Akmal Syaroni

DIVISION OF TROPICAL INFECTIOUS DISEASES DEPARTMENT OF INTERNAL MEDICINE MOH. HOESIN HOSPITAL PALEMBANG

 Dengue

virus (DEN) : dengue fever (DF) and dengue hemorrhagic fever (DHF) / dengue shock syndrome in human. Virus : Aedes (Stegomyia), Aedes aegypti, Aedes albopictus dan Aedes polynesiensis. Tropical and subtropical area; nearly 2,3 billion people DEN virus. Recently, there arise 100 millions case of DEN and hundred thousands case of DHF/DSS annually

Epidemiology
DHF case (1968) in Surabaya and Jakarta, the prevalance rate of DHF raised and spreaded to all regencies in Indonesia

High prevalence rate of DHF estimated every 5 year, with the highest mortality rate in the early year of 1968 found DHF case and the highest prevalance rate of DHF in the year of 1988

3.

Mortality rate of DHF case remains high, especially late coming DHF patient with grade 4
High prevalence rate(KLB) firstly was DHF in Asia (Manila,1954) reported by Quintas. o KLB DHF disease Thai in Bangkok-Thonburi and surroundings in 1958 o Found DHF cases in Singapura with the result of dengue virus isolates showing type 1 (DEN 1) and type 2 (DEN 2) in 1960 o Reported DEN virus serotype often causes outbreak in Indonesia o The DEN-2 serotype caused outbreak in Thailand

4.

Pathogenesis of DHF
Dengue virus Encephalitis Japanese virus Yellow Fever famili flaviviridae

4 characters of dengue virus genomic serotype and differed from biotype nature (virus duplication nature)

Virus Morphology in Flaviviridae family

Antigen Antibody Theory

Antigen antibody complex complement activation C3A and C5A anafilaktosin C3a and C5a anafilaktosin have characteristics as follows: mediator vasoactive plasma leakage procoagulant

BLEEDING

HYPOVOLEMIC SHOCK

Infection Enhancing Antibody Theory

Mononuclear phagocytes cell ab non neutralization macrophage

Macrophage + ab non neutralization

IL-1. IL-6, TNF alpha

Platelet Activating Factor (PAF)

BLEEDING

Antibody Appears After Dengue Virus Infection

Ab HI

Immune Response
Symptom NS1 Ag

Antibody Bite DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

ACUTE PHASE CRITICAL PHASE CONVALESENCE PHASE

Ag/Ab level

IgM NS1 Ag

IgG

Day

Clinical Manifestation
Diagnosis Criteria, WHO 1997
Clinical Criteria 1. Abrupt high fever, intermittently 2-7 days 2. Bleeding manifestation marked by
Positive tourniquet test Spontaneous bleeding; ptechiae, ecchymosis, epistaxis, gum bleeding, hematemesis and or melena
3. 4.

Hepatomegaly Shock is marked by rapid and weak pulse accompanied by lowering blood pressure, hypotension, cold hands and feet, clammy skin and confusion

Laboratory Criteria 1. Thrombocytopenia (< 100.000 cell/ml) 2. Hemoconcentration (increment Ht 20% compared to convalesce phase)

Grade of the Disease

Grade I : Fever accompanied by unspecific symptoms, tourniquet test (+) Grade II : Grade I + spontaneous bleeding in skin or other sites bleeding Grade III : Found circulation failure Grade IV : Severe shock

Laboratory Diagnosis
1. 2. 3. 4. 5. 6. 7.

Hemeagglutination inhibition test Neutralization test Complement fixation test Hemeadsorption immunosorbent technique ELISA Anti-Dengue IgM test Dengue blot test Virus isolation

Management
Criteria:
1.

2.

3.

Precise management in action plan constituted in accordance with indications Practical in the action Considering cost effectiveness

DIC (+)

DIC (-)

1.

Good General condition/consciousness & hemodynamic, without fever Generally, normal range in Hb, Ht & thrombocytes count and stable within 24 hours, but to some conditions, though it has not yet achieved normal count (over 50.000/mm), patient can be discharged when discharged before day 7, or un normal range in thrombocytes count, urged to control within 24 hours, or if deteriorating, patient admitted to emergency room

2.

Immune Response Humoral in the DHF Infected Patient