Republic of the Philippines

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES
Marawi City

CASE STUDY:
DENGUE

SUBMITTED BY:
ADOMPING, Basmah A.
LEVEL III
DEFINITION
Dengue (DENG-gey) fever is a mosquito-borne illness that occurs in tropical and subtropical
areas of the world. Mild dengue fever causes a high fever and flu-like symptoms. The severe
form of dengue fever, also called dengue hemorrhagic fever, can cause serious bleeding, a
sudden drop in blood pressure (shock) and death. Millions of cases of dengue infection occur
worldwide each year. Dengue fever is most common in Southeast Asia, the western Pacific
islands, Latin America and Africa. But the disease has been spreading to new areas, including
local outbreaks in Europe and southern parts of the United States.
Researchers are working on dengue fever vaccines. For now, in areas where dengue fever is
common, the best ways to prevent infection are to avoid being bitten by mosquitoes and to take
steps to reduce the mosquito population.
ETIOLOGY
When a mosquito bites a person infected with a dengue virus, the virus enters the mosquito.
Then, when the infected mosquito bites another person, the virus enters that person's bloodstream
and causes an infection.
INCIDENCE RATE
On average, 170,503 symptomatic DENV infections and 750 deaths were officially reported to
the Philippines Department of Health (DoH) annually from 2010 to 2014, i.e., an incidence of
about 178 symptomatic dengue episodes per 100,000 population and a reported case fatality rate
of approximately 0.44%.
INCUBATION PERIOD
Dengue is a severe, flu-like illness that affects infants, young children and adults, but seldom
causes death. Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after
the bite from an infected mosquito.
CAUSATIVE AGENT
Dengue fever is among the most common mosquito-borne virus infections. Causative agent of
the disease is the Dengue virus, of which four different types are known. The virus cannot be
transmitted from human to human. In order to spread the disease needs a mosquito as alternate
host. The virus multiplies within the organism of the female mosquitoes of the Aedes aegypti
(yellow fever mosquito) and Aedes albopticus (Asian tiger mosquito) genus and is transmitted by
bite. Contrary to the Malaria mosquito these mosquitoes bite both during the day and at dawn.
For breeding the mosquitoes rely on reservoirs of tap water or rain water such as pans, cans and
basin
Dengue is a mosquito-borne viral disease that has rapidly spread in all regions of WHO in recent
years. Dengue virus is transmitted by female mosquitoes mainly of the species Aedes aegypti
and, to a lesser extent, Ae. albopictus. These mosquitoes are also vectoring of chikungunya,
yellow fever and Zika viruses. Dengue is widespread throughout the tropics, with local variations
in risk influenced by rainfall, temperature, relative humidity and unplanned rapid urbanization.
PORTAL OF ENTRY
Dengue is transmitted to people by the bite of an Aedes mosquito that is infected with a dengue
virus. The mosquito becomes infected with dengue virus when it bites a person who has dengue
or DHF and after about a week can transmit the virus while biting a healthy person.
MODE OF TRANSMISSION
Dengue fever is transmitted to humans through the bites of infective female Aedes mosquitoes.
When a patient suffering from dengue fever is bitten by a vector mosquito, the mosquito is
infected and it may spread the disease by biting other people. The disease cannot be spread
directly from human to human.
MOSQUITO-TO-HUMAN TRANSMISSION
The virus is transmitted to humans through the bites of infected female mosquitoes, primarily the
Aedes aegypti mosquito. Other species within the Aedes genus can also act as vectors, but their
contribution is secondary to Aedes aegypti.
After feeding on an DENV-infected person, the virus replicates in the mosquito midgut, before it
disseminates to secondary tissues, including the salivary glands. The time it takes from ingesting
the virus to actual transmission to a new host is termed the extrinsic incubation period (EIP). The
EIP takes about 8-12 days when the ambient temperature is between 25-28°C. Variations in the
extrinsic incubation period are not only influenced by ambient temperature; a number of factors
such as the magnitude of daily temperature fluctuations virus genotype, and initial viral
concentration can also alter the time it takes for a mosquito to transmit virus. Once infectious, the
mosquito is capable of transmitting virus for the rest of its life.
HUMAN-TO-MOSQUITO TRANSMISSION
Mosquitoes can become infected from people who are viremic with DENV. This can be someone
who has a symptomatic dengue infection, someone who is yet to have a symptomatic infection
(they are pre-symptomatic), but also people who show no signs of illness as well (they are
asymptomatic). Human-to-mosquito transmission can occur up to 2 days before someone shows
symptoms of the illness, up to 2 days after the fever has resolved.
Risk of mosquito infection is positively associated with high viremia and high fever in the
patient; conversely, high levels of DENV-specific antibodies are associated with a decreased risk
of mosquito infection (Nguyen et al 2013 PNAS). Most people are viremic for about 4-5 days,
but viremia can last as long as 12 days.
PREDISPOSING CAUSES
You live or travel in tropical areas. Being in tropical and subtropical areas increases your risk of
exposure to the virus that causes dengue fever. Especially high-risk areas include Southeast Asia,
the western Pacific islands, Latin America and Africa.
You have had dengue fever in the past. Previous infection with a dengue fever virus increases
your risk of severe symptoms if you get dengue fever again.
PATHOPHYSIOLOGY
The transmission cycle of dengue virus by the mosquito Aedes aegypti begins with a dengue
infected person. This person will have virus circulating in the blood a viremia that lasts for about
five days.
During the viremic period, an uninfected female Aedes aegypti mosquito bites the person and
ingests blood that contains dengue virus.
Then, within the mosquito, the virus replicates during an extrinsic incubation period of eight to
twelve days.
The mosquito then bites a susceptible person and transmits the virus.
The virus then replicates in the second person and produces symptoms. The symptoms begin to
appear an average of four to seven days after the mosquito bite. This is the intrinsic incubation
period, within humans. It can range from 3-14 days.
While viral replication takes place in target dendritic cells. Infection of target cells. Primarily
those of the reticuloendothelial system, such as dendritic cells, hepatocytes, and endothelial cells.
This result in the production of immune mediators that severe to shape the quantity, type, and
duration of cellular and humoral immune response to both the initial and subsequent virus
infections.
SYMPTOMS/MANIFESTATION
Many people experience no signs or symptoms of a dengue infection. When symptoms do occur,
they may be mistaken for other illnesses such as the flu and usually begin four to 10 days after
you are bitten by an infected mosquito.
Dengue fever causes a high fever — 104 F (40 C) — and any of the following signs and
symptoms:
 Headache
 Muscle, bone or joint pain
 Nausea
 Vomiting
 Pain behind the eyes
 Swollen glands
 Rash
Most people recover within a week or so. In some cases, symptoms worsen and can become life-
threatening. This is called severe dengue, dengue hemorrhagic fever or dengue shock syndrome.
Severe dengue happens when your blood vessels become damaged and leaky. And the number of
clot-forming cells (platelets) in your bloodstream drops. This can lead to shock, internal
bleeding, organ failure and even death.
Warning signs of severe dengue fever — which is a life-threatening emergency — can develop
quickly. The warning signs usually begin the first day or two after your fever goes away, and
may include:
  Severe stomach pain
 Persistent vomiting
 Bleeding from your gums or nose
 Blood in your urine, stools or vomit
 Bleeding under the skin, which might look like bruising
 Difficult or rapid breathing
 Fatigue
 Irritability or restlessness
SYSTEMIC INVASION
Neuropathogenesis is likely associated with direct invasion of the CNS by the virus, autoimmune
reactions, and metabolic alterations. The dengue virus is considered to be non-neurotropic.
However, recent reports associating dengue with neurological complications have changed this
view. This virus was described in cerebro-spinal fluid (CSF) more than two decades ago (Lum et
al., 1996; Thisyakorn et al., 1999). Chaturvedi et al. demonstrated that the bloodbrain barrier
(BBB) is damaged during infection by the dengue virus in experimental animal experiments,
indicating viral invasion. Meanwhile, immunoreactive neurons, astrocytes, microglia, and
endothelial cells were found in cerebral tissues of a fatal case with hemorrhagic dengue fever in
1998 (Ramos et al., 1998). Domingues et al. proposed that dengue virus can actively enter the
CNS (Domingues et al., 2008). Data obtained in Vietnam also support direct invasion by dengue
virus as pathologically important. Autoimmune reactions and metabolic alterations have been
demonstrated in most neurological complications of dengue fever cases.
Most neurological manifestations of dengue virus infection have been reported in case reports or
short series, and its spectrum is diverse; thus, the classification of neurological manifestations is
difficult to apply in practice. The new (2009) World Health Organization (WHO) classification
groups dengue infection into three categories, including dengue with no warning signs, disease
with warning signs, and severe dengue (WHO, 2009). Different from the traditional system, the
revised classification includes CNS involvement as severe dengue. However, neurological
complications are not well described and very little is known about these manifestations.
Until 2012, neurological complications of dengue virus infection were classified into three
categories based on pathogenesis as proposed by Murthy, Marzia and colleages: (1) metabolic
disturbance, e.g., encephalopathy; (2) viral invasion, including encephalitis, meningitis, myositis,
and myelitis; (3) autoimmune reactions, including acute disseminated encephalomyelitis,
neuromyelitis optica, optic neuritis, myelitis, encephalopathy, and Guillain-Barré syndrome
(Murthy, 2010; Puccioni-Sohler et al., 2012). In recent years, Solbrig et al. reported neurological
involvements of the CNS and eyes, associated peripheral nervous system (PNS) syndromes, and
convalescent or post-dengue immune-mediated syndromes.
COMPLICATIONS
Severe dengue fever can cause internal bleeding and organ damage. Blood pressure can drop to
dangerous levels, causing shock. In some cases, severe dengue fever can lead to death.
Women who get dengue fever during pregnancy may be able to spread the virus to the baby
during childbirth. Additionally, babies of women who get dengue fever during pregnancy have a
higher risk of pre-term birth, low birth weight or fetal distress.
DIAGNOSIS/DIAGNOSTIC EVALUATION
 Diagnosing dengue fever can be difficult because its signs and symptoms can be easily
confused with those of other diseases — such as chikungunya, Zika virus, malaria and
typhoid fever.
 Your doctor will likely ask about your medical and travel history. Be sure to describe
international trips in detail, including the countries you visited and the dates, as well as
any contact you may have had with mosquitoes.
 Your doctor may also draw a sample of blood to be tested in a lab for evidence of
infection with one of the dengue viruses.
PROGNOSIS
The prognosis of adults that have contracted Dengue fever is usually good. A past infection does
offer limited protection against the particular Dengue virus for a short time. This means that no
protection exists against the remaining three virus types. In case of reinfection the course of
disease is often more severe. The complications of Dengue fever like DHF or DSS cause
problems that may increase the mortality among infants up to 30%.
MODALITY OF TREATMENT (SYMPTOMATIC/ASYMPTOMATIC)
Mosquitoes can become infected from people who are viremic with DENV. This can be someone
who has a symptomatic dengue infection, someone who is yet to have a symptomatic infection
(they are pre-symptomatic), but also people who show no signs of illness as well (they are
asymptomatic). There is no specific treatment for dengue fever. Fever reducers and pain killers
can be taken to control the symptoms of muscle aches and pains, and fever.
 The best options to treat these symptoms are acetaminophen or paracetamol.
 NSAIDs (non-steroidal anti-inflammatory drugs), such as ibuprofen and aspirin should be
avoided. These anti-inflammatory drugs act by thinning the blood, and in a disease with
risk of hemorrhage, blood thinners may exacerbate the prognosis.
For severe dengue, medical care by physicians and nurses experienced with the effects and
progression of the disease can save lives – decreasing mortality rates from more than 20% to less
than 1%. Maintenance of the patient's body fluid volume is critical to severe dengue care.
Patients with dengue should seek medical advice upon the appearance of warning signs.
PREVENTION
In areas of the world where dengue fever is common, one dengue fever vaccine (Dengvaxia) is
approved for people ages 9 to 45 who have already had dengue fever at least once. The vaccine
is given in three doses over the course of 12 months. The vaccine is approved only for people
who have a documented history of dengue fever or who have had a blood test that shows
previous infection with one of the dengue viruses — called seropositivity. In people who have
not had dengue fever in the past (seronegative), receiving the vaccine appears to increase the risk
of severe dengue fever and hospitalization due to dengue fever in the future.
Dengvaxia is not available for travelers or for people who live in the continental United States.
But in 2019, the U.S. Food and Drug Administration approved the vaccine for people ages 9 to
16 who have had dengue fever in the past and who live in the U.S. territories of American
Samoa, Guam, Puerto Rico and the U.S. Virgin Islands — where dengue fever is common.
Prevent mosquito bites
The World Health Organization stresses that the vaccine is not an effective tool on its own to
reduce dengue fever in areas where the illness is common. Preventing mosquito bites and
controlling the mosquito population are still the main methods for preventing the spread of
dengue fever.
If you live in or travel to an area where dengue fever is common, these tips may help reduce your
risk of mosquito bites:
 Stay in air-conditioned or well-screened housing. The mosquitoes that carry the dengue
viruses are most active from dawn to dusk, but they can also bite at night.
 Wear protective clothing. When you go into mosquito-infested areas, wear a long-sleeved
shirt, long pants, socks and shoes.
 Use mosquito repellent. Permethrin can be applied to your clothing, shoes, camping gear
and bed netting. You can also buy clothing made with permethrin already in it. For your
skin, use a repellent containing at least a 10% concentration of DEET.
 Reduce mosquito habitat. The mosquitoes that carry the dengue virus typically live in and
around houses, breeding in standing water that can collect in such things as used
automobile tires. You can help lower mosquito populations by eliminating habitats where
they lay their eggs. At least once a week, empty and clean containers that hold standing
water, such as planting containers, animal dishes and flower vases. Keep standing water
containers covered between cleanings.

NURSINGMANAGEMENT
Nursing Assessment
Assessment of a patient with DHF should include:

 Evaluation of the patient’s heart rate, temperature, and blood pressure.

 Evaluation of capillary refill, skin color and pulse pressure.
 Assessment of evidence of bleeding in the skin and other sites.
 Assessment of increased capillary permeability.
 Measurement and assessment of the urine output.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for a patient with DHF are:
 Risk for bleeding related to possible impaired liver function.
 Deficient fluid volume related to vascular leakage.
 Pain related to abdominal pain and severe headaches.
 Risk for ineffective tissue perfusion related to failure of the circulatory system.
 Risk for shock related to dysfunction in the circulatory system.
Nursing Care Planning and Goals
The goals in a patient with DHF are:
 Be free of signs of bleeding.
 Display laboratory results within normal range for individuals.
 Maintain fluid volume at a functional level.
 Report pain is relieved or controlled.
 Follow prescribed pharmacologic regimen.
 Demonstrate adequate tissue perfusion.
 Display hemodynamic stability.
 Be afebrile and free from other signs of infection.
Nursing Interventions
Nursing interventions appropriate for a patient with DHF include:
 Blood pressure monitoring. Measure blood pressure as indicated.
 Monitoring pain. Note client report of pain in specific areas, whether pain is
increasing, diffused, or localized.
 Vascular access. Maintain patency of vascular access for fluid administration or
blood replacement as indicated.
 Medication regimen. There must be a periodic review of the medication regimen
of the client to identify medications that might exacerbate bleeding problems.
 Fluid replacement. Establish 24-hour fluid replacement needs.
 Managing nose bleeds. Elevate position of the patient and apply ice bag to the
bridge of the nose and to the forehead.
 Trendelenburg position. Place the patient in Trendelenburg position to restore
blood volume to the head.
Evaluation
A successful nursing care plan has achieved the following:
 Absence of signs of bleeding.
 Displayed laboratory results within normal range for individuals.
 Maintained fluid volume at a functional level.
 Reported pain is relieved or controlled.
 Followed prescribed pharmacologic regimen.
 Demonstrated adequate tissue perfusion.
 Displayed hemodynamic stability.
 Afebrile and free from other signs of infection.
HOME CARE
With Fever:
Bed rest:
 Let your sick child or family member rest as much as possible.
Control high fever:
 Do not give ibuprofen (Motrin, Advil), aspirin, or aspir in- containing drugs.
 Sponge the patient’s skin with cool water if fever remains high.
 Give acetaminophen or paracetamol (Tylenol) every 6 hours if needed for high fever
(maximum 4 doses per day).
Prevent dehydration
 Give plenty of fluids, and watch for signs of dehydration, which occurs when a person
loses too much body fluid from fever, vomiting, or if he or she does not drink enough
fluids.
Prevent spread of dengue inside your house
Mosquitoes that bite the affected family member can go on to bite and infect others.
 Allow the sick child or family member to rest and sleep under a bed net or use insect
repellant while feverish.
 Kill all mosquitoes in the house and empty containers that carry water on patios.
 Place screens on windows and doors to prevent mosquitoes from entering the house.
References:

1. https://www.mayoclinic.org/diseases-conditions/dengue-fever/symptoms-causes/syc-
20353078
2. https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue
3. https://saltidin.com/uploads/tx_lxsmatrix/denguefever.pdf
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5660970/
5. https://nurseslabs.com/dengue-hemorrhagic-fever/