DENGUE FEVER
World Distribution of Dengue 1999
Areas infested with Aedes aegypti
Areas with Aedes aegypti and recent epidemic dengue
Infants and Young Children
- undifferentiated febrile disease
- maculopapular rash
Older Children and Adult
high fever
headache
retro orbital pain
Myalgia
nausea
/vomiting
Rash
Arthralgia
Laboratory Results
• Leukopenia
• Thrombocytopenia
Manifestation of Dengue Virus Infection
Dengue virus infection
Asymptomatic Symptomatic
Dengue Haemorrhagic Fever
Undifferentiated Dengue Fever
(Plasma Leakage)
Fever Syndrome
(viral syndrome)
Without With No Shock Dengue Shock
Haemorrhage Unusual Syndrome
Haemorrhage
Dengue Fever Dengue Fever
Dengue Hemorrhagic Fever
4 Major Clinical Manifestations:
1. high fever
2. hemorrhagic phenomenon
3. hepatomegaly
4. circulatory failure
Dengue Hemorrhagic Fever
Labs: Moderate to marked thrombocytopenia
: Hemoconcentration
Major Pathophysiological change: plasma leakage
THE SEVERITY OF THE DISEASE CAN BE
MODIFIED BY EARLY DIAGNOSIS AND
REPLACEMENT OF PLASMA LOSS
DENGUE SHOCK SYNDROME
[Link] weak pulse
[Link] of Pulse pressure<20mmHg
[Link] clammy skin
[Link]
[Link] effusion and ascites
[Link] acidosis
[Link] bleeding
[Link]
Labs: Thrombocytopenia below 100,000 permm3
Hemoconcentration increase of 20%
Leukopenia
Neutropenia>Recovers within 2-3days
>Good Urine
CONVALESCENCE
Albuminuria Output and
IN PATIENTS WITHReturn of
CORRECTED
Appetite
DSS
Reduction of fibrinogen,prothrombin, factor VIII,XII
Reduction of levels of Factors V,VII,
>Herman’s SignIX and X
Prolonged Partial thromboplastin time and prothrombin time
>Bradycardia/Cardiac Arrythmia
Reduced C3
Hypoproteinemia
Hyponatremia
Metabolic Acidosis
Pleural Effusion
COMPLICATIONS AND UNUSUAL MANIFESTATIONS
CNS Phenomena
Encephalopathy
Intracranial Bleeding and brain stem herniation
Sepsis, Pneumonia, Wound Infection, Overhydration
Liver Failure
Acute Renal Failure and Hemolytic Uremic Syndrome
CASE DEFINITION FOR DENGUE FEVER
-an acute febrile illness with two or more of the following
manifestations:
--headache
--retro-orbital pain
--myalgia
--arthralgia
--rash
--hemorrhagic manifestations
--leukopenia
--Positive IgM Antibody test on a late acute or convalescent-phase
CASE DEFINITION FOR DENGUE HEMORRHAGIC
FEVER
--fever lasting 2-7days
--hemorrhagic tendencies
-positive tourniquet test
-petechiae, ecchymoses or purpura
-bleeding from mucosa, gastrointestinal tract
-hematamesis or melena
--thrombocytopenia(<100,000 cells per mm3)
--evidence of plasma leakage
-hemoconcentration
-pleural effusion, ascites and hypoproteinemia
CASE DEFINITION FOR Dengue Shock Syndrome
All the four criteria for DHF plus
--rapid and weak pulse
--narrow pulse pressure(<20mmHg)
--hypotension
--cold clammy skin and restlessness
Dengue Infection
Fever Positive Increased Vascular Hepatomegaly Thrombocytopenia Grade 1
Tourniquet test Permeability
Other Haemorrhagic
Grade 2
manifestations Leakage of plasma
Hypovolaemia
Coagulopathy Grade 3
Shock Disseminated
Intravascular
coagulation
Grade 4
Severe Bleeding
DEATH
Positive Tourniquet Test
GRADING SEVERITY OF
Dengue Hemorrhagic Fever
GRADE I: Fever + non-specific constitutional symptoms
+ positive tourniquet test
And or easy bruising
GRADE ll: All manifestations of Grade I + Spontaneous Bleeding
GRADEIII Circulatory failure
GRADEIV Profound shock with undetectable blood pressure or pulse
Management and treatment
• [Link] expander or fluid and electrolyte
solution
• [Link] administration
[Link] vital signs 1-2hours
•[Link]
[Link]
urineof metabolic and electrolyte
output
disturbance
9.D5Lr/Dextran
•[Link]
[Link] recognition of shock
•[Link]
[Link] therapy
hematocrit and platelet count
[Link] Transfusion
determination
• [Link]
ESSENTIAL LABORATORY TESTS
-Hematocrit and Platelet count
-Serum electrolytes and blood gas
studies
-prothrombin time, partial
thromboplastin time and thrombin time
-liver function tests
5% Fluid Deficit
Initiate Intravenous Therapy 5%
glucose in physiological saline
Improvement No improvement
Reduce IV Therapy VS or Hct worsen Increase IV Therapy
Improvement Improvement No improvement
Reduce IV Therapy Increase IV Therapy
Further Improvement Unstable VS, Urine
output falls, sign of
shock
Discontinue IV therapy
after 24-48 hrs Establish Central venous
access and urinary catheter,
administer rapid fluid bolus
VS and Hct Stable
adequate diuresis Hct Rises (or Distress) Hct Falls
Intravenous Colloid therapy Blood Transfusion
Improvement
UNSTABLE VS, Urine output falls,
sign of shock
Immediate rapid volume replacement [Link]-1 LR, Ringer’s
lactate, Ringer’s acetate or 5 % glucose diluted in physiological
saline, as intravenous bolus(repeat if necessary)
Improvement No improvement
Adjust Intravenous Therapy Oxygen
Hct Rises (or Distress)
Hct Falls
Blood transfusion 10-20 [Link]-1 plasma,
plasma subsitute or 5%
([Link]-1 if Hct is still >35%)
albumin, as intravenous
bolus(repeat if
necessary)
INDICATIONS FOR HOSPITALIZATION
Signs of Significant dehydration
>Tachycardia
>Increased Capillary refill time(>2s)
>Cool,mottled or pale skin
>Diminished peripheral pulses
>Changes in mental status
>Oliguria
>Hemoconcentration
>Narrowing of pulse pressure
>Hypotension
Criteria for
DISCHARGING >Absence of fever for at least
INPATIENTS 24 hours without the use of
antipyretics
>Return of appetite
>Visible clinical improvement
>Good urine output
>Stable hematocrit
>Passing at least 2 days after
recovery from shock
>No respiratory distress from
pleural effusion/ascites
>Platelet count of more than
50,000per mm3
The End
A lecture in Dengue Fever by
