Dengue Syndrome by Dr Faisal Ahmed Abbas

Dr Ahmed Faisal Abbas
Indoor Medical Officer
Medicine Unit: Green
M Abdur Rahim Medical College
Hospital , Dinajpur


1st part of presentation 2nd part of presenttion
a.Introduction & Epidemiology of
dengue
a. Dengue Case Management
b.Pathophysiology & Clinical
mnifestation of Dengue infection
c.Lab investigation for Dengue
diagnosis & management

 We mourn deeply for
the departed soul of
“Dr NIGAR NAHID
DIPU” (From MMC-32)
who passed away due to
Dengue Hemorhagic
Shock on 02.O7. 2019
 I would like to request
all my repected
audiences to stand and
keep silence for one
minute

 Dengue is a disease caused by an Arbovirus
 Has 4 related virus serotypes
 Most important arthropod transmitted human viral
disease
 Constitutes an important worldwide health problem
including Bangladesh
 After incubation period of 4-10 days, illness begins
abruptly and is followed by three phases-febrile,
critical and recovery
Source: National Guideline For Clinical Management Of Dengue Syndrome
2018

 Genus: Flaviviruses
 Four serotypes: DENV-1, DENV-2, DENV-3 & DENV-4
 Infection with anyone of these serotypes confers
lifelong immunity to that virus serotype
 Antigenically similar but they elicit cross
protection for only few months
 Secondary infection with another serotype or
multiple infection with different serotypes result
in more severe form of diseases
Source: National Guideline for Clinical Management Of Dengue Syndrome 2018

 Aedes mosquitos (Tiger
Mosquito): Distinguished by
white stripes on black body
 Important members of Aedes
family: A. Aegypti, A. Vittatus.
A, Albopictus
 Aedes aegypti is highly
domesticated and strongly
anthropophilic
 Aedes Albopictus: Aggressive
feeder, prefers natural larval
habitats including Tree holes,
latex collecting cups in rubber
plantations, leaf axils, bamboo
stumps, cocconut shells, etc

 In 2000, 5551 dengue infections
were reported from Dhaka,
Chittagong and Khulna cities
-Dengue fever: 62.4% cases
-Dengue hemorrhagic fever: 37.6% cases
 Aedes Aegypti was the main
vector responsible for epidemic
 Aedes Albopictus: Potential
vector in Chittagong
 Worst outbreak occurred in 2002
with 6232 cases and 58 deaths

 Dengue virus has four distinct serotypes
> DEN-1
> DEN-2
> DEN-3
> DEN-4
 After mosquito bite Local replication
Local lymphnode Blood Various tissues
 The virus circulate in the blood typically for 4 days
during febrile phase and is cleared within a day of
defervescence

 Primary Dengue Infection: Develops serum
antibodies that can neutralize the homologous
serotype and gives life long type specific immunity
 Secondary Dengue Infection: Secondary infection
by viruses of heterogenous DENV serotype occur
frequently in endemic areas and results in
manifestation of severe disease
 DHF and DSS occur in individuals who are immune
to one virus serotype and are then infected with
another
source: National Guideline for Clinical Management Of Dengue
Syndrome 2018

 Pathogenesis of severe disease is not well understood
 Suggested mechanisms are:
1.ADE (Antibody-Dependant Enhancement)
2.Compliment activation by virus-antibody complex
3.T-cell mediated immunopathology
4.Cytokine abundance
 Bleeding in DHF results from combination of:
1.Vascular endothelial cell damage
2.Platelet dysfunction
3.Thrombocytopenia
4.Blood clotting defects
Source: National Guideline for Clinical Management Of Dengue Syndrome
2018

 Incubation period: 4-7 days (3-14 days)
 Prodrome: 2 days of malaise and headache
 May be:
>Asymptomatic
>Symptomatic
 Symptomatic manifestations are grouped into “Dengue
Syndrome” which encompass the following:
A. Undifferentiated fever
B. Dengue fever
C. Dengue Heamorrhagic fever
D. Expanded Dengue Syndrome (rare)

 Undifferentiated Fever:
>Occurs in dengue viral infection specially for
first time
>Simple fever indistinguishable from other viral
infection
>Maculopapular rashes may accompany the
fever or may appear during defervescence
>Upper RTI and GIT symptoms are common

1.FEVER:
>Sudden onset with a sharp rise of temperature
>Body temperature is usually between 39*C
and 40*C(102*F to 104*F)
>Biphasic fever, lasting 2-7 days in majority of
cases
>Often associated with flushed face and
headache
>Occasional chills may be present
2.Rash:
>1st 2-3 days: Diffuse flushing or fleeting
eruptions seen on face,neck,chest
>3rd and 4th day: Conspicuous rash may be
maculopapular or rubelliform
>Afebrile period or defervescence: Petechiae
may appear on extensor surfaces

3. Other features:
-Retro-orbital pain on eye movement or eye pressue
-Photophobia
-Backache and pain in muscles and joints/bones
-Anorexia and altered taste sensation
-Constipation, colicky pain and abdominal tenderness
These symptoms and signs vary markedly in frquency
and severity
4.Hemorrhagic manifestations:
*Petechiae
*Massive Epistaxis
*Menorrhagia
*GIT bleeding (Rarely)
Torniquet test will be positive in this case

 Acute onset of high fever; similar signs
and symptoms of DF in early febrile phase
 Clinical course of illness has 3 phases:
*Febrile phase
*Critical phase (Plasma leakage)
*Convalescent phase

 Febrile phase:
*Sudden onset of fever, biphasic fever
*Lasting 2-7 days
*Commonly associated with headache,flushing
and rash
*Maculopapular or rubelliform rash usually
appear after 3-4days of fever
*Commonly seen in face, neck and other part
of the body
*Usually fades away in later part of febrile
phase

 Critical phase:
*Hallmark of DHF
*Heralded by the onset of plasma leakage
*Usually occurs after 3 to 4 days of onset of
fever
*Abnormal haemostasis and plasma leakage
leads to shock, bleeding ,accumulation of fluid
in pleural and abdominal cavity
*Period persists for 36-48 hours
*Platelet count is <100000 per/cumm of blood

 Evidence of Plasma leakage:
*Haematocrit (HcT): A 20% rise of HcT from baseline
is indicative of significant plasma leakage
*Plasma leakage is due to increased capillary
permeability
*Plasma leakage is selective and lasts for 24-48 hrs
*Ascites and pleural effusion may develop
 Other evidences:
*Non-fasting serum cholesterol <100 mg/dl
*the degree and the rate of plasma leakage can vary
* Severe leakage may develop shock, which may be
complicated with organ impairment, metabolic
acidosis and disseminated intravascular coagulation
(DIC)

 Bed side examinations:
* Torniquet Test (TT)
(Clinical test for detecting
overt hemorrhage)
*Capillary Refill Time
(Clinical examination for
volume status of the body)

 Convalescent Phase:
>Usually occurs after 6-7 days of fever
>Usually lasts for 2-3 days
>Reabsorption of extravaseted fluid
occurs
>Features:
-Improved general wellbeing and appetite
-Appearance of convalescent rash
-Generalized itching
-Hemodynamic stability
-Diuresis
-Stabilization of HcT
-Rise in WBC count followed by rise in
Platelet count

 Criteria of DHF plus signs of circulatory
failure:
*Rapid and weak pulse
*Narrow pulse pressure(</20 mmHg)
*Hypotension for age
*Cold clammy skin
*Restlessness
*Undetectable pulse and blood pressure

 Patients with dengue illness can
sometimes develop unusual
manifestations such as involvement of
liver, kidney, brain or heart with or
without evidence of fluid leakage and
therefore does not fall into category of
DHF
 These conditions are very rare and
management is symptomatic

1.Complete blood count:
Total leucocyte count, total platelet count and Hct should
be done on first consultation day to have the baseline:
Recommendations:
*All febrile patients at the first visit within one week
*All patients with warning signs
 Leucopenia:
*Common in both adults and children with DF
*WBC count </5000 cells/mm3 and ratio of neutrophils to
lymphocyte(neutrophil< lymphocytes) is useful to predict the critical period of
plasma leakage
*This finding precedes thrombocytopenia or rising HcT

 Thrombocytopenia:
*Observed in some patients of DF
*A sudden drop in platelet count below 100000 occurs before the onset of
shock or subsidence of fever
*The level of platelet count is correlated with severity of DHF
*Severe thrombocytopenia (<100000/mm3) usually precedes/accompanies
overt plasma leakage
 Heamatocrit:
* Rising Hct 20% from baseline eg. From Hct 35% to 42% is objective
evidence of plasma leakage

2)Biochemical tests:
-AST and ALT levels are frequently elevated in both adults
and children with DF and DHF
-AST and ALT levels are significantly higher (5 to 15 times
of upper limit of normal) in DHF
-In special cases:
*Hyponatremia/ hypoalbuminaemia
*Hyponatremia is frequently observed in DHF and is more severe in
shock
*Hypocalcemia (corrected for hypoalbuminaemia) in DHF
*Metabolic acidosis is found with prolonged shock
*BUN is elevated in prolonged shock

3.Coagulation profile:
*Partial thromboplastin time and prothrombin time
are prolonged in about half and one third of DHF
cases respectively
*Thrombin time is also prolonged in severe cases
4.Other tests:
*Urine R/M/E: Albuminuria
*Stool test: Occult blood is often found in stool
*Chest Xray and Ultrasonography: Detection of pleural
effusion or ascites
*Other tests for exclusion: Malaria (MP/ICT), Typhoid fever
(Blood culture)
*Other tests for Dengue expanded syndrome: Serum albumin,
LFT, RFT, serum electrolytes, imaging, ECG, Echo, CSF etc

 Detection of antigen: NS1 antigen
*NS1 antigen rapid test: Positive within minutes of starting symptoms
*ELISA NS1 antigen: Positive on 1st day of illness
*The test becomes negative from day 4-5 of illness
 Dengue IgM/ IgG test (MAC ELISA or Rapid ICT)
*Anti-dengue IgM specific antibodies can be detected after 5 days of
onset of fever and highest level achieved after 7 days
*It can be detected in low level up to 1-3 months of fever
*In primary dengue infection: IgM > IgG in early period and then IgG at
9th or 10th day of fever
*In secondary dengue infection:IgG> IgM. The higher IgG levels remain
for 30-40 days

 Nucleic Acid detection:
*The reverse transcriptase polymerase chain reaction (RT-PCR)-
confirm diagnosis (<5 days of illness)
 Dengue virus isolation:
*Isolation of dengue virus from serum, CSF or autopsy samples
*Detection of dengue virus or antigen in tissue, serum or CSF by:
>Immunohistochemistry
>Immunofluorescence or
>ELISA
*Detection of Dengue virus genomic sequence by RT-PCR

 For clinical purpose, Complete blood count, NS1
antigen and SGOT (AST) and or SGPT(ALT) within
three days will confirm the diagnosis and guides
for monitoring and management

 Tests should be done during 1st consultation day to
have the baseline if patient presented within 3
days of fever
 Follow up testing- On 1st afebrile day, But should
be done daily if DHF suspected
 A regular HcT is more important for management
than thrombocytopenia
 Once the platelet count begins to rise and
reaches>/50,000/mm3, daily lab investigation may
be discontinued

In a Nut shell of 1st part:
*Dengue has become a life threatening outbreak in recent years
*Differentiating point of DF & DHF is plasma leakage
*Critical phase is the period of plasma leakage which persists for 36-48 hrs
*Rising Heamatocrit with >/20% from baseline indicates plasma leakage
*Leucopenia (wbc count</5000/mm3) with lower ratio of Neutrophil to
lymphocyte useful to predict critical period of plasma leakage
*A sudden drop of platelelet below 100000/mm3 may indicate upcoming
shock or plasma leakage
*In first 3 days CBC, NS1 antigen and SGPT or SGOT will confirm the
diagnosis
*Early intervention may be life saving

Dr Ahmed Faisal Abbas
Indoor Medical Officer
Medicine: Unit Green
M Abdur Rahim Medical College Hospital
Dinajpur

 The clinical guide of WHO uses 3 categories of
case classification (A,B,C), after a patient fulfills
the criteria for probable dengue
 Patients Group A:
*Dengue patients without warning signs
*May be sent home
*Able to tolerate adequate volumes of oral fluid, pass
urine at least once every 6 hours

 Patients Group B:
*Dengue patients with warning signs
*They should be admitted for in-hospital management for close
observation as they approach the critical phase
*Rapid fluid replacement prevents progression to shock
 Patients Group C:
*Severe Dengue patients who require emergency treatment& referral
*They are in the critical phase of the disease and have:
>Severe plasma leakage leading to dengue shock and/or fluid accumulation with
respiratory distress
>Severe organ impairment (hepatic damage, renal impairment)
>Myocarditis, Cardiomyopathy, Encephalopathy, Encephalitis
>Severe metabolic abnormalities (Metabolic acidosis, severe hypocalcaemia)

 No clinical improvement or worsening of the situation
just before or during the transition to afebrile phase
or as the disease progresses
 Persistent vomitting
 Severe abdominal pain
 Lethargy and/or restlessness,sudden behavioural
changes
 Bleeding: Epistaxis, black stool,
haematemesis,excessive menstrual bleeding, dark
coloured urine(haemoglobinuria) or heamaturia
 Giddiness
 Pale, cold and clammy hands and feet
 Less or no urine output for 4-6 hours
 Liver enlargement >2cm
 Heamatocrit >20%

 Pregnancy
 Infancy
 Old age
 Obesity
 Hypertension
 Diabetes mellitus
 Heart failure
 Renal failure
 Chronic heamolytic disease (Sickle cell disease and
autoimmune disease),those with certain social
circumstances(such as living alone or living far from
health facility without reliable means of transport)

 Group A:
*Adequate bed rest
*Adequate fluid intake
Plain water alone may cause electrolyte imbalance
*Take paracetamol (not more 3 gms per day for adults)
*Tepid sponging
*Elimination of mosquito breeding places
* Avoid Acetylsalicylic acid (aspirin), mefenemic acid,
ibuprofen or other NSAIDs, steroids,antibiotics
*If there are warning signs,patient should be immedately
taken to hosptal

 Group B:
 Obtain a reference Haematocrit before Iv fluid
therapy
 Intravenous fluid therapy in DHF during Critical
phase
Indications for IV fluid:
*When patient cannot have adequate oral fluid intake or is vomitting
*when Hct continues to rise 10%-20% despite oral rehydration
*Impending shock/ Shock

 The following fluids are recommended both crystalloids and
colloids:
 Crystalloids:
1.0.9% NaCl(isotonic normal saline solution) (0.9% NS) (Preferable)
2.0.45% half strength normal saline solution(0.45%NS) (For children)
3.5% dextrose in lactated Ringer”s solution (5% DRL)
4.5% dextrose in acetated Ringer”s solution (5% DRA)
5.Hartman solution
 Colloids:
1.Dextran 40 3.Plasma 5. Human albumin
2.Hemaceel 4.Blood &blood components

 Isotonic crystalloid solutions should be used throughout the
critical period
 Indications of Hyper-oncotic colloid solutions (Dextran 40
or starch solutions):
*Patients with massive plasma leakage
*Those not responding to minimal volume of crystalloids
 A volume of about Maintenance+5% dehydration is given to
maintain “Just Adequate” intravascular volume and
circulation
 Those with shock duration of IV fluid therapy should be 24-
48 hours
 For non-shock patients the duration should be longer but
not more than 60-72 hours

 Fluid requirement:
*Both oral and intravenous in critical phase (48 hours): M+ 5% deficit
(Maintenance +5% deficit)
*5% deficit is calculated as 50 ml/kg upto 50 kg
 Calculation for normal maintenance of intravenous fluid
infusion (Holliday-Segar formula)
*4ml/kg/hr for 1st 10 kg body weight
+2 ml/kg/hr for next 10 kg body weight
+1ml/kg/hr for subsequent kg body weight
 For overweight or obese patients maintenance fluid needs to be
calculated based on ideal body weight (IBW)

 Maintenance (for 1day) +5% deficit (oral and IV fluid
together) to be administered over 48 hrs
ex: for a 60 kg adult man maintenance for 1 day is
(Holliday Segar formula)
for 1st 10 kg body wt: 40 ml/hr (4 ml/kg/hr)
for next 10 kg body wt: 20 ml/hr (2ml/kg/hr)
for subsequent 40 kg BW: 40 ml/hr (1 ml/kg/hr)
So, total Maintenance of fluid is 100 ml/hr= 2400 ml/day
So total fluid requirement: M+5% deficit= 2400 ml+ (50* 60) ml
=5400 ml
 This volume of fluid needs to be given over 48 hrs in non-
shock patients

 Escalation& de-escalation
method:
*Fluid should be given at a rate of
1.5 ml/kg/hr or 40 ml/hr
(12d/min) for 6 hours.
*If patient does not have stable
vital signs, adequate urine output,
the fluid should be escalated to 3
ml/kg/hr or 80 ml/hr (20 d/min)
for 6 hrs
*The fluid can be escalated to 5
ml/kg/hr (120 ml/hr or 30 d/min)
and then 7 ml/kg/hr (200 ml/hr or
50 d/min) for every 6 hours if
patient does not have stable vital
sign
*In 6 hrs escalation,if patient has
stable vital signs, the fluids can be
gradually decline from 7 to 5 to 3
to 1.5 (ml/kg/hr)

 Parameters that should be monitored include:
*Vital signs and peripheral perfusion (1-4 hourly until the patient is out
of critical phase)
*Urine output (4-6 hourly)
*Haematocrit (before and after infusion , then every 6-12 hourly)
*Blood glucose
*And other organ functions (Renal profile, liver profile, coagulation
profile)

 Indication of Platelet transfusion:
*Very severe thrombocytopenia who need urgent surgery
*Clinical judgement of the treating physician
 If platelet concentrate is not available, then whole
blood may be transfused

 DSS definition: DSS is a hypovolemic shock
caused by plasma leakage and characterized by
increased systemic vascular resistance,
manifested by narrow pulse pressure (SBP is
maintained with increased diastolic pressure,
e.g: 100/90 mmHg)

 Laboratory investigations
(ABCS) should be carried
out in both shock and
non-shock cases when no
improvement occurs
inspite of volume
replacement

 Cessation of plasma leakage
 Stable BP, pulse and peripheral perfusion
 Heamatocrit decreases in the presence of good pulse
volume
 Apyrexia (without the use of antipyretics) for more than
24-48 hours
 Improving urine output
 Continuing iv fluid therapy beyond 48 hrs of critical phase
will put the patient at risk of pulmonary edema and other
compliations such as thrombophlebitis

 Risk factors of bleeding:
*Patients having profound/prolonged/refractory shock
*Hypotensive shock and multi-organ failure
*Are given NSAIDs
*Are on anticoagulant therapy
*Have pre-existing Peptic ulcer disease
*Have any form of trauma, including intamuscular
injection

 Persistent and/or severe overt bleeding
 A decrease in Hct level, after bolus of fluid resuscitation
 Refractory shock that fails to respond to consecutive fluid
resuscitation of 40-60 ml/kg
 Hypotensive shock with inappropriately low/normal
haematocrit
 Persistent or worsening metabolic acidosis
 A well-maintained SBP, especially in those with severe
tenderness and distension

 Stop bleeding ex: Nasal adrenal packing
 Aliquots of 5-10 ml/kg of fresh packed red cells or r 10-20 ml/kg of
fresh whole blood (FWB) at an appropriate rate
 Oxygen inhalation 2-4 L/min
 Repeating the blood transfusion
 No evidence of transfusion of platelet concentrates and/or fresh-frozen
plasma except in surgeries
 H-2 antagonist or PPIs in gastrointestinal bleeding
 Careful NG tube or bladder catheter insertion to minimize haemorrhage

 Hyperglycemia and hypoglcemia can occur during the
critical phase
 Hyperglycemia will resolve with adequate fluid
resuscitation
 In repeated hyperglycemia, undiagnosed DM or IGT should
be considered
 Hypoglycemia should be treated with 0.1-0.5 g/kg of
glucose
 Euglycemia should be maintained with a fixed rate of
glucose-isotonic solution

 Hyponatremia is corrected by isotonic solution
 Hyperkalaemia is associated with severe metabolic acidosis
or AKI
 Life-threatening hyperkalemia should be managed by
Resonium A ,Calcium-gluconate infusions and/or insulin-
dextrose
 Renal support therapy may need to be considered
 Hypokalaemia should be corrected with potassium
supplements in parenteral fluids
 Calcium level should be monitored

 Early sign of hypovolemia and shock
 Lactic acidosis is the common cause of metabolic acidosis in DSS
 Correction of shock and adequate fluid replacement
 If not corrected by this method, consider severe bleeding and check
the haematocrit. Transfuse FWB or fresh packed red cells urgently
 Sodium bicarbonate is not recommended
 Hyperchloremia (CL level 154 mmol/L) may cause metabolic acidosis
with normal lactate level
 Hartman solution or Ringer’s lactate should be used as crystalloid in
this case

Signs of recovery Discharge Criteria
Stable pulse, BP and breathing
rate
No fever for atleast 24 hrs
without the usage of antipyretic
drugs
Normal temperature Atleast 2days have lapsed after
recovery from shock
No evidence of external or
internal bleeding
Good general condition with
improving appetite
Return of appetite Normal HcT at baseline value or
around 38-40% when baseline
value is not known
No vomitting, no abdominal pain No distress from pleural
effusions
Good urinary output No ascites
Stable hematocrit at baseline
level
Platelet count has risen
>50,000/mm3

 Management of fluid overload
*Review all iv fluid therapy, check and correct for ABCS
*All hypotonic solutions should be stopped
*Switch from crystalloid to colloid solutions as bolus fluids
*Dextran 40 is effective as 10 ml/kg bolus infusions, but the dose is
restricted to 30 ml/kg/day because of its renal effects

 In the late stage:
*IV Furosemide
*If patient is in shock, 10 ml/kg/hr of colloid (dextran) should be given
*Within 10-30 mins when BP is stable, administer IV 1 mg/kg/dose of
furosemide and continue with dextran infusion until completion
*IV fluid should be reduced to as low as 1 ml/kg/h until when Hct
decreases to baseline or below

 The following points should be noted:
*Urinary bladder catheter to monitor urine output
*IV Furosemide should be administered during Dextran infusion
*Vital signs should be monitored for 15 mins for 1 hr to note its
effects
>No urine output: Check intravascular volume status (CVP/Lactate)
>Adequate intravascular volume: Exclusion of Pre-renal failure/AKI
>Inadequate intravascular volume:Check ABCS and Electrolytes
>No responses to furosemide, repeat and doubling doses of
furosemide
>RRT should be considered in oliguric renal failure
>Pleural and/or abdominal tapping may be needed with severe
respiratory distresses and failure of above management

 Principal of treatment: Prevent rise of ICP
 CT scan or MRI is recommended to rule out intracranial hemorrhage
 Supportive therapy:
A)Oxygenation. Maintain ICP by following measures:
*Minimal IV fluid (Not >80% fluid maintenance)
*Switch to colloid solution
*IV diuretics in pts with fluid overload
*Positioning of the patient with the head up by 30*
*Early intubation to avoid hypercarbia and protect airway
*Dexamethasone 0.15 mg/kg/dose IV every 6-8 hours

B )Decrease Ammonia production:
>Lactulose 5-10 ml every 6 hours
>Local antibiotics get rid of bowel flora
C) Maintain blood sugar (Level at 80-100 mg/dl per cent)
D) Correct Acid-base and electrolyte imbalance
E) Anticonvulsants: Phenobarbtal, dilantin and diazepum IV as indicated
F) Blood transfusion preferably fresh packed red cells
G) Empiric antibiotic
H) H2 receptor blocker or PPIs (Gastrointestinal bleeding)
I) Plasmapheresis /Haemodialysis /RRT in clinical deterioration

 Pitfalls:
*Failure to suspect dengue infections in febrile patients with a history
of travel to dengue endemic areas within 2 weeks of onset of illness
*Failure to suspect, identify and treat other diseases: Meningits or
Malaria
*Failure to admit patients with S/S of intravascular volume loss
*Failure to administer appropriate fluids to DHF or DSS in proper rate
*Failure to refer critical cases in time
*Failure to notify public health authorities
 Special Concerns:
*Older pts with CHF must not be given excessive Iv fluids
*Dengue should be suspected in pregnant pts with compatible clinical
features

 Integrated vector management: Larval source reduction
 Household level actions:
*Wearing protective clothes during day time
*Use mosquito coils, aerosols, mats etc
*Use mosquito net (insecticide-treated) during day time
*Use repellents and creams during day
*Placing screens/wire mesh on doors and windows
*Water in containers should not be allowed to store >5 days
 Community Level actions:
 Institutional level actions

 Worldwide to control dengue, CYD-TDV ( Caimeric Yellow fever Dengue-
Tetravalent Dengue Vaccine) has been started to use
 This can be a hope for our country, invented by Sanofi-Pastur , a
pharmaceutical company of France
 Invented on 2015, it has brought enormous success applying over
people of Philipines
 9 years or above aged persons: 76% effective
 No negative effect on Pregnant mothers and neonates
 Circle of 3 doses: 1st dose stat then 2nd dose after 6 months and 3rd dose
after 1 year
 These vaccines are capable of preventing severe life threatening
menifestations of Dengue syndrome
Source: Daily Jugantor Newspaper

 Pregnancy & labour
 Elderly patient
 Infant patient
 Mandatory surgery
 Chronic liver disease
 Chronic kidney disease
 Cardiac diseases: Heart failure, IHD, Hypertension
 Diabetes & Dengue
 Patient on steroid therapy
 Fluid hypersensitivity & anaphylaxis

 What needs to be done:
*Admission is required & close follow up with CBC daily is very
important
*Important factors:
-Gestation and the phase of dengue
-Multi-discplinary team involvement
*Look for warning signs and admit to hosital
*Urgent referral to physician
*Explanation to family members
 The signs, symptoms and lab investigations may be confused
with other compliations of pregnancy such as Toxaemia and
HELLP syndrome(Haemolysis, Elevated liver enzymes and low
platelets).
 Increased incidence of abruptio placenta, death in utero and
prematurity are reported

 Complications:
*Fetal complications:
a) Premature fetal loss or vertical transmission
b)Vertical transmission in fetus is evidenced by fever,
thrombocytopenia, raised liver enzymes, gastric bleeding, pleural
effusion,convalescent rash and Dengue-specific IgM(+)
*Maternal complications:
a) Raised liver enzymes, thromocytopenia, febrile illness, gum
bleeding, bilateral pleural effusions
b)Uncomplicated pregnancy may be complicated with DHF

 Baseline parameters on first day of illness:
*Pulse, BP, Pulse pressure (Baseline BP is often lower, pulse pressure
wider, heart rate may be higher)
*CBC: Hb%, HCT & platelet count may be lower than in nonpregnant
patient
*SGOT/SGPT
*Ultrasound scan to detect:
-Pleural effusion
-Ascites (Gallbladder edema may be seen in both DF and DHF)
 Fluid volume for the critical period (M+5% deficit) for a
pregnant mother should be calculated (based on the weight
prior to pregnancy)

 Management of pregnant patients with DF/DHF close to
delivery:
a) Avoid Lower uterine segment Caesarian Section (LUCS) or induction
of labour during critical phase
b) Avoid obstetric procedure (Amniocentesis or external cephalic
verson)
c) If obstetric procedures undertaken:
*Maintain platelet count above 50,000/mm3
*Apheritic platelet (Single donor platelet transfusion preferred)
*Episiotomy to prevent vaginal tear (Spontaneous Labour)
*In fetal compromise, priority should be given to mother’s life
*Counselling family on probable outcome

 Monitoring:
*Monitoring constantly until it is certain that the danger has passed
*Pulse, BP, RR & temp be taken every 15-30 minutes until shock
resolves
*HCT and Hb studies should be performed every 2 hours for 1st 6
hours, then every 4 hours thereafter until patient is stable
*Accurate record of intake output including type of fluid

 Clinical manifestations:
*Little is known about dengue in the elderly
*Similar clinical manifestations to younger adults
*Less frequent:
-Rash, hepatomegaly, mucocutaneous hemorrhages
-Fever, abdominal pain, bone pain
*Highly frequent:
-Concurrent Bacteraemia, GIT bleeding , acute renal failure, pleural
effusion
-Higher Prothrombin time & lower mean Hb levels
-Higher incidence of plasma leakage and case fatalities

 Issues in management:
*About 10% elderly patients may have no fever
*Higher rates of acute renal failure
*The impact of increased co-morbidities
*Age-related decline in cardiopulmonary function is important
consideration during fluid replacement and/or resuscitation
*Complications such as congestive heart failure and acute pulmonary
edema
*Frequent assessments and adjustment of fluid regimes required

 Dengue in infancy:
*Symptoms:
-Fever, runny nose, cough, lose motion, vomitting, seizures
*Signs:
-high fever, sore throat, dehydration, bulged fontanel, neck rigidity,
hepatomegaly, splenomegaly
*Investigations:
-Leukopenia unlikely, positive Dengue NS1 antigent during febrile period,
Anti dengue IgM positive during defervescence, hypoglycemia, hyponatremia,
hypocalcemia, raised AST , USG: hepatosplenomegaly, ascites, Cxray: pleural
effusion

 Treatment:
*Home care
*Caution on over hydration
*Insecticide-treated mosquito net for infants
*fluid restriction
*Frequently evaluated for oral fluid intake and urinary output
(cathetrization needed)
*Fluid therapy during plasma leakage phase
*Half strength normal saline in 5% dextrose for <6 months infants
*Normal saline in 5% dextrose in infants>6 months
*Colloids (dextran 40) should be considered when high rates of
crystalloids are required

 Prior to surgery, proper assessment of patient,
heamatological, biochemical investigations should be
available
 Fresh blood or platelet concentrate need to be available
 Platelet concentrate should be raised up to 100000/mm3
 Fluid replacement should be according to stage of DHF

 Significantly higher risk of severe dengue and mortality
 Warning signs are similar to those of uraemia in CKD
 Ascites and/or pleural effusion, and signs of plasma leakage in dengue
are not uncommon findings in patients with CKD and fluid retention
 Patients with CKD have a low baseline HCT and platelet count
 A low baseline platelet count is found in dialysis patients
 Challenges in fluid management:
*Narrow window of fluid tolerance
*Urine output
*Limited effect of diuretics

 Acid base balance and electrolyte balance:
-Risk of developing metabolic acidosis and electrolyte imbalance
-Dialysis may be considered after heamodynamic stability
 Platelet dysfunction, in CKD with severe thrombocytopenia (+-)
coagulopathy may lead to severe bleeding

 Common co-morbidities: Valvular heart disease or IHD
 High fever, tachycardia and increased metabolic demands may
precipitate decompensation of cardiac functions
 Limted ability to compensate for hypovolemia or hypervolemia
 Fluid therapy should be guided by frequent clinical assessments, HCT
and blood gas determinations
 In Cardiac decompensation: NIPPV ; In failure of this Mechanical
ventilation
 Loop diuretics:
*After hemodynamic stability, when IV fluid has been discontinued or
reduced
*Patients with fluid overload

 Aspirin/clopidogrel should be avoided for certain days,
until the patient recovers from DHF
 Patients with IHD are more prone to cardiac dysrythmia,
cardiac failure and thrombo-embolism

 Interpretation of BP:
*Patients with chronic hypertension should e considered hypotensive
when the mean arterial pressure (MAP) declines by 40 mmHg from the
baseline, even if it still exceeds 60 mmHg.
 Management issue:
*Beta-blockers: cause bradycardia and block the tachycardic reponse
in shock
*Calcium channel blockers: may cause tachycardia. Tachycardia in
these pts may not indicate hypovolemia
 Impact on hypotension:
* Careful evaluation of continuation of drugs during plasma leakage
phase
* Antihypertensive effect or diuretic therapy may exacerbate
hypoperfuson

 Hyperglycemia causes osmotic diuresis
 Exacerbates shock state
 Risk of bacterial infection
 DKA & HHS:
*Similar clinical manifestations to warning signs of severe dengue
*DSS may be misdiagnosed as DKA
 Hypoglycemia:
*Patients who take OHA ( long acting sulphonylurea)
*Hypoglycemia could be aggravated by severe hepatitis from dengue
*Metformin may aggravate lactic acidosis, particularly in DSS

 Management:
*Immediate admission to hospital for close observation
*In GIT disturbances, Intravenous regular short acting insulin
*Target blood glucose level : <150 mg/dl or 8.3 mmol/L
*A source of glucose my be maintained once the target is achieved
*Blood glucose should be monitored every 1-2 hours until glucose
values are normal, then every 4 hourly

 Leukocopenia <5000 cells/mm3 indicates that within next 24 hrs
patient will enter the critical phase
 What should not be done is as important as what should be done
 What should be done should not be overdone
 Heamorrhage during febrile phase signifies DF with unusual hemorrhage
;
 Hemorrhage without fever should e assessed for DHF
 Multiplying Hb level by 3 is usually found to be around HCT level
 Sudden pallor signifies internal bleeding
 When Hct can’t be done or not available:
*If massive GIT bleeding from gut or other sites: Lower HCT
*If surface/ mild bleeding: Higher HCT
*Sudden unexplained deterioration of heamodynamic status or refractory to
adequate fluid therapy: Low HCT level
*In complicated situations frequent consultation and multi disciplinary
approach are useful

Dengue Syndrome by Dr Faisal Ahmed Abbas

Dengue Syndrome by Dr Faisal Ahmed Abbas

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Similar a Dengue Syndrome by Dr Faisal Ahmed Abbas

Similar a Dengue Syndrome by Dr Faisal Ahmed Abbas (20)

Último

Último (20)

Dengue Syndrome by Dr Faisal Ahmed Abbas