DENGUE SPECTRUM AND

MANAGEMENT

Presented by – Lt Mridul M
Lt Leen Jose
Moderated by Lt Col Shyam K Mishra
Dengue fever

• Agent: flavivirus group (group B arborvirus)

• Four serotypes Denv 1 to 4

• Incubation period: 5-6 days

• Vector :Aedes egyptii, A albopictus less commonly

• Domestic day biting mosquito

• Prefers to feed on humans

• Breeds in stored water

Clinical Spectrum

1.Dengue fever
2.Dengue hemorrhagic fever (DHF )
3.Dengue shock syndrome
 Dengue fever
• Clinical Features WHO case definition for DF:

1.Prodrome: 02 days -malaise , headache

2.Acute onset: fever, backache, arthralgia, headache, Acute Febrile illness with 2 or > of the following:

generalised bodyache (bone breaking fever), retro-orbital • Headache

pain, lacrimation, scleral congestion. • Retro-orbital pain

3.Fever: continous kor ‘saddle back type’ usually lasts 7-8 • Myalgia
days
• Arthralgia
4.Rash: transient maular rash on first 1-2 days, scarlet
• Rash
morbilliform rash on days 3-5 on trunk spreading
• Hemorrhagic manifestations
centrifugally, spares palms and soles
• Leukopenia
5.Convalescence: slow
Dengue hemorrhagic fever

WHO Criteria for diagnosis

• There is fever along with presence of Often occurs with defervescence of fever, swelling

Petechiae All of the following must be present:

• Fever
• Hemorrhagic tendencies:
Ecchymoses • +ve tourniquet test
• Petichiae, ecchymosis or purpura
epistaxis • Bleeding from other sites

GI bleed • Thrombocytopenia (<=100,000/cu mm)

• Evidence of plasma leak

Bleeding diathesis • Rise in hematocrit > 20% above average
• Drop in Hct
• Pleural effusion/ascites/hypoproteinemia
Dengue Shock syndrome
• Occur commonly in children
• Occurs after three days of fever
• There is fever +
• Features of DHF +
• Severe hypotension and circulatory failure
with features of capillary leak syndrome
• Adults do not have classical DSS but have
• GI hemorrhage
• Haemostatic abnormalities
• Increased liver enzymes
WHO Criteria for diagnosis
All of the above + evidence of circulatory
failure:
• Rapid, weak pulse
• Narrow pulse pressure < =20 mm hg
• Cold clammy skin
• Restlessness
Often present with abdominal pain;
mistaken for acute abdominal emergency
 Lab Diagnosis
• Serological tests : 1)Antibody Detection

2)Virus isolation

3)Antigen isolation

4)Genome detection
Antibody Detection
• IgM-first antibody to appear
50% of pt-Day 3 to 5

99% of pt-Day 10

IgM peaks at 2 weeks

Declines to undetectable levels over 2-3 months

• IgG increasing slowly after 2nd week

Detectable after several months

Antigen Detection

• Sample-Serum

• NS1 & E/M Antigens-ELISA and Dot Blot Assay

• Upto 9 days after onset of illness in both primary and secondary infections

• NS1 antigen ELISA- sensitivity86% and Specificity 100%

• Rapid Tests
Virus Isolation
• Sample Used :

serum,Plasma,Anticoagulated Whole Blood,CSF

Tissue from dead patients

Mosquito

Limitation: Will be available only during Viremia (early 5day)

Slow results –takes days

Expensive

Strict Storage & Transporation needs

Genome Detection
• RT-PCR

• Real Time RT-PCR

• NASBA-Nucleic Acid Sequence Based Amplification

 Warning signs
Bleeding: epistaxis, scanty haemoptysis, hematemesis, gum bleeding, black coloured stools,
excessive menstrual bleeding, dark-coloured urine or haematuria.
Lethargy and/or restlessness
Sudden behavioural changes
Convulsions.
Difficulty in breathing or palpitation or breathlessness.
Persistent vomiting >3 times a day.
Severe abdominal pain
Postural hypotension - dizziness.
Pale, cold clammy extremities.

Not able to drink and no urine output for 4-6 h or urine output less than 0.5 ml/kg/h.
 Additional danger signs for clinicians

Enlarged and/or tender liver

Rising haematocrit together with rapid fall in platelet count.
Metabolic acidosis.
Derangement of liver/ kidney function tests.
 Pleural effusion/ ascites/ gall bladder oedema clinically or by imaging.

KEY POINTS:
 Warning signs between days 3 and 7 of illness.
Increased capillary permeability causing plasma leakage is the main
pathophysiology.
 A rising haematocrits the earliest sign of plasma leakage
 A patient’s history to be asked
1. Date of onset of fever (date is
preferable to the number of days of 6. Shortness of breath
fever)
2. A history of dengue fever among
households and neighbor, living in or 7. Bleeding from any orifice, any
recent travel to a dengue endemic bleeding spot on skin/mucosa
region

3. History of chills, rash and facial 8. Reduced urine output, cold

flush peripheries

4. Retro-orbital headache, 9. Profuse sweating, postural

arthralgia, malaise dizziness, blurring of vision5.

5. Persistent vomiting/diarrhea, 10. Yellowish discoloration of skin and

pain abdomen mucosa, altered sensorium
 Ask 3 golden questions

Assess hydration status 1. Oral fluid intake-quantity and types of fluids

from history 2. Urine output-quantify in terms of frequency and
estimated volume and time of most recent voiding
3. Types of activities performed during this illness (e.g., can the patient go to
school, work, market, etc.)

These questions, though not • Other fluid losses-such as vomiting

specific to dengue, give a good indication of or diarrhea
patient’s hydration status and how well the •Presence of warning signs, particularly after the first
patient copes with his illness. 72 hours of fever

• Medications (including non-

prescription or traditional medicine) in use and the
Other Relevant History time they were last taken
• Risk factors
 Peripheral Perfusion: Hold the
patient’s hand and assess peripheral
Temperature perfusion by the Color, Capillary
refill time, Temperature of the
extremities, Pulse Volume and
Pulse Rate (CCTVR)

Blood pressure Tachypnea/Acidotic

breathing/Pleural effusion

Mental state Abdominal

tenderness/Hepatomegaly/ Ascites

Maculopapular or macular Tourniquet test (repeat if previously

confluent Rash; Conjunctiva negative)
Be sent home(Group A)
Patients able to tolerate adequate
volumes of oral fluids
Do not have any warning signs
ORS ,fruit Juice and other fluids
containing electrolytes
Paracetamol
Advised about warning signs
Be referred for in-hospital
management(Group B)
Patients who need close
observation
Patients with warning signs
Patients with complications like
pregnancy,infants,old age,obesity
IV fluids if presence of warning
signs
Oral fluids if tolerated
Paracetamol
Monitoring of TPR,HCT,CBC&urine
output
Require emergency
treatment and urgent
referral(Group C)
Patients who require emergency
treatment
Patients who are having:
- severe plasma leakage
- severe hemorrhage
- severe organ impairment
IV
fluids,antiemetics,antipyretics,Iono
tropes,SDP transfusion
Monitoring:
-Organ function tests
-Peripheral perfusion monitoring
-Urine output
-ABG
-Blood glucose
-USG abdomen
 General Management
• Management of dengue fever is symptomatic and supportive

• Bed rest is advisable during the acute phase.

• Use cold/ tepid sponging to keep temperature below 38.5 ° C. •Paracetamol as Antipyretic to lower

body temperature is preferable in the recommended

• Encourage oral intake of at least 5 glasses of other fluids (with electrolytes) in addition to normal daily

intake of plain fluid. Small frequent sips for those with nausea and anorexia.

• Patients should be monitored for development of complications till 24 to 48 hours after they become

afebrile. Fluids to be Taken

Complications:

• Post viral manifestation:

•Coinfection • Profound weakness

• Giddiness

• Wt loss
•Hospital acquired infection
• Arthralgia

• Loss of appetite
•Fluid overload • Gastritis

• Oral ulcers
 - having no fever for at least 24 - 48 hours,
- normal blood pressure,
- no respiratory distress from pleural effusion or ascites,
- improvement in clinical status (general well-being,
Discharge
criteria return of appetite, adequate urine respiratory distress),
output, no
- persistent platelet count >50,000/cu.mm
Hospital Statistics of Dengue Fever at MH
Roorkee of month Sep-Oct 2022
Total number of MIRoom registration for Sep-Oct 7480
Total number of fever patient 1650(22% of total registration)
Total number of pt diagnosed dengue (NS1/IgM) 310(19% of total fever pt)
Pt requiring hospital admission 53(17% of total dengue pt)
Pt with thrombocytopenia (<100000 cells/cumm) 39(74%of admitted pt)
Pt requiring ICU admission 10(18% of admitted pt)
Pt with bleeding manifestation (DHF) 8(15% of admitted pt)
Pt requiring Inotropes 3(5% of amitted pt)
Pt requiring platelets transfusion (< 20000 cell/cumm) 6(10 % of admitted pt)

Pt with feature of severe dengue symptoms 33(64% of admitted pt)

( abdominal pain, vomiting, loose stools, breathing
difficulty)
Case Presentations
Case 1: Classical Dengue Fever
• A 20yr old serving soldier came with c/o :
Fever -03days
moderate to high degree
Associated with chills,
Headache diffuse, retroorbital
Generalized Weakness, myalgia
joint pains

• No h/o cough, breathlessness, sore throat,

• No h/o vomiting,loose stool, abdominal pain
• No h/o rashes over skin, eschar, bleeding from orifices,
• No h/o loss of consciousness, postural symptoms
On Examination
General Examination

• Vitals: bp-110/68mmhg

• pulse-98/min, regular, normovolumic

• SpO2-96% @ room air

• T-101 F

• No palor, icterus, cyanosis, lymphadenopathy, clubbing,edema

• No ecchymoidal patches, conjunctival hemorrhages

Systemic Examination:

• CVS-S1,S2 heard, no murmurs

CNS-Conscious, well Oriented to time, place and person

Resp-B/L vesicular breaths sounds heard

Per Abdomen-Soft, Non-tender, No organomegaly

INVESTIGATIONS

• CBC:Hb-13.6, TLC-4100, Platelets-117,000 HCT- 49.8%

• RFT: Urea -23 Creat- 0.8

• LFT: Bil Total-0.9 direct-0.1 SGOT-42 SGPT-54

• MP /Paracheck- Neg

• Typhidot-Neg

• Dengue NS1Ag-Postive

Dengue serology -IgG- Negative, IgM-Positive

 Management
• Bed rest
• IV fluids as per clinical assessment & Hct value
• Paracetamol 1 gm IV 8 hrly
• PPIs
• TPR monitoring

Course in Hospital
• Pt responded well, became afebrile, showed no warning signs during convalescent phase, lab
investigations were WNL
• Pt was discharged with adequate advise of rest, hydration and follow up.
Case 2: Dengue Hemmorrhagic Fever
• A 27yr old serving soldier came with c/o :

Fever X 05days,

moderate to high degree

Associated with chills,
Headache diffuse, retroorbital
Generalized Weakness, myalgia
joint pains,

-Bleeding from Gums -02 days after brushing the teeth which subsided after 10minutes

• No h/o cough, breathlessness, sore throat,

• No h/o vomiting, loose stool, abdominal pain
• No h/o rashes over skin, eschar, bleeding from orifices,
• No h/o loss of consciousness, postural symptoms
On Examination
General Examination
• Vitals: bp-108/74mmhg
• pulse-98/min, regular, normovolumic
• SpO2-96%@room air
• T-99.8 F
• No palor,icterus,cyanosis,lymphadenopathy,clubbing,edema
• Red,swollen gums +
• No conjunctival hemorrhages, ecchymoidal patches

Systemic Examination:
Cvs-S1,S2 heard,no murmurs
CNS-Conscious,well Oriented to time,place and person
Resp-B/L vesicular breaths sounds heard
Per Abdomen-Soft,Non-tender,
Spleen Tip palpable
INVESTIGATIONS
• CBC:Hb-14.4, TLC-2,600, Platelets-17,000 HCT-52.3%

• RFT: Urea -16 Creat- 1.0

• LFT:Bil Total-0.9 direct-0.1 SGOT-102 SGPT-193

• MP Paracheck- Neg

• Typhidot-Neg

• Dengue NS1Ag-Postive

• Dengue serology IgG/ IgM- Negative ,

• USG abdomen – moderate ascites,mild pleural effusion, splenomegaly.

 Management
• Bed rest
• IV fuids NS@120 ml/hr + oral fluid as tolerated
• Paracetamol 1 gm IV 8 hrly
• PPIs
• TPR monitoring
• 1 Single Donor Platelets (SDP) transfusion was given
• TPR & bleeding Monitoring

• Course in hospital-
• pt remain symptomatic with bleeding for 2 days which stopped after SDP transfusion. No further

bleeding manifestation.

• He was given HCt based hydration, his general condition improved over 2 days. No warning signs during

convalescent phase.

• Discharged after 6 days with advise for bed rest, adequate hydration and follow up
 Case 3: Dengue Shock Syndrome
A 28yr old w/o serving soldier came with c/o :

• Fever with chills X 05days,

moderate to high degree

Associated with chills,
Headache diffuse, retroorbital
Generalized Weakness, myalgia
joint pains, decrease oral intake
recurrent vomiting and loose stool

• Abdominal Pain- 01days ,generalized , constant ,dull aching, increase after taking fluid/ food

• Giddiness while sitting/ standing -01day

• No h/o loose stools,

• No h/o loss of consciousness,

• No h/o reddish patches over skin,blood in stool,bleeding from PR,black tarry stool,blood in vomitus
On Examination
General examination
• Vitals: bp-88/42mmhg p
• pulse-112/min, regular, feeble
• SpO2-93% @room air
• T-102 F
• Periphery cold
• No palor,icterus,cyanosis,lymphadenopathy,clubbing,edema,ecchymoidal patches

Systemic Examination:
• Cvs-S1,S2 heard,no murmurs
• CNS-Conscious,well Oriented to time,place and person
• Resp-absent breaths sounds rt axillary and scapular area
• Per Abdomen-Soft,
no guarding & rigidity
tenderness + in epigastrium& rt hypochondrium
shifting dullness present
Spleen palpable below lt costal margin
Investigations
• CBC:Hb-15.2, TLC-1,400, Platelets-46,000 HCT-50.3%

• RFT: Urea -48mg/dl Creat- 1.6mg/dl

• LFT:Bil Total-0.9 direct-0.1 SGOT-163 SGPT-201

• MP Paracheck- Neg

• Typhidot-Neg

• Dengue NS1Ag- Negative

• Dengue IgG- Negative , IgM-Positive

• Abdominal USG-splenomegaly

Mild ascites, GB wall edema

Mild pleural effusion in rt lung

Management
• IV fluids-NS/RL/DN 4unit fast then @125 ml/hr
• Ionotropes-Noradrenaline Infusion ( target MAP >65 mmhg)
• PPI
• Antiemetics
• Paracetamol 1 gm IV 8 hrly
• TPR, bleeding monitoring
• Daily HCT ,CBC monitoring, CXR every 3 day

Course in hospital
• Patient responded well to the IV Fluids and iontropes
• BP normalised over 02 days with adequate urine output
• Platelets showed upward swing, liver enzyme started to fall
• Patient was discharged after 08 days with adequate advise for bed rest, hydration and
follow up
THANK YOU