CASE 6:

• A 5 year old patient was admitted because of fever for 3 days, he was
brought to the emergency room where cbc with platelet was done and NS1
was (+). Patient was admitted, venoclysis was started and cbc monitored. On
third hospital day, patient was 12 hours afebrile when he was noted to have
cardiac rate of 45, bp papatory, CRT 3 seconds. He was given PNSS at 20 cc/g
for 20 minutes, which improved BP to palpatory 100. He was transferred to
PICU, another 20 cc/kg was given. BP did not improved. He was given
another 20 cc/kg. BP went down to 80 palpatory. Dopamine started at
10mcg/kg/minute at the PICU
• BP 90 palpatory, CR 40, temperature 37, weight 20kg
• Distended neck vein
• No intercostal retraction, decreased breath sound right base, no murmur,
distant heart sound
• Distended abdomen, liver 4 cm below right subcostal margin
• Thready pulse with CRT at 3 seconds
PERTINENT FINDINGS and PATHO

• FEVER – fever is a sign of infection, microbial antigen will activate the inflammatory
mediators and causes immune response leading to production of pyrogenic cytokines (IL1,
IL2, TNF, IFN) in circulation that will affect the hypothalamic endothelium by producing
PGE2 that will activate cAMP causing elevated thermoregulatory set point
• NS1 (+) – present in the serum of dengue infected person directly at the onset of clinical
symptoms that produces strong humoral response
• Afebrile on third day – this is the most critical stage of dengue fever where most severe
conditions may occur in patient such as severe organ impairment, severe plasma leakage,
severe hemorrhage
• Cardiac rate of 45 – one of the complication of dengue fever is myocarditis leading to
development of dilated cardiomyopathy which lessens the ability of the heart to pump
leading to decrease HR and cardiac output
• Palpatory BP: is a sign of shock due to intravascular fluid loss that is associated with
increase vascular permeability. Increase in vascular permeability may lead to fluid shifting
from IV to Interstitial space > IV fluid loss
PERTINENT FINDINGS and PATHO

• Decrease breath sound right base – due to severe plasma leakage,

fluids shift going to the pleural space leading to development of
pleural effusion
• Distended abdomen- ascites may develop due to severe plasma
leakage; also may be due to Hepatitis which is also one of the
complication of dengue
• Liver 4cm below right subcostal margin – caused by dengue infection,
a sign of hepatitis
• Thready pulse with CRT at 3 second – signs of shock, developed due
to poor circulation in the peripheral areas of the body
PATHOPHYSIOLOGY
COURSES OF DENGUE ILLNESS
IMPRESSION

SEVERE DENGUE
LABORATORY TESTS

• CBC with PC
• Leukopenia, often with lymphopenia (near the end of febrile phase)
• Lymphocytosis, with atypical lymphocytes (before defervescence or shock
• Hematocrit increase >20% (hemoconcentration and precedes shock)
• Thrombocytopenia in up to 50% of dengue fever
• PC <100,000 cells/uL (DHF or DSS)
 Dengue NS1
• Adjunct to serologic testing
• Identification of early DV infection
• Detectable within 24 hours of infection and up to 9 days following
symptom onset
• Uses serum by enzyme immunoassay
 Dengue IgM
and IgG
• IgM-class Ab: consistent with acute-phase infection.
 Detectable 3 to 7 days following infection and may remain
detectable for up to 6 months or longer following disease
resolution.
• IgG-class Ab: presence of this to DV consistent with exposure to this
virus sometimes in the past.
3 weeks following exposure, nearly all immunocompetent individuals should
have developed IgG antibodies to DV.
 Group A
• Patients who may be sent home
• Able to tolerate adequate volumes of oral fluids and pass urine at
least once every 6 hours
• No warning signs, particularly when fever subsides
 Home Care Card for Dengue
• Adequate bed rest
• Adequate fluid intake
• Milk, fruit juice and isotonic electrolyte solution (ORS) and barley/rice water
• Plain water alone may cause electrolyte imbalance
• Take paracetamol (not >4g per day)
• Tepid sponging
• Look for mosquito breeding places in and around the home and eliminate them
• Avoid: do not take NSAIDs and antibiotics are not necessary
• Go immediately to the nearest hospital when warning sign are observed
 Group B
• Patients who should be referred for in-hospital management
• Patients with the following features:
• Warning signs
• Co-existing conditions that may make dengue or its management more
complicated (pregnancy, infancy and old age, obesity, DM, renal failure,
chronic hemolytic diseases, etc.)
• Social circumstances such as living alone or living far from health facility or
without a reliable means of transport
 Management for Dengue with
Warning Sings
• Obtain a reference hematocrit before fluid therap
• Give only isotonic solutions such as 0.9% NaCl, RL,
Hartmann’s solution
Start with 5-7ml/kg/hr for 1-2 hours, then
Reduce to 3-5ml/kg/hr for 2-4 hours, and then
Reduce to 2-3ml/kg/hr or less according to clinical response
• Reassess the clinical status and repeat the hematocrit
• If the hematocrit remains the same or rises only minimally, cont.
with the same rate (2-3ml/kg/hr) for another 2-4 hours.
Management for Dengue with
Warning Sings
• If there are worsening of vital signs and rapidly rising hematocrit,
increase the rate to 5-10ml/kg/hr for 1-2 hours
• Reassess the clinical status, repeat hct and review fluid infusion
rates accordingly
• Give the minimum IVF volume required to maintain good perfusion
and urine output of about 0.5ml/kg/hr
 IVF are usually needed for only 24 to 48 hours
• Reduce IVF gradually when rate of plasma leakage decreases
towards the end of critical phase
 Indicated by: urine output and/or OFI is/are adequate OR
hct decreases below the baseline value in a stable patient
 Group C
• Patients with severe dengue requiring emergency treatment and
urgent referral:
• Severe plasma leakage with shock and/or fluid accumulation with respiratory
distress
• Severe bleeding
• Severe organ impairment
 PREVENTION AND CONTROL

4-S AGAINST DENGUE

• Search and destroy
• Cover water drums and pails
• Replace water in flower vases once a week
• Clean gutters of leaves and debris
• Collect and dispose all unusable tin cans, jars, bottles and other
items that can collect and hold water
• Self-protection measures
• Wear long pants and long sleeved shirts
• Use mosquito repellant every day
• Seek early consultation
• Consult the doctors immediately if fever persists after 2 days and
rashes appears
• Say yes to fogging when there is an impending outbreak or a
hotspot
 Vaccine
• The first dengue vaccine: Dengvaxia (CYD-TDV) by Sanofi Pasteur
• First licensed in December 2015 in Mexico
• Registered for use in individuals 9-45 years of age living in endemic areas
• Live recombinant tetravalent vaccine based on the yellow fever 17d
backbone
• Registered as a 3-dose vaccine given on a 0/6/12 month schedule
• Administered SC in the upper arm (deltoid)