Guideline for the management of

Dengue Fever
Dengue Hameorrhagic Fever
Dengue Shock Syndrome

BY
DR.MUHAMMAD ATHAR
RESIDENT PEADS
MEDICINE
LNH
Overview:

 The most rapidly spreading mosquito-borne viral

disease in the world.

 Dengue viruses cause symptomatic infections or

asymptomatic seroconversion.

 Symptomatic dengue infection is a systemic and

dynamic disease.
History of Dengue:

 The origins of the word dengue are not clear, but

one theory is that it is derived from the Swahili
phrase "Ka-dinga pepo", meaning "cramp-like
seizure caused by an evil spirit".

 The Swahili word "dinga" may possibly have its origin

in the Spanish word "dengue" meaning fastidious or
careful, which would describe the gait of a person
suffering the bone pain of dengue fever
Dengue virus :
 4 serotypes : DEN1, DEN2,DEN3, and DEN4
 Family flaviviridae
 genus Flavivirus
 Single stranded RNA virus

 Infection with one serotype does not protect

against the others, and sequential infections put
people at greater risk for dengue hemorraghic fever
(DHF) and dengue shock syndrome (DSS).
 Aedes aegypti is the principal mosquito vector of
dengue.

 The secondary vector for dengue virus is Ae

albopictus, which contributes significantly to
transmission in Asia and whose presence is
spreading in Latin American countries
Significance of problem

 500,000 cases of severe dengue require

hospitalisation each year, of which a very large
proportion is in children.

 The first epidemic of severe dengue was reported in

the Philippines in 1953.

 Before 1970 only nine countries had experienced

severe dengue epidemics, a number that had
increased more than four-fold by 1995
 The burden of disease is greatest in Asia, where in
many countries dengue is a leading cause of
paediatric hospitalisation.
Dengue Transmission
Clinical Features:

 Incubation period 4-10 days.

 Disease progress abruptly, followed by 3 phases

1. Febrile (2 – 7 days)
2. Critical and (3 – 8 days)
3. Recovery phase (48 – 72 hours after critical phase)
Febrile Phase:

 Usually lasts 2−7 days

 It can be difficult to distinguish dengue clinically from non-

dengue febrile diseases in the early febrile phase.

 A positive tourniquet test in this phase indicates an increased

probability of dengue.

 Mild haemorrhagic manifestations such as petechiae and

mucosal membrane bleeding may be seen

 The earliest abnormality in the full blood count is a progressive

decrease in total white cell count.
Torniquet Test:

 measure of capillary fragility and

thrombocytopaenia.

 Blood pressure cuff should be inflated on the upper

arm to a point midway between the systolic and
diastolic pressures for five minutes, and then the
number of resulting petechiae in an area 6.25 cm2
(2.5 x 2.5 cm) should be counted.
 The TT is considered positive when 20 or more
petechiae are observed within the square
 Critical Phase:

Day 3–7 of illness

● Progressive leukopenia, rapid ↓platelet count plasma leakage

● Patients without ↑capillary permeability will improve

● Patients with ↑capillary permeability : worse, lose plasma volume

● The degree of increase above the baseline HCT

reflects severity of plasma leakage

• Shock-
WBC may increase in patients with severe bleeding as s stress response
 With profound and/or prolonged shock,
hypoperfusion results in metabolic acidosis,
progressive organ impairment, and disseminated
intravascular coagulation.
Warning sign
 Recovery Phase:

● Gradual reabsorption of extravascular compartment fluid takes place

in the following 48–72 hours

● Well-being improves, appetite returns, GI symptoms abate,

hemodynamic status stabilizes and diuresis ensues

● Hct stabilizes or lower due to the dilutional effect of reabsorbed fluid

● WBC usually rise soon after defervescence but the recovery of platele
count is typically later than that of WBC

● Signs of fluid over load will occur during this phase if excessive
intravenous fluids have been administered
 Some patients have a confluent erythematous or
petechial rash with small areas of normal skin,
described as “isles of white in the sea of red”
Course of dengue illness:
The WHO case definitions of
dengue fever (DF), dengue
haemorrhagic fever (DHF), and
dengue shock syndrome (DSS)
WHO Classification:

Dengue fever (DF)

● Dengue haemorrhagic fever (DHF)
 4 severity grades
 grades III and IV : dengue shock syndrome (DSS)

● Currently the classification into

DF/DHF/DSS continues to be widely
used
Diagnosis of Dengue Infection

● Antibody detection
 Hemagglutination Inhibition (HAI)
 ELISA (IgG/IgM)
 Rapid test (IgG/IgM)
● Antigen detection
 NS1 antigen
● RNA detection
 PCR
● Viral isolation
Interpretation of dengue
diagnostic tests

Highly suggestive confirmed

One of the following One of the following

1. IgM +ve in single serum 1. PCR +ve

sample 2. Viral culture +ve
2. IgG+ve in a single seum 3. IgM seroconversion in
sample with a HI titer of paired sera
1280 or greater 4. IgG seroconversion in
paired sera or fourfold
IgG titer increase in
paired sera
Primary Infection

● NS1 antigen : Day 1 after onset of fever and up to day 9

● IgM antibody :
 Day 5 of infection, sometimes as early as Day 3
 IgM levels : peak in 2 weeks, followed by a 2 week rapid
decay
 Undetectable 2 to 3 months after infection

● Low levels of IgG are detected in the early convalescent

phase, not during the acute phase.
Stepwise approach to the
management of dengue infection

Early
Refer when
recognition of Management
necessary
disease
Treatment according to Groups
Group A (May be sent home)

 Who donot have warning sign

 And
 Who are able to tolerate adequate fluids
 Or passes urine atleast once every 6 hour.
 Patients with ≥ 3 days of illness should be reviewed
daily for disease progression (indicated by
decreasing white blood cell and platelet counts
and increasing haematocrit, defervescence and
warning signs) until they are out of the critical
period.
Encourage plenty of oral fluids

Paracetamol for high fever. NEVER use ASPIRIN,

Ibuprofen or other Nsaids

Inform about the warning sign

Warning sign:

 brought to hospital immediately if any of the following

occur:
 no clinical improvement,
 deterioration around the time of defervescence,
 severe abdominal pain,
 persistent vomiting,
 cold and clammy extremities,
 lethargy or irritability/restlessness,
 bleeding (e.g. black stools or coffeeground vomiting),
 shortness of breath,
 not passing urine for more than 4−6 hours.
Group B – in Patient Hospital
management

 Patient with any of the following features:

 Co-existing condition such as pregnancy, infancy,
old age, diabetes mellitus
 Social circumstances such as living alone or living far
from hospital
 Or
 Existing warning signs
 Rapid fluid replacement in patients with warning
signs is the key to prevent progression to the shock
state.
 If the patient has dengue with co-existing conditions
but without warning signs, the action plan should be
as follows:
 Encouragement for oral fluids or If not tolerated,
start intravenous fluid therapy 0,9% saline or Ringer
Lactate at maintenance rate
 If the patient has dengue with warning signs, the
action plan should be as follows and applies to
infants, children and adults:
 Obtain a reference haematocrit before intravenous
fluid therapy begins.
 Isotonic solution (0.9% saline or Ringer lactate) is
preferrable
 5−7 ml/kg/hour for 1−2 hours
 Then reduce to
 3−5 ml/kg/hour for 2−4 hours,
 and then reduce to
 2−3 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 (2−3
ml/kg/hour)for another 2−4 hours.
 If the vital signs are worsening and the haematocrit
is rising rapidly, increase the rate to 5−10 ml/kg/hour
for 1−2 hours. Reassess the clinical status, repeat the
haematocrit and review fluid infusion rates
accordingly.
 Minimum iv fluids required to maintain the good
perfusion and urine output of about 0.5ml/kg/hr.
 Reduce intravenous fluids gradually when the rate
of plasma leakage decreases towards the end of
the critical phase.
 This is indicated by
 urine output and/or oral fluid intake improving,
 or the haematocrit decreasing below the baseline
value in a stable patient.
Monitoring:

 Vital signs and peripheral perfusion (1-4 hourly until

patient is out of critical phase
 Urine output (4-6 hourly)
 Hct (before and after fluid replacement, then 6-12
hourly)
 Blood glucose
 Other organ functions (renal profile, liver profile,
coagulation profile, as indicated)
Group C (ER treatment)

 These are patients with severe dengue who require

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 haemorrhages;
 severe organ impairment (hepatic damage, renal
impairment, cardiomyopathy, encephalopathy or
encephalitis).
Treatment of compensated shock

Treatment of hypotensive shock

Treatment of Haemorrhagic shock

Treatment of Haemorrhagic
Shock

 Mucosal bleeding may occur in any patient with

dengue but if the patient remains stable with fluid
resuscitation/replacement, this should be
considered as a minor issue.

 In patients with profound thrombocytopenia, ensure

strict bed rest and protection from trauma. Do not
give intramuscular injections
 Patients at risk of severe bleeding are those who:
 have profound/prolonged/refractory shock;
 have hypotensive shock and multi-organ failure or
severe and persistent metabolic acidosis;
 are given non-steroidal anti-inflammatory agents;
 have pre-existing peptic ulcer disease;
 are on anticoagulant therapy;
 Have any form of trauma including intra muscular
injection
 stop bleeding if the source of bleeding is identified e.g. severe
epistaxis may be controlled by nasal adrenaline packing.

 Blood transfusion is life-saving and should be given as soon as

severe bleeding is suspected or recognized.

 Do not wait for the haematocrit to drop too low before

deciding on blood transfusion.

 5−10 ml/kg of fresh -packed red cells or 10−20 ml/kg of fresh or

fairly fresh whole blood (FWB) at an appropriate rate and
observe the clinical response.
 Consider repeating the blood transfusion if there is
further overt blood loss

 Or no appropriate rise in haematocrit after blood

transfusion in an unstable patient

 There is no evidence that supports the practice of

transfusing platelet concentrates and/or fresh-frozen
plasma for severe bleeding in dengue
 In gastrointestinal bleeding, H-2 antagonist and
proton pump inhibitors have been used, but their
efficacy have not been studied.
Interpretation of Hematocrit

 A rising or persistently high haematocrit

 with unstable vital signs (such as narrowed pulse

pressure) indicates active plasma leakage and the
need for a further bolus of fluid replacement.

 with stable haemodynamic status and adequate urine

output does not require extra intravenous fluids
 A decrease in haematocrit:

 with unstable vital signs

(narrowed pulse pressure, tachycardia,
metabolic acidosis and poor urine output)

may indicate major haemorrhage. If there is

severe haemorrhage, urgent blood transfusion
should be given.

 with stable haemodynamic status

(adequate urine output, indicates haemodilution and/or reabsorption of extravasated
fluids)

In this case intravenous fluids must be discontinued immediately to avoid pulmonary

oedema.
When to stop intravenous fluid
therapy:

 When any of the following signs are present:

 signs of cessation of plasma leakage;
 stable BP, pulse and peripheral perfusion;
 haematocrit decreases in the presence of a good
pulse volume;
 apyrexia (without the use of antipyretics) for more than
24–48 hours;
 resolving bowel/abdominal symptoms;
 improving urine output
Protection against Mosquitoes
Protect Yourself and Family
from Mosquito Bites

 Keep the Inside of Your Home Mosquito-free

 • Use screens on doors and windows and don’t

leave doors propped open for mosquitoes to fly inside.

 • Don’t allow mosquitoes to fly inside your home. If

you have an air conditioner, use it instead of opening
windows and doors.
 • Weekly, look for and dump out any standing
water where mosquitoes lay eggs.

 • Kill mosquitoes inside your home. If using

insecticide, always follow label instructions. Prevent
Mosquito Bites

 • When outside, use insecticides such as

permethrin (pesticide and repellent) and allethrin
(candles and lanterns).
 • When weather permits, wear long sleeve shirts,
long pants, socks and closed shoes to avoid
mosquito bites.

 • Use repellents containing DEET (N, N-diethyl-m-

toluamide), picaridin. These products provide long-
lasting bite protection
 Dengue Vaccine:

 The first dengue vaccine, Dengvaxia

(CYD-TDV) by Sanofi Pasteur, was first
registered in Mexico in December, 2015.

 CYD-TDV is a live recombinant

tetravalent dengue vaccine that has
been evaluated as a 3-dose series on a
0/6/12 month schedule in Phase III
clinical studies.

 It has been registered for use in

individuals 9-45 years of age living in
endemic areas