disease affecting the tropical and subtropical regions of the world.
It affects up to 100 million people each year,
with 500.000 cases of DHF and DSS and around 30.000 deaths, mostly among children. Dengue virus is a ss-RNA virus with a genome of 10.7 kb in length, enveloped, spherical 50 nm in size. There are four antigenically distinct DV serotypes, DENV-1, DENV-2, DENV-3 and DENV-4 and each serotype contains four to five genotypes on the basis of their genomic sequences. Infection with one serotype leads to lifelong protection against homotypic reinfection, do not confer cross immune protection to each other. Studies have shown that heterotypic secondary infection is associated with higher risk of contracting DHF and DSS possibly through : Antibody-dependent enhancement Original antigenic sin Cytokine storm, or Autoimmune response Viremic individuals are the main source of infectious virus. Virus is transmitted following mosquito bites of these viremic individuals. Transmision DENV is transmitted through a human- mosquito cycle with the aid of Aedes aegypti and Ae. Albopictus mosquito vectors. The liver is one of the major target organs of DV and hepatocellular damage can occur. Hepatic dysfunction is in dengue- infected individuals, including painful hepatomegaly and increased levels of the hepatic enzymes, AST and ALT. The elevation of liver enzymes, predominantly AST is significantly greater in DHF and DSS than DF. The increase in transaminase reaching maximum values around the 9th day after onset of fever. Dengue fever is characterized by : Fever Myalgia Rash Leucopenia Thrombocytopenia Suspected dengue cases were defined as Patients with reported or documented fever of > 38 C of less than7 days duration. Two or more symptoms or signs (headache, rash, eye pain, myalgia, arthralgia, hypo- tension, hemorrhage, hemoconcentration (elevated hematocrit >20% for age and gender, thrombocytopenia < 150.000/uL Clinical Feature Clinical features are often described according to three phases : Febrile phase Critical phase Convalescent phase Dengue Fever Dengue fever is characterized by sudden onset of high grade fever with non specific symptoms such as headache, malaise, anorexia, nausea, vomitting, weakness, rash and body aches, flushing of the face. DHF DHF is caused by increased vascular permeability cause severe plasma leakage and may progress to hypovolemic shock, marked thrombocytopenia, and a bleeding diathesis. Mortality rate for untreated patients varying between 10% and 20% but can reach as high as 40% with involvement of shock. cont.. DHF is characterized by the presence of : Hemorrhagia Thrombocytopenia < 100.000/uL Clinical evidence of plasma leak resulting from increased vascular permeability. Manifestasi Hemoragik Capillary fragility Petechiae, ecchymoses or purpura Bleeding from mucosa, gastrointestinal tract or other sites Haematemesis or melena Severe clinical disease manifestations such as : Fluid leakage Bleeding Shock Are seen during the critical phase which begins around day 4-7 of the illness and usually lasts 48-72 hours. DENGUE SHOCK SYNDROME Disertai kegagalan sirkulasi, nadi cepat dan lemah Tekanan darah turun Kulit dingin, lembab Pasien gelisah WHO criteria DHF grade I is manifested by fever accompanied by nonspecific constitutional symptoms, with a positive tourniquet test result. DHF grade II is the appearance of spontaneous bleeding in addition to constitutional symptoms. cont.. DHF grade III is circulatory failure with signs of rapid and weak pulse, narrowing of pulse pressure or hypotension, and the presence of cold clammy skin. DHF grade IV is profound shock with undetectable blood pressure and pulse. Grade III and IV are grouped as DSS The 1997 WHO classification Acute febrile illness as dengue fever based on headache, retro- orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, and leukopenia. The 2009 WHO classification Uses two or more clinical manifestations for probable dengue classification : Nausea/vomiting, rash, aches and pains, tourniquet test positive, leucopenia and any warning signs. For this analysis, leukopenia was defined as below 4500/uL, and arthralgia/myalgia was include under aches and pains. To have rapid and sensitive laboratory assay for early detection of the disease. There are two main methods for diagnosing dengue infection : Virus detection includes viral isolation, PCR, detection of NS1 antigen. Antibody detection includes haemagglutination inhibition (HAI) tests and ELISA for detection of dengue IgM and IgG antibodies. The major of diagnostic methods currently available are : Viral culture by cell culture (in C6/36 mosquito cell line) and subsequent detection by immunofluorescence, though the gold standard. It is costly and time consuming as more than 7 days. Viral RNA detection by RT-PCR, the requirement of a highly trained staff, need of a sophisticated equipment as well as cost factor. Serological tests such as IgM-ELISA, has low sensitivity in the first four days of illness. NS1 (non structural protein 1) is a highly conserved glycoprotein that is essential for the viability of DV and is produced both membrane-associated and secretory forms by the virus. The NS1 is a present at high concen- tration in sera of dengue infected patients during the early phase of disease, and is found from day 1 and up to day 9 after onset of fever in sample of primary or secondary dengue-infected patients. The IgM become detectable on day 3 to 5 of illness in case of primary dengue infection and persist for 2 to 3 months, whereas IgG appear by the fourteenth day and persist for life. Secondary infection shows that IgG rises within 1 to 2 days after onset of symptoms, simultaneously with IgM antibodies. Laboratory-positive dengue cases are confirmed by ELISA of specific dengue IgM, fourfold increase of dengue- specific IgG titers in convalescent serum. Laboratory Finding Positive tourniquet test was define if there are more than 20 petechiae in a define 2,5 cm area. Leucopenia < 4000/ cmm Thrombocytopenia < 150.000/cmm Prolong aPTT > 38 sec Elevated serum AST or ALT > 39 U/L Low C-reactive protein < 20 mg/L Diagnosis Banding Demam tifoid Campak Influenzae Leptospirosis Chikungunya Currently, there are : No commercially available vaccines for prevention of dengue. No antiviral drugs for dengue but severe dengue may be successfully treated with aggressive intravenous rehydration. Pemberian komponen darah Trombosit : bila ada perdarahan nyata dan berat, diberikan sampai perdarahan berhenti Kriopresipitat : bila fibrinogen di bawah 100 mg/dl