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CASE DISCUSSION:
BACKGROUND
EPIDEMIOLOGY
As of September 2015, a total of 92,807 dengue cases were reported nationwide. This figure is
23.5% higher compared to the same period last 2014 (75,117 cases)
A total of 269 deaths (0.3%) were reported in 2015 which is lower than in 2014 with 316 deaths
(0.4%)
Ages of the cases range from less than 1 month to 99 years old.
Majority of the cases were male. Most of the cases were from the 5-14 years age group
Most of the cases were reported from Cental Luzon of Region III (14,127 or 15.2%), CaLaBarZon or
Region IV-A (14,082 or 15.2%), and National Capital Region (10,385 or 11.2%)
UPDATE: A total of 33,760 dengue cases were reported nationwide from January 1 to May 6, 2017.
This number is 32% lower (49,565 cases) compared to the same period in 2016
ETIOLOGY
Dengue Virus 1-4 serotypes
Most common isolated serotypes in the Philippines; Den-1 and Den-2
Infection with one serotype does not protect against the others, and sequential infections put
people at greater risk for dengue hemorraghic fever (DHF) and dengue shock syndrome (DSS)
TRANSMISSION
Aedes aegypti and Aedes albopictus
A mosquito must feed on a person during a 5- day period when large amounts of virus are in the
blood.
The virus will require an additional 8-12 days incubation before it can then be transmitted to
another human.
The mosquito remains infected for the remainder of its life, which might be days or a few weeks.
Adult, female mosquitoes lay their eggs on the inner, wet walls of containers with water, above the
waterline.
Mosquitoes generally lay 100 eggs at a time.
Eggs are very hardy; they stick to the walls of a container and can survive drying out for up to 8
months.
Bowls, cups, fountains, tires, barrels, vases and any other container storing water makes for a great
nursery.
Male mosquitoes feed on nectar from flowers.
Female mosquitoes feed on humans and animals for food and to produce eggs.
Mosquitoes can fly 1 to 1.5 miles per hour.
Dengue Fever
Dengue fever presents in a nonspecific manner and may not be distinguishable from other viral or bacterial
illness. According to the Pan American Health Organization (PAHO), the clinical description of dengue fever
is an acute febrile illness of 2-7 days duration associated with 2 or more of the following:
Up to half of patients with dengue fever develop a characteristic rash. The rash is variable and may be
maculopapular or macular. Petechiae and purpura may develop as hemorrhagic manifestations.
Hemorrhagic manifestations most commonly include petechiae and bleeding at venipuncture sites. A
tourniquet test is often positive. Other hemorrhagic manifestations include nasal or gingival bleeding,
melena, hematemesis, and menorrhagia.
Findings for dengue hemorrhagic fever are similar to those for dengue fever and include the following:
Biphasic fever curve
Hemorrhagic findings more pronounced than in dengue fever
Signs of peritoneal effusion, pleural effusion, or both
Minimal criteria for the diagnosis of dengue hemorrhagic fever, according to the World Health
Organization (WHO), are as follows:
Fever
Hemorrhagic manifestations (eg, hemoconcentration, thrombocytopenia, positive tourniquet test)
Circulatory failure, such as signs of vascular permeability (eg, hypoproteinemia, effusions)
Hepatomegaly
In addition, conjunctival injection develops in approximately one third of patients with dengue hemorrhagic
fever. Optic neuropathy has been reported and occasionally results in permanent and significant visual
impairment. Pharyngeal injection develops in almost 97% of patients with dengue hemorrhagic fever.
Generalized lymphadenopathy is observed.
Hepatomegaly is present more often in dengue shock syndrome than in milder cases. Hepatic transaminase
levels may be mildly to moderately elevated. Encephalopathy is a rare complication that may result from a
combination of cerebral edema, intracranial hemorrhage, anoxia, hyponatremia, and hepatic injury.
Hypotension
Bradycardia (paradoxical) or tachycardia associated with hypovolemic shock
Hepatomegaly
Hypothermia
Narrow pulse pressure (< 20 mm Hg)
Signs of decreased peripheral perfusion
Undifferentiated Fever
DIAGNOSTICS
Tourniquet Test
The tourniquet test is part of the new WHO case definition for dengue. The test is a marker of
capillary fragility and it can be used as a triage tool to differentiate patients with acute
gastroenteritis, for example, from those with dengue. Even if a tourniquet test was previously done,
it should be repeated if
It was previously negative
There is no bleeding manifestation
Complete Blood Count Monitoring- Characteristic findings in dengue fever are thrombocytopenia
(platelet count < 100 x 109/L), and leukopenia.
A hematocrit level increase greater than 20% is a sign of hemoconcentration and precedes shock.
The hematocrit level should be monitored at least every 24 hours to facilitate early recognition of
dengue hemorrhagic fever and every 3-4 hours in severe cases of dengue hemorrhagic fever or
dengue shock syndrome.
Laboratory diagnosis method for confirming Dengue viral infection involves use of one or
combination of any of the following four different methods:
Microscopy and Staining
Culture
Serology
Detection of Antigen
Detection of Antibody
Molecular Diagnosis
Note: Early stages of the disease: After the onset of illness, virus can be detected in blood (serum,
plasma) or tissues; methods employed are; virus isolation, nucleic acid or antigen detection.
At the end of acute phase of infection: Serology is the method of choice.
Note: For virus culture, it is important to keep blood samples cooled or frozen to preserve the
viability of the virus during transport from the patient to the laboratory.
Fig 1: Comparison of Dengue virus diagnostic tests according to their accessibility and confidence
Microscopy and Staining: In this case, direct visualization of the virus in the sample (using electron
microscopy or via fluorescent staining technique) is not done in diagnostic laboratories.
Culture: Virus isolation in cell culture is difficult and is not the commonly used method in
diagnostic laboratories because it is demanding procedure (both in terms of infrastructure and
technical expertise). Virus may be recovered from serum, plasma and peripheral blood
mononuclear cells. Inoculation of a mosquito cell line with patient serum, coupled with nucleic acid
assays to identify the recovered virus is commonly used approach.
Fig
2: Approximate time-line of primary and secondary dengue virus infections and the
diagnostic methods that can be used to detect infection
Serological Test: Serological tests are the mainstay in the diagnosis of viral infections.
Detection of Viral Antigen: Dengue NS1 Antigen detection
useful for the diagnosis of acute dengue infections.
has been detected in the serum of DENV infected patients as early as 1 day post onset of symptoms
(DPO), and up to 18 DPO.
NS1 ELISA based antigen assay is commercially available
NS1 assay may also be useful for differential diagnostics between flaviviruses because of the
specificity of the assay
Detection of Anti-dengue antibodies in serum or other body fluids by ELISA or other rapid
tests. Various methods (IgM/IgG ELISA, Hemagglutination Inhibition Test, or Rapid diagnostic kits)
are available to detect Anti-Dengue Antibodies;IgM detection: Useful for the diagnosis of primary
Dengue infection and in distinguishing dengue from other flavivirus infections. IgM antibodies are
detectable in 99% of patients by day 10 after onset of illness.IgM levels peak about two weeks after
the onset of symptoms and then decline to undetectable levels over 23 months. Sensitivity: 65-
75% sensitive in single acute serum sample.
Fig 3: Rapid ICT
based Test for the diagnosis of Dengue Infection
IgG detection: Tests that detect IgG are useful in diagnosing secondary disease (IgG is the dominant
immunoglobulin type in secondary infection). The test is complicated by cross-reactivity of IgG
antibodies to heterologous flavivirus antigens (West Nile virus, tick-borne encephalitis virus, yellow
fever virus, Zika virus).
Note: To distinguish primary and secondary dengue infections, IgM/IgG antibody ratios are now
more commonly used than the haemagglutination-inhibition test (HI).
Molecular diagnosis: detection of viral RNA in plasma or serum or tissues using Nucleic Acid
Amplification Tests (NAAT). RT-PCR based methods for rapid identification and serotyping of
dengue virus in acute phase serum are available.
Fig 4: Summary of operating characteristics and comparative costs of dengue diagnostic methods
turn buckets and watering cans over and store them under shelter so that water cannot accumulate
remove excess water from plant pot plates
scrub containers to remove mosquito eggs
loosen soil from potted plants, to prevent puddles forming on the surface
make sure scupper drains are not blocked, and do not place potted plants and other objects over
them
use non-perforated gully traps, install anti-mosquito valves, and cover any traps that are rarely used
do not place receptacles under an air-conditioning unit
change the water in flower vases every second day and scrub and rinse the inside of the vase
prevent leaves from blocking anything that may result in the accumulation of puddles or stagnant
water
Practice 4s
Stop means dropping everything and shifting current task for mosquito control. When the clock
strikes 4 p.m., look for the breeding sites of dengue-carrying mosquitoes and carry out systematic
search and destroy activities to eliminate them.
Listen entails heeding the instructions from local authorities, community leaders or work
supervisors for a synchronous implementation of the 4 oclock habit.
DENGVAXIA
RECOMMENDATIONS:
Note: Since Dengue Fever is usually self-limiting disease management of this is geared towards
symptomatic treatment and palliative care. There is no specific antiviral treatment currently
available for dengue fever.