DENGUE FEVER

DENGUE FEVER is an acute illness characterized by

FEVER, MYALGIA, ARTHRALGIA and RASH.
SEVERE DENGUE infection is characterized by
ABNORMALITIES IN HEMOSTASIS and by
MARKED PLASMA LEAKAGE from the capillaries; the latter may
LEAD TO SHOCK (DENGUE SHOCK SYNDROME)

DENGUE VIRUS . Arbovirus,(Family FLAVI VIRUS)

 Four serotypes DENV-1, DENV-2, DENV-3, and DENV-4

 Infection with any one serotype confers lifelong immunity to the
virus serotype
 But NOT to OTHER Serotype infection ,
 DENV serotypes to utilize pre-existing heterotypic flavivirus
antibody to enhance infection
 Secondary infections associated with increased risk of severe disease
outcome
VECTOR : Aedes  mosquito (female) (Ae. Aegypti , Ae Albopictus , Ae
Polynesiensis , Ae Neveus)
INCUBATION PERIOD
Extrinsic incubation period(mosquito) - 8 to 10 days
Intrinsic incubation period (Human) 4 to 7 days (range 3–14 days).
PATHOGENESIS
 Capillary leakage and Shock
 Coagulopathy

CLINICAL MANIFESTATION (CLASSIFICATION)

1. Undifferentiated dengue Fever (UDF)
 In primary dengue infection patient may develop mild to
moderate fever
 Often difficult to distinguish from other viral infections
 Maculopapular rash may or may not appear during fever or
defervescence
 The symptoms of DF may not be very distinguished
 signs of bleeding or capillary leakage may be absent.
2. Severe dengue Fever
1. Severe manifestations like shock, plasma leakage, bleeding
and organ involvement.
2. Based on Thrombocyte count, Haematocrit, evidence of
capillary leakage, bleeding and hypotension.
3. DHF has been divided into four grades.
4. NON SEVERE CASES ( DF and DHF grade I and II without
significant bleeding)
5. SEVERE DENGUE
 DHF III and IV with or without significant bleeding
 DHF grade I and II may be severe when they present with
significant bleeding or with metabolic and electrolyte
abnormalities.
 DF may present with life threatening significant bleeding
without evidence of capillary leakage or haemoconcentration
 Some dengue Fever patients may also present with multiple
organ involvement without bleeding and shock. In some
patient there may be unusual atypical presentation also.
 High morbidity and mortality in DF/DHF is due to
involvement of the following organs during illness:
• Hepatic • Renal • Cardiac • Pulmonary • CNS
3. Dengue Fever with warning signs and symptoms:
indicators of disease progression and severity of DF/DHF/DSS:
1. Recurrent vomiting
2. Abdominal pain or discomfort
3. Hepatic dysfunction or hepatomegaly
 4. Palpitation, breathlessness
5. Decrease urinary output
6. Minor bleeding from different sites,( scanty haemoptysis,
haematemesis, haematuria, increase menstrual flow, gum
bleeding, etc.)
7. High HCT (>45%)
8. Rapid fall in platelet count
9. Cold clammy extremities
10. Narrow pulse pressure
11. Rapid pulse
12. Hypotension Pleural effusion/ ascites/ gall bladder
oedema on imaging
4. High Risk group
may have severe manifestations or complications with DF/DHF,
therefore this group of patients should be closely monitored for the
development of severity:
1. Pregnancy
2. Infant
3. Elderly
4. Obesity
5. Peptic ulcer diseases
6. G6PD deficiency
7. Thalassemia
8. Coronary Artery Disease
9. Chronic diseases: diabetes, COPD, bronchial asthma,
hypertension
10.Patients on steroid, antiplatelet, anticoagulant drugs
11.HIV infected persons/ Immuno-compromised persons
5. EXPANDED DENGUE SYNDROME (EDS)

System Unusual or atypical manifestations

CNS involvement Encephalopathy, encephalitis, febrile seizures, I/C bleed
Acute Hepatitis / fulminant hepatic failure, cholecystitis,
G. I. involvement
cholangitis acute pancreatitis
Renal Acute renal failure, haemolytic uremic syndrome, acute
involvement tubular necrosis
Cardiac Cardiac arrhythmia, cardiomyopathy, myocarditis, pericardial
involvement effusion
Pulmonary oedema, ARDS, pulmonary haemorrhage. pleural
Respiratory
effusion
Conjunctival bleed, macular haemorrhage, visual impairment,
Eye
optic neuritis
6. NEWBORN (Vertical Transmission)
 Periparum infection increases the risk
 vary from mild to severe illness
 as fever with petechial rash, thrombocytopenia and
hepatomegaly,
 severe illness withpleural effusion, gastric bleeding,
circulatory failure, massive intracerebral haemorrhage.
 Clinical presentation in the newborn infant does not related
with maternal disease severity or dengue immune status or
mode of delivery. However,
 timing of maternal infection may be important;
 Passive transfer of maternal dengue antibodies to the
foetus influences the occurrence of a severe development of
the disease.
7. Manifestations of dengue in infants:
1. Abrupt onset high fever .usually lasts 2–7 days.
2. Upper respiratory tract symptoms (cough, nasal congestion,
runny nose, dyspnoea),
3. Gastrointestinal symptoms (vomiting, diarrhoea),
4. Febrile convulsions are more common

CLINICAL FEATURES
Natural Course, THREE PHASES
1. Febrile phase
2. Critical phase
3. Convalescent phase
FEBRILE PHASE (2-7 days)
 Sudden onset of fever
 commonly associated with Head ache , Flushing and Rash
  Pain : (Retro orbital , Muscle , Joints )
 Rash (3-4th Day of fever) Maculopapular /Rubelliform Rash (face ,
neck , other parts , fades by later part of febrile phase
 Petechiea : Localised cluster over limbs
 Febrile phase may Biphasic
CRITICAL PHASE (LEAKAGE PHASE)
 After 3 to 4 days of onset of fever (lasts 36-48 hrs)
 plasma leakage and high haemoconcentration
 may develop hypotension
 Abnormal haemostasis and leakage of plasma leads to shock,
bleeding, accumulation of fluid in pleural and abdominal cavity
 High morbidity and mortality in DHF/DSS are commonly
associated with various organ involvements and metabolic
derangement.
CONVALESCENT PHASE (RECOVERY PHASE)
 Usually after 6-7 days of fever and last for 2-3 days
 Extracellular fluid which was lost due to capillary leakage returns
to the circulatory system and signs and symptoms improve.
 Longer convalescence may be expected in some of the patients
with severe shock, organ involvement and other
 May develop pulmonary oedema due to fluid overload if the fluid
replacement is not optimized carefully

Clinical Criteria for DF / DHF/DSS

1. Dengue Fever (DF):

 An acute febrile illness of 2-7 days duration with two or more of the
following manifestations:
 Headache, Retro-orbital pain, Myalgia, Arthralgia, Rash, Haemorrhagic
manifestations.
 2. Dengue Haemorrhagic Fever (DHF):
a). A case with clinical criteria of dengue Fever
plus
b). Haemorrhagic tendencies evidenced by one or more of the
following
1.Positive tourniquet test
2.Petechiae, ecchymoses or purpura
3.Bleeding from mucosa, gastrointestinal tract, injection sites or
other sites
Plus
c). Thrombocytopenia (<100 000 cells per cumm)
plus
d). Evidence of plasma leakage due to increased vascular
permeability, manifested by one or more of the following:
1. .A rise in average haematocrit for age and sex > 20%
2 .A more than 20% drop in haematocrit following volume
replacement treatment compared to baseline
3.Signs of plasma leakage (pleural effusion, ascites, hypoproteinemia)
 Dengue Shock Syndrome (DSS):
All the above criteria for DHF with evidence of circulatory failure
manifested by rapid and weak pulse and narrow pulse pressure ( mm
Hg) or hypotension for age, cold and clammy skin and restlessness.
Dengue Case Definition

Probable DF/DHF:
A case compatible with clinical description (Clinical Criteria) of dengue Fever
during outbreak.:
OR
Non-ELISA based NS1 antigen/ IgM positive.
(A positive test by RDT will be considered as probable due to poor sensitivity
and Specificity of currently available RDTs.)
Conifrmed dengue Fever:
 A case compatible with the clinical description of dengue fever with at
least one of the following
 Isolation of the dengue virus (Virus culture +VE) from serum, plasma,
leucocytes.
 Demonstration of IgM antibody titre by ELISA positive in single serum
sample.
 Demonstration of dengue virus antigen in serum sample by NS1-ELISA.
 IgG seroconversion in paired sera after 2 weeks with Four fold increase
of IgG titre.
 Detection of viral nucleic acid by polymerase chain reaction (PCR)
Grading of DF/DHF

DF
 Fever of 2-7 days with two or more of following-
 Headache, Retro orbital pain, Myalgia, Arthralgia with or
without leukopenia, thrombocytopenia and no evidence of
plasma leakage.
DHFI:
 Above criteria plus
 positive tourniquet test and evidence of plasma leakage.
 Thrombocytopenia with platelet count less than 100000/ cu.mm
and Hct rise more than 20% over baseline
DHFII:
 Above plus
 some evidence of spontaneous bleeding in skin or other
organs (black tarry stool, epistaxis, gum bleeds) and
abdominal pain
  Thrombocytopenia with platelet count less than 100000/
cu.mm and Hct rise more than 20% over baseline.

DHFIII (DSS)
 Above plus(GHF II)
 circulatory failure (weak rapid pulse, narrow pulse
pressure < 20 mm Hg, Hypotension, cold clammy skin,
restlessness).
 Thrombocytopenia with platelet count less than 100000/
cu.mm and Hct rise more than 20% over baseline.
DHFIV (DSS):
 Profound shock with undetectable blood pressure or pulse.
 Thrombocytopenia with platelet count less than 100000/
cu.mm and Hct rise more than 20% over baseline.

Dengue Viral infection >>>Asymptomatic & Symptomatic

 1. MILD DENGUE

Manageme
A- Undifferentiated Dengue Fever

Home
B- Fever without complications like bleeding ,

nt
Hypotension , Organ involvement
C- Fever without evidence of capillary leakage
2. MODERATE DF
A - WITH HIGH RISK & CO-MORBID CONDITIONS
 Infants
 Old Age
 Pregnancy
 Diabetics
 Hypertension
 CAD
 Haemoglobinopathies Close
 Immunocompromised Monitoring*
 On steroids , immune suppressants, and possibly
 On Anticoagulants Hospitalizati
B . DF WITH WARNING SIGNS & SYMPTOMS on
 Recurrent vomiting
 Abdominal pain/ tenderness
 General weakness/ letharginess/ restless
 Mild pleural effusion/ascites
 Hepatomegaly
 Increased Hct>20%
C - DHF I & II WITH MINOR BLEEDS
3-- SEVERE DF
 DF DHF with significant Haemorrhage
 DHF with shock (DHF III & IV- DSS)
Tertiary
 Severe organ involvement (Expanded Dengue
level care
Syndrome)
 Severe Metabolic Disorder

LABORATORY DIAGNOSIS
1. ELISA-based NS1 antigen tests ( first 5 days)
2. IgM-capture enzyme-linked immunosorbent assay (MAC-
ELISA)- after 5 days in some cases as early as 2.4 days
3. CBC : Leucopenia , Thrombocytopenia , Rise HCT
4. LFT may altered