DENGUE
HISTORY
Thrombocytic fever syndrome, Non-specific
symptom, upper respiratory symptom
Duration of fever: 2-7 days
Compulsory question:
- Live in dengue area – recent fogging - DENGUE
- Visit waterfall, river/ freshwater source,
outbreak of leptospirosis, many rats in the area
– EXCLUDE LEPTOSPIROSIS
- Gone to jungle trekking, bush area, farm etc –
EXCLUDE MALARIA & SCRUB TYPHUS
- Have been infected with dengue before –
SECONDARY DENGUE
Systemic revision: no cough sputum, diarrhea,
headache, photophobia, neck stiffness – TO RULE
OUT OTHER GENERAL POTENTIAL CAUSES FOR
FEVER
7 WARNING SIGN! (6 CLINICAL + 1 LAB)
PHYSICAL EXAMINATION
- Rash: [CHANGES: maculopapular  platelet
low  petechiae]
- petechiae (not blanching: when press
does not disappear, unlike
maculopapular rash)
- Abdominal pain & tenderness: increase
intravascular volume  reduction in blood
supply
- Severe Dengue: AKI, hepatitis, myocarditis &
encephalitis (confusion: low blood supply to
the brain due to fluid leakage)
- Evidence of fluid leakage:
- low volume pulse (< 20 mmHg)
- increase capillary fill time
- evidence of fluid accumulation:
o pleural effusion: CXR - meniscus
sign, reduced chest expansion,
homogenous opaque/
opacification at the lower zone (if
patient standing up straight)
o Ascites (peritoneal effusion):
stony dull percussion, shifting
dullness
MANAGEMENT: AVOID NSAIDs (because dengue
patient tend to bleed  GI bleed gastritis/
INVESTIGATION
Basic investigation (Dx & Monitoring)
FBC: haemoconcentration, leucopenia,
thrombocytopenia
Increasing lactate ( hypoperfusion  not
enough circulation to the periphery 
hypovolaemic shock  reduced intravascular
volume  dengue shock)
Dx Severe Dengue (organ failure)
1. Renal profile: creatinine and urea  AKI
(acute kidney injury)
2. Liver Fx Test: ALT & AST >1000 
hepatitis cause by Dengue
3. Creatine kinase (CK) elevated:
leptospirosis > myocarditis (if
suspected)
Specific Test:
Rapid Combo Test, ELISA: NS1 Ag (day1-day5),
 Dengue IgM Ab (little late, up to 3 months)
*false +ve for NS1 are very rare
RECOVERY PHASE:
1-Abdominal pain/ tenderness
2-Persistent vomiting (3/ >3 times per day)
3-Persistent diarrhea (3/ >3 times per day)
4-Clinical fluid accumulation: ascites and pleural
effusion
5-Mucosal bleed
6-Lethargy, confusion and restlessness
7-Tender liver
8-Lab investigation: increase HCT + rapid decrease in
Plt
CRITERIA FOR ADMISSION: WARNING SIGN
*When patien already admitted: stable patient/
compensated shock/ decompensated shock
ulcer cause of death) (need to avoid for
monitor the fever  interfere with the
defervescence phase)
FEBRILE PHASE (2-7 days):
give minimal IV fluid to avoid dehydration
DEFERVESCENE:
when body temperature starts slowing reducing
into below 40 degree Celcius
*PCM interfere with the time calculation into
defervescene.
CRITICAL PHASE (24-48 hours):
increase frequency of assessment (blood test)
MAJORITY patient dies in this phase
Marker: increase in platelet, isles of white in the
sea of red (rare)
FLUID MANAGEMENT: THE BEST ONE:
crystalloid (isotonic, normal saline)  NO
OPTION: colloid (hypertonic, etc: albumin, for
decompensate/ compensated shock – pleural
effusion)  THE LAST OPTION: blood (any
bleeding: GI bleed & THE LAST OPTION)
*no drug, no antiviral that you can give
PREVENTION: begin even before patient is
admitted, as soon as you see the patient

COMPENSATED SHOCK Dengue vaccine is not well develop

OR
DECOMPENSATED SHOCK:
increase frequency of monitoring & blood test

*no need to memories fluid management

DIFFERENTIAL DIAGNOSIS RULED OUT BY Hx RULED OUT BY Investigation

TROPICAL INFECTION:
MALARIA Hx of jungle trekking and camping Thick and thin blood film
LEPTOSPIROSIS Hx of visiting waterfall, rive or other freshwater Microscopic agglutination test (MAT), CK
source, outbreak of leptospirosis, many rats in elevated (rare)
the area
SCRUB TYPHUS (RICKETTSIAL Dz) – tick bite Hx of jungle trekking and camping Immunofluorescent (IF)
TYPHOID FEVER Hx of eating out, go into typhoid outbreak area, Blood culture/ Stool culture (if have diarrhea)
acute gastroenteritis-like symptom but diarrhea
less likely
NON-TROPICAL INFECTION:
PNEUMONIA Cough sputum -
URINARY TRACT INFECTION Dysuria, frequency -
ACUTE GASTROENTERITIS Diarrhea, vomiting -
MENINGITIS Headache, photophobia, neck stiffness
THROMBOCYTIC FEVER: non-specific symptom, no pointing towards UTI or RSP tract infx, , non-specific fever BUT have thrombocytopenia (+ DENGUE,
MALARIA & LEPTOSPIROSIS)

SEVERE GRAM –VE SEPSIS (UTI with E.coli  Elderly Blood culture
blood)
VIRAL ILLNESSES: Viral test
INFLUENZA Upper respiratory tract symptom: flu like illness – PCR-based test
rhinorrhea, cough +/- sputum, sore throat
HIV SEROCONVERSION Risk factor: unprotected sex, sharing needles Serology/ ELISA – looking for Ab
INFECTION MONONUCLEOSIS (EBV) - Monospot test
RUBELLA +rash -
CHIKUNGUNYA +very severe joint pain (clinically diagnosed) -

CPG: what is in the box are important

*Highlights the keywords: endovascular leaking, intravascular volume depletion, hypovolemic shock

*Common question (same starting point, difference: where is end): pathophysiology of fluid leakage  pathophysiology of decompensated dengue shock,
pathophysiology of antibody enhancement (why second dengue is more severe), how lactic acid increase?