DENGUE FEVER

World Distribution of Dengue 1999

Areas infested with Aedes aegypti

Areas with Aedes aegypti and recent epidemic dengue
 Infants and Young Children

- undifferentiated febrile disease

- maculopapular rash
 Older Children and Adult

high fever
headache

retro orbital pain

Myalgia
nausea
/vomiting

Rash

Arthralgia
Laboratory Results

• Leukopenia
• Thrombocytopenia
 Manifestation of Dengue Virus Infection

Dengue virus infection

Asymptomatic Symptomatic

Dengue Haemorrhagic Fever

Undifferentiated Dengue Fever
(Plasma Leakage)
Fever Syndrome
(viral syndrome)

Without With No Shock Dengue Shock

Haemorrhage Unusual Syndrome
Haemorrhage

Dengue Fever Dengue Fever

Dengue Hemorrhagic Fever

4 Major Clinical Manifestations:

1. high fever

2. hemorrhagic phenomenon

3. hepatomegaly

4. circulatory failure
 Dengue Hemorrhagic Fever

Labs: Moderate to marked thrombocytopenia

: Hemoconcentration

Major Pathophysiological change: plasma leakage

THE SEVERITY OF THE DISEASE CAN BE
MODIFIED BY EARLY DIAGNOSIS AND
REPLACEMENT OF PLASMA LOSS
DENGUE SHOCK SYNDROME

1.Rapid weak pulse

2.Narrowing of Pulse pressure<20mmHg
3.Cold clammy skin
4.Restlessness
5.Pleural effusion and ascites
6.Metabolic acidosis
7.Gastrointestinal bleeding
8.Encephalopathy
Labs: Thrombocytopenia below 100,000 permm3
Hemoconcentration increase of 20%
Leukopenia
Neutropenia>Recovers within 2-3days
>Good Urine
CONVALESCENCE
Albuminuria Output and
IN PATIENTS WITHReturn of
CORRECTED
Appetite
DSS
Reduction of fibrinogen,prothrombin, factor VIII,XII
Reduction of levels of Factors V,VII,
>Herman’s SignIX and X
Prolonged Partial thromboplastin time and prothrombin time
>Bradycardia/Cardiac Arrythmia
Reduced C3
Hypoproteinemia
Hyponatremia
Metabolic Acidosis
Pleural Effusion
COMPLICATIONS AND UNUSUAL MANIFESTATIONS

CNS Phenomena

Encephalopathy

Intracranial Bleeding and brain stem herniation

Sepsis, Pneumonia, Wound Infection, Overhydration

Liver Failure

Acute Renal Failure and Hemolytic Uremic Syndrome

 CASE DEFINITION FOR DENGUE FEVER

-an acute febrile illness with two or more of the following

manifestations:

--headache
--retro-orbital pain
--myalgia
--arthralgia
--rash
--hemorrhagic manifestations
--leukopenia
--Positive IgM Antibody test on a late acute or convalescent-phase
 CASE DEFINITION FOR DENGUE HEMORRHAGIC
FEVER

--fever lasting 2-7days

--hemorrhagic tendencies
-positive tourniquet test
-petechiae, ecchymoses or purpura
-bleeding from mucosa, gastrointestinal tract
-hematamesis or melena
--thrombocytopenia(<100,000 cells per mm3)
--evidence of plasma leakage
-hemoconcentration
-pleural effusion, ascites and hypoproteinemia
CASE DEFINITION FOR Dengue Shock Syndrome

All the four criteria for DHF plus

--rapid and weak pulse

--narrow pulse pressure(<20mmHg)
--hypotension
--cold clammy skin and restlessness
 Dengue Infection

Fever Positive Increased Vascular Hepatomegaly Thrombocytopenia Grade 1

Tourniquet test Permeability

Other Haemorrhagic
Grade 2
manifestations Leakage of plasma

Hypovolaemia

Coagulopathy Grade 3

Shock Disseminated
Intravascular
coagulation
Grade 4

Severe Bleeding

DEATH
Positive Tourniquet Test
 GRADING SEVERITY OF
Dengue Hemorrhagic Fever

GRADE I: Fever + non-specific constitutional symptoms

+ positive tourniquet test
And or easy bruising
GRADE ll: All manifestations of Grade I + Spontaneous Bleeding
GRADEIII Circulatory failure
GRADEIV Profound shock with undetectable blood pressure or pulse
 Management and treatment

• 1.Plasma expander or fluid and electrolyte

solution
• 2.Fluid administration
7.Check vital signs 1-2hours
•8.Monitor
3.Correction
urineof metabolic and electrolyte
output
disturbance
9.D5Lr/Dextran
•10.Sedatives
4.Early recognition of shock
•11.Oxygen
5.Repeat therapy
hematocrit and platelet count
12.Blood Transfusion
determination
• 6.Antipyretics
ESSENTIAL LABORATORY TESTS

-Hematocrit and Platelet count

-Serum electrolytes and blood gas
studies
-prothrombin time, partial
thromboplastin time and thrombin time
-liver function tests
 5% Fluid Deficit

Initiate Intravenous Therapy 5%

glucose in physiological saline

Improvement No improvement

Reduce IV Therapy VS or Hct worsen Increase IV Therapy

Improvement Improvement No improvement

Reduce IV Therapy Increase IV Therapy

Further Improvement Unstable VS, Urine

output falls, sign of
shock
Discontinue IV therapy
after 24-48 hrs Establish Central venous
access and urinary catheter,
administer rapid fluid bolus

VS and Hct Stable

adequate diuresis Hct Rises (or Distress) Hct Falls

Intravenous Colloid therapy Blood Transfusion

Improvement
 UNSTABLE VS, Urine output falls,
sign of shock

Immediate rapid volume replacement 10-20ml.kg-1 LR, Ringer’s

lactate, Ringer’s acetate or 5 % glucose diluted in physiological
saline, as intravenous bolus(repeat if necessary)

Improvement No improvement

Adjust Intravenous Therapy Oxygen

Hct Rises (or Distress)

Hct Falls

Blood transfusion 10-20 ml.kg-1 plasma,

plasma subsitute or 5%
(10ml.kg-1 if Hct is still >35%)
albumin, as intravenous
bolus(repeat if
necessary)
 INDICATIONS FOR HOSPITALIZATION

Signs of Significant dehydration

>Tachycardia
>Increased Capillary refill time(>2s)
>Cool,mottled or pale skin
>Diminished peripheral pulses
>Changes in mental status
>Oliguria
>Hemoconcentration
>Narrowing of pulse pressure
>Hypotension
Criteria for
DISCHARGING >Absence of fever for at least
INPATIENTS 24 hours without the use of
antipyretics
>Return of appetite
>Visible clinical improvement
>Good urine output
>Stable hematocrit
>Passing at least 2 days after
recovery from shock
>No respiratory distress from
pleural effusion/ascites
>Platelet count of more than
50,000per mm3
 The End
A lecture in Dengue Fever by