Dengue Fever

 DENGUE FEVER

 

Contents:

1. Introduction
2.  Clinical presentation
3. Diagnosis
4. Treatment
5. Diet
   

 Introduction:

• Dengue fever is a viral infection caused by dengue virus.
• Dengue virus is an RNA virus of genus flavi virus.
• —There are four serotypes dengue virus that is DENV-1, DENV-2, DENV-3, DENV-4
• —Dengue virus transmitted by Aedes aegypti mosquito
  

 

Aedes aegypti mosquito

 

Aedes aegypti mosquito known to transmit Dengue virus, Yellow fever virus, Chikungunya virus, and Zika virus and it also suggest as a potential vector of Venezuelan Equine Encephalitis  virus and studies shown it is capable to transmit West Nile virus as well.

Clinical Presentation:

Divides into 4 categories : 

1. Dengue without warning sign 
2. Dengue with warning sign 
3. Severe dengue / dengue hemorrhagic fever
4. Dengue shock syndrome

 

Remember Note:

• Not all patient goes in all these phases.— 
• Majority of patient develops dengue without warning sign and they cure self or general treatment.
•  But few patients who are not manage properly or the patient who are immunocompromised and who have weak immune system, they can progress from dengue without warning sign to dengue shock syndrome.

 Dengue without warning sign:

• Incubation period 4-10 days (2-14 days)
•  —High grade fever 40˚C (104˚f)       

                               +

  Following any of two are present

•  Severe headache
•  Retro orbital pain
•  Myalgia, arthralgia (break bone fever)
•  Maculopapular widespread rashes.
•  Generalised lymphadenopathy.

 

Dengue with warning sign

 Critical period begins - —  

3-7 days after symptoms onset  

Warning signs appear after fever subsides

  

Population who are at risk –

•  —Pt. with severe comorbidities
•  —Infants less than 1 year of age
•  —History of previous or recurrent dengue infection.

  

Warning Signs Include:

1.  Abdominal pain with or without tenderness. 
2. Persistent vomiting (>3 times in 24 hours) 
3. —Bleeding from nose or gums. 
4. —Blood in vomiting or blood in stool or blood in urine. 
5. —Lethargy, restlessness, irritable. 
6. —Enlarge liver > 2 cm

 

Severe Dengue / Dengue haemorrhagic fever

 Re-infected with different serotype

 This phase begins after fever subside

 —Temperature (hypothermia to second fever spike)

—Plasma leak resulting in pleural effusion, ascites, haematocrit drops

 —Hemorrhagic manifestations such as gingival bleed, epistaxis, petechiae, ecchymosis, purpura, thrombocytopenia,

 —Severe organ involvement like hepatomegaly, liver failure

 —Changes in mental status - confusion

 

Petechiae and Purpura

 

 

Ecchymosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gingival Bleeding

 

  Dengue Shock Syndrome

Severe hemorrhagic dengue

                   +

Shock (circulatory collapse)

—Severe hemorrhagic fever with circulatory collapse is called dengue shock syndrome

—It is fatal if not manage properly

 

Diagnosis

 Serologic test to detect IgM (Initial 3-4 days the antibodies will be negative but patient having infection.

 —NAAT to detect viral RNA

 —NS-1 antigen to detect dengue non structural protein 1 (NS 1 antigen can be detected directly after onset  of symptoms, before even IgM production begins)

 —Positive capillary fragility test.  

 

When test become positive

 

TOURNIQUET FRAGILITY TEST –

Tourniquet applied to arm.  Inflated to a point b/w systolic and diastolic pressure for 5 minutes.

Positive test : If 10 or more petechiae appear per square inch on forearm.

 

Treatment Approache

Don’t do this

—Don’t use corticosteroids due to increase risk of GI bleeding, hyperglycemia.

—Do not give platelet transfusion for low platelet count b/c it leads to fluid overload.

—Do not assume that IV fluid are necessary, use minimum amount of IV fluid to keep patient profused.

—Do not give ½ NS b/c it leads to ascites, pleural effusion etc.

You can do this

—Do recognize the clinical period

—Monitor fluid intake output, vital sign HCT level etc.

—Do administer colloids such as albumin for refractory shock who do not responds 2-3 boluses of isotonic saline.

—Do give PRBCs or whole blood for significant bleeding.

 

Dengue without warning sign Treatment approach 

—Paracetamol, cold sponging for fever (don’t give aspirin, ibuprofen)

—Prevent dehydration (oral fluid – ORS)

 

Dengue with warning sign treatment approache

—Admit in hospital

—Check hematocrit value

—If oral fluid intake inadequate give isotonic crystalloid (normal saline, RL)

—Stepwise manner, 5-7ml/kg/hour for 1-2 hours followed by 3-5ml/kg/hour for 2-4 hours (increase rate if vital signs worsening.

—Control fever with paracetamol and cold sponging.

—Continue monitor – Haematocrit, fluid intake urine output, vital signs

 

Severe Dengue / Dengue haemorrhagic fever

—Admit patient for emergency management.

—Monitor fluid intake/output

—Give controlled fluid 5-7ml/kg/hr for 1-2 hours, 3-5ml/kg/hr for next 2-4 hours, 2-3ml/kg for next 2-4 hours.

 

Check haematocrit level

DECREASING

—Transfusion 5-10ml/kg PRBCs.

         Or

—10-20ml/kg whole blood immediately

 

INCREASING

 —Give controlled crystalloid (NS, RL) 10-20 ml/kg bolous over 1 hour  

 

Dengue Shock Syndrome

—If patient have hypotensive shock: Give isotonic crystalloid or colloid bolus 20ml/kg within 15 min.

—If  condition improve than continue crystalloid and colloid and slowly taper.

—If condition not improve than check haematocrit.

—If hematocrit decrease than transfuse 5-10ml/ kg PRBCs or 10-20ml/kg whole blood.

If hematocrit increase than give colloid 10-20ml/kg bolus over 30 min – 1 hour 

 

What can we do at home

—Cold sponging to control fever.

—ORS to maintain hydration.

—Papaya leaf juice/papaya to maintain or increase platelet count. Papaya leaf extract is good for digestion which contain papain and chympapain.

—Avoid heavy work or routine work.

 —Increase fruits (specially citrus fruits) in diet.

 

What should eat

—Vitamin-C : It has antiviral and anti-oxidative properties and it boost immunity and it help to absorb another helpful nutrients such iron from intestine. Sources – Orange, lemon, papaya, pineaple etc.

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—Vitamin-K : Sprouts, broccoli, and green leafy vegetables.

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—High-calorie foods: Milk, rice, potato etc.

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Water 

 

What should avoid to eat

—Red or brown colored : Drink or food like chocolate, violet colored juices b/c it misleads the disease progression.

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—Caffeine : Energy drinks, coffee, tea b/c these act as diuretics which make difficult to maintain hydration.

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—Spicy foods : Avoid spicy foods b/c it stimulates the stomach for more acid production which may cause stomach or intestinal bleeding.

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—Fatty foods : Cheese, cuts, butter, deep fried food and avocado etc. Dengue fever  reduces the capacity of digestion and which make difficult to digest for the stomach.