CPD OFFLINE HTWU BIL 1/2016 January 1, 2016

Dengue is one of the most important arthropod-borne viral

diseases in terms of human morbidity and mortality1.
Dengue has become an important public health problem. It
affects tropical and subtropical regions around the world,
predominantly in urban and semi urban areas.
Dengue infection is caused by dengue virus which is a
mosquito-borne flavivirus1. It is transmitted by Aedes
aegypti and Aedes albopictus. There are four distinct
serotypes, DEN-1, 2, 3 and 4. Each episode of the
infection induces a life-long protective immunity to the homologous serotype but confers only
partial and transient protection against subsequent infection by the other three serotypes.
Secondary infection is a major risk factor for DHF due to antibody-dependent enhancement.
The incubation period for dengue infection is 4-7 days. It may be asymptomatic or may result in
a spectrum of illness ranging from undifferentiated mild febrile illness to severe disease, with or
without plasma leakage and organ impairment. Symptomatic dengue infection is a systemic and
dynamic disease with clinical, haematological and serological profiles changing from day to day.
Dengue infection is a dynamic disease2. Its clinical course changes as the disease progresses.
After the incubation period, the illness begins abruptly and will be followed by 3 phases: febrile,
critical and recovery phase.

The principal symptoms of dengue are:

1. High fever 5. Muscle and/or bone pain
2. Severe headache 6. Rash
3. Severe eye pain (behind eyes) 7. Mild bleeding manifestation (e.g., nose
4. Joint pain or gum bleed)

Generally, younger children and those with their first dengue infection have a milder illness than
older children and adults. After being bitten by a mosquito carrying the virus, the incubation
period ranges from three to eight days before the sign and symptoms appear in stages. Dengue
starts with chills, headache, pain upon moving the eyes, appetite loss and low backache. Painful
aching in the legs and joints occurs during the first hours of illness. The temperature rises
quickly with relatively low heart rate and hypotension. The eyes become reddened. A flushing
or pale pink rash comes over the face and then disappears. The lymph nodes in the neck and
 CPD OFFLINE HTWU BIL 1/2016 January 1, 2016

groin are often swollen. High fever and other signs of dengue last for two to four days, followed
by a rapid drop in body temperature with profuse sweating. This precedes a period with normal
temperature and a sense of well-being that lasts about a day. A second rapid rise in temperature
follows. A characteristic itchy rash appears along with the fever and spreads from the extremities
to cover the entire body except the face. The palms and soles may be bright red and swollen.

The dengue management generally based on the patients group categories which can be
categorized into 3 group:

 Group A who can be treated as outpatients

 Group B who need admission and inpatient care
 Group C who require emergency treatment

The standard therapy in dengue is fluid management where oral rehydration can be done among
stable patient. Intravenous fluid therapy, on the other hand, is indicated among patients who
cannot tolerate oral, vomitting or who experienced haemodynamic instability (e.g increased
haematocrit) and usually needed up to 48 hours. Crytalloid fluid (e.g 0.9% normal saline) is used
and colloid fluid (e.g Voluven, Gelafusine) only preferred if patient experienced hypotensive
shock or dengue shock syndrome.

Fluid can be given initially with 5-10ml/kg/hr and 5-7ml/kg/hr over 1-2 hours for Group C and
Group B patients respectively. It is then reduced to 3-5ml/kg or 2-3ml/kg for 2-4 hours or
according to clinical response. Meanwhile, the normal maintainence fluid therapy can be
calculated based on Holliday Segar Formula as listed below which based on ideal body weight
and usually given for 24 – 48 hours.

4ml/kg/hour for first 10kg body weight

+ 2ml/kg/hour for next 10kg body weight

+ 1ml/kg/hour for subsequent kg body weight.

Dengue hemorrhagic fever (DHF) is characterized by a fever that lasts from 2 to 7 days, with
general signs and symptoms consistent with dengue fever. When the fever declines, warning
signs may develop. This marks the beginning of a 24 to 48 hour period when the smallest blood
capillaries become excessively permeable, allowing the fluid component to escape from the
blood vessels into the peritoneum and pleural cavity. This may lead to failure of the circulatory
system and shock, and possibly death without prompt, appropriate treatment.
In addition, the patient with DHF has a low platelet count and hemorrhagic manifestations,
tendency to bruise easily or have other types of skin hemorrhages, bleeding nose or gums, and
possibly internal bleeding. The bleeding in dengue mostly managed by giving blood transfusion.
It may transfused 5-10ml/kg fresh packed cell or 10-20ml/kg fresh whole blood.
Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it.
For typical dengue, the treatment is concerned with relief of the symptoms and signs. Rest and
fluid intake for hydration is important. Pain relievers such as aspirin and nonsteroidal anti-
 CPD OFFLINE HTWU BIL 1/2016 January 1, 2016

inflammatory drugs should only be taken under a physician’s supervision because of the
possibility of worsening bleeding complications.
There is no vaccine to prevent dengue fever3. The best way to prevent the disease is to prevent
bites by infected mosquitoes, particularly if you are living in or traveling to a tropical area. This
involves protecting yourself and making efforts to keep the mosquito population down.
To protect :
 Stay away from heavily populated residential areas, if possible.
 Use mosquito repellents, even indoors.
 When outdoors, wear long-sleeved shirts and long pants tucked into socks.
 When indoors, use air conditioning if available.
 Make sure window and door screens are secure and free of holes. If sleeping areas are not
screened or air conditioned, use mosquito nets.
 If you have symptoms of dengue, speak to your doctor.
 To reduce the mosquito population, get rid of places where mosquitoes can breed. These
include old tires, cans, or flower pots that collect rain. Regularly change the water in
outdoor bird baths and pets' water dishes.
If someone in your home gets dengue fever, be especially vigilant about efforts to protect
yourself and other family members from mosquitoes. Mosquitoes that bite the infected family
member could spread the infection to others in your home.
References
1. World Health Organization. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control - New
Edition 2009. WHO: Geneva; 2009
2. Ministry of Health. Management of Dengue Injection in Adults (2 nd Edition) 2010.
 CPD OFFLINE HTWU BIL 1/2016 January 1, 2016

MULTIPLE CHOICE QUESTIONS (MCQ)

1. Which of the following is/are sign and symptoms of dengue fever:
I. High fever
II. Muscle pain
III. Gum bleed
IV. Rashes
A. I only
B. II and III
C. I, III and IV
D. I, II, III, IV

2. Incubation period for dengue fever is

A. 1 – 3 days
B. 4 – 7 days
C. 1 – 2 weeks
D. None of above

3. After incubation period, disease will progressed and followed by 3 phases which are
I. Febrile phase
II. Recurrence phase
III. Recovery phase
IV. Critical phase
A. I, II and III
B. I, III and IV
C. II, III and IV

4. Dengue hemorrhagic fever is characterized by a fever that last from 2 to 7 days with sign
and symptoms such as high platelet count.
A. True
B. False

5. Fluid management is a standard therapy in dengue and intravenous fluid is indicated among
patient who
I. Vomitting
II. Cannot tolerate oral
III. Increased hematocrit
A. I only
B. II only
C. I and II
D. I, II and III

6. Which of the following is the preferred solution to be use in initial resuscitation among
patients with dengue shock syndrome?
A. Normal Saline
B. Ringer’s Lactate
C. Gelafusine
 CPD OFFLINE HTWU BIL 1/2016 January 1, 2016

7. Among group B patients, fluid therapy can be started with initial rate
A. 5 – 7ml/kg/day
B. 5 – 10ml/kg/day
C. 3 – 5 ml/kg/day
D. 2 – 3ml/kg/day

8. Fluid maintenance therapy usually needed for

A. 10 – 12hrs
B. 12 – 24hrs
C. 24 – 36hrs
D. 24 – 48hrs

9. Dengue fever is caused by virus, therapy may involve the use of antibiotic but no vaccine
can be used for prevention.
A. True
B. False

10. Dengue fever may also lead to haemorrhage manifestation such as:
I. Bruise
II. Gum Bleed
III. Skin Bleed
A. I only
B. I and II
C. II and III
D. I, II and III