Hepatomegaly > 2 cm » CNS: impaired consciousness,
» Rapid increase in haematocrit meningoencephalitis, seizures
N
*Laboratory confirmation important with fall in platelet count » Cardiomyopathy, conduction defects,
G regular medical observation
*Needs arrhythmias
and instruction in the warning signs *Needs medical intervention, e.g. » Other organs, e.g. acute kidney injury,
U
*If there are no warning signs, need intravenous fluid pancreatitis, acute lung injury, disseminated
forEhospitalization is influenced by intravascular coagulopathy, rhabdomyolysis
age, comorbidities, pregnancy and
social factors *Needs emergency medical treatment and
specialist care with intensive care input
11
 Tourniquet Test
1. Take the patient's blood pressure and record it,
for example, 100/70.

D 2. Inflate the cuff to a point midway between SBP

E and DBP, and maintain for 5 minutes, (100 + 70) ÷
N 2 = 85 mm Hg
G
3. Reduce and wait 2 minutes.
U
4. Count petechiae below antecubital fossa.
E
• A positive test is 10 or more petechiae per 1

12 square inch.
 Clinical Features

D
E
N
G
U
E

13
 Previous Classification

D
E
N
G
U
E

14
 Lab features
• Hematocrit

• Leucopenia, neutropenia, thrombocytopenia and elevated alanine aminotransferase

D (ALT) or aspartate aminotransferase (AST).
E
N
G
U
E

15
 Diagnosis
• Dengue NS1 Ag by ELISA day 1 to day 5

• Dengue IgM day 5 onwards

D • PCR
E
N
G
U
E

16
D
E
N
G
U
E

17
 Management- Mild Dengue

D
E
N
G
U
E

18
 Management – Moderate Dengue

D
E
N
G
U
E

19
 Management – Moderate Dengue

D
E
N
G
U
E

20
 Management – Severe Dengue

D
E
N
G
U
E

21
 Prevention

D
E
N
G
U
E

22
 Management At PHC Level

D
E
N
G
U
E

23