Dengue Fever

An Overview

HISTORY
Virus isolation 1943 Hotta & Kimura
1944 Sabin & Schhlessinger
1st epidemic 1953/54 Philippines
2nd epidemic- 1956 Philippines
3rd eidemic 1958 BKK Thailand
1960-70 , epidemics 3-5 yrly in SEA
1970- South pacific islands
1980- Caribbean Basin
1980-1990 Americas
NOW in OVER 100 COUNTRIES!!!

GLOBAL SITUATION
An estimated 2.5 billion people (40% of
worlds population) live in over 100
endemic countries and areas where
dengue viruses can be transmitted
Up to 50 million infections occur
annually
DHF 500 000
Deaths 22,000

Dengue Fever Virus

Aedes Aegypti

Aedes Albopictus

DISTRIBUTION OF DF/
DHF

Before 1960
After 1960

Dengue Viral Infection

(10,000)
Symptomatic
(1000)

Asymptomatic
(majority) (9000)

Viral Syndrome
(500)

DF
(400)

DHF
(100)

Unusual
dengueexpanded
dengue
syndrome(<
<1%)

Plasma leakage

DHF
(98%)
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DSS
(1-2%)
8

WHEN TO SUSPECT DENGUE

FEVER

CRITERIA FOR ADMISSION

MANAGEMENT OF PATIENTS
NOT REQUIRING ADMISSION

DF or DHF ?
DF vs DHF
Important to differentiate
Two different clinical conditions from the
beginning of the illness; Though they
look very similar on the first 2 days
However badly managed DF will
never become DHF (DF does not
progress to DHF)
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12

Natural Course of DHF

Febrile phase:
days

High fever for 2 7

Critical phase:
Plasma leakage
Lasts 24- 48 h
Usually on D5/ D6, but
earliest on D3

Convalescent phase:
09/28/15

2-5 days
13

Natural Course of DF
Febrile phase:
days

High fever for 2 7

No critical phase in DF!!!

Convalescent phase:

09/28/15

2-5 days

14

HOW TO CONFIRM
PLASMA LEAK
Look for evidence of LEAKING

Pleural effusions
Ascites or
Gall bladder wall thickness

Oedema, facial puffiness, leg/arm

swelling are not suggestive of leaking
but only suggest fluid overload

Dengue Haemorrhagic
Fever(DHF)
Key feature is PLASMA LEAK
Haemorrhagic manifestations
+ve Torniquet Test
(tender hepatomegaly- more in DHF)
Plt < 100,000 in ALL
Plasma leakage:
Rising Hct 20% or more rise in HCT
Se Cholesterol <100mg/dl (or drop of
20mg/dl)
Se Albumin <3.5 g/dl
(or drop of
0.5g/dl)
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16

GRADES OF DHF
Grade 1 DHF
Grade 2 DHF

Vitally Stable

Grade 3 DHF

Pulse pressure
<20mmHg

Grade 4 DHF

BP less ,
Pulseless

DETECTION OF CRITICAL
PHASE

Drowsy
Rapid pulse
Narrow pulse pressure (20 mmHg)
Hypotension
Rising Haematocrit
Low Albumin level
Low Cholesterol level

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18

HAEMATOCRIT
Rise of Hct by 20% over the baseline
indicates leakage
Eg: if baseline PCV 35% 42% = 20% rise

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19

MONITORING OF DHF

MONITORING SHEETS USED AT DENGUE

MEDICAL WARDS
DHQ HOSPITAL RAWALPINDI

MONITORING SHEETS USED AT DENGUE MEDICAL

WARDS
DHQ HOSPITAL RAWALPINDI

INVESTIGATION SHEETS USED AT DHQ

TEACHING HOSPITAL

LAKKUMAR FERNANO

FLUID MANAGEMENT IN
DHF

CALCULATION OF FLUIDS

EXAMPLE : 22 Kg PERSON

RATE OF ADMINISTRATION
OF FLUID

MANAGEMENT
OF
DHF PATIENT
IN
SHOCK

INDICATIONS FOR USE OF

COLLOIDS

IV FLUIDS
Normal Saline/ Hartman
Hemaccel
Dextran 40

(Dextran 40 in Saline)
osmolarity of 310 mOsm/L.

High oncotic pressure volume expander

Molecular wt (average 40,000) when given as a bolus all molecules
tend to stay together

6% Hetastarch (voluvan)
osmolality -308mosm/ L
Mol wt 100,000 leaking less
volume expansion less than Dextran 40

About 60% of patients with dengue shock could

be managed only with crystalloids

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32

CAUES OF DEATH IN
DENGUE FEVER

PROLONGED SHOCK
10 hours untreated - Death!!!
> 4 hours untreated
Liver failure- survival 50%
Liver + Renal failure survival 10%
3 organs failure (+respiratory
failure) survival is less than 0.1 %
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34

Complicated DHF
When a pt is deteriorating with no
response to fluid therapy.
A:
B:
C:
S:

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Acidosis
Bleeding
Calcium
Sugar

35

ACIDOSIS
Acidosis is common in profound
shock
Correct acidosis if pH is <7.35 and if
HCO3- level <15 mmol/l
One may use NaHCO3 1ml/kgs slow
bolus (max 50 ml )
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HYPOCALCAEMIA
Every patient with complicated DHF has
hypocalcaemia.
Dengue patients who develop
convulsions are likely to have
hypocalcaemia
Detection of hypocalcaemia:
Measure serum Ca2+ level
Corrected QT interval in ECG
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37

WHEN TO GIVE CALCIUM

If the patient is not showing expected
improvement to IV fluids think of
hypocalcaemia
Give empirical calcium to such pts
Dose : 10ml of 10% Ca Gluconate slow bolus
diluted in N/S over 10-15 min
Can even give every 6Hrs if pt is not
improving
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INDICATIONS FOR
BLOOD TRANSFUSION IN
DHF

Packed Red Cells vs

Whole Blood

HOW MUCH BLOOD TO

GIVE
During critical phase PCV is falsely high
Target PCV is 42 %
5ml/kg PRC or 10ml/Kg WB will raise 5%
of PCV

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41

PLACE OF DOPAMINE AND

DOBUTAMINE
Very limited in DHF
May do harm than good by giving a
false impression about BP
When using1st make sure that there
is enough intravascular volume
shown by increased CVP

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42

 Thailand only in <0.4% of pts with DHF

No prophylaxis platelet transfusion
Initially the platelet drop is due to BM
suppression
But later in critical phase cause of
thrombocytopenia is increased platelet
consumption (the BM is hypercellular at this
stage)

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43

 If platelet count is less than 20,000 and

patient has significant bleed
If platelet count is less than 10,000
If a patient has platelet count less than
20,000 with no significant bleed , Whole
blood should be given

RECOMBINANT FACTOR
VII
No use in cases with prolonged shock
and multiple organs failure
Consider in cases with bleeding where
the cause is not prolonged shock BUT
other reason: peptic ulcer, trauma etc

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45

PREVENTION
Vector Control
Eliminate breeding places ( stagnant
water )
Insecticide sprays
Mosquito netting
Mosquito repellants

Research on Dengue
Fever
Vaccination
Anti virals
Early diagnosis of DF/DHF

DENGUE FEVER
DHQ HOSPITAL
RAWALPINDI
STATISTICS

TOTAL PATIENTS
th
TILL 19 NOVEMBER
2011
TOTAL PATIENTS SEEN AT OPD
=
18867
TOTAL SUSPECTS
= 766
RESULT POSITIVE FROM NIH = 301
RESULT NEGATIVE FROM NIH = 458
RESULT AWAITED
= 07

DENGUE SUSPECTS (766)

DENGUE FEVER
VS
DENGUE HEMORRHAGIC FEVER

OPD TRENDS 9TH SEP to

17TH OCT

OPD TRENDS SINCE 18TH

OCTOBER

NO MORTALITY
FROM

DENGUE FEVER
IN

2011
IN

DHQ TEACHING
HOSPITAL
RAWALPINDI

THANKS