Dengue fever

Dr Leong Kar Nim

 Caused by a flavi-virus
Four serotypes
Infection produces immunity to only
one serotype
No specific treatment

Life cycle of Aedes

CAUSES OF DEATH
IMMEDIATE
CAUSE OF DEATH

NUMBER OF CASES
AND PERCENTAGE (%)

Shock Syndrome

65 (70%)

End/ Multi Organ Failure

49 (53%)

Severe Bleeding

36 (39%)

*cause of death is not mutually exclusive

CONTRIBUTING FACTORS TO DEATH

FACTORS CONTRIBUTING TO DEATH
1.
2.

3.

PATIENT IN ILL CONDITION ON ADMISSION

DELAY IN DIAGNOSIS / ASSESSMENT OF SEVERITY
Low index of suspicion

NUMBER OF
CASES AND
PERCENTAGE (%)
40 (43%)
59 (64%)
37 (40%)

Delay in review by doctor

19 (21%)

Late referral

18 (20%)

Results delayed / not traced / not reviewed

15 (16%)

Infrequent investigations ordered

14 (15%)

INADEQUATE MONITORING / TREATMENT

Inadequate fluid resuscitation

70 (76%)
38 (41%)

Inadequate monitoring of vital signs

29 (32%)

Failure to recognize DSS

25 (27%)

Inadequate monitoring of FBC

26 (28%)

Not sufficient blood products given

21(23%)

Delay in referring patient for ICU care

16 (17%)

Overloading / pulmonary edema

18 (20%)

Clinical symptoms

Non specific
Myalgia, athralgia
Anorexia
Rash may or may not be present

Dengue case classification by severity 2009

Without

with
warning
signs

Criteria for dengue warning signs

Probable dengue
Live in/travel to dengue
endemic area. Fever and
2 of the following
criteria:
Nausea, vomiting
Rash
Aches and pains
Tourniquet test positive
Leucopenia
Any warning sign
Laboratory confirmed
dengue
(important when no sign
of plasma leakage)

Warning signs*
Abdominal pain or
tenderness
Persistent vomiting
Clinical fluid
accumulation
Mucosal bleed
Lethargy; restlessness
Liver enlargement >2cm
Laboratory: Increase in
HCT concurrent with rapid
decrease in platelet count
* Requiring strict
observation

Severe dengue

1.Severe plasma leakage

2.Severe haemorrhage
3.Severe organ
impairment

Criteria for severe dengue

1. Severe plasma
leakage leading to:
Shock (DSS)
Fluid accumulation with
respiratory distress
2. Severe bleeding
as evaluated by clinician
3. Severe organ
involvement
Liver: AST or ALT>=1000
CNS: Impaired
consciousness
Heart and other organs

WHO/TDR 2009

Dengue warning
signs

What are the warning signs?

Atypical presentations

Diarrhoea
ILI
Myocarditis
Encephalitis
Severe bleeding without plasma
leakage
Myositis

Clinical course

Pathophysiology
Capillary leakage
Leakage of serum into the 3rd space ie
pleural cavity, acsites etc
Resulting in intravascular volume
depletion
Reflected in increasing HCT

Diagnostic tests

Non structural protein-1 (NS1 antigen)

Present in high concentrations during early
phase of the disease
The detection rate of primary infection is
75%-97.3% compared to secondary
infection 60-70%.
Detection drops from day 4-5 of illness

Dengue Serology
ELISA method : Ig M and Ig G
Ig M only positive after 5 days 30 to
90 days
Ig G appear later, can be higher in
secondary infection

Laboratory Investigations
Full blood count
Low WBC
Haematocrit or PCV
Marker of plasma leakage
Differentiate DF from DHF
Thrombocytopaenia
More severe disease lower counts
Not predictive of bleeding
Liver function test
Raised AST and ALT
Higher in DHF

In patient management
Frequent monitoring
Vital signs
BP, PR, RR, T, pulse pressure
Capillary refill time, pulse volume

Clinical signs
Abdomen tenderness and pain
Vomiting
Pleural effusion

FBC
PCV
Platelet

How to recognize shock

(CCTV-R)

Maintenance fluid regime

Indicated for :
Those who cannot take orally well
Not in shock

1.2 1.5 mls/kg/hour

Those who cannot take orally

Vomiting, diarrhea
Not in shock
Rising HCT despite receiving
maintenance drip

1.2 1.5 x maintenance

Graded fluid boluses (5,3,2)

Indicated for :
Non shock pts
Persistent warning signs
Rising HCT despite 1.2-1.5 x
maintenance

Graded fluid boluses (5, 3,

2)
WT : 65 kg
5 mls/kg/h for 2
hours
3 mls/kg/h for the
next 2 hours
2 ml/kg/h for the
rest

325 mls/h for 2

hours
195 mls/h for 2
hours
130 mls/h

Repeat FBC at the end of 4 hours

How to recognize shock

Mm Hg

Pulse rate

120
110
100
90
80
70
60
Compensated shock

Decompensated shock

Time

LCS Lum

Bleeding in dengue fever

Suspect occult bleeding when HCT is
inappropriately low for clinical condition of pt
Most common site of major bleeding is the
GIT
Further reduction of the intravascular volume
Metabolic acidosis due to tissue
hypoperfusion

 Thrombocytopenia does not predict

bleeding in Dengue infection
Bleeding is due to prolonged
unrecognized shock

Dengue infection

Plasma leakage into 3rd

space

Reduced intravascular
volume

Shock

Metabolic acidosis

Major Bleeding

In case of major bleed

Give packed cells or whole blood
Minor bleeds (no need for
transfusion)
Epistaxis
Gum bleeding
Menstrual bleed

Recovery phase
After critical phase leakage will stop
Reabsorption will start fluid in the
3rd space will start moving back into
the intravascular space
Reflected by a gradual decline in HCT

 Over zealous fluid resuscitation

during the critical phase excessive
fluid in the 3rd space
Giving excessive fluid in the
reabsorption phase will result in
accumulation in 3rd space
Reabsorption will take a longer time

Intravascular
space

3rd space ie
ascites, pleural
effusion

Cut down fluid or stop once pt is

improving clinically and HCT is stable

MANAGEMENT AS
OUTPATIENT

TRIAGING AT ED & OPD

To determine whether urgent attention required
Look out for warning signs of shock
Triage Checklist (TO BE SEEN STAT)
1. History of fever (during critical phase of DHF,
patient is afebrile)
2. Abdominal Pain
3. Vomiting
4. Dizziness/ fainting/ restlessness
5. Bleeding tendencies
Vital parameters to be taken:
Mental state, BP, pulse, temp., cold or warm
peripheries; CRT

IF ADMISSION NOT
INDICATED
WHAT NEXT?
Daily or more frequent f/u from day 3 of
illness until afebrile for at least 2448
hours
Provide Dengue monitoring record & Home
Care Advice Leaflet
Include fluid advice
Advise patient to return to hospital as soon
as the warning signs develops

Home care advice leaflet

Encourage adequate intake of fluids
eg: fruit juice/barley water/isotonic
drink/milk
Ensure patient pass urine every 4-6
hours
PCM/ tepid sponging for fever
Avoid NSAIDs

CRITERIA FOR HOSPITAL REFERRAL /

ADMISSION

Symptoms:
1. Warning signs
2. Bleeding
manifestations
3. Inability to
tolerate oral fluids
4. Reduced urine
output
5. Seizure

Signs:
1. Dehydration
2. Shock
3. Bleeding
4. Any organ failure

CONSIDER EARLY ADMISSION

Co-morbitity: DM, HPT, IHD, morbid obesity,
renal failure, chronic liver disease
Elderly > 65 years old
Pregnancy
Social factors: live alone, far away from
health facilities
Laboratory criteria
Rising HCT accompanied by rapid reduction of
platelet

CASE STUDY

45 year old man

Fever for the past 3 days

No comorbids
Poor appetite
Nausea
Epigastric discomfort
Life long non smoker

WT : 65 kg

 Temp 38.2
HR 80-90 per minute
BP 130/80
NS1 positive

Day of admission (D3 of

illness)
HB : 13.6
TWC 3.4
PCV 42 %
Plat 110

 Warm peripheries
CRT < 2 seconds
How much fluids to give?

Maintenance fluid regime

WT : 65 kg
1.2 1.5 mls/kg/hour
Total fluid = 1.2 x 65 x 24 = 1.872 L
per day

Day 4 of illness
Temp 37.2
Still poor appetite and vomited x 1
Appears lethargic
HR 100/min
BP 120/80

HB 14.8
TWC 3.4
PCV 48% (42)
Plat 70 (110)

What is happening to the pt?

Leakage

hemoconcentration

Graded fluid boluses (5, 3,

2)
WT : 65 kg
5 mls/kg/h for 2
hours
3 mls/kg/h for the
next 2 hours
2 ml/kg/h for the
rest

325 mls/h for 2

hours
195 mls/h for 2
hours
130 mls/h

Repeat FBC at the end of 4 hours

Repeat FBC results

HB 14
PCV 45% (48)
Plat 50 (70)
TWC 3.2

How much fluid to give now?

Cut down to 1.5 x maintenance = 1.5
(1.872 L)

Day 5 of illness (24 hours since

deferverscence)

Looks unwell
Vomitted x 2
Temp 37
BP : 100/90
HR 110/min
CRT > 2 seconds

FBC
HB 12 (14)
PCV 36% (45)
Plat 45 (50)
HCO3 : 16
Lactate : 4.3
What is going on?

After 1 pint of PC
HB 13 (12)
PCV 42 (36)
Plat 45

HR 90 /min
BP 115/80
HCO3 19, lactate 3.0
Pt is more alert now

Day 6 of illness (48 hours after

deferverscence)
Able to take oral fluids now
Looks more cheerful

Temp 36.9
BP 120/90
HR 80/min
CRT < 2 seconds

 HB 12.5 (12)
PCV 41% (42)
Plat 50 (45)
IVD 117 mls/H (1.5 x maintenance)

Day 7 of illness (72 hours after

deferverscence)

Able to take porridge

Able to walk on his own to the toilet
C/o abdominal discomfort
PCV 40% (41)

US abdomen moderate ascites and

bilateral pleural effusion

 Fluid accumulation in the 3rd space

Drip stopped
Pt discharged on day 9

Thank you