THE DENGUE

GUIDELINES
1997.They
2009.
2011
How
Different
Pembimbing : Prof. W.H.Sibuea, Sp.PD

Dengue Guidelines
1997

2009

2011

Guideline for
Guidelines for
treatment of DF and
diagnosis, treatment,
DHF in small hospitals prevention, and
control

Comprehensive
guideline for
prevention and
control of Dengue and
DHF

Pages : 33

212

160

Clinical Manifestation, Chapter : 6

Diagnosis, Case
Epidemiology and
Management
burden of disease,
clinical management,
vector management,
lab diagnostic tests,
surveillance and
emergency response,
new avenues

Chapter : 15
Epidemiology, disease
burden, clinical
manifestation and
diagnosis, lab
diagnosis,
management,
surveillance, vector,
vector management,
IVM, COMBI, PHC
approach, case
investigation,

Secondary Heterologous
Infection

Antibody dependent
enhancement

PATOGENESIS

Proposed model for the pathogenesis of DF, DHF, and DSS, based on an integrated view of
the data presented (see section The Integrated View in the text).

Martina B E E et al. Clin. Microbiol. Rev. 2009;22:564-581

PATOGENESIS

Association of Leukocyte and Thrombocyte

Counts as a
Predictor of Bleeding Outcomes among
Dengue Patients
Gener D. Rubio Jr., M.D. and Larissa Lara Torno, M.D.
San Pedro Hospital, Davao City

Leukopenia in dengue patients may be caused by

virus-induced destruction or inhibition of myeloid
progenitor cells.
While thrombocytopenia may result from destruction
of
peripheral
platelet
or
bone
marrow
megakaryocytes by viruses which consequently
reduce the platelet production.
With the severity of thrombocytopenia and acut off
value of < 4,000 mm3 leukocyte count as a
predictor of bleeding, physicians can wisely utilize
these values and be a guide on when to order serial
leukocyte and platelet count monitoring especially to
unfortunate patients who are financially incapable.
Philippine Journal of Microbiology and Infectious Diseases
Vol. 36 Nos. 1 & 2, January-June 2007

Diagnosis Classification
1997

2009

2011

Dengue fever

Dengue without
warning signs

Dengue fever

DHF grade I

Dengue with warning

signs

DHF grade I

DHF grade II
DHF grade III

DHF grade IV

DHF grade II
Severe dengue (for
management it is
divided into two :
severe dengue with
compensated shock
and severe dengue
with hypotensive
shock)

DHF grade III

DHF grade IV
* Expanded dengue
syndrome

1997 CLASSIFICATION

Probable an acute febrile illness with

two or more of the following
manifestation :
Headache
Retro orbital pain
Myalgia
Athralgia
Rash
Haemorrhagic manifestations
Hepatomegali
Leukopeni
and
Supportive serology (Ig G and Ig M antibody)

WHO Dengue Classification

DF

DHF

1. Fever 2-7 days

2. Bleeding Tendency
-Positive tourniquet test or
-Spontaneous bleeding

+/-

3. Thrombocytopenia
100.000/mm3

+/-

4. Plasma leakage
- Pleural effusion/ ascites/
hypoproteinaemia
- 20% increase in Hematocrit

Grad
e
DF

Without plasma leakage

DHF

Fever with non specific constitutional

symptoms; the only hemorrhagic
manifestation is a positive tourniquet
test

DHF

II

DHF grade I plus spontaneous

bleeding

DHF

III

Circulatory failure manifested by a

rapid, weak pulse, narrowing of pulse
pressure, or hypotension, cold &
clammy skin, restlessness

DHF

IV

Profound shock with undetectable

blood pressure

Thrombocytope
nia ( platelet
count
<100.000/l)

2009 CLASSIFICATION

Dengue case classification

by severity

Dengue +/- warning sign

dengue
without

With
warning
signs

Probable
Criteriadengue
for dengue Warning
warning signs*
signs
Live in/travel
dengue
Abdominal pain or
severetodengue
endemic area. Fever
tenderness
and 2 of
Persistent vomiting
the following criteria:
Clinical fluid
Nausea, vomiting
accumulation
Rash
Mucosal bleed
Aches and pains
Lethargy; restlessness
Tourniquet test positive
Liver enlargement
Leucopenia
>2cm
Any warning sign
Laboratory: Increase
Laboratory confirmed
in HCT
dengue
concurrent with rapid
(important when no sign
decrease in platelet
of
plasma leakage)
count

Severe

1.Severe plasma
leakage
2.Severe
haemorrhage
3.Severe organ
impairment
Criteria
for
1. Severe
plasma
leakage leading to:
Shock (DSS)
Fluid accumulation
with
respiratory distress
2. Severe bleeding
as evaluated by
clinician
3. Severe organ
involvement
Liver: AST or
ALT>=1000

2011 CLASSIFICATION

Manifestations of dengue virus

infection
Dengue virus infection

Asymptomatik

Symptomatik

Undifferentiated
Dengue Fever Dengue Haemorrheagic Expanded
Dengue syndrome
fever
fever (DHF) Isolated Organopathy
(viral syndrome)
(with plasma leakage)
(Unsual
manifestation)

Without
Haemorrhage
Syndrome (DSS)

with unsual
Haemorrhage

DHF DHF with shock

Non shock Dengue Shock

WHO classification of dengue infections and

grading of severity of DHF
DF/
DHF

Gra
de

DF

Signs and Symptoms

Laboratory

Fever with two of the following:

Headache.
Retro-orbital pain.
Myalgia.
Arthtralgia/bone pain.
Rash.
Haemorrhagic manifestations.
No evidence of plasma
leakage.

Leucopenia (wbc 5000

cells/mm3).
Thrombocytopenia
(Platelet
Count <150 000 cells/mm3).
Rising haematocrit
(5% 10% ).
No evidence of plasma
loss.

DHF

Fever and haemorrhagic

manifestation
(positive tourniquet test) and
evidence of plasma leakage

Thrombocytopenia <100
000 cells/mm3; HCT rise
20%

DHF

II

As in Grade I plus spontaneous

bleeding

Thrombocytopenia
<100 000 cells/mm3; HCT
rise 20%.

DHF

III

As in Grade I or II plus circulatory

Failure (weak pulse, narrow pulse
pressure
(20 mmHg), hypotension,
restlessness).

Thrombocytopenia
<100 000 cells/mm3; HCT
rise 20%.

DHF

IV

As in Grade III plus profound shock

Thrombocytopenia

Laboratory Diagnosis

Laboratory Diagnosis

Fluid Management
1997

2009

2011

DHF Grade I-II

Dengue with warning signs DHF grade I-II

6-7ml/kg/hour
5ml/kg/hour
3ml/kg/hour
Monitor/6 hour
Stop after 24-48
hour

Isotonic solution such as

0,9% saline, Ringers
Lactate, or Hartman
solution. Start with
57ml/kg/hour for 1-2 hours,
then reduce to 35ml/kg/hour for 2-4 hours,
and then reduce to 23ml/kg/hour or less
according to the clinical
response.

Maintenance (for one

day) + 5% deficit
(oral and IV fluid
together), to be
administered over 48
hours

1977

2009

2011

DSS

Severe Dengue
Compensated Shock

DHF grade III

10-20 ml/kgBB bolus,

repeat if necessary

Isotonic crystalloid
solutions at 5-10
ml/kg/hour 0ver one
hour. reassess

10ml/kg in children or
300-500 ml in adults
over one hour by
bolus, if necessary
further, fluid
administration should
follow the graph

2009

2011

Severe dengue hypotensive

shock

DHF grade IV

Initiate intravenous fluid

resuscitation with crystalloid or
coloid solution ( if available) at
20ml/kg as a bolus given over 15
minutes to bring the patient out
of shock as quickly as possible.

10ml/kg of bolus fluid should be

given as fast as possible, ideally
within 10 to 15 minutes. When
the blood pressure is restored,
further intravenous fluid may be
given as in grade 3. if shock is
not reversible after the first
10ml/kg, a repeat bolus of
10ml/kg and laboratory results
should be persued and corrected
as soon as possible.

Tranfusion in Severe
Bleeding
2009
Give 5-10 ml/kg of fresh PRC or
10-20 ml/kg of fresh Whole blood
at an appropriate rate and
observe the clinical response

2011
10ml/kg of fresh whole blood or
5ml/kg of freshly PRC reassess,
repeat if necessary

Criteria

Discharge criteria
1997

2009

2011

Absence of
fever

24 hours
without the
use of anti
fever
therapy

48 hours

24 hours
without the
use of anti
fever
therapy

Clinical
improvement

+ (general well-being,
appetite,
hemodynamic status,
urine output, no
respiratory distress)

Return of
appetite

Good urine
output

Stable
Hematocrit

+ (without Intravenous
fluid)

Elapse from
shock recovery

At least 2
days

At least 2-3
days

High-Risk Patients (2011)

Infants and the elderly

Obesity
Pregnant women
Peptic ulcer disease
Women who have abnormal vaginal bleeding or
menstruation
Haemolytic disease such as (G6PD) deficiency
Thalassemia and other Haemoglobinopathies
Congenital heart disease
Chronic diseases such as DM, hypertension, asthma,
ischaemic heart disease
Chronic renal failure, liver cirrhosis
Patients on steroid or NSAID treatment