DENGUE

FEVER D R . J U N S AY,
D R . T U PA S

Revised Dengue Clinical Case Management Guidelines 2011

DENGUE FEVER
- Benign syndrome
- Caused by: Arthropod-borne viruses
- Characterized by:
* biphasic fever
* myalgia or arthralgia
* rash
* leukopenia
* lymphadenopathy
DENGUE HEMORRHAGIC
FEVER
• Philippine, Thai or Singapore hemorrhagic fever, hemorrhagic dengue, acute
infectious thrombocytopenic purpura
- Severe
- Often fatal
- Febrile
- Caused by: 1 to 4 dengue viruses
- Characterized by:
* capillary permeability
* abnormalities of hemostasis
* severe: protein losing shock syndrome
(dengue shock syndrome)
ETIOLOGY
• 4 distinct antigenic type:
dengue 1 , 2, 3 and 4 – Family Flaviviridae
EPIDEMIOLOGY
• Principal vector: Aedes aegypti
- daytime biting mosquito
- has all 4 virus type
- tropical areas
- highly urbanized
- breeding in water stored for drinking or bathing and in
rainwater collected in container
* Epidemics where common in temperate areas of Americas, Europe,
Australia and Asia until early 20th century.
* Now endemic in tropical Asia, South Pacific Islands, Northern Australia,
tropical Africa, Arabian Peninsula, Caribbean, Central and South America.
DENGUE LIKE DISEASES
PATHOGENESIS
dengue virus immune complexes
attach to macrophage Fc receptor

suppress immunity

enhance viral production

 EARLY IN ACUTE STAGE OF SECONDARY
INFECTION
Shock: elevated blood
Depressed C1q, C3.
Rapid activation of levels of TNF receptor,
C4, C5-C8 and C3
complement system interferon Y, interleukin
proactivators
2

Viral non structural

protein 1 may interact
Increased vascular Elevated C3 catabolic
with endothelial
permeability rates
cells,blood clotting
factors and platelets.

Activated blood
Depressed factor XII
clotting and fibrinolytic
(Hageman Factor)
systems
• Mechanism of bleeding in hemorrhagic dengue fever is not known, but
a mild degree of disseminated intravascular coagulopathy, liver damage,
and thrombocytopenia may operate synergistically.
- Capillary damage allows, fluid, electrolytes, small proteins and in some
instances RBC’s to leak into extravascular spaces.This internal redistribution of fluid,
together with deficits caused by fasting, thirsting and vomiting results in
hemoconcentration, hypovolemia, increased cardiac work, tissue hypoxia, metabolic
acidosis and hyponatremia.

• Usually no pathologic lesions to account for death

CLINICAL MANIFESTATIONS
Incubation period: 1- 7 days

INFANTS AND OLDER CHILDREN AND

YOUNG CHILDREN ADULTS

- Fever (1-5 days) - Sudden fever onset

- Pharyngeal inflammation - Temperature rapidly increasing to 39.4 to 41.1’C
- Rhinitis - Frontal or retroorbital pain
- Mild cough - Occasionally severe back pain precedes the fever
(back-break fever)
- Transient, macular, generalized rash that blanches
under pressure (1st 24 to 48 hrs of fever)
- Pulse rate maybe slow relative to the degree of fever
- Myalgia and arthralgia occur soon after fever and
increased severity over time
- 2nd-6th day of fever: fever, n/v, generalized
lymphadenopathy, cutaneous hyperesthesia or
hyperalgesia, taste aberrations and anorexia
CLINICAL MANIFESTATION

• Approximately after 1-2 days after defervescence, a generalized,

morbilliform, macupapular rash appears that spares palms and soles.
Disappears in 1-5 days. Desquamtion may occur.
– Rarely, there is edema of the palms and soles

• About the second time rash appears, body temperature which has previously
decreased to normal may become slightly elevated and demonstrate biphasic
pattern.
DENGUE HEMORRHAGIC
FEVER
First phase:
fever
malaise
headache
anorexia
cough
 DENGUE HEMORRHAGIC
FEVER
Second phase:
- cold and clammy extremities, warm trunk, flushed face, diaphoresis,
restlessness, irritability, midepigastric pain, decreased urinary output
- petechiae (forehead & extremities), ecchymoses, easy brusing, bleeding
at sites of venipuncture
- macular, maculopapular rash, circumolar, peripheral cyanosis
- rapid and labored respiration
- weak, rapid and thread pulse, faint heart sounds
- liver may enlarge 4-6cm below costal margin, usually firm somewhat
tender
DIAGNOSIS:
• WHO Criteria for Dengue Hemorrhagic Fever:
- Fever (2-7 days in duration or biphasic)
- Minor or major hemorrhagic manifestation
- Thrombocytopenia (<100,000/uL)
- Increased capillary permeability (>20%)
- Pleural effusion or ascites
- Hypoalbuminemia
DIAGNOSIS
• WHO Criteria Dengue Shock Syndrome
- Include those for dengue hemorrhagic fever
- Hypotension
- Tachycardia
- Narrow pulse pressure (<20 mmHg)
- Signs of poor perfusion (cold extremities)
ACCORDING TO WHO:
Dengue is the most rapidly spreading mosquito-borne viral
disease in the world. In the last 50 years, incidence has increased 30-fold
with increasing geographic expansion to new countries and in the
present decade, from urban to rural settings.
Between 2001 and 2008, more than a million cases reported in
Cambodia, Malaysia, Philippines and Vietnam – the four countries in
Western Pacific Region, with the highest cases of deaths (4,798)
DENGUE IN THE PHILIPPINES
Dengue is an all year round disease in the Philippines
* 2008 – one of the countries with the highest cases and deaths in
Western Pacific Region.
* 2010 – all regions reported cases of dengue and several outbreaks
were reported in the provinces and municipalities.
The cases totaled to 135,355 which is 135% higher compared to
57, 636 cases in 2009
REVISED DENGUE CASE
CLASSIFICATION
• Dengue without Warning Signs
• Dengue with Warning Signs
• Severe Dengue
OLD AND NEW CASE DEFINITION AND CL ASSIFICATION FOR DENGUE
DENGUE WITH WARNING
SIGNS
1. Obtain a reference hematocrit before fluid therapy
2. Give only isotonic solutions such as 0.9% NaCl
(saline), Ringer’s Lactate, 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 clinical response
3. Reassess the clinical status and repeat the
hematocrit
DENGUE WITH WARNING
SIGNS
4. If the hematocrit remains the same or rises
only minimally, continue with the same rate (2-3
mL/kg/hr) for another 2-4 hours.
5. If there are worsening of vital signs and
rapidly rising hematocrit, increase the rate to 5-
10 mL/kg/hour for 1-2 hours
6. Reassess the clinical status, repeat hematocrit
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 critical phase)
• Urine output (4-6 hourly)
• Hematocrit (before and after fluid replacement,
then 6-12 hourly)
• Blood glucose
• Other organ functions (such as renal profile, liver
profile, coagulation profile, as indicated)
 SEVERE DENGUE
Management for Compensated Shock

1. Start intravenous fluid resuscitation with isotonic

crystalloid solutions at 5-10 mL/kg/hr over 1 hour,
then reassess the patients condition (vital signs, capillary
refill time, hematocrit, urine output) and decide
depending on the situation:
2. If the patients 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 • To reduce further depending on
hemodynamic status, which can be maintained for up to
24 to 48 hours
 SEVERE DENGUE
Management for Compensated Shock

3. If vital signs are still unstable (shock persists),

check the hematocrit after the first bolus:
• If hematocrit increases or is still high (>50%),
repeat a second bolus of crystalloid solution at 1020
mL/kg/hr for 1 hour. After this second bolus, if there
is improvement, then reduce the rate to 7-10
mL/kg/hr for 1-2 hours, and then continue to reduce
as above
 SEVERE DENGUE
Management for Compensated Shock
• If hematocrit decreases compared to the initial
reference hematocrit (<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
4. Further boluses of crystalloid or colloidal solutions
may need to be given during the next 24 to 48 hours
 SEVERE DENGUE
Management for Hypotensive Shock
Patients with hypotensive shock should be managed more
vigorously
1. Initiate intravenous fluid resuscitation with crystalloid or
colloid solution (if available) at 20 mL/kg as a bolus given
over 15 minutes to bring the patient out of shock as
quickly as possible.
2. If the patient’s condition improves, give a crystalloid/
colloid infusion of 10 mL/kg/hr for 1 hour, then continue
with crystalloid infusion and gradually reduce • To 5-7 mL/kg/hr
for 1-2 hours, then • To 3-5 mL/kg/hr for 2-4 hours and then •
To 2-3 mL/kg/hr or less, which can be maintained for up
to 24 to 48 hours
 SEVERE DENGUE
Management for Hypotensive Shock
3. If vital signs are still unstable (shock persists), check
hematocrit after the first bolus:
• If hematocrit increases compared to the previous value
or remains very high (>50%), change intravenous fluids to
colloid solutions at 10-20 mL/kg as a second bolus over
½ to 1 hour. After this dose, reduce the rate to 7-10
mL/kg/hr for 1-2 hours, then change back to crystalloid
solution and reduce rate of infusion as mentioned above
when the patient’s condition improves
• If hematocrit decreases compared to the previous value
(<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
SEVERE DENGUE
Management for Hypotensive Shock

4. Further boluses of fluid may need to be given

during the next 24 hours. The rate and volume of
each bolus infusion should be titrated to the
clinical response. Patients with severe dengue
should be admitted to the high dependency or
intensive care areas.
 SEVERE DENGUE
Management of Hemorrhagic complications
Who are at risk of major bleeding?
• Patients with prolonged/refractory shock
• Patients with hypotensive shock and renal or liver
failure and/or severe and persistent metabolic acidosis
• Patients given non-steroidal anti-inflammatory agents
(NSAIDs)
• Patients with pre-existing peptic ulcer disease
• Patients on anticoagulant therapy
• Patients with any form of trauma, including
intramuscular injection
 SEVERE DENGUE
Management of Hemorrhagic complications
How to recognize severe bleeding
• Persistent and/or severe overt bleeding in the presence of
unstable hemodynamic status, regardless of the hematocrit
level
• A decrease in hematocrit after fluid resuscitation together
with unstable hemodynamic status
• Refractory shock that fail to respond to consecutive fluid
resuscitation of 40-60 mL/kg.
• Hypotensive shock with low/normal hematocrit before fluid
resuscitation
• Persistent or worsening metabolic acidosis ± a well-
maintained systolic blood pressure, especially in those with
severe abdominal tenderness and distension
 SEVERE DENGUE
Management of Hemorrhagic complications
Action Plan
• Give 5-10 mL/kg of fresh packed red blood cells or 10-
20 mL/kg of fresh whole blood at an appropriate rate
and observe the clinical response
• A good clinical response includes improving
hemodynamic status and acid-base balance.
• Consider repeating the blood transfusion if there is
further blood loss or no appropriate rise in
hematocrit after blood transfusion
• Although there is little evidence to support the
practice of platelet concentrates and/or fresh frozen
plasma transfusion for severe bleeding, they may be
given judiciously.
DISCHARGE CRITERIA
ALL of the following conditions must be present
1. No fever for 48 hours
2. Improvement in clinical status (general well-being,
appetite, hemodynamic status, urine output, no
respiratory distress)
3. Increasing trend of platelet count
4. Stable hematocrit without intravenous fluids