Dengue Must Knows

• Dengue is a systemic and dynamic disease.

• A wide clinical spectrum that includes severe
and non-severe forms of clinical manifestations.

1
 Dengue is a systemic disease
Neck (Cervical)
lymph nodes
Thymus

The virus localizes Armpit (Auxiliary)

lymph nodes
and replicates in
various target organs. Spleen
Liver

i.e. local lymph nodes

and the liver. Groin (Inguinal)
lymph nodes
 2 Pathophysiological changes in Dengue
Virus Infection

 Increased Vascular Permeability

 Resulting to plasma leakage
 gives rise to loss of plasma in vascular
comparment  hemoconcentration, low
pulse pressure, shock

 Disorder in Hemostatis
 involving vascular changes,
thrombocytopenia and coagulopathy
 Dengue is dynamic

Clinical presentation of
Dengue with no warning
sign and the early phase of
severe dengue are similar.

It can be difficult to differentiate

between the two forms early in
the course of illness.
 Course of Dengue

• After the incubation period, the illness begins

abruptly and will be followed by 3 phases:

Febrile Critical Recovery

Phase Phase Phase

5
 Dengue in Febrile Phase
Usually lasts 2-7 days
Neck (Cervical)
lymph nodes
Thymus
Dengue viremia is Armpit (Auxiliary)
lymph nodes
typically highest in
the first 3 to 4 days
Spleen
after onset of fever Liver

Groin (Inguinal)
lymph nodes
 Clinical signs and symptoms

• Fever • AND
• Headache • Nausea • Laboratory test CBC
• Body • Vomiting • And/or dengue
malaise • Diarhhea NS1antigen test or
• Myalgia • Flushed dengue IgM antibody
• Arthralgia skin test
• Retro • Rash
orbital (petechial,
pain Hermanns
• Anorexia sign)
 DENGUE STANDARD CASE DEFINITON

  A. Dengue without Warning signs

• Person with acute febrile illness of 2-7
days duration plus two of the following:
- headache
- body malaise
- myalgia
SUSPECT
- Arthralgia
- retro-orbital pain
- anorexia, nausea, vomiting, diarrhea,
  flushed skin, rash (petechial).
 DENGUE STANDARD CASE DEFINITON

A. Dengue without
 
Warning signs
A suspected case and with a
Laboratory test result of any of
the following:
- Decrease WBC with or
PROBABLE
without thrombocytopenia
(decrease platelet .
- Positive Dengue NS1
- Positive antigen test or
dengue IgM antibody test
 
 DENGUE STANDARD CASE DEFINITON

A. Dengue without
 
Warning signs
A suspected case with
positive results for:

- Viral culture isolation

CONFIRMED
- Polymerase Chain
Reaction (PCR)
 
 DENGUE STANDARD CASE DEFINITON

B. Dengue with Warning Signs

Person with acute febrile illness of 2-7 days duration
plus any one of the following:
- Abdominal pain or tenderness
- Persistent vomiting
  - Mucosal bleeding
- Clinical signs of fluid accumulation
- Liver enlargement, and/or
- Lethargy, restlessness
 
- Lab: ↑ in Hct and with↓ platelet count.
 
 DENGUE STANDARD CASE DEFINITON

C. Severe Dengue
 
A person with acute febrile illness of 2-7 days duration and any
of the clinical manifestations for dengue with or without
warning signs, Plus any of the following:

- Severe plasma leakage leading to shock

- Fluid accumulation with respiratory distress, Severe bleeding
- Severe organ impairment:
Liver: AST or ALT >1000,
CNS: e.g. seizures, impaired consciousness, Heart: e.g.
myocarditis, and/or
Kidneys: e.g. renal failure.
 
 How to do Tourniquet Test
• TT is a marker of capillary fragility and it
can be used as a triage tool to
differentiate patients
1. Take the patient's blood pressure (i.e. BP 100/70)
2. Inflate the cuff to a point midway between SBP and
DBP @ 85 mm Hg maintain for 3-5 minutes. [(100 +
70) ÷ 2 = 85 mm Hg]
3. Slowly reduce the cuff and wait 2 minutes.
4. Count petechiae below antecubital fossa.
 A positive test is 10 or more petechiae per 1
square inch.
 TT is more likely to be positive near time of
defervescence.
 Less likely to be positive in patients with shock

@talea211md10/04/18
 Early Diagnosis :
simple clinical & lab.
• Tourniquet test
• CBC
PPV = 70-80%
Tourniquet test positive + leucopenia*
= Dengue infection
*Leucopenia = wbc ≤ 5,000 cells/cumm.
• At least day 3 of fever
• CBC everyday if possible
• Close follow up until 24 hours of defervescence
 Febrile Phase... Cont...

Dengue viremia is typically

highest in the first 3 to 4
days after onset of fever

but then falls quickly to

undetectable levels over the
next few days.
 Febrile Phase... Cont...

The level of viremia and

fever usually follow each
other closely, and anti-
dengue IgM anti-bodies
increase as fever abates.
 Febrile Phase... Cont...

• Defervescence occurs on
day 3 – 7 of illness

– When the
temperature
drops
to 37.5-38oC or less
and remains below
this level
 Lab Picture Awaiting Lysis of Fever &
Entering Critical Phase

• leucopenia (WBC <5,000

cells/mm3)
• Lymphocytosis
•↑ atypical lymphocytes
W
B
indicate that fever will likely C

dissipate within 24 hrs and

patient is entering into the
Critical Phase.
The Critical (Plasma Leak) Phase:

When the fever abates, the

patient enters a period of
highest risk for developing
the severe manifestations of
plasma leak and hemorrhage.
 Critical Phase

• Around the time of defervescence

• Day 3-7 of illness
• Patients can either improve or deteriorate.
• Those who improve after defervescence have
dengue without warning signs
• Those who deteriorate will manifest warning signs:
dengue with warning signs

20
 7 Warning signs that may occur at or
after defervescence

(the presence of one or more of these signs indicates the need for immediate
medical evaluation):

Abdominal pain or tenderness

Persistent vomiting
Mucosal bleeding
Clinical fluid accumulation (i.e., pleural effusion or ascites)
Increases in hct concurrent with rapid decrease in plt
Liver enlargement (≥2cm)
Lethargy or restlessness
Abdominal Pain or Tenderness
Persistent Vomiting
Mucosal Bleeding
Clinical Fluid Accumulation
Increases in hematocrit concurrent with
rapid decrease in platelet count
Liver enlargement (≥2cm)
Lethargy or restlessness
 Critical Phase – 7 Warning signs

• Warning signs are the 7 WARNING SIGNS

result of a significant • Abdominal pain or tenderness
increase in capillary • Persistent vomiting
permeability. • Clinical fluid accumulation
• Marks the beginning of • Mucosal bleed
the critical phase. • Lethargy; restlessness
• Liver enlargement >2cm
• Laboratory: Increase in HCT
concurrent
With rapid decrease in
platelet count
 High Risk Patients

• Infants less than one year of age

• Prolonged shock
• Massive bleeding
• Obesity
Infant less than one year of age

Newborns may contract dengue infection through vertical transmission

The age of peak incidence was 8 months with a range of 5–11 months
Prolonged Shock
Massive Bleeding
Obesity
5 Indicators for Critical Phase

•sudden change from high

(>38.0°C) to normal or subnormal
temperatures
• thrombocytopenia (≤100,000
cells/mm3) with a rising or
elevated hematocrit (≥20%
increase from baseline)
•new hypoalbuminemia or
hypocholesterolemia
•new pleural effusion or ascites,
•signs and symptoms of
impending or frank shock.
The Critical (Plasma Leak) Phase...
Cont...

4 Evidence of plasma leak:

•sudden increase in hct

(≥20% increase from baseline)
Pleural Effusion
• presence of ascites

• a new pleural effusion on

lateral decubitus chest x-ray

• low serum albumin

The Critical (Plasma Leak) Phase...
Cont...

• vital to watch for evidence

of hemorrhage and plasma
leak into the pleural and
abdominal cavities

• implement appropriate
therapies replacing
intravascular losses and
stabilizing effective volume.
The Critical (Plasma Leak) Phase...
Cont...

If left untreated, this can

lead to intravascular volume
depletion and cardiovascular
compromise.
Critical Phase – Warning signs... Cont...

May deteriorate to severe

dengue with:

Severe plasma leakage

leading to DSS

respiratory distress
Severe bleeding and/or
Severe organ impairment
 Days of illness 1 2 3 4 5 6 7 8 9 10

Temperature 40

Adapted from WCL Yip, 1980 by Hung NT, Lum LCS, Tan LH
Shock Reabsorption
Dehydration
Monitoring for defervescence & warning
Potential clinical issues Bleeding Fluid overload

signs are crucial to recognise the progression

Organ Impairment

to the critical phase. Platelet

Laboratory changes
Hematocrit

Viraemia IgM/IgG

PLASMA LEAKAGE
Serology and virology

Course
Course of
of dengue
dengue illness:
illness: Febrile
Febrile Critical
Critical Recovery
Recovery Phases
Phases
 Critical Phase – Warning
signs... Cont...
The period of clinically
significant
plasma leakage usually
lasts
24 to 48 hours.
 6 Hemodynamic Parameters in
Compensated Shock

increased heart rate

(tachycardia) especially in the
absence of fever
weak and thready pulse
Patients
cool extremities exhibiting signs of increasing
intravascular depletion, impending or frank
narrowing pulse pressure (systolic
shock, or severe hemorrhage should be
blood pressure minus diastolic blood
admitted
pressure <20 mmHg)for monitoring and intravascular
volume replacement.
delayed capillary refill (>2 seconds),

decrease in urination (i.e., oliguria).

 Hemodynamic Parameters in
Compensated Shock... Cont...

Anticipatory management
and monitoring indicators
are essential in effectively
administering therapies as
the patient enters the Critical
Phase
 Hemodynamic Parameters in
Compensated Shock... Cont...

Once a patient experiences

frank shock he or she will be
categorized as having Severe
Dengue
 Critical Phase: Prolonged Shock

•main factor associated with

complications that can lead to
death
 Critical Phase: Profound Shock

Patients with Severe

Dengue remain alert
and lucid throughout
the course of the
illness, even at the
tipping point of
profound shock.
Complications of Prolonged Shock

•Hemorrhage

•Metabolic
abnormalities
(e.g., hypocalcemia,
hypoglycemia, hyperglycemia,
lactic acidosis, hyponatremia)
 Prolonged shock

• > 10 hours untreated - Death!!!

• > 4 hours untreated
Liver failure- prognosis 50%
Liver + Renal failure - prognosis10%
3 organs failure (+respiratory failure) –
Prognosis is a miracle!!!
 Critical Period:
Less than 48 Hours
Fortunately, the
Critical Period lasts
no more than 24 to
48 hours.
The Recovery (Reabsorption)
Phase:
The third phase begins when
the Critical Phase ends

Characterized when plasma

leak stops and reabsorption
begins
 Recovery Phase... Cont...

Period of increased vascular

permeability is time-limited
(lasting 24 to 48 hours)

Functional change in
vascular endothelium
appears to be entirely
reversible with no known
permanent structural
defect.
 Recovery Phase

• A gradual reabsorption
of extravascular
compartment fluid
takes place in the next
48–72 hours.
• General well being
improves,hemodynamic
status stabilises and
diuresis ensues.
 Indicators that the patient is
entering the Recovery Phase

• sense of improved well

• return of appetite
• increased urine output
Indicators that the patient is entering
the Recovery Phase... Cont...

• stabilizing vital signs (widen

pulse pressure, strong
palpable pulse), bradycardia
•hematocrit levels returning
to normal

hct
Indicators that the patient is entering
the Recovery Phase... Cont...

appearance of the
characteristic
Convalescence Rash of
Dengue
(i.e., a confluent
sometimes pruritic,
petechial rash skin).
 Recovery Phase... Cont...

• May have a classical

rash of “isles of white
in the sea of red.”

• HCT stabilises or may

be lower due to the
dilution effect of
reabsorbed fluid.
Recovery Phase:Lab Picture

• WBC usually starts

to rise soon after

defervescence.
• Recovery of platelet
count is typically
later than that of
White Blood Cell.
The Recovery (Reabsorption)
Phase:

During this phase,

fluids that leaked
from the
intravascular space
(i.e., plasma and
administered intravenous
fluids) during the
Critical Phase are
reabsorbed.
 Recovery Phase... Cont...

care must be taken

to recognize signs
indicating that the
intravascular volume
has stabilized (i.e.,
that plasma leak has
halted) and that
reabsorption has
begun.
 Recovery Phase... Cont...

Modify the rate and

volume of IVF (and often
times discontinuing
intravenous fluids
altogether)

Avoid fluid overload as

the extra-vasated fluids
return to the IV
compartment
 Recovery Phase

Complications that arise

are frequently related to
the IV management.

Isotonic Hypertonic Hypotonic

solution(equal solution(higher solution(lower
concentration of concentration of concentration of
ions in solution ions in solution ions in solution
and cell) than in cell) than in cell)
 Recovery Phase... Cont...

Fluid overload may

result from use of
hypotonic IVF or over
use or continued use
of isotonic
intravenous fluids .
 Recovery Phase... Cont...

Nearly all patients with Severe Dengue recover

rapidly with timely initiation of judicious fluid
management and careful monitoring.
 Recovery Phase... Cont...

Even those with

complications, if
managed successfully,
often recover fully
without sequelae.
Summary of clinical problems

• Febrile phase – dehydration; high fever may cause

febrile seizures in young children; neurological
disturbances
• Critical phase – shock from plasma leakage; severe
haemorrhage; organ impairment
• Recovery phase – hypervolaemia (only if IVF
therapy has been excessive and/or extended into
this period)
Final Words on Dengue

With close monitoring of key indicators,

the development of severe dengue can be
detected at the time of defervescence so
that early and appropriate therapy can be
initiated.
 Final Words on Dengue

The key to successfully managing patients with dengue

infection and lowering the probability of medical
complications or death due to severe dengue or DSS is
early recognition and anticipatory treatment.