DENGUE INFECTION

Isbandiyah, dr, SpPD

 Epidemiology

• In India first outbreak of dengue was recorded in 1812

• A double peak hemorrhagic fever epidemic occurred in India for the first
time in Calcutta between July 1963 & March 1964

• In New Delhi, outbreaks of dengue fever reported in 1967,1970,1982, &1996

 Dengue Virus
1. Causes dengue and dengue hemorrhagic fever
2. It is an arbovirus
3. Transmitted by mosquitoes
4. Composed of single-stranded RNA
5. Has 4 serotypes (DEN-1, 2, 3, 4)
 DENGUE VIRUS INFECTION

Asymptomatic Symptomatic

Dengue
Haemorrhagic fever
Undiffrentiated fever Dengue fever
(viral syndrome) (syndrome)
(Plasma
Dengue Fever leakage)

Dengue Shock
Syndrome (DSS)
No Shock
Dengue
Haemorrhagic fever
 Clinical manifestation
• Asymptomatic
• Dengue fever
• Dengue hemorrhagic fever
• Dengue shock syndrome

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 Dengue fever
• Acute febrile illness with two or more of the following
– Headache, retro-orbital pain, myalgia,
arthralgia, rash, hemorrhagic manifestation,
leukopenia
• Lab for confirmation
– Isolation of dengue virus, fourfold rising in
reciprocal IgG or IgM, PCR (genomic
sequence), immunostaining (dengue antigen)

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 Dengue hemorrhagic fever
• Fever (last 2-7 days), occasionally biphasic
• Hemorrhagic tendency
 Tourniquet test, petechiae, bleeding from mucosa
 Enlargement of the liver (hepatomegaly)

• Thrombocytopenia (< 100,000 cell/mm3)

• Evidence of plasma leakage
– Hct increase >20%, Hct drop >20% after
volume replacement, pleural effusion, ascites,
hypoproteinaemia

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 Dengue hemorrhagic fever
Febrile phase
– High fever 2-7 days
– Facial flushing, skin erythema, myalgia, arthralgia, headache, nausea, vomiting, sore
throat, injected pharynx, conjunctival injection and diarrhea.
– Leucopenia, mild thrombocytopenia

Critical phase (Leakage phase)

– Heralded by the onset of plasma leakage
– Occurs towards the late febrile phase, after 3rd fever, usually 5th – 6th day fever, last
for 24-48 hr

Convalescent phase (recovery phase)

– Starts after the end of the critical phase and usually lasts 2-5 days.
– Signs of overload (respiratory distress due to pulmonary oedema or large
pleural effusions) if excessive IV fluids in critical phase 8
 Dengue shock syndrome
• Evidence of circulatory failure
• Narrow pulse pressure < 20
mmHg
• Hypotension
• Rapid and weak pulse
• Cold, calmy skin, restlessness
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 Tourniquet Test
• Fever day 1 50%
• Fever day 2 70%
• Fever day 3 > 90%
False negative TT
• Obese patients
• Thin patients
• Not good technique
• During shock

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 Dengue Diagnosis

1. Virus isolation
2. Viral DNA detection by reverse
transcription-PCR
3. Serological test :
ELISA, Rapid test
4. NS-1 Ag

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 Indications for admission
• Shock
• Platelet 100,000 cells/cumm. c no
good clinical conditions; poor appetite..
• High risk patients: Obese, infants, bleeding,
underlying diseases, consciousness change
• No care-taker
• Live far away
• Mass-media families

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 Warning signs of shock
• Clinical deterioration/ not improve when no
fever/ low
grade fever
• Abdominal pain
• Vomiting
• Restless, shortness of breath, persistent crying
in infants
• Sweating, cold clamy skin
• Behavior change, drowsy
• No urine 4 - 6 hours
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 Prolonged shock
• > 10 hours untreated - Death!!!
• > 4 hours untreated
• Liver failure- prognosis 50%
• Liver + Renal failure – prognosis 10%
• 3 organs failure (+respiratory
• failure) – Prognosis is a miracle!!!
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Algorithm for fluid management in compensated shock

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Algorithm for fluid management in hypotensive shock

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Platelet and Fresh Frozen Plasma Transfusion

• Prophylatic transfusions of platelet and FFP is

not recommended
o Platelet transfusions :
required for pts thrombocytopenia who is undergo urgent
surgery, active bleeding which continues in spite of repeated
blood transfusions, DIC or intracranial haemorrhage.
o FFP transfusions :
Dengue pts with hepatic encephalopathy and active bleeding

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 Criteria for discharging patients
1. Absence of fever for at least 24 hours without the use of anti-
fever therapy.
2. Return of appetite.
3. Visible clinical improvement.
4. Satisfactory urine output.
5. A minimum of 2–3 days have elapsed after recovery from
shock.
6. No respiratory distress from pleural effusion and no ascites.
7. Platelet count of more than 50 000/mm3.
 If not, patients can be recommended to avoid traumatic activities for at least 1–2 weeks
for platelet count to become normal
 In most uncomplicated cases, platelet rises to normal within 3–5 days.

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Programs to Minimize the Impact of Epidemics

•Education of the medical community

•Implementation of emergency contingency plan

•Education of the general population