Dengue Milanie F.
Valenton Medical Resident
The virus Family Flaviviridae
Single-stranded RNA virus
4 serotypes (DEN-1, DEN-2 to 4)
Distinguished by serologic methods Infection in humans by one serotype produces lifelong immunity against reinfection by that same serotype, but only p artial and temporary immunity against other serotypes
The Vectors Aedes aegypti a tropical and subtropical species of mosquito found around the globe Limited by altitude usually not found above 1000m One of the most efficient mosquito vectors highly anthrophilic thrives in close proximity to humans lives indoors
The Vectors Ae. albopictus, Ae. polynesiensis, Ae. scutellaris complex dengue outbreaks but each has its own geographical distribut ion A factor complicating eradication of the vector Ae. aegypti eggs can withsta nd long periods of desiccation, sometimes more than a year
The Host In humans, each of the 4 dengue virus serotypes has been associated with DF and with DHF. ency in 2 immunologically defined groups DSS occurs with higher frequ
Children who have experienced a previous dengue infection Infants with waning le vels of maternal dengue antibody
The Host Following an incubation of 3-14 days, the acute phase lasts about 5-7 days, followed by and immune response. Transmission of dengue virus from infected humans to feeding mosquitoes is determined by the magnitude and duration of viremia in the human host.
Pathogenesis 2 main pathophysiological changes occur in DHF/DSS vascular permeability Disorder in hemostasis
Pathogenesis vascular permeability Loss of plasma from the vascular compartment Hemoconcentra tion, low pulse pressure, and other signs of shock
Pathogenesis Disorder in hemostasis involves Vascular changes Thrombocytopenia Coagulopathy
Pathogenesis Activation of complement system, with profound depression of C3 and C5 levels, is a constant. both qualitative and quantitative. Platelet defects may be
Clinical Diagnosis Dengue virus infections may be asymptomatic or may lead to undifferentiated fever, DF or DHF with plasma leakag e that may lead to hypovolemic shock (DSS)
Dengue Fever Clinical features of DF frequently depend on the age of the patient. Infants and young children may have an undifferentiated febr ile disease, often with a maculopapular rash. Older children and adults may have either a mild febrile syndrome or the classic incapacitating disease with high fever of abrupt onset, sometimes with 2 peaks (saddlebacked), severe headache, p ain behind the eyes, muscle and bone or joint pains, nausea and vomiting, and ra sh.
Dengue Fever Skin hemorrhages (petechiae) are not uncommon Leukopenia Thrombocytopenia Recovery may be associated with prolonged f atigue and depression, especially in adults
Dengue Fever In some epidemics, DF may be accompanied by bleeding complications epistaxis, gingival bleeding, GI bleeding, hematuria, menorrhagia Case-fatality rate of DF - <1% Diffentiate DF with unusu al bleeding from cases of DHF with vascular permeability (hemoconcentration)
Dengue Hemorrhagic Fever Characterized by 4 major manifestations High fever Hemorrhagic phenomena Hepatomegaly Circulatory failure
Dengue Hemorrhagic Fever Moderate to marked thrombocytopenia with concurrent hemoconcentration is a distinctive clinical laboratory finding. Leakage of plasma
Major pathophysiological change that determines the severity of disease and diff erentiate it from DF Manifested by hematocrit, a serous effusion or hypoproteine mia
Dengue Hemorrhagic Fever Sudden rise in temperature accompanied by facial flush and constitutional signs and symptoms resembling DF Other findings
Sore throat and injection of pharynx but rhinitis and cough are infrequent Mild conjunctival injection Epigastric discomfort, tenderness at the right costal mar gin and/or generalized abdominal pain
Dengue Hemorrhagic Fever Temperature is usually high (>39) and remains so for 2-7 days. Most common hemorrhagic phenomenon
(+) tourniquet test Easy bruising Bleeding at venipuncture sites
Dengue Hemorrhagic Fever Discrete fine petechiae scattered on the extremities, axillae, face and soft palate are usually seen during the early feb rile phase. Epistaxis and gum bleeding occur infrequently
Dengue Hemorrhagic Fever Liver is usually palpable early in the febrile phase and varies in size from just palpable to 24 cm below the costal margin Liv er size is not usually The critical stage of the disease course is reached at th e end of the febrile phase . After 27 days of fever, a rapid fall in temperature is often accompanied by signs of circulatory disturbance of varying severity
Dengue Hemorrhagic Fever Many patients recover spontaneously, or after a short period of fluid and electrolyte therapy. In severe cases, shock ensues and can rapidly progress to profound shock and death if not properly treated. The s everity of the disease can be modified by early diagnosis and replacement of pla sma loss. Thrombocytopenia and hemoconcentration are usually detectable before t he subsidence of fever and the onset of shock.
Dengue Shock Syndrome Patients who progress to shock suddenly deteriorates after a fever of 2-7 days. Characterized by a rapid, weak pulse wit h narrowing of pulse pressure, regardless of pressure level or hypotension with cold, clammy skin and restlessness
Dengue Shock Syndrome Most remain conscious
Duration of shock is short: typically
patient dies within 12-24 hours, or recover rapidly following appropriate volume -replacement therapy. Once shock is overcome, patients recover within 2-3 days. Good prognostic signs- good urine output, return of appetite
Case Definition: Dengue Fever Probable an acute febrile illness with 2 or more of the following manifestations Headache Retro-orbital pain Myalgia Arthralgia Rash orrhagic manifestations Leukopenia, and Supportive serology titer or a (+) IgM a ntibody test on late acute or convalescent-phase serum Or - Occurrence at the sa me location and time as other confirmed cases of DF
He
Case Definition: Dengue Fever Confirmed a case confirmed by laboratory criteria Reportable any probable or confirmed case should be reported
Case Definition: Dengue Fever Laboratory criteria
Isolation of dengue virus from serum or autopsy samples Demonstration of a 4-fol d or greater change in reciprocal IgG or IgM antibody titers to one or more deng ue virus antigens Demonstration of dengue virus antigen in autopsy tissue, serum or CSF by immunohistochemistry, immunofluorescence, or ELISA Detection of dengu e virus genomic sequences in autopsy tissue, serum or CSF by PCR
Case Definition: DHF The following must all be present
Fever, or history of fever, lasting for 2-7 days, occasionally, biphasic Hemorrh agic tendencies Thrombocytopenia ( 100,000/ mm3) Evidence of plasma leakage due t o the vascular permeability Hemoconcentration Drop in hematocrit following volum e-replacement treatment 20% of baseline Pleural effusion, ascites, hypoproteinem ia
Case Definition: DSS All 4 criteria of DHF + evidence of circulatory failure Rapid, weak pulse, and Narrow pulse pressure Hypotension for age, and Cold clamm y skin and restlessness or
Grading Severity of DHF Grade I: fever with non-specific s/sx; only hemorrhagic manifestation is (+) TT and/or easy bruising Grade II: all of G rade I + spontaneous bleeding Grade III: (+) circulatory failure Grade IV: profo und shock with undetectable BP or pulse
Treatment Supportive
Hydration Correction of electrolyte and metabolic disturbances Sedation Oxygen t herapy Blood transfusion
