Dengue

Group Members: Rachel Albert, Sabrina Ali, Salisha Baksh, Cherisse Choya,
Tichad Francois, Matthew Maturasingh, Shanaz Narine, Leah Ragbir, Rhea
Ragobar, Dharindra Sawh.

Group E 11/05/18
Outline

1. Aetiology
2. Epidemiology
3. Pathophysiology
4. Case Definition
5. Clinical Manifestations
6. Investigations
7. Differential Diagnosis
8. Management
9. Public Health Control Measures
 Aetiology
Dengue, as known as “Breakbone Fever”, is a febrile illness caused by one of four dengue virus (DENV) serotypes:
1) DENV-1
2) DENV-2
3) DENV-3
4) DENV-4

The DENV viruses are RNA viruses which belong to the Flavivirus genus.

It is transmitted by Aedes aegypti (primarily) or Aedes albopictus mosquitoes during the taking of a blood meal. These adult mosquitoes
only fly within a 400m radius within their lifespan.
DENV may also be transmitted via blood products, mucocutaneous exposure or needlestick injury.

It is believed to have originated from Asia or Africa and has spread globally via international travel and transportation of goods.

It is essentially a human virus, though some serotypes have sylvatic cycles (involving wild animals).

Infection with any one serotype confers lifelong immunity to that specific serotype. There is cross-protection to the other serotypes
lasts only a few months. Individuals living in a dengue-endemic area with all types co-circulating are at risk for infection with any and all
DENV types.
 Epidemiology
● Transmission is affected by temperature, humidity, variations of rainfall, degree of
urbanization, quality of vector control.
● Endemic in more than 100 countries: The Americas, South-East Asia, Western Pacific

● 2013 study estimates 390 million dengue infections annually.

Fig 1: Distribution of Dengue Fever worldwide

 Epidemiology
Pan-American

● 46 countries report weekly:

Number of dengue cases, incidence rate,
number of severe cases, number of
deaths, case fatality rates.

● 2017 Number of Reported cases (PAHO)

1) Brazil 255, 287
2) Mexico 89,518
3) Peru 75,842
24)Trinidad & Tobago 300
 Epidemiology
Trinidad and Tobago
● Endemic ● 2010 frequency of reported cases by counties (MOH):
1) Tobago
● More than one subtype in 2) Caroni
circulation. 3) Victoria

FIgure showing Trinidad and Tobago counties

Pathophysiology

Overview:
1. Virus inoculated into humans with mosquito saliva
2. Virus binds to Langerhans cells and begins to replicate
3. Langerhans cells migrate to nearest lymph nodes while viral particles are
exocytosed into circulation.
4. New viral particles enter other WBC while an innate and adaptive response is
induced
Pathophysiology

Severe disease:

❏ Due to secondary infection with a different strain

❏ Due to antibody- dependent enhancement
❏ This leads to capillary leak syndrome, hematological abnormalities,
hypotension
❏ Can cause Dengue Hemorrhagic Fever or Dengue Shock Syndrome
Case Definition

•Dengue fever is most commonly an acute febrile illness defined by the presence
of fever and two or more of the following, retro-orbital or ocular pain, headache,
rash, myalgia, arthralgia, leukopenia, or haemorrhagic manifestations
•Does not meet the case definition of dengue haemorrhagic fever.
•Anorexia, nausea, abdominal pain, and persistent vomiting may also occur but
are not case-defining criteria for DF

(WHO 1997)
WHO classification for dengue severity is divided into Dengue without Warning
Signs, Dengue with Warning Signs, and Severe Dengue (2009)
Dengue haemorrhagic fever
● Fever lasting from 2-7 days
● Evidence of hemorrhagic manifestation or a positive tourniquet test
● Thrombocytopenia (≤100,000 cells per mm3)
● Evidence of plasma leakage shown by haemoconcentration (an increase in
haematocrit ≥20% above average for age or a decrease in haematocrit
≥20% of baseline following fluid replacement therapy), pleural effusion,
ascites or hypoproteinemia.
Clinical Manifestations
The incubation period 3-14 days

Symptoms typically develop between 4 and 7 days after the bite of an infected mosquito.

● Dengue virus infection consists of three phases:

1)Febrile Phase- Viremia-driven high fevers

2)Critical Phase- Sudden onset of varying degrees of plasma leak into the pleural and
abdominal cavities

3)Convalescent Phase- Sudden arrest of plasma leak with concomitant reabsorption of

extravasated plasma and fluids
Febrile phase
● Usually lasts 2-7 days
● Patients present with;
○ sudden onset high grade fever,accompanied by; facial flushing, skin erythema, myalgia,
arthralgia, retro-orbital pain and headache, anorexia, nausea, vomiting and a transient rash in
some cases.
● Difficult to differentiate from non-dengue febrile illness during this phase
● Hemorrhagic manifestations may be occur (e.g petechiae, mucosal bleeding)
 Undifferentiated macular or maculopapular rash may occur over the face,
thorax, abdomen, and extremities during the acute phase of dengue. The rash is
typically macular or maculopapular and may be associated with pruritus.
Critical Phase

● Occurs around the time of defervescence (between day 3-8 of the illness)
● Patients can develop a systemic vascular leak syndrome characterized by plasma leakage,
bleeding, shock, and organ impairment.
Lasts around 24-48 hours.
● Warning signs (may occur at or after defervescence)
○ Abdominal pain/tenderness
○ Vomiting
○ Fluid build up (e.g. - ascites, pleural effusion)
○ Spontaneous mucosal bleeding
○ Lethargy
○ Hepatomegaly
○ Increased haematocrit with rapid decrease in platelet count
Convalescent Phase

● Occurs within 1-2 days of defervescence.

● Typically lasts 1-5 days
● Extravascular fluid is reabsorbed.
● Improved overall well-being of patient
● Appetite returns
● Vital signs stabilize
● Characteristic rash may be seen
Characteristic rash which may be seen in the convalescent phase. A confluent,
erythematous eruption with small islands of unaffected skin that is often
pruritic.
Investigations

1)Detection of Dengue Virus via: 3) Hematological Test

a)Isolation of the virus

b)Detection of viral Nucleic acid 4) Rapid test

c)Detection of viral antigens

2)Detection of Anti-Dengue Antibodies.

Investigations
Differential Diagnosis

Chikungunya- similar symptoms to dengue and transmitted by the same mosquito

vector. Joint swelling is highly specific for chikungunya. Diagnosed via serology or
RT-PCR

Zika- similar clinical manifestations to dengue and transmated wiitted by the

same mosquito vector. Zika commonly associth conjunctivitis. Diagnosed via
serology or RT-PCR

Malaria- characterised by fever, malaise, nausea, vomiting, abdominal pain,

diarrhoea, myalgia and anemia. Diagnosed by visualisation of parasites on
peripheral smear
Differential Diagnosis

Leptospirosis- characterised by fever, conjunctival suffusion, rigors, myalgia and

headache. Diagnosed via serology

Sepsis/bacteremia- characterised by fever, tachycardia and altered mental status.

Diagnosis requires blood culture

Hepatitis- (A,B,C,D,E)characterised by fever, fatigue, jaundice, nausea and

vomiting. Diagnosed with serology

Other haemorrhagic fevers- yellow fever, hantavirus, Marburg virus, Ebola virus,
Lassa virus. Diagnosed based on epidemiologic exposure, PCR or serology
 Management
There is no direct antiviral therapy available against the dengue viruses (DENVs). Management is supportive, which largely consists of
maintaining adequate intravascular volume.

Assess patients carefully!

Outpatient management: Outpatient management is appropriate for patients with presumptive diagnosis of dengue infection in the
absence of warning signs or coexisting conditions (pregnancy, infancy, old age, diabetes, renal failure, underlying hemolytic disease,
obesity, or poor social situation); such patients should be able to tolerate oral fluids, urinate at least once every six hours, and have near
normal blood counts.

Fever may be controlled with acetaminophen; nonsteroidal anti-inflammatory drugs and aspirin-based products should not be used out of
concern for their effect on platelet function and the potential increased risk for bleeding.

Patients should be instructed to take plenty of fluids and watch for signs of dehydration (decrease in urination, few or no tears, dry mouth
or lips, sunken eyes, listlessness or confusion, cold or clammy extremities, sunken fontanelle in an infant); these findings warrant prompt
clinical evaluation. As fever declines (three to eight days after onset of symptoms), patients should be instructed to seek prompt attention
for any of the following: severe abdominal pain, persistent vomiting, skin rash, bleeding from nose or gums, vomiting blood, dark stools,

drowsiness or irritability, pale or cool skin, and difficulty breathing .

Inpatient management:

● Fever: Fever and myalgias should be managed with acetaminophen (maximum 60 mg/kg/day in children; 4 g/day in
adults). Aspirin or nonsteroidal anti-inflammatory agents should be avoided because of the risk of bleeding complications
and because of the potential risk of Reye's syndrome in children

● Management of plasma leakage: Plasma leakage should be managed with intravascular volume repletion to prevent or
reverse hypovolemic shock . In mild cases, particularly when medical attention is received early, oral rehydration may be
sufficient. Administration of intravenous fluid is warranted in patients with established intravascular volume loss. Blood
transfusion is appropriate in patients with significant bleeding or low hematocrit and failure to improve with fluid
resuscitation.

● Treatment of shock: Intravenous fluid therapy

● Management of bleeding — Gastrointestinal bleeding, epistaxis, or menorrhagia may be severe enough to warrant blood
transfusion. Significant internal bleeding should be suspected in patients with signs of intravascular hypovolemia without
elevation of hematocrit. In these circumstances, blood transfusion should be performed (5 mL/kg of packed red blood cells
or 10 mL/kg whole blood in children; 1 unit of packed red blood cells or whole blood in adults).
The World Health Organization has established the following grading system for severity of
dengue hemorrhagic fever:
■ DHF Grade I – Fever, hemorrhagic manifestation (positive tourniquet test), and
evidence of plasma leakage.
■ DHF Grade II – DHF Grade I plus spontaneous bleeding.
■ DHF Grade III – DHF Grade I or DHF Grade II plus narrowing pulse pressure or
hypotension.
■ DHF Grade IV – DHF Grade III plus profound shock with undetectable blood
pressure and pulse.

Dengue shock syndrome consists of DHF Grade III and DHF Grade IV.
Shock due to plasma leakage often presents with a narrow pulse pressure or elevated
diastolic pressure with preserved systolic pressure, whereas shock due to bleeding often
presents with hypotension or low systolic pressure. Other causes of shock must also be
considered (such as hypoglycemia, excessive vomiting, or bacterial coinfection.
In the absence of shock, use the following algorithm:

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In the presence of shock,

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 Public Health
Control Measures
“DETECT, PREVENT, RESPOND”
Summary

● Dengue belongs to a group of viruses known as Flavivirus.

● Endemic in over 100 countries including Trinidad and Tobago.
● Presents as an acute febrile illness with or without haemorrhagic
signs.
● Treatment and management of dengue entails a multidisciplinary
approach involving arms of the state as well as personal responsibility.
● Vector control mainly involves the use of biological, chemical and
physical methods.