Goku Notes

Flavivirus DENGUE VIRUS

Lecturer: Dr. Jaime Santos
Causes dengue and dengue hemorrhagic fever
I. Powerpoint Transmitted by mosquitoes
Has 4 serotypes (DEN- 1, 2, 3, 4)
FLAVIVIRIDAE
Aedes aegypti
>68 viruses
Spherical Dengue transmitted by infected female mosquito.
Enveloped Primarily a daytime feeder
Single stranded RNA Lives around human habitation
Cross related Lays eggs and produces larvae preferentially in
artificial containers with clean stagnant water
Flaviviruses
Clinical Presentations
Yellow fever virus
Dengue viruses Undifferentiated fever – may be the most common
St. Louis encephalitis virus presentation
Zika virus Classic dengue fever
West Nile virus Dengue hemorrhagic fever
Murray Valley encephalitis virus, tick- Dengue shock syndrome
borne encephalitis viruses and others
Clinical Characteristics of Dengue Fever

YELLOW FEVER Fever

Headache
Vector: Aedes aegypti Muscle and joint pain
Latin America, Carribean, Africa Nausea/vomiting
Inapparent to severe infection (jaundice, Rash
hemorrhage, albuminuria) Hemorrhagic manifestations
Hepatic necrosis, Councilman and Torres bodies
Hemorrhagic Manifestations of Dengue Fever
Diagnosis
Skin hemorrhages – petechiae, purpura,
Cell culture ecchymoses
Serology Gum bleeding
PCR Nose bleeding
Immunohistochemistry GIT bleeding – hematemesis, melena,
hematochezia
Treatment Hematuria
Increased menstrual flow
Supportive
Tourniquet Test
Prevention
Inflate a blood pressure cuff to a point midway
Live attenuated 17D Vaccine between systolic and diastolic pressure for 5
minutes.
Positive test – 20 or more petechiae per 1 inch2
2
(6.25 cm )

Goku Notes Page 1

 Goku Notes

4 Necessary Criteria for Dengue Fever Warning Signs for Dengue Shock

Fever, or recent history of acute

fever Alarm Signals:
Hemorrhagic manifestations 4 Criteria for DHF:
Low platelet count (100,000/mm3 or Severe
less) abdominal pain
Fever
Objective evidence of “leaky Prolonged
Hemorrhagic
capillaries” vomiting
manifestations
Abrupt change
Excessive
Elevated hematocrit (20% or more from fever to
capillary
over the baseline) hypothermia
permeability
Low albumin Change in the
≤ 100,000/mm3
Pleural or other effusions level of
platelets
consciousness
(irritability or
Clinical Case Definition for Dengue Shock somnolence)
Syndrome
Initial Warning
4 Criteria for DHF Signals:

Evidence of circulatory failure Disappearance

manifested indirectly by all of the of fever
following: Drop in
platelets
Rapid and weak pulse Increase in
Narrow pulse pressure (≤20 hematocrit
mmHg) or hypotension for age When patients
Cold, clammy skin develop DSS:
Altered mental status
3-6 days after
Frank shock is direct evidence of onset of
circulatory failure. symptoms

Clinical Evaluation in Dengue Fever

Blood Pressure Laboratory Tests in Dengue Fever

Evidence of bleeding on skin and other sites
Hydration status Clinical Laboratory Tests
Evidence of increased vascular permeability –
pleural effusions, ascites CBC – WBC, platelets, hematocrit
Tourniquet test Albumin
Liver function tests
Urine – check for microscopic hematuria

Goku Notes Page 2

 Goku Notes

Dengue Specific Tests Diagnosis

Virus isolation CSF analysis

Serology EEG
IgM ELISA
Laboratory Methods for Dengue Diagnosis NT
HI
Virus isolation to determine the serotype of infecting CF
virus PCR
IgM ELISA for serologic diagnosis
Dengue NS1 antigen test – positive during viremic Treatment
(febrile) phase
Supportive
Management
Prevention
No hemorrhagic manifestations and patient is well
hydrated – home treatment Available locally
Hemorrhagic manifestations or hydration borderline Chimeric vaccine with 17D yellow fever virus
– consider hospitalization backbone containing prM and env genes from JEV
Warning signs (even without profound shock) or
DSS – hospitalize ZIKA VIRUS

Mosquito Barriers First discovered in 1947 and named after the Zika
forest in Uganda
Only needed until fever subsides, to prevent Aedes In 1952, the first human cases of Zika virus disease
aegypti mosquitoes from biting patients and were detected and since then, outbreaks of Zika
acquiring the virus have probably occurred in many locations.
Keep patient in screened sickroom or under In May 2015, the Pan American Health Organization
mosquito net. issued an alert regarding the first confirmed Zika
virus infection in Brazil and in Feb. 1, 2016, the
Prevention WHO declared Zika virus a public health emergency
of international concern.
Public Education Local transmission has been reported in many other
Vector control countries.
Dengue quadrivalent recombinant (chimeric) vaccine
(given at 0, 6 month schedule) from 9-45 years old Transmission

JAPANESE ENCEPHALITIS VIRUS Transmitted to human primarily through the bite of

infected Aedes mosquito
Single serotype Nonhuman and human primates are likely the main
5 genotypes based on E protein reservoirs of the virus, and anthroponotic (human to
Asia including SEA vector to human) transmission occurs during
Cycle: birds outbreaks.
Culex mosquitoes (Culex tritaeniorhynchus) – swine, Perinatal, in utero, and possible sexual and
humans, horses transfusion transmission events have also been
99% subclinical reported.
Lethargy, behavioral changes, motor abnormalities Zika virus RNA has been identified in asymptomatic
blood donors during an outgoing outbreak.

Goku Notes Page 3

 Goku Notes
Features
1 in 5 people infected becomes symptomatic.
Clinical findings are acute onset of fever with
maculopapular rash, arthralgia, conjunctivitis,
myalgia and headache.
Clinical illness is usually mild with symptoms lasting
for several days to a week.
Severe disease requiring hospitalization is
uncommon and case fatality is low.
No vaccine and specific treatment available yet
Investigators are looking at the possible association
between Zika virus and a reported increase in the
number of babies born with microcephaly.
There have been cases of Guillain Barre syndrome
reported in patients following Zika virus infection.
Diagnosis
1st week after onset of symptoms – diagnosed by
reverse transcriptase polymerase chain reaction
(RT-PCR) on serum
Virus specific IgM and neutralizing antibodies
typically develop toward the end of the first week of
illness.
Cross-reaction with related flaviviruses (e.g. dengue
and yellow fever) is common and may be difficult to
discern.
RT-PCR and virus isolation can be performed on
other body fluids (e.g. urine, amniotic fluid, semen,
saliva which are transmitted to lab cold or frozen).
II. Recording
FLAVIVIRUSES
There are now more than 70 Flaviviruses and these
are RNA viruses which are very small and are round,
spherical in shape and they possess an envelope
like the flu viruses.
They consist of a single stranded RNA like most
RNA viruses and they tend to be cross related to
each other.
When a person gets infected with a certain flavivirus,
the antibodies developed against that particular virus
tend to cross react with another type of flavivirus.
Goku Notes
Flaviviruses
Yellow fever virus
Dengue viruses
St. Louis encephalitis virus
Zika virus
West Nile virus
Murray Valley encephalitis virus, tick-
borne encephalitis viruses and others
Hepatitis C is considered a flavivirus.
YELLOW FEVER
A historical illness
In the early part of the last century, it is already a
diagnosed illness.
It is common in Latin America and parts of Africa.
It is vector transmitted like a lot of flaviviruses.
The vector is the Aedes aegypti which is also the
vector for Dengue virus.
It causes a lot of inapparent infections but when
infection tends to be severe, the patient develops
jaundice due to liver involvement (reason why it was
called Yellow fever).
Hemorrhage is also common together with renal
involvement.
Hepatic necrosis, when a biopsy is done,
Councilman and Torres bodies are seen on the
stained smear.
Diagnosis is through culture, serology and PCR.
There is no treatment for Yellow fever but it is
preventable.
OFWs should be vaccinated with Yellow fever
vaccine from the Bureau of Quarantine especially if
they are bound for Africa or Latin America.
DENGUE
It is caused by 4 serotypes of the dengue virus
(DEN- 1, 2, 3, 4).
Previously called Breakbone fever and Philippine
Hemorrhagic fever
Infection with a certain serotype may confer
protection for that particular serotype but it lasts only
for a short period of time.
A patient can be infected with 4 serotypes of dengue
in his life.
Page 4
 Goku Notes

Infection is dependent on the prevalent serotype Dengue Hemorrhagic Fever

order during the time when infection developed.
It is transmitted by Aedes aegypti and it is common There is a rise in temperature, initially very high,
in tropical areas which are heavily populated. which continues to rise further and falls gradually
It is not common in Russia, Europe or the northern within 3-7 days.
part of Africa due to their cold climate. It leads to Dengue shock syndrome sometimes.
It is seen mostly in Asia and in the northern tip of Generally more benign than the other group but they
Australia. are caused by the same virus.
In Mexico, it is also seen. There is neurologic involvement and severe dengue
In US, the illness is occasionally seen near the gulf correlates with severe viremia and production of
because it is near the tropical areas and it also cytokines
correlates with the vector density. This is the body’s immune response to severe
Female mosquitoes are the only ones which bite dengue.
humans because male mosquitoes feed on plants.
Aedes aegypti mosquitoes are daytime feeders as Dengue Shock Syndrome
opposed to Culex and Anopheles mosquitoes which
are night time feeders. Clinical Characteristics of Dengue Fever
They live around human inhabitations. (distinct signs)
They can be found in areas where there are lots of
houses, predominantly urban areas. Fever
They are not common in the mountains. Headache
This vector does not have a long flight range. Muscle and joint pain
It cannot fly a long distance. Nausea/vomiting
It tends to go from house to house. Rash –not always present
They tend to breed in human inhabitations. Hemorrhagic manifestations
They lay larvae and eggs in clean, stagnant water.
Waters found in clean containers, tires, plants and
rooftops serve as a medium for laying eggs. Hemorrhagic Manifestations of Dengue
They do not breed in dirty canals. Fever
The first infection of dengue is mild.
The second infection is more symptomatic but cases Skin hemorrhages – petechiae,
of first infection can be severe. purpura, ecchymoses
Generally it is estimated that out of 100 people who Gum bleeding
gets the virus, only about 25 may show symptoms. Nose bleeding – very common
GIT bleeding – hematemesis, melena,
Clinical Presentations hematochezia which can lead to
significant blood loss
Undifferentiated fever which is flu like in nature Hematuria (bleeding occurs in
Unless specific testing is done, it will not be thought kidneys)
of as dengue. Increased menstrual flow

Classic Dengue Fever Tourniquet Test

Another classic presentation is the biphasic fever
where the patient has a rise in temperature, then for
about 2-3 days it goes down then goes up again
after 1 day.
They develop a rash and symptoms develop
anytime during this phase.
Inflate a blood pressure cuff to a point midway
between systolic and diastolic pressure for 5
minutes.
If systolic is 100 or 110 and diastolic is 70, inflate the
cuff at 90 for 5 minutes.

Goku Notes Page 5

 Goku Notes
2
Positive test – 20 or more petechiae per 1 inch
(6.25 cm2)
Not specific for dengue
Cases of severe dengue can have a negative
tourniquet test especially if they are coming with
shock or hypotension.
New Classification for Dengue Fever
Dengue without Warning Signs
Dengue with Warning Signs
Severe Dengue
Criteria for Severe Dengue Fever
4 Necessary Criteria for Dengue Fever
Fever, or recent history of acute fever
Hemorrhagic manifestations – a positive
tourniquet test may suffice
3
Low platelet count (100,000/mm or less)
Objective evidence of “leaky capillaries”
Elevated hematocrit (20% or more over
the baseline)
Low albumin – due to leakage of
plasma
Pleural or other effusions
In severe dengue, plasma goes out of the blood
vessels due to the inflammation on the blood vessel
wall, they leak out plasma so the blood becomes
concentrated.
If it is not replaced with fluid, patient will die of
hypotension and shock.
This is dengue shock syndrome.
rd
Plasma leaks out and goes to the 3 space and
patient can have ascites or pleural effusion.
If there is pleural effusion in a patient with dengue, it
is severe dengue because there is an evidence of
leaky capillaries.
The most common sign of leaky capillary in severe
dengue is a rise in the hematocrit of the patient.
The most common site for pleural effusion in dengue
is the right pleural space.
Goku Notes
Course of Dengue Fever
Starts with a very high fever
Fever becomes continues and goes down between
day 3 to day 7.
Fever can be as short as 3 days.
During the times when the patient is febrile there is
viremia and there is virus in the blood.
They also have lack of appetite, headache,
anorexia, abdominal pain, vomiting, muscle and joint
pain and there can already be a positive tourniquet
test.
Patient looks flushed and reddish.
Sometimes, maculopapular rashes are seen similar
to other viral exanthems.
When the fever is going down, platelet count falls.
As the fever goes down, decline in platelet count is
seen.
Soon after the decline in platelet count, plasma
starts to leak out of the capillaries.
There will now be rising hematocrit levels.
Patient can go into shock from the time that the
fever went down up to about 2 days after.
Some people mistake that the patient already
recovered because the fever has already gone
down.
The patient does not necessarily bleed but can die
of shock due to plasma loss.
Those that bleed oftentimes have a preceding
shock.
If the patient is not given fluids the patient can die of
fluid loss.
Patients may have rash when he has fever but a lot
of patients do not have rash.
There can also be rash when the patient is
recovered already and it is called Herman rash.
These are itchy and tend to be more on the lower
extremities but sometimes also seen on the upper
extremities.
If this is seen in a patient, the patient is probably
nearing recovery.
There are 2 types of rash, one that can develop
during the fever and one that can develop as the
patient is nearing recovery.
There can be rapid pulse, narrowed pulse pressure
and cold clammy skin as signs of shock.
Page 6
 Goku Notes
Clinical Evaluation
Blood pressure monitoring other than hematocrit
monitoring
When the systolic and diastolic BP is narrow or
come near each other, if fluids are not given, the BP
will narrow further, and when it continues to narrow,
the patient will have hypotension and shock.
Together with narrowing of the pulse pressure, it can
be a determinant of how strong the pulse is.
If the pulse is weak, the patient has a narrow pulse
pressure.
The skin gets cold and clammy.
They also have decreased urine output which is a
sign of diminished intravascular volume.
Clinical Evaluation in Dengue Fever
Blood Pressure
Evidence of bleeding on skin and
other sites
Hydration status – patient can die of
dehydration
Evidence of increased vascular
permeability – pleural effusions,
ascites
Tourniquet test
Warning Signals:
Severe abdominal pain
Prolonged vomiting
Abrupt change from fever to
hypothermia
Change in the level of consciousness
(irritability or somnolence)
Organ involvement
Liver failure
Renal failure
Usually sets in when there is drop of
fever, decrease in platelet and
increase in hematocrit.
Laboratory Tests in Dengue Fever
Clinical Laboratory Tests
CBC – WBC, platelets, hematocrit
Goku Notes
Albumin
Liver function tests – the virus can affect the liver
Urine – check for microscopic hematuria
Culture is difficult and takes a long time
Serology
Laboratory Methods for Dengue Diagnosis
Virus isolation to determine the serotype of infecting
virus
IgM ELISA for serologic diagnosis
Dengue NS1 (non-structural 1) antigen test –
positive during viremic (febrile) phase because what
is being detected in NS1 is antigen for the virus
itself.
If the virus is no longer present in the blood it will be
negative.
It is negative when the patient is in shock.
It will be negative when the patient is about to be
discharged.
IgM ELISA – is positive in day 4 or 5 of illness
IgG ELISA
ELISA testing may have cross reaction with other
flaviviruses.
Management
No hemorrhagic manifestations and patient is well
hydrated – home treatment, adequate fluid intake
Hemorrhagic manifestations or hydration borderline
– consider hospitalization
Warning signs (even without profound shock) or
DSS – hospitalize
Treatment
There is no treatment.
Give fluids with paracetamol.
Avoid Ibuprofen because it can cause bleeding.
It can also do damage in dehydration.
Stick to Paracetamol with right doses because it can
damage the liver if given too much.
Monitor BP, hematocrit, level of consciousness and
urine output.
Blood products are only given when there is
significant bleeding.
There is no need to give platelets.
Page 7
 Goku Notes

Mosquito Barriers Prevention

Needed until the fever subsides Available locally

Rooms of the patients should be screened. Chimeric vaccine with 17D yellow fever virus
backbone containing prM and env genes from JEV
Prevention is inserted
Vaccine is derived from yellow fever
Public Education Given in 2 doses from 9 months to 17 years (1 year
Vector control apart, 1 primary dose and 1 booster)
Dengue quadrivalent recombinant (chimeric) vaccine 18 and above – only one dose of the vaccine
(given at 0, 6 and 12 month schedule) from 9-45
years old ZIKA VIRUS

JAPANESE ENCEPHALITIS VIRUS First discovered in 1947 and is named after the Zika
forest in Uganda
Single serotype In 1952, the first human cases of Zika virus disease
Most common cause of encephalitis in Asia were detected and since then, outbreaks of Zika
Vector borne have probably occurred in many locations.
5 genotypes based on E protein Not famous in the Philippines
Culex mosquitoes (Culex tritaeniorhynchus) is the In May 2015, the Pan American Health Organization
vector which is common in rural areas – bites swine, issued an alert regarding the first confirmed Zika
humans, horses virus infection in Brazil and in Feb. 1, 2016, the
The virus is transferred when the mosquitoes bite WHO declared Zika virus a public health emergency
birds (waterbirds specifically with long necks and of international concern because it spread to certain
long legs) parts of Latin America.
Humans can be bitten and can be infected but Local transmission has been reported in many other
viremia level is low. countries.
No human to human transmission through mosquito
bites Transmission
99% subclinical
Lethargy, behavioral changes, motor abnormalities Transmitted to human primarily through the bite of
infected Aedes mosquito
Nonhuman and human primates are likely the main
Diagnosis reservoirs of the virus, and anthroponotic (human to
vector to human) transmission occurs during
CSF analysis outbreaks.
EEG Main reservoirs are monkeys as well as humans.
IgM ELISA on the CSF Perinatal, in utero, and possible sexual and
IgG in the blood and see if it is a 4 fold rising titer transfusion transmission events have also been
from the serum 2 weeks later reported.
Nuclear testing Zika virus RNA has been identified in asymptomatic
HI blood donors during an outgoing outbreak.
CF
PCR Features

Treatment 1 in 5 people infected becomes symptomatic.

Clinical findings are acute onset of fever with
Supportive maculopapular rash, arthralgia, conjunctivitis,
myalgia and headache.

Goku Notes Page 8

 Goku Notes

Clinical illness is usually mild with symptoms lasting

for several days to a week.
Severe disease can occur.
Severe disease requiring hospitalization is
uncommon and case fatality is low.
No vaccine and specific treatment available yet
Investigators are looking at the possible association
between Zika virus and a reported increase in the
number of babies born with microcephaly.
There have been cases of Guillain Barre syndrome
(ascending symmetric type of paralysis) reported in
patients following Zika virus infection.

Diagnosis

st
3 days to 1 week after onset of symptoms –
diagnosed by reverse transcriptase polymerase
chain reaction (RT-PCR) on serum
Virus specific IgM and neutralizing antibodies
typically develop toward the end of the first week of
illness.
Cross-reaction with related flaviviruses (e.g. dengue
and yellow fever) is common and may be difficult to
discern.
RT-PCR and virus isolation can be performed on
other body fluids (e.g. urine, amniotic fluid, semen,
saliva which are transmitted to lab cold or frozen).

END
Special thanks to KTRC for the rcording and
ppt pictures.

Goku Notes Page 9