Dengue Hemorrhagic fever/ Dengue Shock

Syndrome/ severe dengue

Definition associated with dengue virus
infection, particularly those occurring against
background of previous exposure to another
dengue virus serotype.The transient heterotypic
protection after dengue virus infection is
replace within several weeks by potential
heterotypic infection due to typical dengue
fever or uncommonly enhance disease
(secondary DHF/DSS)
Epidemiology rarely primary infection lead to
HF syndrome. Southeast Asian serotype 2 strain
more potential to cause DHF/DSS. Most patient
response well to supportive therapy, and overall
mortality rate at an experienced center in the
tropics probably at low as 1%. Widespread in
southeast asian and west pacific region.
Occuring in most tropical country in asia. DHF
occur exclusively in children under 16 years old
and is associated with secondary dengue
infection. DHF is usually associated with
secondary dengue infection but can appear
during a primary infection, especially in infants
under the age of 1 year, all of whom possess
maternal IgG dengue antibody

A diagnostic (four-fold) increase in dengue

antibody by the haemagglutination inhibition
test can usually be demonstrated from paired
sera obtained early in the febrile phase or on
admission, and 35 days later. A third specimen
23 weeks after onset is, however, required to
confi rm diagnosis of primary dengue
infection.
Serological diagnosis by detection of antidengue IgM and IgG by enzyme-linked
immunosorbent assay (ELISA) is now widely
used to document primary and secondary
infection. IgM antibody capture (MAC) ELISA is
a relatively new test. It is specific in
distinguishing dengue from other flavivirus
infections and has the advantage over the
haemagglutination test in that a definite
diagnosis can be made from an acute blood
specimen alone.

Diagnosis
DHF bleeding tendencies ( tourniquet test.
Petechiae) or overt bleeding in the absence of
underlying causes such as preexisting GI lesion.
DSS hemorrhagic signs, is much more serious
and result in increase vascular permeability
leading to shock.
Mild DHF/DSS restlessness, lethargy,
thrombocytopenia (<100,000/L) and
hemoconcentration are detected 2-5 days after
onset of typical dengue fever, usually at the
time of defervescence.
More severe case, frank shock is apparent, with
low pulse pressure, cyanosis, hepatomegaly,
pleural effusions, ascites and some cases
severe ecchymosed and GI bleeding
Virological diagnosis
Aetiological diagnosis can be confirmed by
serological testing and virus detection by
isolation or molecular technique from the blood
during the early febrile phase. Antibodies to
dengue virus antigens increase rapidly in
patients with secondary dengue infection.

Pathophysio hallmark of DHF are plasma

leakage and abnormal haemostasis

The induction of vascular permeability and

shock depends on multiple factors, including the
following:
1. Presence of enhancing and non neutralizing
antibodies Transplacental maternal antibody
may be present in infants <9 months old, or
antibody elicited by previous heterologous
dengue infection may be present in older
individuals. T cell reactivity is also intimately
involved.
2. AgeSusceptibility to DHF/DSS drops
considerably after 12 years of age.
3. SexFemales are more often affected than
males.
4. RaceWhites are more often affected than
blacks.

5. Nutritional statusMalnutrition is protective.

6. Sequence of infectionFor example, serotype
1 followed by serotype 2 seems to be more
dangerous than serotype 4 followed by serotype
2.
7. Infecting serotypeType 2 is apparently more
dangerous than other serotypes.
Prevention - Elimination of breeding sites is an
effective and definitive method of controlling
the vector and preventing dengue transmission.
The use of larvicides and insecticides during
outbreaks has some limitations. Efforts are now
focusing on health education and community
participation in an attempt to control the
vector(s) by eliminating or reducing the
breeding sites