DENGUE

FEVER

Introduction
Acute viral infection, causes asymptomatic to fatal disease
Transmitted by a mosquito bite
AKA Break Bone Fever (severe myalgia and arthralgia)
Recurrent epidemics: Major Public Health Issue
Pathogenesis
Dengue Virus

+ss RNA Virus, Flaviviridae family

Four Serotypes DV1, DV2, DV3, DV4
All four can cause subclinical mild infection to fatal DHF/DSS
No long term cross protection, lifelong immunity against the infecting
serotype
Secondary infections cause severe disease
Virus genome is composed of three structural protein genes: Core protein
(C), Membrane protein (M) and Enveloped glycoprotein (E); and seven
non-structural (NS) proteins (one of these is NS1, utilized as a
diagnostic marker for the infection)

Vector

Ae. Aegypti predominantly, daytime feeder

Vector control is significant to prevent the disease transmission

Incubation period: 4-7 days

Female mosquitoes ingest dengue virus circulating in the blood of viraemic
humans. The virus then infects the mosquito and subsequently spreads
systemically. After this, the virus can be transmitted to other humans during
subsequent feeding.
Major clinical features are due to T cell and complement activation leading to
Ag/Ab reaction and their deposition in various tissues and platelets.
A transient and reversible imbalance of inflammatory mediators, cytokines and
chemokines occurs during severe dengue leading to dysfunction of vascular
endothelial cells, derangement of the haemocoagulation system then to plasma
leakage, shock and bleeding.

Clinical Manifestations:

May be a symptomatic or asymptomatic infection

Most patients recover following a self-limiting non-severe clinical course
Wide spectrum of illness from AUFI to hemorrhage and shock
Organ Involvement: Liver, Kidneys, Heart, Lungs, CNS, DIC

Classic Dengue Rash

Grading of DF/DHF

Unusual Presentations: Acute abdomen as acalculous cholecystitis, edematous
GB on USG, ICH, Optic Neuritis

Physical examination (things you must look at)

Mental state
Hydration status
Vitals Signs, Capillary Refill Time
Checking for acidotic breathing/pleural effusion
Abdominal tenderness/hepatomegaly/ascites
Rash and bleeding manifestations
Tourniquet test: Apply a BP cuff and inflate to the midpoint between the
SBP and DBP for five minutes. The test is considered positive if there are
more than 10 to 20 petechiae per square inch.

Usual Course and Stages of DF:

Febrile: Abrupt fever, lasts 2-7 days, flushing, myalgia+, arthralgia, rash,
dehydration, headache, retroorbital pain, febrile, seizures, N&V, sore
throat, injected pharynx, hepatomegaly, leukopenia
Critical: 3-4 days after the onset of fever, low grade fever, increased
capillary permeability, elevated Hct. Classic sequence is leukopenia,
thrombocytopenia followed by capillary leak, shock and MODS. Based on
the degree of leak, may have effusions and ascites. This phase persists for
about 48 hours and needs close observation.
Recovery: Sense of general well-being, platelet and leucocyte counts
improve. may develop ascites/ pleural effusion if overhydrated during the
initial resus!

Diagnosis:

Differential Diagnosis

Labs (Have at least a baseline platelet count and Hct,

Individualise)

CBP
LFT
Urea, Creat, Electrolytes
Coags
CXR, USG Abdomen/ Chest
IgM ELISA (Send after day 5)
NS1 Ag ELISA

Influenza
Scrub Typhus
Meningitis
Malaria
Leptospirosis
Viral Hepatitis
Acute Abdomen

Management
Classify them as
A. Mild disease/ DF/ Group A: No warning sings Outpatient
Management + Safety Net

B. Moderate disease/ DHFI and II/ Group B: Warning signs+ or co
morbidities Inpatient Management

C. Severe disease/ DHF III and IV/ Group C: Plasma leakage, Hemorrhage,
Shock, SOB, Organ failure Resus and Admit
Warning Signs/ Red Flags:

Admission Criteria

Abdominal Pain/
Tenderness
Persistent Vomiting
Mucosal Bleed
Hepatomegaly > 2cm
Ascites/Effusion
Lethargy, Restlessness
Rising hematocrit with
dropping platelets

Any warning sign +

Symptoms of hypotension (Postural
giddiness, presyncope etc)
Bleeding regardless of platelet counts
Organ Impairment
Rising Hct (Effusion, ascites, GB
thickening)
Co existing conditions (Pregnancy,
DM, HTN, Hemolytic anemias,
extremes of age)
Social circumstances

ED Management (Group B and Group C)

1. ABCs
2. Hydration: Oral/IV (can make life and death difference), reduces risks of
hospitalization, prevents disease progression to DHF. Colloids or
Crystalloids. Oral > IV if tolerates
3. Antipyretics if temp > 39C and sponging for high fever (No NSAIDs)
a. Watch for bleeding and stay calm if platelets are > 50,000 (Don't
freak out - Dengue Panic Syndrome!). Close watch if platelets
less than 50,000.
4. Platelets: Stop chasing a normal platelet count. First, send a manual
platelet count to avoid relying on an underestimated clumped value. No
prophylactic platelet transfusion unless < 10,000. No great evidence
supporting the use of platelets + risk of volume overload.
Indications of Platelet transfusion

Platelets < 10,000 without bleeding (some use a threshold of 20,000)

Hemorrhage regardless of platelet counts

5. Other Blood products:

Blood transfusion: Transfuse if Hct dropping or actively bleeding active

bleeding
FFP/ Cryo: Guided by coagulation parameters

6. Supportive Care: Pressors/ Inotropes/ Dialysis/ Mechanical Ventilation

Say NO to

Discharge Criteria

Steroids (increase risk of GI

bleed/ immunosuppression)
NSAIDs (cause platelet
dysfunction and increase
risk of bleeding)
0.45NS (may worsen
ascites/ effusions)
Antibiotics

No fever for 24 hours

Clinical improvement (BP, UO)
Increasing platelet counts

Safety Net (Verbal + Written for Group A)

Tell your patients what to watch for (decreased UO, sunken eyes, cold
extremities, abdomen pain, black stools, SOB, petechiae, confusion)
Paracetamol and tepid sponging for fever, Bed Rest
Prevent dehydration, No Abx, No NSAIDs/ Steroids
Mosquito nets, insect repellants, eliminate larval habitats

Take Home:

All patients with Dengue do not require admission

Patient education and community participation is the key to prevention
Know the warning sings and tell them what they need to look for
Treatment should be focused on hydration (not platelets and Abx)

References:
1. http://nvbdcp.gov.in
2. http://www.who.int/r/publications/documents/dengue-diagnosis.pdf

Thanks!
Questions/Comments/Feedback
Lakshay Chanana
drlakshay_em@yahoo.com
Twitter: @EMDidactic
EM Academy @ Facebook