Dengue Fever

Dengue Fever/Dengue Hemorrhagic Fever

o 4 serotypes (1-4)
o Dengue virus- enveloped RNA arbovirus, Family Flaviviridae
o Aedes aegypti – day biting female mosquito
o Incubation period: 4-6 days

Dengue Fever:

o Is a benign syndrome caused by several arthropod-borne viruses

o Char: biphasic fever, myalgia/arthralgia, rash, leukopenia and LAD

Dengue Hemorrhagic Fever:

o Severe, fatal, febrile disease

o Char: capillary permeability, abnormalities of hemostasis, and severe
– protein-losing shock syndrome(DSS)

WHO Criteria for diagnosis of DHF :

o Fever
o Major/minor hemorrhagic manifestations
o Thrombocytopenia (<=100,000)
o Objective evidence of capillary permeability( inc HCT =20%, pleural
effusion, hypoalbuminemia)

Dengue Shock Syndrome:

o DHF +
o Hypotension
o Narrow pulse pressure (=20 mmHg)

Pathogenesis of DHF:

o Increase capillary fragility- immune- complex reaction similar to

anaphylactic reaction that produce toxic substances (histamines, serotonin,
bradykinins) which damage capillary walls
o Thrombocytopenia -faulty maturation of megakaryocytes – decreasing
production of platelet
 Consumption of platelet due to generalized intravascular
clotting
o Dec blood coagulation factor(fibrinogen) and Factors II,V,VII,and IX.

Hypothesis that explain why DHF occurs in some individuals:

o Changes in virulence in some serotypes

 o Virus interaction with environment/ infectious agent
o Differences in genetic susceptibility/ host factors
o Immunologic enhancement of dengue infection by antibody acquired
from previous infections with different dengue serotype.
o Antibody –dependent enhancement of infection: most popular

Person who develop antibody from 1st infection fail to neutralize a 2nd
dengue viral infection and even enhance the entry of virus to monocytes and
macrophages – increases viral load and larger # of infected cells

Clinical manifestations:

o Maculopapular rash (Herman’s rash)- 5 th to 7 th day of illness

o Fever (39-40C), acute in onset
o Headache, periorbital pain, joint pains, and rash
o Patient is flushed and acutely ill
o Conjunctival infection
o Anorexia, vomiting with abdominal pain
o Temperature- biphasic
o 2 ND / 3 RD DAY – hyperpyrexia persists
o Palms and soles are flushed
o torniquet test often (+)
o Petechiae seen in pressure areas
o 5 th – 7 th day – Herman’s Rash w/c last for 2-3 days

Stages :

Febrile Stage ( 1-4 days )

 Sudden onset of fever & Headache

 Flushed skin
 Anorexia, vomiting, abdominal pain
 Hepatomegaly
 Petechia observed in pressure areas ( tourniquet test )

Afebrile Stage ( 5- 7 days )

 Lethargy
 More severe abdominal pain
 Restlessness
 Hemorrhagic manifestation ( epistaxis, gum bleeding )

Convalescent Stage

 Improvement of appetite
 Petechial rash
 Herman’s rash
  Good prognostic sign
 Glove & Stocking’s rash
 Pruritus

Grading of DHF acc to severity:

Grade 1: fever, non-specific symptoms, (+) torniquet test

Grade 2: grade 1 + spontaneous bleeding

Grade 3: grade 1 &2 + circulatory failure (rapid weak pulses, narrow pulse
pressure 20 or less), hypotension, cold clammy skin and restlessness

Grade 4: profound shock

Tourniquet test procedure

 Get blood pressure properly by covering 2/3 of arm with cuff

 Get the mean blood pressure :
 Mean blood pressure = systole + diastole / 2
 Maintain for 5-10 minutes at mean blood pressure
 Check for petechiae using a 1x1 inch opening on a cardboard
 A positive tourniquet test means at least 20 Petechiae per
square inch

Clinical Criteria of DHF:

o Fever w/ acute onset, high continuous, lasting 2-7 days

o (+) torniquet test and any of petechiae, purpura, ecchymosis, gum
bleeding and epistaxis
o Hepatomegaly
o shock

Laboratory criteria of DHF:

o Plt 100,000 or less

o Hemoconcentration – hct increased by 20% or more
o WBC in DHF is variable

o Primary infection – no detectable antibody in acute phase serum

samples collected on or before day 5 of illness
o Secondary infection – antibody titer is detectable in the early acute
phase serum

Treatment:

o DF:
  Supportive
 Bedrest
 Antipyretics/Analgesics
 Aspirin is contraindicated
 Fluid and electrolyte replacement of deficits by sweating,
fasting, thirsting, vomiting and diarrhea.

o DHF:

Immediate evaluation of vital signs and degrees of hemoconcentration,

dehydration and electrolyte imbalance.

Close monitoring is essential for at least 48 hr because shock may occur or

recur precipitously early in the disease.

Oxygen– cyanotic/labored breathing

Rapid IV replacement of fluids and electrolytes can sustain patients until

spontaneous recovery occurs.

Avoid overhydration- contribute to cardiac failure.

Transfusions of fresh blood or platelets suspended in plasma– control

bleeding

Prognosis

DF- adversely affected by passively acquired antibody or by prior infection with a

closely related virus that predisposes to development of dengue hemorrhagic
fever.

DHF-death has occurred in 40-50% of patients with shock

> Survival is directly related to early and intense supportive treatment

> Residual brain damage caused by prolonged shock or by intracranial

hemorrhage.

Criteria for discharge

o Absence of fever for 46 hours

o Return of appetite
o Visible clinical improvement
o Good urine output
o Stable hematocrit
o Recovery from shock
o Platelet count of 150,000

Prevention

o Avoiding mosquito bites by use of insecticides, repellants, body

covering with clothing, screening of houses
o Elimination of A. aegypti breeding sites
o Insecticides/Larvicide
o Fogging
o Vaccine – Sabin-Schiessinger Vaccine (attenuated dengue virus)