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Positive tourniquet test or
Spontaneous bleeding
+/- +
3. Thrombocytopaenia
≤ 100,000/mm³
+/- +
4. Plasma leakage
Pleural effusion /ascites
- +
/hypoproteinaemia
≥ 20% increase in HCT from baseline
Lancet Inf Dis 2006; 6: 297-302
WHO/TDR 2009
• CNS: Impaired
dengue
(important when no sign of plasma * Requiring strict observation consciousness
leakage) and medical intervention • Heart and other organs
Dengue without warning signs
Probable dengue
live in /travel to dengue endemic area.
Fever and 2 of the following criteria:
• Nausea, vomiting
• Rash
• Aches and pains
• Tourniquet test positive
• Leucopenia
• (Any warning sign)
Dengue with warning signs
Warning signs ( appear in the critical period)*
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy, restlessness
Liver enlargement >2 cm
Increase in HCT concurrent with rapid decrease in
platelet count
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Severe Dengue
Severe plasma leakage leading to:
• Shock (DSS)
• Fluid accumulation with respiratory distress
Severe bleeding as evaluated by clinician
Severe organ involvement
Liver: AST or ALT ≥ 1000
CNS: Impaired consciousness
Heart and other organs
Evidence from 2009 Dengue Guideline
Multicentre prospective study on dengue
classification in four South-east Asian and
three Latin American countries
(Neal Alexander et.al, 2011)
2011
Asymptomatic Symptomatic
Expanded Dengue
syndrome/isolated
Undefferentiated
organophaty (unusual
fever
manifestation)
(viral syndrome)
Dengue Haemorrhagic
Dengue Fever
Fever (DHF)
(DF)
(with plasma leakage)
DF/
DHF
Grade Signs and Symptoms Laboratory
DF Fever with two of the following: • Leucopenia (WBC <5000 cells/mm3)
• Headache • Thrombocytopenia <150.000
• Retro-orbital pain cells/mm3)
• Myalgia • Rising Hct (5-10%)
• Athralgia/bone pain • No evidence of plasma loss
• Rash
• Haemorrhagic manifestations
• No evidence of plasma leakage
DHF I Fever and haemorrhagic manifestation Thrombocytopenia <100.000 cells/mm3
(positive tourniquet test) and evidence Hct rise >20%
of plasma leakage
DHF II As in Grade I plus spontaneous bleeding Thrombocytopenia <100.000 cells/mm3
Hct rise >20%
*DHF III As in Grade I or II plus circulatory Thrombocytopenia <100.000 cells/mm3
failure Hct rise >20%
*DHF IV As in Grade III plus profound shock with Thrombocytopenia <100.000 cells/mm3
undetectable bloodpressure and pulse Hct rise >20%
*DHF III and IV are DSS
clinical and laboratory finding from patients
Hospitalized in pediatric ward RS Dr. Sardjito – 2006
DF (%) DHF (%) OR (95%CI)
24 48
Cough-coryza 5 (20) 8 (16) 0.76 (0.22-2.63),p=0.91
Headache 12 (50) 29 (60) 1.52 (0.57-4.00), p=0.55
Abdominal pain 7 (29) 25 (52) 2.64 (0.92-7.5), p=0.11
Nausea-vomiting 10 (41) 18 (37) 0.84 (0.30-2.30), p=0.93
Arthralgia 18 (75) 37 (77) 1.12 (0.35-3.5), p=0.92
Hepatomegaly 12 (50) 40 (83) 5 (1.66-15.00),p<0.01
Bleeding 5 (20) 17 (35) 1.28 (0.48-3.5), p=0.80
-epistaxis 6 (25) 15 (31)
-petekie 0 (0) 14 (29)
-gastrointestinal 0 2 (1)
-hematuria
Leucopenia 15 (62) 40 (83) 3 (0.97-9.21), p=0.09
(AL<4000)
Platelet <100.000 12 (50) 41 (85) 5.85 (1.88-18.17), p=<0.01
Confirmed by serology26
Admission criteria
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1997
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