Pearls and pitfall in diagnosis and treatment of DHF

James l Alvin Sinaga

Introduction
More than 2.5 billion people are at risk of infections in over 200 countries worldwide. There are probably tens of millions of cases of dengue each year, and at least five hundred thousand cases of DHF with a mortality of about five per cent in most countries. The vast majority of cases, nearly 95 per cent, are among children of less than 15 years of age.
WHO

 30 % of DHF patient will become shock and the case fatality rate almost 5 %. Management focused on fluid and prevention of shock Many pearls can guided us for better management but sometimes pittfall a head For better management understanding the clinical course of diseases is important

Clinical spectrum of dengue infection

Dengue Fever
Acute febrile illness with 2-7 days of fever 2 of this following manifestation - headache - retro-orbital pain - myalgia/arthralgia - rash - hemorrhagic manifestation (petechia and (+) TT - Leucopenia
WHO-SEARO

Dengue hemorrhagic fever

Clinical 2-7 days of fever Hemorrhagic manifestation - Positive TT - Petechia, ecchymosis, purpura - Bleeding from mucosa - Hematemesis or melena Hepatomegali shock Laboratory Thrombocytopenia Plasma leakage - A rise in 20 % hematocrite for age and sex - 20 % drop in hematocrite following fluid treatment - sign of plasma leakage (pleural effusion, ascites or hypoproteinemia) Diagnosis criteria : 2 clinical criteria + laboratory criteria + serologic test

Severity of DF/DHF WHO new classification

Clinical course

Figure : Dengue deseases phases : fever, critical and recovery

Clinical course

CDC

Clinical manifestation of DF/DHF

Turk J Pediatr 2011; 53: 626-631.

Laboratory diagnosis

IgG and IgM

Pearls in diagnosis
In a child with acute onset of high fever: flushed face without coryza, with petechiae and/or positive tourniquet test should suggest the possibility of dengue infection. Additional hepatomegaly (=tenderness) increases the possibility of DHF. WHO-SEARO

pearls in diagnosis
Curigai DHF pada anak dengan panas + hepatomegali pada akhir periode panas : leukopenia, relative lymphocytosis Bila thrombosit mendadak turun dengan kenaikan Ht (20%) dugaan kuat DHF lakukan intervensi segera !
Ismujianto. Pearls and pittfals pada dengue UKK Infeksi dan Pediatri tropik IDAI

Pearls in diagnosis
Serial platelets and HCT determinations for a drop in platelets and rise in HCT, which represent major pathophysiological changes (abnormal haemostatic and plasma leakage), are essential for early diagnosis of DHF. Rising HCT by 20 per cent or more simultaneously with or shortly after a drop in platelet count that occurring before subsidence of fever or onset of shock) reflects significant plasma losses and indicates a need for volume replacement.
WHO-SEARO

Pittfalls in diagnosis
Misdiagnosis - age < 2 years + high fever, diarrhea, convulsion sugested as encephalitis dengue encephalopathy - Older child +fever + abdominal pain has been diagnosed as acute appendicitis or acute pancreatitis Hasil rapid sero negatif palsu pada panas hari ke 2-3
Ismujianto. Pearls and pittfals pada dengue

UKK Infeksi dan Pediatri tropik IDAI

Pittfals in diagnosis
Diagnosis based on single laboratory test Diagnosis not based on clinical criteria

Management
Consensus 1. Management of DHF/DSS 1.1 No specific antiviral agent is recommended. 1.2 Supportive/Symptomatic treatment is effective and life-saving if given appropriately. 1.3 Prognosis depends on early diagnosis of DHF and early recognition of potential shock cases. 1.4 Early and effective replacement of lost plasma with electrolyte and colloidal solution results in favorable outcome. Plasma substitute is as good as plasma when there is massive leakage. It is the volume expander, not plasma factors that is needed during the period of leakage. Plasma factors or other blood elements are needed only in cases with massive bleeding and severe DIC.

1.5 Serial follow-up of platelets and hematocrit is helpful.in the early recognition of plasma leakage; and if present, fluid replacement is indicated. 1.6 Platelet transfusion as prophylaxis is not recommended. Studies have shown that there is no transfusion was administered or not. There was no difference in the bleeding episodes between the 2 groups either.

management
1.7 Steroids have no benefit, it has been documented by several studies that high dose corticosteroids have no benefit in the management of DHF/DSS. 1.8The use of Vitamin K is of no benefit because bleeding in DHF is due to DIC, thrombocytopenia, and impaired platelet function. The administration of heparin in DHF with prolonged shock with DIC needs further studies. IV Immunoglobulin needs further investigation.
Nimmanitya . Workshop 8. Management of Dengue Hemorrhagic Fever http://www.psmid.org.ph/vol25/vol25num1topic7h.pdfr

Management of fever
- Antipyretic helps in reducing the height of fever, but cannot shorten the duration of fever - antipyretic of choice : paracetamol - aspirin is contraindicated Reyes syndrome - How about ibuprofen and metamizol ?

Pearls in fluid Management

Early replacement of plasma losses with isotonic salt solution can prevent shock and/or modify severity. I.V. fluid therapy before leakage as prophylaxis for shock is not recommended as it may do some harm. Early and effective replacement of lost plasma with electrolyte and colloidal solution results in favorable outcome. Plasma substitute is as good as plasma when there is massive leakage. It is the volume expander, not plasma factors that is needed during the period of leakage. Plasma factors or other blood elements are needed only in cases with massive bleeding and severe DIC.
Suchitra N, Esperanza R. Workshop 8: Management of Dengue Hemorrhagic Fever. www.psmid.org.ph/vol25/vol25num1topic7h

Pearls on management of thrombocytopenia

Platelet transfusion as prophylaxis is not recommended. Studies have shown that there is no differences in the duration of thrombocytopenia or increase in platelet count wether given or not. Platelet transfusion given if DIC is present with evidence of bleeding
Suchitra N, Esperanza R. Workshop 8: Management of Dengue Hemorrhagic Fever. www.psmid.org.ph/vol25/vol25num1topic7h

Criteria for platelet transfusion

Pearls and pitfalls in the management of bleeding

Stagnant acidemia blood promotes occurrence/enhances severity of DIC; acidosis must be corrected. Coagulogram should be evaluated. Platelet-rich plasma transfusion as prophylaxis for bleeding in all shock cases is not recommended. There are abnormal haemostatic changes that potentiate bleeding in DHF/DSS, severe bleeding (may be concealed) often occurs in cases with prolonged shock and further perpetuates shock. Refractory shock despite adequate volume replacement and a drop in HCT (at any rate, e.g. from 50 per cent to 40 per cent) indicates significant bleeding and a need for FWB transfusion (10 ml/kg/dose if HCT >35 vol%). WHO-SEARO 2006

Pitfall in treatment
No IVFD monitoring - overhydration Pleural effusion, respiratory distress - prolonged volume replacement lung edema, respiratory distress Failure to detect acidosis check blood gas analysisi in severe cases Failure to detect bleeding decrease of Hb and Hct concomittently

Management of shock
Fluid of choice majority of children with DSS can be treated successfully with isotonic crystalloid solutions.
Paediatr Int Child Health. 2012 May; 32(s1): 3942.

Both colloidal solutions are safe in DHF patients with no allergic reaction observed and no interference in renal functions and hemostasis.
J Med Assoc Thai. 2008 Oct;91 Suppl 3:S97-103.

Management of shock
Initial resuscitation with Ringer's lactate is indicated for children with moderately severe dengue shock syndrome. Dextran 70 and 6 percent hydroxyethyl starch perform similarly in children with severe shock, but given the adverse reactions associated with the use of dextran, starch may be preferable for this group.
N Engl J Med. 2005 Sep 1;353(9):877-89.

Management of shock
There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids
Cochrane Database Syst Rev. 2012 Jun 13;6.

Pearls and pitfalls in the management of shock

DSS is hypovolemic shock due to plasma losses: volume replacement with isotonic salt solution, plasma or plasma substitute for the period of plasma leakage (24-48 hours) is life-saving. Volume replacement should be monitored according to the rate of plasma leakage (as reflected by HCT, vital signs, urine output) to avoid fluid overload (the rate of leakage is more rapid in the first 6-12 hours).

 Dextran 40 is as effective as plasma (maximum dose 30 ml/kg/day), with some advantages. Over-replacement with more volume and/or for longer period of time will cause pulmonary congestion/oedema, particularly when reabsorption of extravasated plasma occurs.