An acute fibrile illness syndrome caused by arboviruses that characterized by biphasic fever, myalgia, arthralgia, leukopenia, rash & lymphadenopathy.A.k.a dengue / breakbone fever Only 1/3 of DHF patient develop shock and circulatory failure ( outpatient Tx is enough , bring back when there are alarming signs) .Early plasma, fluid & electrolyte replacement proved to have favourable outcome( maintain circulation). In DHF/DSS case, great care taken to reduce invasive procedures while managing shock

1. DENGUE FEVER

2. DEFINITION

3. EPIDEMIOLOGY

5. AETIOLOGY
Caused by 4 distinct but related viruses, DEN-
1/2/3/4- classified under Flaviviridae family
ssRNA viruses, enveloped and spherical (50 nm)
Infection by one type confer lifelong immunity
towards that type, but only partial towards other
type.
Evidence increase risk for DHF if there is sequential
infection

6. Vector : Aedes aegypti (main), Aedes albopictus &
Culex quinquefasciatus
A.aegypti (day-time bitting mosquito)
-must be infective female
-prefer feeds on human (abundant around
human.
-breeds in clear water
-bitting activity reduced in low temperature
14ºC(transmission less in winter)

7. Transmission

8. Classification

9. Clinical Manifestation
Dengue Fever
- 1◦ Infection with DEN-2 and DEN-4 are thought to be
inapparent, regardless of age
- 1◦ infection with DEN-1 & DEN-3 in adult produces
biphasic fever and rash.
- Manifestation varies,
 in infant & young child –asymptomatic to 1-5 days
fever, rhinitis, mild cough, pharyngeal inflammation
In classic dengue fever
- after incubation 2-7 d, rapid & sudden onset of fever

10. Accompanied by frontal or retro-orbital headache
Back pain (precedes fever,occassionally)
Macular rash (transient, generalized,in first 2 days of
fever)
Pulse rate is slow ( in proportion to fever)
Myalgia ( increase in severity)
Nausea & vomiting (on 2-6 D of fever)
 Generalized Lymphadenopathy , followed by of period of
Defervescence.
Generalized mobiliform, maculopapular rash(palm &
soles spare)- disappear in 1-5 D (Biphasic ◦C curve)

11. At any stage, petechiae,epistaxis & purpuric lesion occur
(not common)
After febrile stage, prolonged asthenia, bradycardia &
extrasystole note( common in adult)

12. Dengue Hemorrhagic Fever( DHF).
~Other suggestive signs: hepatomegaly, circulatory
disturbance, hematocrite fall after fluid replacement

13. Clinical Manifestation
Dengue Hemorrhagic Fever (DHF/ DSS)
 An acute vascular permeability syndrome followed with
abnormal in hemostasis.
Progression of illness is characteristics (in children).
In mild 1st phase: abrupt onset of fever, malaise,
cough, vomiting, headache & anorexia ( after 2-5 Days of
rapid deteroriation & physical collapse)
In 2nd phase: has clammy hand, cold, warm trunk.
Flush face & diaphoresis.
Restlessness, irritated, complained of mid-epigastric
pain.
Peripheral cyanosis may occur.

14. Scattered petechiae on forehead, extremities, spontenous
ecchymoses, easy bruising and bleeding at site of
venupuncture( common findings).
Respiration is rapid & often laboured.
The pulse pressure is usually narrow (≤20 mmHg),
systole & diastolic pressure may be low or unobtainable.
Liver become tender ( 2-3 fingerbeadth below costal
margin, firm & nontender)
Bilateral or unilateral pleural effusion (radiograph)
After 2-3 Days of crisis, convalescence is rapid in
children who recovered.
Temperature may return to normal during or before
shock.

15. PATHOGENESIS

16. On micrscopic exam.maturation arrest of megakaryocytes in BM( D/t vasoactive
amines )

17. Diagnosis

18. WHO Grading of DHF/DSS
Grade 1 Grade 2 Grade 3 Grade 4
-Fever with
constitutional
symptoms.
-Positive Hess
test
-Spontenous
bleeding(skin
±other
bleeds) in
addition to
manifestation
of Grade 1
-Circulatory
failure (rapid
weak pulse,
narrow pulse
pressure
<20mmHg,
but systolic
BP still
normal.
-Profound
shock
(hypotension,
undetectable
BP & HR).
-Grade 3 & 4 is Dengue Shock Syndrome (DSS).
-Thrombocytopenia & hemoconcentration differentiate Grade 1
& 2 of DHF from DF.

19. Investigation

20. TREATMENT & MANAGEMENT
Dengue Fever:
 Mostly supportive.
Antipyretic drugs or cold sponging (< 40ºC).
Fluid & electrolyte are given when necessary.
Aspirin is contraindicated ( avoid Reye Synd.)
DHF/DSS:
 No antiviral given, only supportive measures.
Antipyretic to avoid convulsion .
Fluid intake is monitored (by mouth)

21. Observe sign of shock in children.
Oral & parenteral fluid therapy for rehydration (to correct
metabolic aacidosis or dehydration).
Shock
Need admission.
obtainIV access. & resuscitate.
Monitor : vital signs, PCV, ABG, BP hourly until stable,
platelet count 6 hourly, BUSE & urine output.
Fluid maintenance- continue with .45%saline 5%
dextrose(1-2 maintenance)

22. Electrolyte and metabolic disturbance.
-correction of hypoglycemia.
Transfusion of blood & blood products.
Monitor coagulation profile.
O2 supplement.
Vitamin K & H2 antagonist.

23. Prevention & Control
-Education

24. Prognosis
Only 1/3 of DHF patient develop shock and
circulatory failure ( outpatient Tx is enough , bring
back when there are alarming signs) .
Early plasma, fluid & electrolyte replacement proved
to have favourable outcome( maintain circulation).
 In DHF/DSS case, great care taken to reduce
invasive procedures while managing shock.
In children,
-in shock with unobtainable BP,
Has poor
-in shock but delayed admission,
prognosis
-in shock with GIT bleeding