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DENGUE FEVER

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What is dengue fever?
Dengue fever (DF) is caused by any of four
closely related viruses, or serotypes: dengue
1-4. Infection with one serotype does not
protect against the others, and sequential
infections put people at greater risk for
dengue hemorrhagic fever (DHF) and dengue
shock syndrome (DSS).
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most commonly an acute febrile illness
presence of fever and two or more of the
following:
retro-orbital or ocular pain
Headache
Rash
Myalgia
Arthralgia
Leukopenia
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hemorrhagic manifestations (e.g., positive
tourniquet test, petechiae;
purpura/ecchymosis; epistaxis; gum
bleeding; blood in vomitus, urine, or stool;
or vaginal bleeding) but not meeting the
case definition of dengue hemorrhagic
fever.
anorexia, nausea, abdominal pain, and
persistent vomiting may also occur but are
not case-defining criteria for DF.
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What is dengue hemorrhagic fever?
Fever lasting from 2-7 days
Evidence of hemorrhagic manifestation or a
positive tourniquet test
Thrombocytopenia (100,000 cells per mm3)
Evidence of plasma leakage shown by
hemoconcentration (an increase in hematocrit
20% above average for age or a decrease in
hematocrit 20% of baseline following fluid
replacement therapy), or pleural effusion, or
ascites or hypoproteinemia.
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What is dengue shock syndrome?
Dengue shock syndrome has all of
criteria for DHF plus circulatory failure
as evidenced by:
Rapid and weak pulse and narrow pulse
pressure (<20mm Hg), or
Age-specific hypotension and cold, clammy
skin and restlessness.

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Epidemiology

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Transmission
Dengue is transmitted between people by the
mosquitoes Aedes aegypti and Aedes
albopictus, which are found throughout the
world.
Symptoms of infection usually begin 4 - 7 days
after the mosquito bite and typically last 3 - 10
days.
In order for transmission to occur the
mosquito must feed on a person during a 5-
day period when large amounts of virus are in
the blood;
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After entering the mosquito in the blood
meal, the virus will require an additional
8-12 days incubation before it can then
be transmitted to another human. The
mosquito remains infected for the
remainder of its life, which might be days
or a few weeks.
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Pathogenesis
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1. Vascular permeability
Loss of plasma from vascular compartment
Hemoconcentration
Low pulse pressure
2. Disorder in hemostasis
Vascular changes
Thrombocytopenia
coagulopathy

Symptoms
Dengue without Warning Signs
Fever and two of the following:
Nausea, vomiting
Rash
Aches and pains
Leukopenia
Positive tourniquet test

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Dengue with Warning Signs**
Dengue as defined above with any of the
following:
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation (ascites, pleural effusion)
Mucosal bleeding
Lethargy, restlessness
Liver enlargement >2 cm
Laboratory: increase in HCT concurrent with rapid
decrease in platelet count
**requires strict observation and medical
intervention

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Dengue with at least one of the following
criteria:
Severe Plasma Leakage leading to:
Shock (DSS)
Fluid accumulation with respiratory distress

Severe Bleeding as evaluated by clinician
Severe organ involvement
Liver: AST or ALT 1000
CNS: impaired consciousness
Failure of heart and other organs

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Symptoms
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1. Febrile phase
Patients typically develop a high-grade fever
suddenly.
This acute febrile phase usually lasts 27 days
accompanied by facial flushing, skin erythema,
generalized body ache, myalgia, arthralgia,
retro-orbital eye pain, photophobia,
rubeliform exanthema and headache
Anorexia, nausea and vomiting are common.
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2. Critical phase
patients with increased capillary
permeability
Temperature drops to 37.538C or less
and remains below this level, usually on
days 38 of illness.
Progressive leukopenia
rapid decrease in platelet count usually
precedes plasma leakage

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An increasing hematocrit above the
baseline.
The period of clinically significant
plasma leakage usually lasts 2448
hours.
A rising hematocrit precedes changes
in blood pressure (BP) and pulse
pressure.
Warning Signs:
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days 37 of illness
Persistent vomiting and severe abdominal pain
becomes increasingly lethargic but usually
remains mentally alert.
Weakness, dizziness or postural hypotension.
Spontaneous mucosal bleeding or bleeding at
previous venipuncture sites
Increasing liver size and a tender liver is
frequently observed.
A rapid and progressive decrease in platelet
count to about 100 000 cells/mm3 and a rising
hematocrit above the baseline may be the
earliest sign of plasma leakage. This is usually
preceded by leukopenia ( 5000 cells/mm3)
Symptoms
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3. Recovery phase
a gradual reabsorption of extravascular compartment fluid
takes place in the following 4872 hours.
General well-being improves, appetite returns,
gastrointestinal symptoms abate, haemodynamic status
stabilizes, and diuresis ensues.
isles of white in the sea of red
Some may experience generalized pruritus.
Hematocrit stabilizes or may be lower due to the dilutional
effect of reabsorbed fluid.
The white blood cell count usually starts to rise
Respiratory distress from massive pleural effusion and ascites,
pulmonary edema or congestive heart failure
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Diagnosis
CLINICAL FINDINGS
Indicators of DHF/DSS:
High fever of acute onset
Hemorrhagic manifestations (at least +
tourniquet test)
shock

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Diagnosis
LABORATORY FINDINGS
Thrombocytopenia (100,000 cells/mm3)
Hemoconcentration (Hct elevated at least
20% above average)


2 clinical + 1 laboratory = sufficient to
establish a provisional diagnosis of DHF

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Diagnosis
For virus isolation or detection of DENV RNA
Serum specimens by serotype-specific, real-time
reverse transcriptase polymerase chain reaction
(RT-PCR), an acute-phase serum specimen should
be collected within 5 days of symptom onset.
Serologic diagnosis:
a convalescent-phase serum specimen is needed
at least 6 days after the onset of symptoms
IgM antibodies to dengue with an IgM antibody-
capture enzyme-linked immunosorbent assay
(MAC-ELISA).
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Management
GROUP A
able to tolerate adequate volumes of oral fluids, pass urine at
least once every six hours and do not have any of the warning
signs
bed rest and frequent oral fluids.
Patients with 3 days of illness should be reviewed daily for
disease progression
(indicated by decreasing white blood cell and platelet counts
and increasing hematocrit, defervescence and warning signs)
until they are out of the critical period.
Encourage oral intake to replace fluid loss from fever and
vomiting
Small amounts of oral fluids should be given frequently for
those with nausea and anorexia.
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Management
Oral rehydration solution or soup and fruit juices may be
given to prevent electrolyte imbalance.
Commercial carbonated drinks that exceed the isotonic level
(5% sugar) should be avoided.
Sufficient oral fluid intake should result in a urinary frequency
of at least 4 to 6 times per day.
Give paracetamol for high fever if the patient is
uncomfortable.
The recommended dose is 10 mg/kg/dose, not more than 34
times in 24 hours in children and not more than 3 g/day in
adults).
Do not give acetylsalicylic acid (aspirin), ibuprofen or other
non-steroidal anti-inflammatory agents (NSAIDs) or
intramuscular injections, as these aggravate gastritis or
bleeding.
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Management
Group B
patients with warning signs, those with co-existing
conditions that may make dengue or its
management more complicated (such as pregnancy,
infancy, old age, obesity, diabetes mellitus,
hypertension, heart failure, renal failure) and those
with certain social circumstances (such as living
alone, or living far from a health facility without
reliable means of transport).
Rapid fluid replacement in patients with warning
signs is the key to prevent progression to the shock
state.
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Management
Obtain a reference hematocrit
Give only isotonic solutions such (0.9% saline,
Ringer's lactate).
Start with 57 ml/kg/hour for 12 hours, then
reduce to 35 ml/kg/hour for 24 hours, and then
reduce to 23 ml/kg/hour or less according to the
clinical response
Reassess the clinical status and repeat the
haematocrit.
If the haematocrit remains the same or rises only
minimally, continue at the same rate (23
ml/kg/hour) for another 24 hours.
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Management
If the VS are worsening and the Hct is rising
rapidly, increase the rate to 510 ml/kg/hour
for 12 hours.
Intravenous fluids are usually needed for only
2448 hours.
Reduce intravenous fluids gradually when the
rate of plasma leakage decreases towards the
end of the critical phase.
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Management
Parameters that should be monitored include:
vital signs and peripheral perfusion (14 hourly),
urine output (46 hourly)
Hct (before and after fluid replacement,
then 612 hourly)
blood glucose
other organ functions
(such as renal profile, liver profile, coagulation
profile, as indicated).


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Management
GROUP C
emergency treatment and urgent referral because
they are in the critical phase of the disease and have:
severe plasma leakage leading to dengue shock
and/or fluid accumulation with respiratory distress;
severe hemorrhages
severe organ impairment (hepatic damage, renal
impairment, cardiomyopathy, encephalopathy or
encephalitis).
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Management
Judicious intravenous fluid resuscitation is the
essential and usually sole intervention required.
All shock patients should have their blood group
taken and a cross-match carried out.
Blood transfusion should be given only in cases with
established severe bleeding, or suspected severe
bleeding.
Larger volumes of fluids (e.g. 1020 ml/kg boluses)
are administered for a limited period of time under
close supervision, to evaluate the patients response
and to avoid the development of pulmonary edema.
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Management
Goals of fluid resuscitation:
improving central and peripheral circulation i.e.
decreasing tachycardia, improving BP and pulse
volume, warm and pink extremities, a capillary refill
time < 2 seconds;
improving end-organ perfusion i.e. achieving a
stable conscious level (more alert or less restless),
and urine output 0.5 ml/kg/hour or decreasing
metabolic acidosis
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Prevention
Environmental Management
Biological Control
Chemical Control
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Sources:
WHO
Center for Disease Control
DOH
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