Dengue Management in

Primary care
By : Daniel Raj
 Introduction
• Mosquito borne flavivirus
• Transmitted by Aedes aegypti and Aedes albopictus.
• Four distinct serotypes, DENV-1,2,3 and 4.
• Each episode of infection induces a life-long protective immunity to the
homologous serotype but confers only partial and transient protection
against other serotypes.
Clinical Course of Dengue Infection
Incubation period : 4 - 7 days (range 3 - 14
days)
After the incubation period, the illness begins
abruptly.
Febrile phase : 2 - 7 days. Commences at
symptom onset
Critical phase : Usually after D3 of fever
(maybe earlier). Commences around time of
defervescence*. Coincides with increase in
capillary permeability. Lasts 24 - 48 hours.
* Definition : Body temperature <38 degrees
& remains below this level.
Recovery phase : Reabsorption of
extravascular fluid.

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Febrile phase
Viraemia : Fever, headache, N&V, flushing,
myalgia, joint pain, rash, retro-orbital pain, mild
haemorrhage (petechial, mucosal bleed)

Progressive decrease in total white cell

count followed by platelet reduction

Haematocrit
male < 60 years – 46%
male > 60 years – 42%
female (all age groups) – 40%

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Critical phase
Increase vascular permeability: Third
space loss, organ dysfunction

*Leukopenia with relative

lymphocytosis
*Haemoconcentration
*Thrombocytopenia
Prolonged APTT
AST > ALT

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 • The pathophysiology dengue infection is mainly caused by an acute increase in vascular permeability that
leads to leakage of plasma into the extravascular compartment , resulting in haemoconcentration and
hypovolaemia or shock.

Skin : Coolness, pallor,delayed capillary

Hypovolaemia leads to reflex tachycardia refill time
and generalised vasoconstriction due to
increased sympathetic output.
CVS: Raised DBP and narrowing of pulse pressure
*PP=SBP-DBP, normal value is 40
-Fluid resuscitation must be started promptly to prevent refractory shock state.
-Inadequate fluid resuscitation can decrease myocardial tissue perfusion leading
to anaerobic glycolysis and lactic acidosis compromising myocardial contractility
worsening hypotension
GIT: Persistent
nausea,vomitting,diarrhea
can lead to metabolic
acidosis, UGIB/LGIB Respi : Tachypnea, RR>20

Renal: AKI
CNS:
Lethargy,restlessness,disorientation Hematologic: DIC

Resproductive: PV
bleeding
Recovery phase
Classical rash of “isles of white in the
sea of red” with generalised pruritus

*HCT level stabilises and

drops further due to
haemodilution
*Recovery of white cell
count (WCC).
* Recovery of platelet count

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ARNING SIGNS
TRIAGING AT EMERGENCY
 Other important relevant histories :
Clinical history Family or neighbourhood history of dengue or travel to dengue
endemic area
• Date of onset of fever Jungle trekking and swimming in waterfall ( DD:
• leptospirosis/malaria/typhus)
Assess warning signs (last BO/Vomit)
• *Oral intake : quantity and quality ? Recent unprotected sexual or IVDU (DD : acute HIV
>1.5L/day seroconversion illness)

• *Urine output : frequency, volume & time of
most recent voiding (last PU)? <6hours
• What activities could do patient do during
the febrile illness ? ADL independent, no MC
• Change in mental state/seizure/dizziness
Co-morbidities (DD : sepsis particularly in diabetes mellitus)
Medications : *anticoagulants/antiplatelet NSAIDS,
OTC/traditional meds/IM injections/anti-HPT/all meds with last
time taken
*Risk factors: pregnancy, obesity, diabetes mellitus,
hypertension, IHD, coagulopathy, renal failure, CLD, COPD.
Age>65yo.

*Social factors that limit follow up blood ix

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 Clinical Examination
• Look for tachypnoea / acidotic breathing / pleural
effusion
• Assess GCS • Check for abdominal tenderness / hepatomegaly /
ascites
• Assess hydration: Eye,lip,
• Abdominal pain in febrile phase: omentum
tongue, skin turgor ischaemia due to dehydration
• Assess haemodynamic: • Abdominal pain in critical phase: acute stretch
of liver capsule
• CCTVR • Abdominal pain in recovery phase: ascites
• BP • Examine for bleeding tendency
• Pulse pressure (>20mmHg) • Petechiae
• Urine output (>0.5ml/kg/hr, not • Purpura
Tourniquet
concentrated) test • Ecchymoses
• Malaena
• Bleeding gingiva
• Epistaxis
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INVESTIGATIONS
Disease monitoring tests
• FBC: Thrombocytopenia, leucopenia, inc HCT
• Coagulation profile
• RP/ LFT
• Lactate
• Blood gases
• Special test: CK

Diagnostic test
• rapid combo test
• dengue antigen and serology test by ELISA
• NS1 antigen & IgM/IgG antibodies
• Dengue viral RNA detection
Diagnostic tests
Diagnostic tests based on history
Diagnostic Investigation
• Dengue NS1 antigen test and
rapid combo tests (NS1
antigen and dengue IgM/IgG
antibodies)
• Interpret within 15-20 minutes
• Invalid after 20 minutes
• sensitivity 93.9%; specificity
92%
• Dengue Viral RNA Detection
(Real time RT PCR)
• Determine Dengue serotype
• Virus Isolation
• NS1 Antigen : sensitivity drop day 4-5. In
defervescence, usually non-detectable. If
present >D5, predict severe dengue.
False positive in Yellow Fever.
• IgM : >D5 of illness, peaks about 2/52
then wanes down over 1 hour.
• IgG : After Day 7.
*Check titre,if 1 : 2560, indicates
secondary dengue
False positive in JE, malaria, leptospirosis,
toxoplasmosis, syphilis, RA
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 Disease Monitoring Investigation
Complication (when in suspect severe dengue)
Identify phase of dengue
• TWC, HCT, Platelet • Hepatitis: AST or ALT >=1000 (AST>ALT)
• Coagulopathy: Coagulation profile (prolonged APTT)
• Acute renal failure: UFEME, Renal profile (RP)
Markers of plasma leakage • Myocarditis: Troponin and Creatine Kinase (CK), Echo,
and hypovoleamia ECG
• HCT (haemoconcentration) • Myositis: CK
• VBG (metabolic acidosis • Pleural effusion: CXR, US Thorax
• Lactate (adequate<2 • Ascites / gallbladder wall edema: US Abdomen
mmol/L) • Neurological (Encephalopathy/encephalitis): CT Brain,
Lumbar puncture
• GXM 19
Diagnosis: Dengue fever D? of illness (point taken @time date), in ? Phase with/without warning signs of ?, currently
hemodynamically stable/resolved compensated shock. 23
 CRITERIA FOR HOSPITAL ADMISSION AND REFERRAL

Decision for referral and admission must not be basesd on a single clinical parameter but should depend on
the TOTAL ASSESSMENT of the patient.
SYMPTOMS
a. Warning signs
b. Bleeding manifestations
c. Inability to tolerate oral fluids
d. Reduced urine output
e. Seizure

SIGNS
f. Dehydration
g. Shock
h. Bleeding
i. Any organ failure

SPECIAL SITUATION
j. Patients with comorbidities as diabetes, HPT, IHD, Coagulopathy, Morbid Obesity, Renal Failure, Chronic Liver disease , COPD
k. Elderly mor than 65 years old
l. Patients who are on anti platelet and anti coagulant.
m. Pregnancy
n. Social factors that limit follow up as living far from health facility, no transport or living alone.

LAB CRITERIA
o. Rising HCT with reduced platelet count
 Fluid management
1. Is the haemodynamic status stable or compromised?
2. Which phase of disease?
3. Can the patient tolerate orally well?
4. Is there a warning sign?
5. What is the aim for fluid therapy?

Common pitfalls in fluid therapy:

-Warning signs as the sole parameter without considering other clinical parameters.
-Treating patients with unnecessary fluid boluses based on raised HCT or excessive and
prolonged fixed fluid regime in stable patients.
-Infrequent monitoring and adjustment of infusion rate.
-Continuation of intravenous fluid during the recovery phase.
-Excessive fluid therapy in patients with co-morbidities (such as heart disease and renal disease)
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 Stable patient without shock
• Encourage oral fluid intake
-2-3L daily, and 1.2-1.5 times the normal
maintenance during the critical phase for
dengue patient without comorbidities.

• IVD 0.9% maintenance

-increasing HCT with evidence of ongoing plasma
leakage, despite increased oral intake
-Vomiting, unable to tolerate oral fluid, severe
diarrhoea
-Review infusion rate within 2-4 hours (IO chart
monitoring)

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Patient with persistent warning signs with
increasing or persistently high HCT
• Graded bolus fluid regime
• Frequent monitoring of
clinical and laboratory
parameters every 2-4
hours until patients
improve.
• Aim for urine output of
0.5-1.0 ml/kg/hr.

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FLUID RESPONSIVENESS PARAMETERS
 GRADE OF DENGUE SHOCK
SYNDROME
⚫ Grade l : Fever accompanied by non-specific constitutional symptoms; the only
haemorrhagic manifestation is a positive tourniquet test and / or easy bruising.

⚫ Grade ll : Spontaneous bleeding, in addition to the manifestations of Grade l

patients, usually in the form of skin or other haemorrhages.

⚫ Grade lll : Circulatory Failure manifested by a rapid, weak pulse and narrowing
of pulse pressure or hypotension with the presence of cold, clammy skin and
restlessness.

⚫ Grade lV: Profound shock with undetectable blood pressure or pulse.

Patient in shock
• Bolus fluid regime
• Shock can happen in any
phases of dengue.

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Non responder to initial resuscitation
• If the first two cycles off fluid resuscitation (40cc/kg) fails to establish stable
haemodynamically and HCT remains high the 3rd cycle colloid should be
considered.
• If the repeated HCT drops but clinically patient still in shock we must
suspect of significant bleed (occult bleed).
• Other possible causes of persistent shock are:
-Sepsis
-Cardiogenic shock (due to myocarditis ,RV / LV dysfuction , pericardial
effusion or cardiac ischaemia )
-Cytokine storm
-Acute liver failure with lactic acidosis
Management of Dengue Fever in pregnancy
MANAGEMENT OF SIGNIFICANT OCCULT
BLEEDING
• Transfuse blood (5-10 ml/kg of packed red cells) and observe the
clinical response. Consider blood components if required

• Consider repeating the blood transfusion if there is further blood

loss or no appropriate rise in HCT after blood transfusion

• OGDS is indicated if these patients have persistent bleeding despite

optimum medical therapy.
 DISCHARGE CRITERIA
• Afebrile for 48 hours
• Improved general condition
• Improved appetite
• Stable hematocrit
• Rising platelet count
• No dyspnoea or respiratory distress from pleural
effusion or ascites
• Resolve bleeding episodes
• Resolution or recovery of organ dysfunction
Admission criteria:
• Age<12m
• Warning signs
• Features of severe dengue
• Comorbids
• Logistic issues

• Daily vital signs monitoring i.e. temperature, pulse

rate/volume, BP and CRT
• Daily FBC monitoring specifically HCT and platelet count. Initial
HCT can be used as a baseline during the monitoring. Critical
phase of plasma leakage is preceded by decreasing WBC count,
platelet count and increasing HCT. Thus, daily FBC is
recommended until the critical phase has resolved.
• Daily fluid intake and urine output. Caregivers should be
advised to record oral fluid intake and urine output. Urine
output of 4 - 6 times/ day signifies adequate fluid intake.
• Advise caregivers to bring the child for reassessment by
healthcare providers if the child’s condition worsens i.e.
presence of warning signs.
Case Scenario 1
Mr A is a 39 yrs old gentleman with NKMI, presented with the below
symptoms;
1. Fever for 3/7 with chills and rigor,
-No doc temp
-Not on PCM
2. Vomitting
-Projectile in nature
-2 episodes amounting to about ½ a cup each time.
Further history?
-History of recent fogging, one of his neighbour was admitted 1 month ago for dengue
fever
-Able to tolerate orally
Denied ;
-Retroorbital pain
-Right hypochondriac pain
-Hemetemesis
-Malenic stools
-Rashes
-Jungle trekking/rodent infestation/swimming in water bodies
-Denied high risk behaviours
On examination
O/E: GCS 15,good pulse volume,warm peripheries,not septic
looking,tongue moist,no sunken eyes,skin turgor normal.
BP: 126/84
HR: 86
T: 37.5
RR: 18
Lungs/CVS/PA: Normal findings
No rashes seen
Investigation
1) FBC; TWC 3.2,Hb 12.8,Plt 178,HCT 48
2) Dengue IgM+/IgG-/NS1+

Dengue Fever Day 3 of illness in febrile

phase,hemodynamically stable without warning signs
Management
1. Allow home
2. T.PCM 1g PRN
3. Encourage fluid intake 2L to 3L per day
4. OD FBC
5. Home monitoring record and Dengue monitoring checklist
6. If afebrile for 48 hours and platelet is going uptrend with no
hemoconcentration can allow discharge
Case scenario 2
Mrs M is a