Management

of
Dengue
By Maneesh Kumar
Roll No. 31
Diagnosis
• Dengue infection is a systemic and dynamic disease. It has a wide
clinical spectrum that includes both severe and non-severe clinical
complex manifestations.
• After the incubation period, the illness begins abruptly and is followed
by the three phases -- febrile, critical and recovery.

Febrile phase Dehydration; high fever may

cause neurological disturbances
and febrile
seizures in young children

Critical phase Shock from plasma leakage;

severe haemorrhage; organ
impairment
Recovery phase Hypervolemia (only if
intravenous fluid therapy has
been excessive and/or
has extended into this period)
 The diagnosis is generally made clinically on the basis of symptoms and physical examination.
 Probable diagnosis can be made on the finding of fever plus two of:
 Nausea and vomiting
 Rash
 Generalized Pain Warning signs
 Low WBC count • Worsening abdominal pain
 Positive Tourniquet test • Ongoing vomiting
 Any warning sign • Liver enlargement
• Mucosal Bleeding
 Investigations are required to exclude the differentials like: • High hematocrit with low
 Chickengunya platelets
 Malaria • Lethargy and restlessness
 Meningococcal disease • Serosal effusions
 Measles
 Influenza
 Zika fever
Diagnostic Methods
Clinical Sample Diagnostic Method Methodology Time for result
Virus detection and Acute fever (1-5 days Viral Isolation Mosquito cell culture >1 week
its components of fever) and inoculation
necropsy tissue
Nucleic Acid RT-PCR/ Real time RT-PCR 1-2 days
Detection
Antigen detection NS 1 Ag rapid test Minutes
NS 1 Ag ELISA 1 day
Immuno-histochemistry 2-5 days
Serological Response Paired sera IgM or IgG ELISA, HIA 1-2 days
1st – 1-5 days seroconversion
2nd – 15-21 days Neutralization Test Minimum 7 days

Serum after 5 days of IgM detection ELISA 1-2 days

fever
Rapid Test Minutes
igG detection IgG ELISA, HIA 1-2 days
IgG (1st)

IgG (2nd)

IgM

NS1

Viremia

0 1 2 3 4 5 6 7 8 9
 Stepwise approach given by WHO

Step 1: Overall Assessment

Step 2: Diagnosis
Assessment of Disease phase and severity
Step 3: Management
Depending on clinical manifestations and other circumstances, patients
may:
be sent home- GROUP A
be referred for in-hospital management- GROUP B
be required emergency treatment and referral- GROUP C
 History: Physical examination:
• Date of onset of fever/illness • Mental state
• Quantity of oral intake • Hydration state
Step 1: Overall Assessment

• Assessment of warning signs • Hemodynamic state

• Diarrhea • Tachypnea, acidotic breathing, pleural
• Change in mental state, seizures, effusion
dizziness • Abdominal tenderness, hepatomegaly, ascites
• Urine output • Rash and bleeding manifestations
• Other important relevant history • Tourniquet test (Hess Test)
including coexisting conditions.

Investigations:
• Complete blood count
• Hematocrit in early febrile phase, establishes baseline, patients own hematocrit
• Rapid decrease of WBC makes dengue very likely
• Rapid decrease of platelet count with rising hematocrit – suggestive of critical phase of disease.
• LFT, blood glucose, serum electrolyte, urea and creatinine, bicarbonate and lactate, cardiac
enzymes, ECG and urine specific gravity.
• A low serum albumin, high ferritin and a raised CRP are indicative of progress to severe dengue.
 On the basis of step 1 determine:
Step 2: Diagnosis, Assessment of

Whether the disease is dengue or not

Disease phase and severity

If dengue then phase( febrile, critical or recovery)

Warning signs

Hydration and Hemodynamics of patient

Patient requires admission or not.

 Group A
Criteria:
•Tolerate adequate amount of
oral fluid and pass urine 6 hourly
•No warning signs
Treatment Plan:
Fluid Intake: ORS, fruit juice,
Step 3: Management
fluids containing electrolyte,
sugar
Control of fever: Paracetamol
and Tepid sponging.
Immediate hospitalization if no
improvement or bleeding
manifestation.
Daily review of patients- WBC and
warning signs.
Group B
Criteria:
•Warning signs
•Coexisting conditions
•Social circumstances
Treatment Plan:
Isotonic Solutions: NS(0.9%) or RL
Start with 5-7ml/kg/hr for 1-2 hr,
then 3-5 ml/kg/h for 2-4 hr, then 2-3
ml/kg/hr according to the clinical
response.
Reassess and repeat hematocrit
If hematocrit remains the same or
rises slowly then decrease the dose as
given above
If it rises, continue with 5-
10ml/kg/hr
Monitor hematocrit, platelet count,
creatinine, electrolyte, LFT.
Group C
Criteria:
•Plasma leakage Dengue
shock or respiratory distress
•Hemorrhage
•Organ impairment
Treatment Plan:
Rapid isotonic crystalloid
In case of shock by colloids
For Shock
 Isotonic crystalloid solution at
5-10ml/kg/hr over 1hr then
reassess the patient.
 No improvement increase
the fluid infusion rate;
vasopressors and inotropes can
be added.
Treatment of hemorrhagic complicatons:
• Avoid i.m injection
• NSAIDS, antiplatelet, anticoagulant to be withheld temporarily.
• Platelet transfusion if below 10000/mm3 or bleeding manifestations
• Coagulopathy Transfuse plasma
Management of complication properly
Prevention by:
 Mosquito vector control
 Interruption of human-vector control
 No vaccine or antiviral drug available currently…
 Hemorrhagic(Bleeding) tendencies,
Thrombocytopenia

Initiate IV therapy – 6 ml/kg/hr

crystalloid for 1-2 hr

No Improvement

Increase to– 10 ml/kg/hr

Improvement
crystalloid for 2 hr

Reduce to 6 ml/kg/hr No Improvement

Improvement
Reduce to 3 ml/kg/hr Unstable Vitals

Hematocrit Rises Hematocrit falls

Further
Improvement Blood Transfusion
IV colloid Dextran
10 ml/kg/hr for 1 hr
10 ml/kg/hr for 1 hr
Improvement

Discontinue IV
after 24 hr Reduce to 6 ml/kg/hr then 3 ml/kg/hr
 Compensated Shock
PP <=20 mmhg,SBP<90 mmhg, >20% Hct

Initiate IV therapy – 10-20 ml/kg/hr

crystalloid for 1 hr

No Improvement
Improvement

Check Hematocrit

Reduce to 6 ml/kg/hr then

3ml/kg/hr Hematocrit Rises Hematocrit falls

IV colloid Dextran No Improvement Blood Transfusion

Further
10 ml/kg/hr for 1 hr 10 ml/kg whole
Improvement
Improvement
blood for 1 hr

Refractory
IV Inotropes with hypotension
Discontinue IV crystalloid
after 24 hr maintenance
NS 1?
 NS-1
Positive
 Vaccination?

Dengavaxia: CYD-TDV
Thank You…