Dengue fever

Presented by
Dr. Pratik Dattatraya Shrimandilkar
Guided by- Dr Sadhana P. Babel
1
Dr Kiran P. Shinde
Dr Yogesh S. Surse

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 Contents
2

 Introduction
 Dengue virus
 Dengue vector
 Clinical features
 Classification
 Pathogenesis
 Pathophysiology
 Clinical phase
 Investigation
 Management
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 Introduction
3  Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. Symptoms
typically begin three to fourteen days after infection.
 This may include a high fever, headache, vomiting, muscle and joint pains, and a characteristic
skin rash. Recovery generally takes two to seven days.
 In a small proportion of cases, the disease develops into the life-threatening dengue
hemorrhagic fever, resulting in bleeding, low levels of blood platelets and blood plasma
leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs.
 Dengue is spread by several species of mosquito of the Aedes type, principally A. aegypti.
 A number of tests are available to confirm the diagnosis including detecting antibodies to the
virus or its RNA
 An estimated 50 million dengue infections occur annually and approximately 2.5 billion people live in
dengue endemic countries.
 Since 2000, epidemic dengue has spread to new areas and has increased in the already affected areas of the
region.
 India alone accounted for almost 34% of global dengue burden by 2010
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4 Dengue in India
 First isolated in Calcutta in 1945
 Extensive epidemics since 1963
 DHF, DSS epidemics over last 4 decades
 Severe epidemic in Delhi in 1996, 2006;
Lucknow 1998, 2003, 2006
 All 4 serotypes are prevalent
 Viruses prevalent all over except Himalayan region &
Kashmir

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5 Dengue : The virus

 Flavi viruses: RNA

 Arbovirus group
 4 serotypes – Den 1- 4
 Cycle involves humans and mosquitos
 Infection with one virus gives immunity to that serotype only

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6 Dengue: The vector
 Aedes egyptii, A albopictus less commonly
 Domestic day biting mosquito
 Prefers to feed on humans
 Breeds in stored water
 Short flight range
 May bite several people in same household

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7 Reasons for resurgence

 Uncontrolled urbanisation and population growth 

substandard housing, inadequate water, sewer and waste
management
 Deterioration of public health infrastructure
 Faster travel
 Ineffective mosquito control in endemic regions
 Hyperendemicity: prevalence of multiple serotypes

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8 Dengue Fever : Clinical Features

 Incubation period 2-7 days

 Sudden fever 40-41 C (104 F)
 Nonspecific constitutional symptoms
 Severe muscle aches, retro-orbital pain
 Hepatomegaly
 Rash
 Facial flush
 Fever subsides in 2-7 days, may be biphasic

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 Revised WHO classification
9

Probable dengue Warning signs Severe dengue

Live in/travel to endemic area Abdominal pain or tenderness Severe plasma leak
Fever + 2 of : Persistent vomiting Shock
Nausea, vomiting Clinical fluid accumulation Fluid accumulation with
respiratory distress
Rash Lethargy/ restlessness Severe bleeding
Aches & pains Liver enlargement > 2 cm Severe organ involvement
Tourniquet test + ve Laboratory increase in HCT Liver ALT or AST >=1000
concurrent with rapid decrease
in platelet count
Leucopenia Impaired consciousness
Any warning sign Heart or other organs

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11 DHF: Pathogenesis
 Secondary infection with another serotype leads to ‘antibody
mediated enhancement’
 Heterotypic antibodies are non protective and fail to neutralise
the virus
 Virus-antibody complexes taken up by monocytes
 Virion multiplication in human monocytes is promoted
 Activation of CD4+ and CD8+ lymphocytes  release of
cytokines
 Complement system activated with depression of C3 & C5
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12 DHF: Pathophysiology

 Activation of complement  Increased vascular permeability loss

of plasma from vascular compartment  hemoconcentration &
shock
 Disorder of haemostasis involving thrombocytopenia, vascular
changes and coagulopathy
 Severe DHF with features of shock : DSS

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 Clinical phase of DF
13  Febrile phase
characterized by
 Is last 2 to 3 days
 High to grade fever
 A/w Facial flashing , erythema rash over the extrimies,
 myalgia, bodyache, nausea, vomitimg, headache and anorexia
 Some children have sore throat, or arthralgia
 Dengue strongly suspected If above feature A/W mild
hemorrhage include mucosal bleed or positive tourniquet test
 Liver enlarge and tender after few days
 Blood count shows progressive decrease WBC count ,
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  Critical phase
14  Is last 3 to7 days
 Is closely linked to the time of defervescence
 Required closely monitored warming sign
 Epigastric discomfort, tenderness at rt costal margin,abd pain, palpable liver
petechia over extremities axillae face
 Characterized by increase capillary permeability fall in platelet count
 (due to increase permeability results in leakage of plasma into 3 rd space )
 Increased hematocrit value
 Progressive leukopenia F/B rapid decreased platelet counts
 plasma Leakage is significant leads to hypovolemia , hypo perfusion, and
shock
 Organ impairment metabolic acidosis

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15
 Recovery phase
 Plasma starts coming back to the intravascular compartment
 Improvement in the generalized well-being and appetite
 Urine out put improve pain in abd subside
 May excessive iv fluids pulmonary edema and congestive heart
failure manifest the tachycardia dyspnea and raised JVP
 Hct value either normal or decline below normal
 Platelet count starts improving

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16 Severe dengue
 Severe dengue is defined by one or more of the following: (i) plasma leakage
that may lead to shock (dengue shock) and/or fluid accumulation, with or
without respiratory distress, and/or (ii) severe bleeding, and/or (iii) severe
organ impairment.
 As dengue vascular permeability progresses, hypovolaemia worsens and
results in shock.
 It usually takes place around defervescence, usually on day 4 or 5 (range days
3–7) of illness, preceded by the warning signs. During the initial stage of
shock, the compensatory mechanism which maintains a normal systolic blood
pressure also produces tachycardia and peripheral vasoconstriction with
reduced skin perfusion, resulting in cold extremities and delayed capillary
refill time.
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 Investigation
17
 Hematolagy
 Hct more than 20% or 3 time greater than Hb
 Thrombocytopenia platelet less than 100000
 Progressive leukopenia
 Biochemical profile
 Prothrombin(PT) and activated partial thromboplastin time (APTT) are prolong
 Hyponatremia in critical phase
 Metabolic acidosis and elevated blood urea are observed
 SGPT level increased
 Low albumin seen
 Serodiagnosis
 PCR shows 1) Detection of viral nonstructural protin 1(NS1) during initial phase 2)detection
of IgM antibody 3) fourfold rise in dengue IgG
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18

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19 DSS: WHO Criteria for diagnosis

All of the above + evidence of circulatory failure:

 Rapid, weak pulse
 Narrow pulse pressure
 Cold clammy skin
 Restlessness
 Often present with abdominal pain; mistaken for acute abdominal
emergency

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20 Grading of DV infection
DF/DHF Grade Symptoms Lab
DF Fever with 2 or > of: Leukopenia,
headache/retro-orbital pain, occasionally
myalgia, arthralgia thrombocytopen
ia, no evidence
of plasma leak

DHF I Above + +ve tourniquet test Platelets <

100,000, Hct rise
> 20%

DHF II Above + spontaneous bleeding ,,

DHF III/DSS Above + s/o circulatory failure ,,
DHF IV/DSS Profound shock with undetectable ,,
BP and pulse
Lab evidence of
DENGEU FEVER Dv infection
21 Immune response to Dengue
infections

 Primary Infection: IgM antibody in late acute/ convalescent stage;

later IgG which lasts for several decades
 Secondary infection: High IgG level, small rise in IgM
 Cross reactions with other flaviviruses
 Infection with one serotype does not protect against other
serotypes

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22 Management: DF

 No specific Treatment
 Analgesics/antipyretics
 Avoid agents which may impair platelet function eg.
Aspirin etc.

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23 Step I—Overall assessment
History
The history should include:
– date of onset of fever/illness;
– quantity of oral intake;
– assessment for warning signs
– diarrhoea;
– change in mental state/seizure/dizziness;
– urine output (frequency, volume and time of last voiding);
– other important relevant histories, such as family or neighbourhood
dengue,
travel to dengue endemic areas, co-existing conditions (e.g. infancy,
pregnancy, obesity, diabetes mellitus, hypertension), jungle trekking and
swimming in waterfall (consider leptospirosis, typhus, malaria), recent
unprotected sex or drug abuse

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24
Physical examination
The physical examination should include:
– assessment of mental state;
– assessment of hydration status;
– assessment of haemodynamic status
– checking for tachypnoea/acidotic breathing/pleural
effusion;
– checking for abdominal tenderness/hepatomegaly/ascites;
– examination for rash and bleeding manifestations;
– tourniquet test (repeat if previously negative or if there is
no bleeding manifestation).

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25 Investigation
A full blood count should be done at the first visit. A haematocrit test in the
early febrile phase establishes the patient’s own baseline haematocrit. A
decreasing white blood cell count makes dengue very likely. A rapid decrease
in platelet count in parallel with a rising haematocrit compared to the
baseline is suggestive of progress to the plasma leakage/critical phase of the
disease.
Step II—Diagnosis, assessment of disease phase and severity
On the basis of evaluations of the history, physical examination and/or full
blood count and haematocrit, clinicians should be able to determine whether
the disease is dengue,
which phase it is in (febrile, critical or recovery), whether there are warning
signs, thehydration and haemodynamic status of the patient, and whether the
patient requires admission
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 Management
26 Group A – patients who may be sent home
These are patients who are able to tolerate adequate volumes of oral fluids and pass urine at
least once every six hours, and do not have any of the warning signs, particularly when fever
subsides.
Encourage oral intake of oral rehydration solution (ORS), fruit juice and other fluids
containing electrolytes and sugar to replace losses from fever and vomiting.
Adequate oral fluid intake may be able to reduce the number of hospitalizations
• Give paracetamol for high fever if the patient is uncomfortable. The interval of paracetamol
dosing should not be less than six hours. Tepid sponge if the patient still has high fever. Do not
give acetylsalicylic acid (aspirin), ibuprofen or other non-steroidal anti-inflammatory
agents (NSAIDs) as these drugs may aggravate gastritis or bleeding.

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 Group B – patients who should be referred for in-hospital management
27Patients may need to be admitted to a secondary health care centre for close observation, particularly as
they approach the critical phase.
These include patients with warning signs, those with co-existing conditions that may make dengue or its
management more complicated and those with certain social circumstances
If the patient has dengue with warning signs, the action plan should be as follows:
• Obtain a reference haematocrit before fluid therapy.
Give only isotonic solutions such as 0.9% saline, Ringer’s lactate, or Hartmann’s solution. Start with 5–7
ml/ kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or
less according to the clinical response
• Reassess the clinical status and repeat the haematocrit. If the haematocrit remains the same or rises
only minimally, continue with the same rate (2–3 ml/kg/hr) for another 2–4 hours. If the vital signs are
worsening and haematocrit is rising rapidly, increase the rate to 5–10 ml/kg/hour for 1–2 hours.
Reassess the clinical status, repeat the haematocrit and review fluid infusion rates accordingly.
• Parameters that should be monitored include vital signs and peripheral perfusion (1–4 hourly until the
patient is out of the critical phase), urine output (4–6 hourly), haematocrit (before and after fluid
replacement, then 6–12 hourly), blood glucose, and other organ functions (such as renal profile, liver
profile, coagulation profile, as indicated)
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 Treatment of shock
28 The action plan for treating patients with shock is as follows
• Start intravenous fluid resuscitation with isotonic crystalloid solutions at 5–10 ml/kg/hour over one
hour. Then reassess the patient’s condition (vital signs, capillary refill time, haematocrit, urine
output). The next steps depend on the situation.
• If the patient’s condition improves, intravenous fluids should be gradually reduced to 5–7 ml/kg/hr
for 1–2 hours, then to 3–5 ml/kg/hr for 2–4 hours, then to 2–3 ml/kg/hr, and then further depending
on haemodynamic status, which can be maintained for up to 24–48 hours.
• If vital signs are still unstable (i.e. shock persists), check the haematocrit after the first bolus. If the
haematocrit increases or is still high (>50%), repeat a second bolus of crystalloid solution at 10–20
ml/kg/hr for one hour. After this second bolus, if there is improvement, reduce the rate to 7–10 ml/
kg/hr for 1–2 hours, and then continue to reduce as above. If haematocrit decreases compared to the
initial reference haematocrit (<40% in children and adult females, <45% in adult males), this
indicates bleeding and the need to cross-match and transfuse blood as soon as possible (see treatment
for haemorrhagic complications).
• Further boluses of crystalloid or colloidal solutions may need to be given during the next 24–48
hours.

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 The action plan for the treatment of haemorrhagic complications is as
29 follows:
• Give 5–10ml/kg of fresh-packed red cells or 10–20 ml/kg of fresh whole
blood at an appropriate rate and observe the clinical response.
• Consider repeating the blood transfusion if there is further blood loss or no
appropriate rise in haematocrit after blood transfusion. There is little evidence
to support the practice of transfusing platelet concentrates and/or fresh-frozen
plasma for severe bleeding. It is being practised when massive bleeding can not
be managed with just fresh whole blood/fresh-packed cells, but it may
exacerbate the fluid overload.
•

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 DHF: Hct >20% above normal

30
Start IVF RL or DNS 6-7 ml/kg/hr;
Monitor Hct, HR, Pulse pressure, I-O

Hct rises, Pulse pressure

Improves, Hct , BP rises
falls, HR rises

 to 10 ml/kg/hr, if no improvement 15
ml/kg/hr
Reduce to 3 ml/kg/hr
Unstable vitals

Further improvement CVP line, urinary catheter, rapid fluid

bolus
DENGEU FEVER Hct rises 
Hct falls  BT
Discontinue IVF after 24-48 hrs colloids
31 Prevention

 Anti mosquito measures

 Avoid open stagnant water in and around home
 Bed nets
 Long sleeved clothing
 In house spraying
 repellants

 Pediatric dengue vaccine

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32 Reference

 NPH.gov.in/Ayurvedic management of Dengue Fever

 Publish date :- sep,29,2015
 Publish by :- NHP CC DC

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THANK YOU
DENGEU FEVER