DENGUE 2011

C P M 1 5 TH R E V I S E D D E N G U E C L I N I C A L C A S E
MANAGEMENT GUIDELINES
N E L S O N T E X T B O O K O F P E D I AT R I C S 2 0 T H E D I T I O N
DOH 2015
BARAIYA, MRUGA P.
9-2
 OBJECTIVE

•To define dengue

•To present the epidemiology of dengue
•To determine its etiology and understand the
pathogenesis
•To classify dengue
•To discuss the clinical manifestation and
diagnosis of dengue
•To recognize the treatment and prognosis of
patient with dengue
•To discuss prevention of dengue
 DENGUE

Dengue infection is a systemic and dynamic

disease. It has a wide clinical spectrum that
includes severe and non-severe forms of
clinical manifestations.
Patient with dengue are classified according to
the levels of severity as having
i. dengue without warning signs
ii. dengue with warning signs
iii. severe dengue based on clinical
manifestations with or without laboratory
parameters
 EPIDEMOLOGY

 According to WHO, 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
geographical expansion to new countries, from urban to
rural settings.
 It is a all-year round disease in the Philippines. In 2008,
Philippines was was reported as one of the countries
with the highest no of dengue cases and deaths in the
western pacific region.
Cases totaled to 135,355 in year 2010
 ETIOLOGY
Dengue infection is caused by dengue
virus, which is a single-stranded RNA
virus. The virus is in the family
Flaviviridae, genus Flavivirus. The dengue
virus has 4 related but antigenically
distinct serotypes: DENV-1, DENV-2, DENV-
3, and DENV-4.
Poorly planned urbanization combined
with explosive global population growth
brings the mosquito and the human host
into close proximity.
 PATHOPHYSIOLOGY
Hetrotypic absence of cross- reactive
dengue virus immune
infections with neutralizing antibodies
complexes attach to
dengue types 1-4 and presence of enhancing
macrophage Fc receptors
antibodies

Complement system, suppresses innate

the virus itself, or
viral nonstructural
protein 1 (NS1),
rapid activation of
immunity & enhances
the complement
viral production
system

interact with endothelial
cells, blood clotting
factors, and platelets
fluid, electrolytes,
small proteins, leak
Increase vascular
into extravascular
permeability
spaces.
results in
hemoconcentration and
hypovolemia
 CASE CLASSIFICATION

i. Dengue without warning signs

ii. Dengue with warning signs
iii. Severe dengue based on clinical manifestations with or
without laboratory parameters further divided into
compensated and uncompensated shock
Each divided into probable dengue or confirmed dengue.
 CLINICAL MANIFESTATION

It has a wide clinical spectrum that

includes severe and non-severe forms of
clinical manifestations. After the incubation
period, the illness begins abruptly and will
be followed by 3 phases: febrile, critical and
recovery phase.
 Febrile Phase

 The acute febrile phase usually lasts 2-7

days
 Mild hemorrhagic manifestations like
petechiae and mucosal membrane
bleeding (e.g. nose and gums) may be
seen.
Monitoring of warning signs is crucial to
recognize its progression to critical phase.
 Critical Phase

•Phase when patient can either improve or deteriorate.

•Defervescence occurs between 3 to 7 days of illness.
•Defervescence is known as the period in which the body
temperature (fever) drops to almost normal (between 37.5
to 38°C).
•Those who will improve after defervescence will be
categorized as Dengue without Warning Signs, while those
who will deteriorate will manifest warning signs and will be
categorized as Dengue with Warning Signs or some may
progress to Severe Dengue.
•When warning signs occurs, severe dengue may follow
near the time of defervescence which usually happens
between 24 to 48 hours.
 Recovery Phase

•Happens in the next 48 to 72 hours in

which the body fluids go back to normal.
•Patients’ general well-being improves.
•Some patients may have classical rash of
“isles of white in the sea of red”.
•The White Blood Cell (WBC) usually starts
to rise soon after defervescence but the
normalization of platelet counts typically
happens later than that of WBC.
 DIAGNOSIS

DENGUE WITHOUT WARNING SIGNS

•Laboratory test, at least CBC (leukopenia with
or without thrombocytopenia)
•and/or Dengue NS1 antigen test or dengue
IgM antibody test (optional tests)

DENGUE WITH WARNING SIGNS

•increase in Hct and/or decreasing platelet
count

SEVERE DENGUE
•AST or ALT >1000
TREATMENT
 TREATMENT

GROUP A (HOME CARE):

ORS
Paracetamol
Best rest
Fluids
Advice on when to return to hospital
 TREATMENT

GROUP B (REFERRED FOR IN- HOSPITAL

MANAGEMENT):
Dengue with/ without warning signs:
Encourage ORS.
IVF 0.9% saline or LR at maintenance rate, if ORS
not tolerated.
Periodic assessment needed for appropriate fluid
adjustment.
Monitor clinical parameters and correlate with Hct.
Avoid over- and under hydration.
Decrease IVF anytime based on clinical
assessment.
 GROUP C (REQUIRE EMERGENCY
TREATMENT)

GROUP C (REQUIRE IMMEDIATE TREATMENT)

 PROGNOSIS
 Dengue fever is typically self-limiting
disease with a mortality rate of less than
1%
 When treated, dengue hemorrhagic fever
has a mortality rate 2-4%, when left
untreated, dengue hemorrhagic fever has
a mortality rate as high as 50%.
 Survivors usually recover without
sequelae and develop immunity to the
infecting serotype
 PREVENTION

Elimination is the responsibility of

everyone.
The department of health continuously
seeks the participation of communities in
eliminating mosquitoes as well as their
breading sites.