DENGUE FEVER & DENGUE

HEMORRHAGIC FEVER
Kamilah Fernandez
TSMU
YEAR 5 GROUP#1
DENGUE FEVER & DENGUE
HEMORRHAGIC FEVER
Dengue is caused by dengue virus, a single-stranded RNA virus
with an icosahedral nucleocapsid and covered by a lipid envelope.
The virus is in the family Flaviviridae, genus Flavivirus and has 4
serotypes ; DENV-1, DENV-2, DENV-3, and DENV-4.
Dengue is transmitted between people by the mosquitoes Aedes
aegypti and Aedes albopictus, which are found throughout the
world.
Humans serve as the primary reservoir for dengue. Especially in
children younger than 15 years.
Dengue is endemic in at least 100 countries in Asia, the Pacific,
the Americas, Africa, and the Caribbean.
Dengue fever is typically a self-limiting disease with a mortality rate
of less than 1%. When treated, dengue hemorrhagic fever has a
mortality rate of 2-5%, but when left untreated, the mortality rate is
as high as 50%.







Distribution of Dengue in
the Western Hemisphere
Distribution of Dengue in
the Eastern Hemisphere
Transmission and
Pathogenesis of Dengue
Aedes egypti
Aedes Albopticus
Transmission and
Pathogenesis of
Dengue
Pathogenesis of
Dengue
Once inoculated into a human
host, dengue viral replication
takes place in target dendritic
cells. Infection of target cells,
primarily those of the
reticuloendothelial system, such
as dendritic cells, hepatocytes,
and endothelial cells,

result in the
production of immune mediators
that serve to shape the quantity,
type, and duration of cellular and
humoral immune response to
both the initial and subsequent
virus infections.


Pathogenesis of
Dengue
Clinical Presentation
of Dengue Fever
Clinical Presentation
of Dengue Fever
The incubation period is 3-14 days (average, 4-7 days);
Prodrome ; chills, erythematous mottling of the skin, and facial flushing (2-3 days).
Accompanying symptoms in patients with dengue may include any of the following:
Headache
Retro-orbital pain
Severe myalgias: (lower back, arms, and legs) and arthralgias: Usually of the knees and
shoulders,
Nausea and vomiting
Rash
Weakness
Altered taste sensation and Anorexia
Sore throat
Mild hemorrhagic signs (petechiae, bleeding gums, epistaxis, menorrhagia, hematuria)
Lymphadenopathy

Clinical Presentation
of Dengue Fever
Clinical Presentation
of Dengue Fever
1. Febrile phase : high grade fever suddenly, which can last for 2 to 7 days. Facial
flushing, skin erythema, generalised body ache, myalgia, arthralgia and headache.
Some patients may also complain of sore throat and conjunctival redness. Anorexia,
nausea and vomiting are fairly common at this stage.

2. Critical phase: between the 3 and 5 day of illness when there is a rapid fall in
temperature . The patient will may become better if there is no or minimal plasma
leakage, or worse if a critical volume of plasma is lost which can lead to shock. The
critical phase lasts for about 24 to 48 hours.

Clinical Presentation
of Dengue Fever
In more severe plasma leakage, the patients may develop symptoms such as
sweating and restlessness. cool extremities and prolonged capillary refill time.
Tachycardia, increase in diastolic blood pressure and narrowing of pulse pressure as
well as abdominal pain, persistent vomiting, altered conscious level, clinical fluid
accumulation, mucosal bleed or tender enlarged liver are important clinical warning
signs of severe dengue and should alert clinicians to the high possibility of rapid
progression to shock .The patient can deteriorate very quickly to profound shock and
death if fluid resuscitation is not instituted promptly.
3. Recovery phase: around 24 to 48 hours after fever, plasma leakage stops, followed
by reabsorption of extravascular fluid. Patients general condition improves, with
return of appetite, improvement in gastrointestinal symptoms, hemodynamic status
stabilizes and diuresis ensues. Some patients may have a classical rash of isles of
white in the sea of red. Some may experience generalized pruritus. Hematocrit level
stabilizes or drops further due to hemodilution following reabsorption of
extravascular fluid. Platelet count typically recovers earlier than recovery of white cell
count.

Physical Examination
of Dengue Fever
Rash : 50% patients with dengue fever develop a characteristic rash. The rash is
variable and may be maculopapular or macular.
Hemorrhagic Manifestation : Petechiae and purpura on the skin, nasal or gingival
bleeding, melena, hematemesis, and menorrhagia.
A tourniquet test is often positive. This test is performed by inflating a blood pressure cuff
on the upper arm to midway between diastolic and systolic blood pressures for 5 minutes.
The results are considered to be positive if more than 20 petechiae per square inch are
observed on the skin in the area that was under pressure.
Neurologic manifestations such as seizures and encephalitis/encephalopathy have
been reported in rare cases of dengue infection. Some of these cases did not
display other typical features of dengue infection. Other neurologic complications
associated with dengue infection include neuropathies, Guillain-Barr syndrome,
and transverse myelitis.
Physical Examination
of Dengue Fever
Additional findings may include the following:
Injected conjunctivae
Facial flushing, a sensitive and specific predictor of dengue infection
Inflamed pharynx
Lymphadenopathy
Nausea and vomiting
Nonproductive cough
Tachycardia, bradycardia, and conduction defects


Physical
Examination of
Dengue Fever
Physical Examination of
Dengue Fever
Physical Examination
of Dengue Fever
Severe Dengue : Dengue
Hemorrhagic Fever and
Dengue Shock Syndrome
DHF/DSS is caused by an acute increase in vascular permeability which leads to
leakage of plasma into the extravascular compartment. This results in
hemoconcentration and hypovolemia or shock. Clinicians managing dengue patients
therefore need to be aware that the clinical manifestations are, in fact, a continuum of
various pathophysiological changes in a patient who progresses from normal
circulatory state to hypovolemic shock.
DENGUE HEMORRHAGIC FEVER
Findings for dengue hemorrhagic fever are similar to those for dengue fever and include
the following:
Biphasic fever curve
Hemorrhagic findings more pronounced than in dengue fever
Signs of peritoneal effusion, pleural effusion, or both



Severe Dengue : Dengue
Hemorrhagic Fever and
Dengue Shock Syndrome
Minimal criteria for the diagnosis of dengue hemorrhagic fever, according to the WHO, are
as follows
Fever
Hemorrhagic manifestations (eg, hemoconcentration, thrombocytopenia, positive
tourniquet test)
Circulatory failure, such as signs of vascular permeability ( hypoproteinemia, effusions)
Hepatomegaly
Conjunctival injection (~1/3). Optic neuropathy may cause permanent and significant
visual impairment. Pharyngeal injection develops in almost 97% of patients with dengue
hemorrhagic fever. Generalized lymphadenopathy
Hepatic transaminase levels may be mildly to moderately elevated.
Encephalopathy is a rare complication that may result from a combination of cerebral
edema, intracranial hemorrhage, anoxia, hyponatremia, and hepatic injury.

Severe Dengue : Dengue
Hemorrhagic Fever and
Dengue Shock Syndrome
Severe Dengue : Dengue
Hemorrhagic Fever and
Dengue Shock Syndrome
Dengue shock syndrome
Findings of dengue shock syndrome include the following:
Hypotension
Bradycardia (paradoxical) or tachycardia associated with hypovolemic shock
Hepatomegaly
Hypothermia
Narrow pulse pressure (< 20 mm Hg)
Signs of decreased peripheral perfusion

Severe Dengue
Severe Dengue
Diagnosis of
Dengue
Because the signs and symptoms of dengue fever are nonspecific, attempting
laboratory confirmation of dengue infection is important.
Laboratory criteria for diagnosis include one or more of the following:
Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy samples.
Demonstration of a fourfold or greater change in reciprocal immunoglobulin G (IgG)
or immunoglobulin M (IgM) antibody titers to one or more dengue virus antigens in
paired serum samples
Demonstration of dengue virus antigen in autopsy tissue via immunohistochemistry
or immunofluorescence or in serum samples via enzyme immunoassay (EIA)
Detection of viral genomic sequences in autopsy tissue, serum, or cerebral spinal
fluid (CSF) samples via polymerase chain reaction (PCR)

Diagnosis of
Dengue
COMPLETE BLOOD CELL COUNT:
Leukopenia ( sometimes lymphopenia) at the end of the febrile phase.
Lymphocytosis, with atypical lymphocytes, commonly develops before defervescence
or shock.
A hematocrit level >20% is a sign of hemoconcentration and precedes shock. The
hematocrit level should be monitored at every 24 hours to facilitate early recognition
of dengue hemorrhagic fever and every 3-4 hours in severe cases of dengue
hemorrhagic fever or dengue shock syndrome.
Thrombocytopenia seen in up to 50% of dengue fever cases. Platelet counts less
than 100,000 cells/L are seen in dengue hemorrhagic fever or dengue shock
syndrome and occur before defervescence and the onset of shock. The platelet
count should be monitored at least every 24 hours to facilitate early recognition of
dengue hemorrhagic fever.


Diagnosis of
Dengue
METABOLIC PANEL
Hyponatremia is the most common electrolyte abnormality in patients with dengue
hemorrhagic fever or dengue shock syndrome.
Metabolic acidosis is observed in those with shock and must be corrected rapidly.
Elevated BUN levels are observed in those with shock.
Transaminase levels may be mildly elevated in patients with dengue hemorrhagic fever
who have acute hepatitis. Low albumin levels are a sign of hemoconcentration.
COAGULATION TEST
Coagulation studies may help to guide therapy in patients with severe hemorrhagic
manifestations. Findings are as follows:
Prothrombin time is prolonged
Activated partial thromboplastin time is prolonged
Low fibrinogen and elevated fibrin degradation product levels are signs of disseminated
intravascular coagulation



Treatment of
Dengue
Dengue Fever
It is usually a self-limited illness. There is no specific antiviral treatment currently
available for dengue fever.
Supportive care
Analgesics, fluid replacement, and bed rest is usually sufficient.
Acetaminophen may be used to treat fever and relieve other symptoms.
Dengue Hemorrhagic Fever and Dengue Shock Syndrome
Successful management of severe dengue requires careful attention to fluid
management and proactive treatment of hemorrhage. Admission to an intensive care
unit is indicated for patients with dengue shock syndrome.
Volume Replacement- Isotonic fluids such as Ringer lactate solution
Blood Transfusion- Blood, Platelet and Fresh Frozen Plasma



Prevention
1. The best way to reduce mosquitoes is to eliminate the places where the mosquito
lays her eggs, like artificial containers that hold water in and around the home.
Outdoors, clean water containers like pet and animal watering containers, flower
planter dishes or cover water storage barrels. Look for standing water indoors such
as in vases with fresh flowers and clean at least once a week.
2. The adult mosquitoes like to bite inside as well as around homes, during the day and
at night when the lights are on. To protect yourself, use repellent on your skin while
indoors or out. When possible, wear long sleeves and pants for additional
protection. Also, make sure window and door screens are secure and without holes.
If available, use air-conditioning.
3. If someone in your house is ill with dengue, take extra precautions to prevent
mosquitoes from biting the patient and going on to bite others in the
household. Sleep under a mosquito bed net, eliminate mosquitoes you find indoors
and wear repellent!

Prevention