PREETHY VINU 09/04/2022 1

DENGUE FEVER

PREETHY VINU 09/04/2022 2

INTRODUCTION

 Dengue is a mosquito-transmitted virus and the leading

cause of arthropod-borne viral disease in the world. It
is also known as break bone fever due to the severity of
muscle spasms and joint pain, dandy fever, or seven-day
fever because of the usual duration of symptoms.
Although most cases are asymptomatic, severe illness
and death may occur. Aedes mosquitoes transmit the
virus and are common in tropical and subtropical parts
PREETHY VINU 09/04/2022 3

of the world.
 The incidence of dengue has increased dramatically over the past
few decades. The infection is now endemic in some parts of the
world. A few people who were previously infected with one
subspecies of the dengue virus develop severe capillary
permeability and bleeding after being infected with another
subspecies of the virus. This illness is known as dengue
hemorrhagic fever.

PREETHY VINU 09/04/2022 4

 DEFINITION

 Dengue fever is an infectious disease carried by mosquitoes and caused

by any of four related dengue viruses that is DEN -1, DEN -2, DEN-
3,and DEN-4. This disease used to be called "break-bone" fever
because it sometimes causes severe joint and muscle pain that feels like
bones are breaking. It is caused by the female aedes aegypti mosquito
bite, which transmit the dengue virus to human.
PREETHY VINU 09/04/2022 5
 INCIDENCE

 Each year an estimated 100 million cases of dengue occur worldwide. The global
incidence of dengue has grown dramatically in recent decades. Dengue fever is found
mostly during and shortly after the rainy season in tropical and subtropical areas of the
Caribbean and Central and South America, Africa, Southeast Asia and China, India, the
Middle East, Australia and the South and Central Pacific. Worldwide, 50 to 100 million
cases of dengue infection occur each year. This includes 100 to 200 cases in the United
States, mostly in people who have recently traveled abroad. Many more cases likely go
unreported because some health care providers do not recognize the disease.

PREETHY VINU 09/04/2022 6

 TRANSMISSION

 Dengue virus can be transmitted from the bite of an infected Aedes

mosquito. Mosquitoes become infected when they bite infected
humans, and can later transmit the infection to other people. Two
main species of mosquito, Aedes aegypti and Aedes albopictus,
have been responsible for all cases of dengue transmitted in
Mexico. Dengue cannot be transmitted from person to person
without a mosquito as the intermediate vector.
PREETHY VINU 09/04/2022 7
 CAUSES

 Dengue infection is caused by dengue virus which is a single stranded RNA The virus
is in the family Flavivirus, and the type specific virus is yellow fever.

 Transmission of dengue virus into the host is through vectors.

 Dengue is transmitted by infected female mosquito.

 A.egypti is a primarily day time feeder. It lives around human habitation.

PREETHY VINU 09/04/2022 8

 Lays eggs and produces larvae preferentially in artificial containers. Only the female
aedes mosquito bites as it needs the protein in blood to develop its eggs.

 The mosquito becomes infective approximately 7 days after it has bitten a person
carrying the virus.

 This is the extrinsic incubation period, during which times the irus replicates in the
mosquito and reach as the salivary glands.

 The mosquito remains infected for the reminder of its life. The lifespan of A aegyti is
usually 21 days but ranges from15 to 65 days.
PREETHY VINU 09/04/2022 9
 PATHOPHYSIOLOGY

 The transmission cycle of dengue virus by the mosquito Aedes

aegypti begins with a dengue infected person. This person will have virus
circulating in the blood – a viremia that lasts for about five days. During the
viremic period, an uninfected female Aedes aegypti mosquito bites the person
and ingests blood that contains dengue virus. Then with in the mosquito, the
virus replicates during an extrinsic incubation period of eight to twelve days.

PREETHY VINU 09/04/2022 10

CONT

 The mosquito then bites a susceptible person and transmits the

virus. The virus then replicates in the second person and produces
symptoms. The symptoms begin to appear an average of fourth
seven days after the mosquito bite- this is the intrinsic incubation
within the human. It can range from 3 to 14 days (average 4-
7days). While viral replication takes place in target dendritic
cells. Infection of target cells, primarily those of the reticulo
endothelial system, such as dendritic cells, hepatocytes, and
endothelial cells.

PREETHY VINU 09/04/2022 11

CONT

 This results in the production of immune mediators that serve to shape the
quantity, type, and duration of cellular and hormonal immune response to both
the initial and subsequent viral infections. Fever typically begin on the third
day of illness and persists 5-7 days, abstaining with the cessation of viremia.
Fever may reach 41 degree C. Occasionally, and more frequently in children,
the fever subsides for a day and reoccur, a pattern that is termed as a saddle
back fever, however, this pattern is more commonly seen in dengue
hemorrhagic fever.

PREETHY VINU 09/04/2022 12

 RISK FACTORS

 Age: all groups are affected

 Pre-existing anti-dengue antibody, either caused by previous infection or to

maternal antibodies passed to infants.

 Higher risk in secondary infection

 Sequence of infection with different dengue serotypes

PREETHY VINU 09/04/2022 13

CONT

 Quality and extent of available medical care

 Pregnancy

 Nutritional status

PREETHY VINU 09/04/2022 14

CONT

 CLINICAL MANIFESTATIONS

 Sudden onset of fever ,lasts 2-7 days and may reach 410C

 Chills

 Severe and generalized head ache

 Retro-orbital pain

 Severe myalgia, especially of the lower back ,arms, and legs

 Arthralgia usually of the knees and shoulders

PREETHY VINU 09/04/2022 15
 Characteristic rash( maculopapular)

 Hemorrhagic manifestations (patechiae, bleeding gums, epistaxis,

menorrhagia, hematuria)

 Thrombocytopenia

 Leukopenia

PREETHY VINU 09/04/2022 16

 Additional findings may include

 Facial flushing, a sensitive and specific predictor of dengue infection

 Inflamed pharynx, lymphadenopathy, hepatic injury

 Nausea and vomiting, nonproductive cough, sore throat

 Tachycardia, bradycardia, anorexia

 Increasing hematocrit and low albumin( signs of hemo concentration proceeding

shock)
PREETHY VINU 09/04/2022 17
 WARNING SIGNS OF DENGUE FEVER

 Abdominal pain( liver may be enlarged)

 Persistent vomiting

 Fluid accumulation such as swelling of the body or abdominal distension

 Breathing difficulty

PREETHY VINU 09/04/2022 18

Cont

 Bleeding from any site

 Excessive sleeping, lethargy or restlessness

 Decreased or absence of urine output for 6 hours or more

 Laboratory investigation may show an increased hematocrit( due to dehydration) with

thrombocytopenia

PREETHY VINU 09/04/2022 19

 PHASES OF DENGUE FEVER

 The course of infection is divided into 3 phases

1. Febrile phase

 High fever, often over 400 C,biphasic in nature breaking and then returning for one or two
days.

 Generalized pain

 Headache

 Rashes occurs in the first or second day of symptoms as flushed skin,or later in the course of
illness (days 4-7 ), as a measles like rash.
PREETHY VINU 09/04/2022 20
 Critical phase

 A critical phase, which follows the resolution of the high fever and typically lasts one to
two days.

 During this phase there may be significant fluid accumulation in the chest and abdominal
cavity due to increased capillary permeability and leakage.

 This leads to depletion of fluid from the circulation and decreased blood supply to vital
organs.

 Organ dysfunction and severe bleeding, typically from the gastrointestinal tract.

 Shock and hemorrhage occur in less than 5% of all cases of dengue.

PREETHY VINU 09/04/2022 21
1. Recovery phase

 Resorption of the leaked fluid into the blood stream

 This usually lasts two to three days

 Severe itiching and a slow heart rate

 During this stage, a fluid overload state may occur, if it affects the brain, it may
cause a reduced level of consciousness or seizures.

  
PREETHY VINU 09/04/2022 22
 CLASSIFICATIONS

 Undifferentiated fever

 Prodrome(early onset of signs and symptoms) of chills, erythematous

mottling of the skin, and facial flushing. The prodrome may last for2-3 days.

PREETHY VINU 09/04/2022 23

 Classic dengue fever

 It begins with sudden onset of fever, chills, and severe aching of the
head, back, and extremities as well as other symptoms. The fever lasts 2-7
days and may reach 410C

 Fever lasts longer than 10 days

PREETHY VINU 09/04/2022 24

Cont

 Dengue hemorrhagic fever

 A syndrome due to the dengue virus that tends to affect
children under 10, causing abdominal pain, hemorrhage
(bleeding) and circulatory collapse (shock). DHF starts abruptly
with high continuous fever and headache plus respiratory and
intestine symptoms with sore throat, cough, nausea, vomiting,
and abdominal pain. Shock occurs after 2 to 6 days with sudden
collapse, cool clammy extremities, weak thready pulse, and
blueness around the mouth.
PREETHY VINU 09/04/2022 25
Cont

 There is bleeding with easy bruising, blood spots in the skin

(petechiae), spitting up blood (hematemesis), blood in the stool
(melena), bleeding gums and nosebleeds (epistaxis). Pneumonia
and heart inflammation (myocarditis) may be present. The
mortality is appreciable ranging from 6 to 30%. Most deaths
occur in children. Infants under a year of age are especially at risk
of death.

PREETHY VINU 09/04/2022 26

Cont

 Dengue shock syndrome

 It is a severe form of dengue hemorrhagic fever. Shock
syndrome is a dangerous complication of dengue infection and is
associated with high mortality. Severe dengue occurs as a result
of secondary infection with a different virus serotype. Increased
vascular permeability, together with myocardial dysfunction and
dehydration, contribute to the development of shock, with
resultant multiorgan failure.

PREETHY VINU 09/04/2022 27

Cont

 The onset of shock in dengue can be dramatic, and its progression relentless.
The pathogenesis of shock in dengue is complex. It is known that endothelial
dysfunction induced by cytokines and chemical mediators occurs. Diagnosis is
largely clinical and is supported by serology and identification of viral
material in blood. No specific methods are available to predict outcome and
progression. Careful fluid management and supportive therapy is the mainstay
of management.

PREETHY VINU 09/04/2022 28

 DIAGNOSTIC EVALUATION

 History collection

 Physical examination

 For patients presenting during the first week after fever onset, diagnostic testing should
include a test for dengue virus (rRT-PCR or NS1) and IgM.

 For patients presenting >1 week after fever onset, IgM detection is most useful, although
NS1 has been reported positive up to 12 days after fever onset

 Complete blood count

PREETHY VINU 09/04/2022 29
Management

GENERAL APPROACH

Dengue fever is usually a self -limited illness.

There is no specific antiviral treatment currently available for dengue fever.
Supportive care with analgesics, fluid replacement, and bed rest is usually sufficient.
Aspirin non -steroidal anti- inflammatory drugs and corticosteroids should be avoided.
Management of severe dengue requires careful attention to fluid management and proactive
treatment of hemorrhage.
 

PREETHY VINU 09/04/2022 30

 NON PHARMACOLOGICAL MANAGEMENT

 Maintain hygiene

 Fluid intake

 Vector control methods

 Mosquito repellents

 Bed rest for DHF/DSS

 Patient education
PREETHY VINU 09/04/2022 31
 VECTOR CONTROL METODS

 BIOLOGICAL AND ENVIRONMENTAL CONTROL

 Place fish in containers to eat larvae.

 Elimination of larval habitats, most likely this method is effective in long term

 CHEMICAL CONTROL

 Larvicides may be used to kill immature aquatic stages.

 Ultra a- low volume fumigation against adult mosquitoes.

PREETHY VINU 09/04/2022 32
Cont

 PHARMACOLOGICAL MANAGEMENT

 Supportive only as there is no antiviral against DENV.

 Oral rehydration therapy is recommended for patients with moderate dehydration

caused by high fever and vomiting.

 Antipyretics (acetaminophen 325-600 mg Q4hr)to be given to reduce fever.

 Patients with known or suspected dengue fever should have their platelet count and
hematocrit measured daily from the third of illness until 1-2 days after effervescence.

PREETHY VINU 09/04/2022 33

 Patients who develop signs of dengue hemorrhagic activates at the first level of care
should focus on :

1. Recognizing that the febrile patient could have dengue

2. Notifying early to the public health authorities that the patient is a suspected case of
dengue.

3. Managing patients in the early febrile phase of dengue.

4. Recognizing the early stage of plasma leakage or critical phase and initiating fluid
therapy.
PREETHY VINU 09/04/2022 34
1. Recognizing patients with warning signs who need to be referred for
admission and or intravenous fluid therapy to a secondary health care facility.

2. Recognizing and managing severe plasma leakage and shock, severe bleeding
and organ damage.

PREETHY VINU 09/04/2022 35

 Admission for IV administration is indicated for patient who develops signs of
dehydration such as:

a) Tachycardia

b) Prolonged capillary refill time

c) Cool or mottled skin

d) Diminished pulse amplitude

e) Altered mental status

PREETHY VINU 09/04/2022 36
a) Decreased urine output

b) Rising hematocrit (polycythemia)

c) Narrowed pulse pressure

d) Hypotension

PREETHY VINU 09/04/2022 37

 Intravascular volume deficits should be corrected with isotonic fluids such as RL.

 Boluses of 10-20ml/kg should be given over 20 minutes and may be repeated.

 Patient with internal or gastrointestinal bleeding may require transfusion, and

patients with coagulopathy may require fresh frozen plasma.

 After patients with dehydration are stabilized, they usually requires IV fluids for
no more than 24-48 hrs.

PREETHY VINU 09/04/2022 38

 Patients with dengue hemorrhagic fever or dengue shock syndrome may be
discharged from the hospital when they meet the following criteria:

 Afebrile for 24hrs without antipyretics

 Good appetite, clinically improved condition

 Adequate urine output, stable hematocrit level

 At least 48hrs since recovery from shock

 No respiratory distress, platelet count greater than 50,000cells/L

PREETHY VINU 09/04/2022 39
 SPECIAL POPULATION

 PREGNANCY

 Dengue in pregnancy must be carefully differentiated from pre eclamsia

 An overlap of signs and symptoms, including thrombocytopenia, capillary leak, impaired liver
function, ascites, and decreased urine output may make this clinically challenging.

 Pregnant women with dengue fever respond well to the usual therapy of fluids, rest, and antipyretics.

 If the mother acquires infection in the peripatum period, newborn should be evaluated for dengue with
serial platelet counts and serological studies.

PREETHY VINU 09/04/2022 40

 PREVENTION OF DENGUE FEVER

 The only way to prevent dengue virus acquisition is to avoid being bitten by a
vector mosquito

 Wear protective clothing, preferably impregnated with permethrin insecticides

 Remain in well screened or air conditioned places.

 The use of mosquito netting is of limited benefits, as aedes are day-biting

mosquitoes.
PREETHY VINU 09/04/2022 41
 Eliminate the mosquito vectors using indoor sprays.

 Reducing open collection of water through environmental modification

 Application of insect repellents.

 No vaccine is currently approved for the prevention of dengue fever.

PREETHY VINU 09/04/2022 42

 NURSES RESPONSIBILITY

 Monitor IV hydration is usually only needed for one or two days

 The rate of fluid administration is titrated to a urinary output of 0.5-1ml/kg/hr.

stable vital signs and normalization of hematocrit.

 Invasive medical procedure such as nasogastric intubation, intramuscular

injections and arterial punctures are avoided or minimized, in view of the
bleeding risk.
PREETHY VINU 09/04/2022 43
 Paracetamol is used for fever and discomfort while NSAIDS are avoided as they
might aggravate the risk of bleeding.

 Blood transfusion is initiated early in patients presenting with unstable vital signs.

 Packed red blood cells or whole blood are recommended, while platelets and FFP
are usually not

 The prevention of dengue requires control or eradication of the mosquitoes

carrying the virus that cause dengue.

PREETHY VINU 09/04/2022 44

 Educate the people to wear long sleeved shirts, long pants socks and shoes when outdoors.

 Aedes mosquitoes usually bite during the day. Therefore special precautions should be
taken during early morning hours before day break and in the late afternoon before the
dark.

 Eliminate stagnant water that serve as mosquito breeding sites at home, workplaces and
their vicinity.

 Using mosquito nets at home and patients need to be kept under mosquito netting until the
second bout of fever is over and they are no longer contagious.

PREETHY VINU 09/04/2022 45

 Cover overhead water tanks to prevent access to mosquitoes.

 Eliminate breeding ground by removing unused plastic pools, old tires, or

buckets and clearing clogged gutters.

 Conducts dengue awareness programs in your apartments complex and

neighborhood advice people showing symptoms of dengue to immediately go
for check-up and get treatment.

PREETHY VINU 09/04/2022 46

  COMPLICATIONS

 Cardiomyopathy.

 Seizures, encephalopathy, and viral encephalitis.

 Hepatic injury.

 Depression.

 Pneumonia.

PREETHY VINU 09/04/2022 47

 Iritis.

 Orchitis.

 Residual brain damage

 Myocarditis

 Disseminated intra vascular coagulation

 Cerebral hemorrhage or edema

PREETHY VINU 09/04/2022 48

Nursing diagnosis

 Hypovolemic shock related to hemorrhage.

 Imbalanced Nutrition: Less than body requirements related to nausea, vomiting, no appetite.

 Increased body temperature related to the process of dengue virus infection.

 Risk for bleeding related to thrombocytopenia.

 Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting and
fever.

 Deficient Knowledge: about the disease process related to a lack of information.

 

PREETHY VINU 09/04/2022 49

PREETHY VINU 09/04/2022 50