DENGUE RECENT UPDATES

FROM
DR.MONIKA

INTRODUCTION
Dengue fever is the most prevalent arthropod
borne disease caused by flavivirus.
4
serotypes of DENV (DENV 1-4) are
transmitted to humans primarily by the bite of
Aedes aegypti mosquito.
Risk of disease is higher with areas having
multiple endemic serotypes
DENV 2 and 3 Severe Disease (Epidemic
DHF)

DENGUE CLINICAL SYNDROME

There are actually four dengue clinical syndromes:

1.

Undifferentiated fever;

2.

Classic dengue fever;

3.

Dengue hemorrhagic fever, or DHF; and

4.

Dengue shock syndrome, or DSS.

Dengue shock syndrome is actually a severe form

of DHF.

EPIDEMIOLOGY

Dengue is the most rapidly spreading mosquito-borne

viral disease in the world.
In the last 50 years, incidence has increased 30-fold
with increasing geographic expansion to new countries
and, in the present decade, from urban to rural settings
An estimated 50 million dengue infections occur
annually and approximately 2.5 billion people live in
dengue endemic countries.
In India first outbreak of dengue was recorded in 1812
A double peak hemorrhagic fever epidemic occurred in
India for the first time in Calcutta between July 1963 &
March 1964
In New Delhi, outbreaks of dengue fever reported in
1967,1970,1982, &1996

GEOGRAPHICAL DISTRIBUTION

GEOGRAPHICAL DISTRIBUTION

DENGUE ENDEMIC AREAS

(1996 TO 2010 )

Risk factors:
Construction activities

Water-storage
practices

Population movement
Heavy rainfall
Vector abundance

Seasonal trends of Dengue / DHF 2003-07

VECTOR OF DENGUE
Dengue is transmitted by the bite of female Aedes
mosquito
Female Aedes mosquito deposits eggs singly on
damp surfaces just above the water line. Under
optimal conditions the life cycle of aquatic stage of
Ae. Aegypti (the time taken from hatching to adult
emergence) can be as short as seven days
The eggs can survive one year without water. At
low temperature, however, it may take several
weeks to emerge.
During the rainy season, when survival is longer,
the risk of virus transmission is greater. It is a day
time feeder and can fly up to a limited distance of
400 meters. To get one full blood meal the mosquito
has to feed on several persons, infecting all of them.

FEW COMMON AND FAVOURED BREEDING

PLACES/SITES OF AEDES AEGYPTI

TRANSMISSION CYCLE OF DENGUE

1.The virus is inoculated into humans with the mosquito saliva.

2.The virus localizes and replicates in various target organs, for example,
local lymph nodes and the liver.
3.The virus is then released from these tissues and spreads through the
blood to infect white blood cells and other lymphatic tissues.
4.The virus is then released from these tissues and circulates in the
blood.
5.The mosquito ingests blood containing the virus.
6.The virus replicates in the mosquito midgut, the ovaries, nerve tissue
and fat body. It then escapes into the body cavity, and later infects the
salivary glands.
7.The virus replicates in the salivary glands and when the mosquito bites

PATHO-PHYSIOLOGY OF DHF

CLINICAL FEATURES
Dengue feverIncubation Period : 7-10 days
Fever : 5-7 days associated with retroorbital pain, myalgias, backpain,
polyarthralgias (break bone fever)
Rash Centrifugal distribution
Erythematous/Urticarial /
Scarlitiniform
Palmo Plantar edema and pruritus

CLINICAL FEATURES

CLINICAL FEATURES
Dengue Hemorrhagic FeverWHO classification of DHF

Thrombocytopenia (platelet count <100,000)

Fever 2-7 days

Hemorrhagic manifestations with a positive tourniquet test

Hemoconcentration or evidence of plasma leakage(HCT >20% ,

Hypoproteinemia ,Effusions )
Mortality is 10-20% if untreated, but decreases to <1% if adequately
treated
Plasma leakage may progress to dengue shock syndrome

CLINICAL FEATURES
Dengue Shock Syndrome SBP <90mm
Narrow pulse pressure <20mm
Fluid accumulation
Severe bleeding
AST /ALT Elevation > 1000
Neurological involvement
MODS

IDENTIFY PRESHOCK STAGE BY WARNING SIGNS

Abdominal pain & tenderness

Persistent vomiting

Clinical fluid accumulation

Mucosal bleeding

Lethargy

Hepatomegaly >2 cm

Increasing Hct. & decreasing Platelet count.

DIAGNOSIS
Diagnosis of Dengue falls in two stages :
Stage I : Fever and viremia accompanied by NS1
antigens in blood
Stage II :Early post-febrile period lasting a few weeks
when IgM and IgG antibodies are in excess.
NS1

Ag : Rapid, sensitive and specific,

(NS1Ag detection by BioRad kit)

IgM

Elisa (Capture)-Sensitivity is 90-97%,detectable after 5-6 days

and lasts 2-3 months
IgG-ELISA is nonspecific and exhibits the same broad crossreactivity among flaviviruses

DIAGNOSIS
Rapid Diagnostic tests Rapid

Diagnostic Test (RDT) kits for anti-dengue IgM

and IgG antibodies are at present commercially
available.

Produces

the results within 15 to 20minutes.

Sensitivity/specificity

of most of these tests is not known

According to WHO guidelines, these kits should not be

used in the clinical settings to guide management of
DF/DHF cases because many serum samples taken in the
first five days after the onset of illness will not have
detectable IgM antibodies.

MANAGEMENT

Dengue is complex in its manifestations but

management is relatively simple, inexpensive,
and very effective in saving lives so long as
correct and timely interventions are instituted.

AIMS OF TREATMENT
Assess the severity of Dengue Infection.
Assurance Usual clinical outcome good
Intercept the progression early by prompt fluid
replacement
Use of Blood /Plasma substitute/ Platelets in
patient with falling hematocrit. or continuous
bleeding.

ASSESSMENT OF THE SEVERITY

GRADING THE SEVERITY OF DENGUE INFECTION

MANAGEMENT OF DENGUE FEVER (DF)

No specific therapy, management of Dengue fever is
symptomatic and supportive
I.
Bed rest is advisable during the acute phase.
II. Use cold sponging to keep temperature below 39C.
III. Antipyretics may be used to lower the body
temperature.
IV. Oral fluid & electrolyte therapy are recommended
for patients with excessive sweating or vomiting.
V.
Patients should be monitored in DHF endemic area
until they become afebrile for one day without the
use of antipyretics and after platelet and
haematocrit determinations are stable, platelet
count is >50,000/ cumm.

INDICATIONS FOR HOSPITALIZATION

Tachycardia
Cold extremities
Weak pulse
Narrow pulse pressure
Hypotension
Changes in mental state
Oliguria
Increasing haematocrit even after fluid replacement
Bleeding

Daily Record Of
Parameters
During
Hospitalization

NEED FOR IV FLUIDS

Plasma volume is reduced

Volume loss may be upto 20%
Evidence of plasma leakage (Pleural Effusion,
Ascites, Increased haematocrit, Hypoproteinemia)
Identify Pre shock Stage; increasing symptoms:
abdominal pain, persistent vomiting, altered mental
state

FLUID CHARTS

FLUID CHARTS

SIGNS OF RECOVERY
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetite
No vomiting
Good urinary output
Stable haematocrit
Convalescent confluent petechiae rash

COMPLICATIONS
Hepatitis - 11%
Meningitis
Encephalitis
DIC
Myositis with Rhabdomyolysis
Increased amylase levels and pancreatic enlargement
on USG in 45%
ARDSAcute onset; Pa02/FiO2<200; Bilateral Infiltrate
on CXR
Myocardial dysfunction
Gram negative sepsis 0.5%
Fatality rate for DHF/DSS 15%

WHEN TO DISCHARGE ?
Absence of fever for at least 24 hours without the
use of antipyretics
Return of appetite
Visible clinical improvement
Good urine output
Stable haematocrit
Passing of at least 2 days after recovery from
shock
No respiratory distress
Platelet count of more than 50,000 per mm 3