Good

Evening
DENGUE
 Viral Hemorrhagic Fevers

 Diverse group of infections that can result in massive bleeding.

 VHFs have four distinct families: arena, filo, bunya, & flaviviruses.

 Typical pattern is a febrile illness proceeding to shock & diffuse bleeding (GI &
mucosal), owing to thrombocytopenia ± DIC.

 Most VHFs are associated with leukopenia and hemoconcentration.

 Therapy is aggressive supportive care of the patients & replacement of

coagulation factors as necessary.
 Dengue
 Dengue (Flavi virus), the most common arthropod-borne viral illness in humans is

transmitted by mosquitoes of the genus Aedes.

 Presents as fever with rash.

ale of the species is more deadlier than

 Dengue serotypes

 Four serotypes (Den-I, Den-II, Den-III, and Den-IV).

 All of them produce a nonspecific febrile illness of varying severity.

Rash & Fever based on admission status
 Rash

Early convalescent macular diffuse rash

“Islands of white in a sea of red”

Pathophysiology
 Pathophysiology

 Leuko/thrombocytopenia - direct destructive actions on bone marrow precursor cells.

 Active viral replication & cellular destruction in bone marrow cause pain.

 Most patients with DHF or DSS have had prior infection with dengue serotypes.

 DHF pts have plasma leakage due to vasoactive mediator induced ↑ed capillary
permeability - hemoconcentration, pleural effusion & ascites.

 Liver damage - ↑ed AST & ALT, ↓ed albumin & deranged PT/aPTT.

 Virus can directly activate plasminogen, fibrinolysis, procoagulant homeostasis &

cause significant abnormalities in all major pathways of coagulation cascade.
Clinical spectrum
Warning Signs
Admission Criteria
 Bleeding

Minor bleeding near injection sites Rash in established DSS Severe bleeding following IV injection
Risk factors for DHF/DSS
Dengue Fever
Criteria for DHF
Criteria for DSS
Differential Diagnosis
Phases in Dengue
Course of Dengue Illness
 Factors affecting severity

 Patient age

 Pregnancy

 Nutritional status

 Ethnicity

 Sequence of infection with different dengue serotypes

 Virus genotype

 Quality and extent of available medical care

 Workup

 Complete blood count

 Metabolic panel

 Liver panel with serum protein and albumin levels

 DIC panel

 Guaiac testing for occult blood in stool to be performed on all suspected

patients.

 Urinalysis identifies hematuria.

 Imaging

 Chest radiography

 Ultrasonography: To detect fluid in chest and abdominal cavities,

pericardial effusion, or a thickened GB wall, in DHF

 Head CT scanning without contrast: To detect intracranial

bleeding or cerebral edema from DHF if needed.
 ABC’s

 Airway

 Breathing

 Circulation
 Airway & Breathing

 Patients with DSS tend to have ARDS due to capillary leakage – Type 1
respiratory failure

 Most often preceded by hemodynamic instability

 Minimal role for NIV

 Will require invasive support if ventilation is indicated

Hemodynamic assessment
 Management of Severe Dengue

 Patients with established DSS should be cared for in an ICU staffed by

experienced medical and nursing personnel

 May need central & arterial lines

 Foley’s catheterization

 Do not interpret a falling Hct value in a clinically improving patient as a sign

of internal bleeding

 RDP/SDP & FFPs as required.

 Other adjuvant therapy

 Inotropes, vasopressors

 RRT if required

 Dengue encephalopathy or fulminant hepatitis management as per

standard protocols

 No evidence in favour of steroids, IVIg, Recombinant factor VIIa.

Monitoring chart
Choice of IV fluid
 Platelet transfusion

Transfuse platelets only when counts˂ 20,000 with hemorrhagic manifestations

Carica Papaya Leaves for Thrombocytopenia
?
Doxycycline as immunomodulator
 Complications

 Cardiomyopathy, conduction abnormalities

 Seizures, encephalopathy, viral encephalitis, depression

 Metabolic – Hypo/hyperglycemia, Electrolytes, Met. Acidosis

 Fluid overload

 Hepatic injury

 Pneumonia, other nosocomial & co-infections

 Iritis, Orchitis, Oophoritis

 Prognosis

 Dengue fever is typically a self-limiting disease with a mortality rate of

less than 1%

 When treated, dengue hemorrhagic fever has a mortality rate of 2-5%

 But when left untreated, the mortality rate is as high as 50%.

 Useful predictors of death

 Atypical presentations

 Significant comorbid illness

 Abnormal serum markers (including albumin and coagulation studies)

 Secondary bacterial infections

Discharge Criteria
 Prevention

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

 Other measures are:

 Wear N,N-diethyl-3-methylbenzamide (DEET)–containing mosquito repellant

 Wear protective clothing, preferably impregnated with permethrin insecticide

 Remain in well-screened or air-conditioned places

 Mosquito netting is of limited benefit, as Aedes are day-biting mosquitoes

 Eliminate the mosquito vector using indoor sprays

 Prevention

 No vaccine available

 Increased health surveillance

 Prompt reporting of new cases

 Heightened professional awareness

 Public education
 Conclusion
 Infants and young children are prone to shock, and adults are at ↑ed risk of bleeding

 Prompt but judicious fluid resuscitation in DSS is the most important therapeutic
intervention

 Dengue has a very dynamic clinical progression, and it is unacceptable to guide

therapy on the basis of blood results taken hours earlier

 Regular clinical assessment of patients should be made & treatment be modified in

light of the clinical situation and results

 Ideally Hct should be measured on the ward (or results made available immediately)

 Overzealous resuscitation in the presence of ongoing capillary leak must be avoided.

Backup slides
Steps in management
Video
Flowtrac/PiCCO guided fluid resuscitation
Ventilatory support - NAVA