DENGUE FEVER-WHO TREATMENT

PROTOCOLS
DR.V.USHAPADMINI M.D.,
SENIOR ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL MEDICINE
COIMBATORE MEDICAL COLLEGE AND HOSPITAL
EPIDEMIOLOGY
Most rapidly spreading mosquito borne viral disease in the
world
50 million dengue infections occur annually
Dengue is a public health emergency of international concern
More than 70% of at risk population for dengue live in
southeast Asia and western pacific
DENGUE VIRUS
Small single stranded RNA virus ,4 distinct serotypes 1,2,3,4
of genus flavivirus and family flaviviridae
Asian genotypes 2 and 3 associated with severe disease
DEDDDD
CLASSIFICATION OF DENGUE
Dengue fever(Classical)(DF)
Dengue haemorrhagic fever(DHF)
Dengue shock syndrome(DSS)

WHO agrees that Dengue is one disease entity with different

clinical presentations and often with unpredictable clinical
evolution and outcome
NEWER CLASSIFICATION
1) Probable Dengue

2)Dengue with warning signs

3)Severe Dengue
PROBABLE DENGUE
Live in/Travel to endemic ,rash, aches and pains

Nausea and Vomiting

Tourniquet test +ve->20 Petechiae per 1 square inch

Leucopenia
DENGUE WITH WARNING SIGNS

Abdominal pain

Vomiting ,Mucosal bleed

Restless

liver>2cm

increased Hct concurrent with decrease in platelet count

SEVERE DENGUE
1)severe plasma leakage(DSS)

2)severe haemorrhage

3)severe organ impairment

TRANSMISSION
Bite of AEDES EGYPTI mosquitoes
Aedes stegomyia,Aedes albopictus(forest species)

Latitude 35deg north to 35deg south

Do not survive in winter

Uncommon above 1000 metres

Water filled habitats in artificial containers and indoors

The indoor habitat is less susceptible to climatic variations and increases the
mosquitos longevity
DENGUE
Incubation period is 4-10 days
Most infections are asymptomatic or subclinical
Primary infection induces lifelong immunity to the infecting
serotype
Individuals are protected from a 2nd infection for 2-3 mo but
no long term cross protective immunity
INDIVIDUAL RISK FACTORS
1)Age

2)Comorbid illnesses-Bronchial asthma,Diabetes,Sickle cell

anaemia

3)Ethnicity

4)Secondary heterotypic infection

What is ADE
ADE-Antibody dependent enhancement

Non neutralising cross reactive antibodies raised during a primary

infection bind to the virus and facilitate cell entry.Inflammatory
cytokines and Mediators cause capillary leakage during the second
infection

Severe Dengue is seen in infants born to Dengue immune mothers

and secondary infection in adults
PHASES OF DENGUE
3 Phases
1) FEBRILE PHASE:(2-7days)Sudden high grade fever,facial
flushing,skin erythema,Myalgia
Arthralgia ,Headache,Sore throat ,Conjunctival injection,
positive tourniquet test,progressive decrease in WBC count
PHASES OF DENGUE
2)CRITICAL PHASE:(3-7days)
As temperature decreases increased capillary permeability and Hct
Plasma leakage lasts for 24-48 hrs
Decreased WBC and Platelets precede plasma leakage
Pleural effusion and Ascites occur
Plasma leak causes shock,Metabolic acidosis and DIVC
PHASES OF DENGUE
3)RECOVERY PHASE:2-3 DAYS
Generalised pruritus and bradycardia
Gradual reabsorption of extravascular compartment fluid
WBC count rises first followed by Platelet count
Excess fluid administration causes pulmonary edema or CCF
DENGUE SHOCK SYNDROME
Shock occurs on day4 or day 5
1)Tachycardia
2)cold extremities
3)Delayed capillary refill time(>3s)
4)Pulse pressure narrows-due to increased
DBP,PP<20mmHg
5)Organ impairment-Liver failure, Renal
failure,Encephalopathy and Cardiomyopathy
RECOMMENDATIONS AND TREATMENT
STEP1:Overall asssessment

History-Date of onset/oral intake/Warning

signs/Diarrhoea/Altered mental status/Urine
output/Neighbourhood dengue/Travel/Comorbid illness
PHYSICAL EXAMINATION
Mental status/Hydration/Hemodynamic status

Respiratory-Tachypnea,Pleural effusion,Acidotic breathing

Abdomen-Tenderness,Ascites,Hepatomegaly/Rash /Bleeding
manifestations/Tourniquet test +ve
INVESTIGATIONS-BASIC
CBC,BaselineWBC ,Hct,LFT

Glucose ,Electrolytes,BUN,Serum creatinine

Bicarbonate ,Lactate

Cardiac enzymes,ECG,Urine S.G,

DIAGNOSTIC TESTS SPECIFIC FOR
DENGUE
NS1 appears first

IgM antibodies appear on days 3-5 in 50%,80% on day 5 and 99%

on day 10

IgM peaks at 2 weeks and undetected at 2-3 months

IgG appears at the end of week 1,detectable for months to life

DENGUE DIAGNOSIS
In secondary Dengue,IgG levels are high even in the early
phase and IgM reduced

Ratios of IgM and IgG

Primary dengue-IgM /IgG->1.2-1.4

Secondary dengue-IgM /IgG-<1.2-1.4

MANAGEMENT OF DENGUE

Classified in to 3 groups
GROUP A:patient sent home

Able to eat and drink orally ,passes urine q 6hrs and no

warning signs

Trt-ORS/Paracetamol q 6hrly/tepid sponging/no aspirin or

NSAIDs
GROUP B
Those patients with warning signs and comorbid illnesses-
Pregnancy,Diabetes,Infancy,Old age and Renal failure-IN HOSPITAL
MANAGEMENT:
Give Isotonic solutions-NS,RL or Hartmanns solution
5ml/kg/ hr -1-2 hrs
3ml/kg/hr-2-4 hrs
and 2ml/kg/hr later
If Hct is stable continue 2ml/kg/hr increasing Hct-5ml/kg/hr
IV fluids only for 24-48 hrs to maintain urine output 0.5ml/kg/hr
MONITORING PARAMETERS
1)I/O chart

2)Vital signs q 1-4 hrs

3)Urine output q1-6 hrly

4)Hct q 6-12 hrly

5)Blood glucose
GROUP C
Dengue Shock Syndrome-EMERGENCY TREATMENT AND
URGENT REFERRAL
IV fluids 5ml/kg/hrx1-2hrs
3ml/kg/hr2-4hrs
2ml/kg/hr later
If Hct increases then fluids 10ml/kg/hr
If Hct decreases then give blood-packed RBCS or Fresh blood
Cutoff value of Hct<40%in child and women <45%in men
ROLE OF CRYSTALLOIDS
In Hypotensive shock,IV crystalloids 20ml/kg for 15 mins
10ml/kgx1hr
5ml/kgx2hrs
3ml/kgx2-4hrs
continued for 48 hrs

Changes in Hct are a useful guide to treatment increase in Hct-

give IV fluids and decrease in Hct-give Blood
BLOOD TRANSFUSIONS
How much to give?
5-10ml/kg of fresh packed cells or 10-20ml/kg of fresh
whole blood

Do not give any IM injections

Prophylactic Platelet transfusions are not effective or

necessary
TREATMENT OF COMPLICATIONS
1)FLUID OVERLOAD:may result in ARDS
Due to rapid administration,hypotonic fluids
Stop IV fluids if afebrile for 1-2 days
If needed Inj.Frusemide 0.1ml/kg/hr infusion
2)Hyper/Hypo glycemia
3)Hyponatremia
4)Hypo/Hyperkalemia
5)Metabolic acidosis
SUPPORTIVE CARE AND ADJUVANT
THERAPY
I)CVVH:Continuous venovenous hemodialysis bcoz in PD
increased bleeding risk

2)Vasopressors and Inotropes

3)THERE IS NO EVIDENCE ON THE USE OF

CORTICOSTEROIDS ,IV Ig OR RECOMBINANT
FACTOR VII
DISCHARGE CRITERIA

1)No fever x 48hrs

2)Increasing platelet count

3)Stable Hct
TAKE HOME MESSAGES
1)Clinical suspicion and Early Diagnosis
2)Aware of Warning signs-Abd.pain,Bleed,Restlessness,Hct
and Platelet changes
3)Diagnostic modalities:NS1,IgM and IgG
4)Judicious IV fluids and blood
5)Strict monitoring
6)Know about complications and treatment