DENGUE VIRAL INFECTIONS

SUSILA UTAMA, AGUS SOMIA, TUTI PARWATI

DIVISI TROPIK DAN PENYAKIT INFEKSI
BAGIAN/SMF PENYAKIT DALAM
FK UNUD/RSUP SANGLAH DENPASAR
The most common epidemic vector of dengue in the world is
the Aedes aegypti mosquito. It can be identified by the white
bands or scale patterns on its legs and thorax.
1.The virus is inoculated into
humans with the mosquito
saliva.

2.The virus localizes and

replicates in various target
organs, for example, local
lymph nodes and the liver.

3.The virus is then released

from these tissues and
spreads through the blood to
infect white blood cells and
other lymphatic tissues.

4.The virus is then released

from these tissues and
circulates in the blood.
5.The mosquito ingests blood containing the virus.

6.The virus replicates in the mosquito midgut, the ovaries,

nerve tissue and fat body. It then escapes into the body
cavity, and later infects the salivary glands.

7.The virus replicates in the salivary glands and when the

mosquito bites another human, the cycle continues.
Four Grades of DHF
Grade 1
Fever and nonspecific constitutional symptoms
Positive tourniquet test is only hemorrhagic manifestation
Grade 2
Grade 1 manifestations + spontaneous bleeding
Grade 3
Signs of circulatory failure (rapid/weak pulse, narrow
pulse pressure, hypotension, cold/clammy skin)
Grade 4
Profound shock (undetectable pulse and BP)
PATHOLOGIC PROCESS MECHANISM

. Leakage of intra vasculer fluid into the extra

vasculer space due to widening of the
endothelial gaps
-hypo volemia, hemo concentration,
weakness, edema and visceral congestion
are resulting as consequences
-systemic capillary leak syndrome as
consequence of systemic inflammatory
syndrome is a pathogenic mechanism due
to inflammatory cytokines
-endothelial gaps as sites for plasma
leakage in inflammation that caused
by loosen inter endothelial cell
adherens junction
-opening endothelial gaps process is a
complex mechanism that depend in
biochemical substance (inflammatory
cytokine), biomechanical factor (shear
stress) and individual host response
DENGUE DIAGNOSIS

1. Virus isolation
2. Viral RNA detection by reverse transcription-PCR (RT-
PCR)
3. Serological test, such as ELISA, rapid test
cannot be used for early diagnostic because Ig M does not
become detectable until 5-10 days after the onset of
illness in case of primary dengue infections and until 4 to 5
days after the onset of illness in secondary infections.
4. NS1 Ag test
present at high concentration in the serum of dengue viral
infections during the early clinical phase of the disease
DIFFERENTIAL DIAGNOSIS

1. influenza, enteroviral infection,

measles, and rubella
2. Epidemiologic settings,
Malaria
Leptospirosis
Typhoid fever
Management
Outpatient Triage

No hemorrhagic manifestations and

patient is well-hydrated: home
treatment
Hemorrhagic manifestations or
hydration borderline: outpatient
observation center or hospitalization
Warning signs (even without profound
shock) or DSS: hospitalize
Patient Follow-Up
Patients treated at home
Instruction regarding danger signs
Consider repeat clinical evaluation
Patients with bleeding manifestations
Serial hematocrits and platelets at least daily
until temperature normal for 1 to 2 days
All patients
If blood sample taken in first 5 days after onset,
need convalescent sample between days 6 - 30
All hospitalized patients need samples on
admission and at discharge or death
Treatment of Dengue Fever
(Part 1)

Fluids
Rest
Antipyretics (avoid aspirin and
non-steroidal anti-inflammatory
drugs)
Monitor blood pressure,
hematocrit, platelet count, level of
consciousness
Treatment of Dengue Fever
(Part 2)
Continue monitoring after
defervescence
If any doubt, provide intravenous fluids,
guided by serial hematocrits, blood
pressure, and urine output
The volume of fluid needed is similar to
the treatment of diarrhea with mild to
moderate isotonic dehydration (5%-8%
deficit)
 Rehydrating Patients Over 40 kg

Volume required for rehydration is twice

the recommended maintenance
requirement
Formula for calculating maintenance
volume: 1500 + 20 x (weight in kg - 20)
For example, maintenance volume for
55 kg patient is: 1500 + 20 x (55-20) =
2200 ml
For this patient, the rehydration volume
would be 2 x 2200, or 4400 ml

Pan American Health Organization: Dengue and Dengue

Hemorrhagic Fever: Guidelines for Prevention and Control.
PAHO: Washington, D.C., 1994: 67.
Treatment of Dengue Fever
(Part 3)

Avoid invasive procedures when

possible
Unknown if the use of steroids,
intravenous immune globulin, or platelet
transfusions to shorten the duration or
decrease the severity of
thrombocytopenia is effective
Patients in shock may require treatment
in an intensive care unit
 Protokol 1. Tersangka
DBD Dewasa:
Observasi & Pemberian
cairan di Ruangan
Observasi

Depkes. Ditjen P2MPL 2001

 Protokol 2.
Penatalaksanaan DBD
Dws tanpa perdarahan dan
syok

Depkes. Ditjen P2MPL 2001

 Protokol 3. DBD dg
perdarahan spontan/masif,
tanpa syok

Depkes. Ditjen P2MPL 2001

 Protokol 4.
Penatalaksanaan DBD dws dgn
syok dan tanpa perdarahan
spontan

Depkes. Ditjen P2MPL 2001

 Protokol 5.
Penatalaksanaan DBD dws dgn
syok dan perdarahan masif

Depkes. Ditjen P2MPL 2001

 Indications for Hospital
Discharge
Absence of fever for 24 hours
(without anti-fever therapy) and
return of appetite
Visible improvement in clinical
picture
Stable hematocrit
3 days after recovery from shock
Platelets  50,000/mm3
No respiratory distress from pleural
effusions/ascites
Pan American Health Organization: Dengue and Dengue
Hemorrhagic Fever: Guidelines for Prevention and Control.
PAHO: Washington, D.C., 1994: 69.