DT DHF Imanuddin

DENGUE INFECTION
Muhammad Imanuddin Nasution

Pendahuluan
• Dengue merupakan penyakit yang disebarkan
oleh nyamuk Aedes aegypti dan Aedes albopictus
• Insidensi global penyakit tersebut meningkat 30
kali lipat dalam 50 tahun terakhir dan terjadi
pada lebih dari 100 negara pada daerah tropis
dan subtropis di dunia
• Faktor penting yang mendukung dinamika
transmisi dengue adalah faktor sosioekonomi,
urbanisasi, dan faktor iklim
Epidemiologi di Indonesia
• Berdasarkan Data
Kemenkes Tahun
2017 :
– Jumlah kasus DBD
 68.407 kasus
– Incidence rate
26,12 per 100000
penduduk
– Kasus meninggal
sebanyak 493 orang
Virologi
• Family: Flaviviridae
• Genus: Flavivirus
• A single-stranded RNA Flavivirus
• 4 types of agents:
– Dengue Virus 1 (DEN-1)
Transmisi Virus
• The Aedes aegypti mosquito is the primary
vector of dengue.
• The virus is transmitted to humans through

Ae. aegypti Ae. albopictus
the bites of infected female mosquitoes.
• After incubation for 4–10 days, infected
mosquito is capable of transmitting the virus
for the rest of its life.
• Patients who are already infected with the
dengue virus can transmit the infection (for
4–5 days; max 12) via Aedes mosquitoes after
their first symptoms appear.

Siklus Virus Dengue
Patogenesis dan Patofisiologi
• In DHF there is no vasculitis and hence no injury to the vessel walls, and plasma
leakage results from cytokine mediated increase in vascular permeability.
Haemorrhagic Manifestations in DHF
• Thrombocytopaenia is initially due to bone
marrow suppression during the febrile
viraemic phase of the illness.
• Progressive thrombocytopaenia with

defervescence result from immune mediated
platelet destruction.
• The low plasma fibrinogen detected in DHF could thus be
a reflection of loss into the interstitial spaces in the setting
of increased vascular permeability
• Heparan sulphate forms an integral part of the glycocalyx
which when damaged by the initial cytokine response in
DHF gets liberated to the circulation and acts like an
anticoagulant which could explain the prolonged APTT
• The disturbance in both these important haemostatic
indices are unlikely to cause spontaneous bleeding.
Haemorrhages are triggered by trauma in this setting of
coagulopathy.
Fase Infeksi
DBD
World Health Organization. Dengue Guidelines For

Diagnosis, Treatment, Prevention And Control. France:
World Health Organization; 2009. p.25-102.
Diagnosis
Pemeriksaan Diagnostik
Immune Response
Sympt
Bit om Antibod
DA e NS1 y 1 1 1
-7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9
Y Ag 0 1 2
CRITI-
ACUT CONVALESENCE
CAL
E PHASE
PHASE
PHAS
Ag/Ab level
E
Ig
Ig
G
NS1 M
Ag
Day
Dengue Markers
█ Response to Primary Infection
1. NS1 antigens
Day 1 after onset of fever and up to Day 9.
Not detectable once anti-NS1 IgG antibodies are
produced.
2. IgM antibodies
Day 5 after onset of fever and rise
for 1-3 weeks, then for up to 60 days.
3. IgG antibodies
Day 14 after onset of fever and persists for life.
Dengue Markers
█ Response to Secondary Infection
1. NS1 antigens
Day 1 after onset of fever and up to Day 9.
Not detectable once anti-NS1 IgG antibodies are
produced
(Appearance in short period )
2. IgM antibodies
Produced at low or undetectable levels or
for a shorter period than in a primary infection.
3. IgG antibodies
Rise rapidly 1-2 days after onset of symptoms.
SD Dengue NS1Ag & IgG/IgM
NS1 Ag IgG/IgM Ab
for early acute phase samples for early convalescence
(day 1~5) phase samples
(after day 3~5)
IgG IgG
IgM IgM
NS1
Ag/Ab level
Ag/Ab level
NS1
Ag Ag
Da Da
0 1 2 3 4 5 6 7 8 ≥9 0 1 2 3 4 5 6 7 8 ≥9
y y
NS1 Ag + Ab Combo
Simultaneous detection of Dengue NS1 Ag and IgG/IgM Ab test
together !
It will be perfect to diagnosis of dengue infection from acute to
convalescent stage !
IgG
IgM
NS1 Ag
Ag/Ab level
Day
0 1 2 3 4 5 6 7 8 ≥9
Pilihan Metode Diagnostik Dengue
Waktu Pengambilan Sampel

Metode Hasil Spesimen
dari Onset Gejala
Isolasi virus Positif / Tumbuh Serum dan
1-5 hari
Deteksi Asam Nukleat RT-PCR positif Jaringan
NS1 Ag positif Serum 1-6 hari
Confirmed Deteksi antigen Immunohistokimia
Jaringan
dengue positif
infection Serokonversi IgM negatif  positif
negatif  positif atau Pada fase akut 1-5 hari dan pada
Serokonversi IgG peningkatan titer > 4 fase konvalesens setelah 15 hari
kali
Serum
Highly IgM IgM positif
suggestive
Kadar IgG yang tinggi (≥ Setelah 5 hari
dengue IgG
1280)
infection
Tatalaksana
 Prinsip utama dari penatalaksanaan infeksi dengue adalah
terapi suportif
 Hal yang penting dalam penanganan DBD adalah
pemeliharaan volume cairan dalam sirkulasi.
 Terapi Non-Farmakologis : Tirah baring
 Terapi Farmakologis: Simtomatis : antipiretik (Paracetamol)
bila demam.
Suhendro, Nainggolan L, Chen K, Pohan HT. Demam Berdarah Dengue. Dalam: Setiati S, Alwi I, Sudoyo AW, Simadibrata M,
Setiyohadi B, Syam AF, penyunting. Buku Ajar Ilmu Penyakit Dalam Jilid II. Edisi ke-VI. Jakarta: InternaPublishing; 2015.
h.539-48.
Protokol Penatalaksanaan DBD
• Protokol 1 : Penanganan DBD dewasa tanpa syok.
 Hb, Ht, trombosit normal atau trombosit antara 100.000–
150.000  pasien dipulangkan dengan anjuran kontrol.
 Hb, Ht normal, Trombosit < 100.000  pasien dirawat
 Hb, Ht meningkat dan trombosit normal atau turun 
dirawat
h.539-48.
• Protokol 2
• Apabila Ht belum meningkat >20%, pemberian cairan pada
tersangka DBD dewasa di ruang rawat menggunakan
rumus:
• 1500 + {20x(BB-20)} ml
• Dilakukan pemeriksaan Hb, Ht, trombosit setiap 12-24 jam
h.539-48.
Protokol
Penatalaksanaan
DBD
• Protokol 3
• Management of
DHF with Increase
of Haematocrite
>20%
• Protokol 4 - Penatalaksanaan perdarahan spontan pada
DBD dewasa.
• PRC diberikan jika Hb < 10 gr/dl.
• Transfusi trombosit hanya diberikan pada pasien DBD
dengan perdarahan spontan dan masif dengan jumlah
trombosit < 10.000 dengan atau tanpa koagulasi
intravascular diseminata.
h.539-48.
Kaur P, Kaur G. Transfusion support in patients with dengue fever. Int J Appl Basic Med Res. 2014;4(Suppl 1):S8-S12.
doi:10.4103/2229-516X.140708
Protokol
Penatalaksanaan
DBD
• Protokol 5
World Health Organization. Dengue Guidelines For

Diagnosis, Treatment, Prevention And Control. France:
World Health Organization; 2009. p.25-102.

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DENGUE INFECTION

Muhammad Imanuddin Nasution

• The virus is transmitted to humans through

• After incubation for 4–10 days, infected

mosquito is capable of transmitting the virus

for the rest of its life.

• Patients who are already infected with the

dengue virus can transmit the infection (for

4–5 days; max 12) via Aedes mosquitoes after

their first symptoms appear.

• Progressive thrombocytopaenia with

World Health Organization. Dengue Guidelines For

Waktu Pengambilan Sampel

World Health Organization. Dengue Guidelines For

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