Dengue

17/8/2020
Diagnosis of Dengue
• Primary DENV Infection vs Secondary DENV infection
• Most sensitive is NS1 on Day 1
• Day 2-3 can be false negative for NS1
• Secondary dengue clears NS1 very fast
• If NS1 positive - definitely not other viruses like Zika or Chikungunya

• IgM - peaks at 7 days of illness

• Ask patient - a few weeks ago, did you have dengue?
• Lasts up to 90 days

• IgG - lasts very long

• 
• IgG and IgM - cross reacts with other viruses like zika, JE
Male <=60 – 46%
Male >60 – 42%
Female – 40%
Step 1: History
• Date and time of onset of fever or illness
• Symptoms and severity
• Golden questions
• How much oral fluid - quality and quantity
• Urine output - frequency, volume, time of most recent voiding
• Activities that you can do during febrile illness
• Other fluid losses - diarrhoea, vomiting
• Presence of warning signs
• Warning signs
• Family or neighbour with dengue, travel
• Medication - OTC, traditional
• Risk factors - infancy, elderly, pregnancy, obesity, diabetes mellitus, hypertension,
chronic organ failure, etc
• A lot of elderly miss diagnosed for MI, from voltaren, no fever
• Obesity - baseline already has raised inflammatory markers
• Jungle trekking or swimming in waterfall - consider leptospirosis, typhus, malaria
Step 2: Clinical examination

• General CCTVR
• Mental state Colour
• Hydration Capillary refill
• Haemodynamic state Temperature
Pulse volume
• Warning signs Pulse rate
• Other important signs
• Rash
• Tachypnoea, acidotic breathing - shock
• Tourniquet test - repeat if negative or if there is no bleeding manifestation
Haemodynamic assessment - clinical parameters

• Organ perfusion (brain) - Conscious level

• Peripheral perfusion
• CRT
• Extremities
• Peripheral pulse volume
• Cardiac output
• HR
• PP
• BP
• Respiratory compensation for tissue hypoxia - RR
• Organ perfusion (kidney) - Urine output
Compensated shock

• SBP maintained
• Rise diastolic pressure (vasoconstriction)
• Narrow pulse pressure - weak pulse
• Tachycardia
• Reduced peripheral perfusion - cool peripheries, increased CRT
• Quiet tachypnoea (no creps or rhonchi) - septic shock, dengue, DKA,
renal failure - any acidotic condition
• LUCID conscious level - decreased urine output
Hypotensive shock
• Increasing tachycardia
• Feeble or absent peripheral pulse
• SBP and DBP disappear suddenly
• Reduced peripheral perfusion
• Kussmaul breathing
• Decreased level of conscious
• Oliguria or anuria
• Key change
• Changes in mental state
• Restless, confused, extremely lethargic
• Seizure
• Agitation alternating with drowsiness
• Infants and children
• Failure to recognise parents, focus or make eye contact
• Listen to parents - something is wrong with my child
• Yet some children and young adults continue to have clear mental state
• Imminent cardiorespiratory collapse
Hemodynamic assessment: Monitoring urine output

• Early shock state - kidneys conserve fluids by reducing urine volue

• In severe shock - no urine is produced
• Outpatient - pass urine about 4-6 times a day
Factors contribute to death

• - Comorbid conditions
• Obesity
• DM
• Extremes of ages
• Heart diseases
• Renal failure
• Pregnant
Dengue in Pregnancy
Physiology of pregnancy
• cardiovascular - tachycardia, lower BP
• lower HCT in 3rd trimester
• Confuse with other pregnancy complications
• Thrombocytopenia
• HELLP syndrome - thrombocytopenia, raised liver enzymes
Management:

• Advice admission
• Pregnancy had haemodilution that reduces haemoglobin and PCV
thus interfering with laboratory assessment for plasma leakage
Effects on Mother

• Maternal death
• Dengue shock with multiorgan failure
• Odds Ratio 3.38 to develop severe dengue
• Severe and prolonged bleeding
Effect of Dengue on Pregnancy

• Preterm birth (3-17%)

• Fever (high grade)
•      Stimulate uterine contractions
•      Heat shcok protein causing damage to placenta and fetus
• Immune response to dengue
 
• low birth weight
• Foetal death
• NTD
Management of dengue in pregnancy

• MDT
• Supportive care
• No NSAIDS
• low threshold for transmission
• Avoid surgery
Mode and Timing of Delivery

• Dengue infection not indication for elective delivery

• SVD preferred MOD
 
• Transfuse platelets during or at delivery (6 hours) 
 
• Advisable to delay breast feeding during acute viraemia stage
Case Scenario