Laboratory Studies

Isolation of virus in serum and detection of immunoglobulins (IgM and IgG) by enzyme-linked immunosorbent assay (ELISA) antibody capture, monoclonal antibody, or hemagglutination Complete blood count o Hemoconcentration (hematocrit increased 20%) o Thrombocytopenia (platelet count <100 x 109/L) o Leukopenia Chemistry panel o Electrolyte imbalances o Acidemia o Elevated BUN Liver function tests o Elevated transaminases o Hypoproteinemia Guaiac test for occult blood in stool DIC panel, as indicated

Imaging Studies

Chest radiography o Bronchopneumonia o Pleural effusion Head CT scan without contrast o For altered level of consciousness o Intracranial bleeding o Cerebral edema

Other Tests

Electrocardiography o Nonspecific changes may be effects of fever, electrolyte disturbances, tachycardia, or medications. o Usefulness of these changes as a marker of cardiac involvement is unclear.

Pathophysiology
Dengue viral infections frequently are not apparent. Classic dengue primarily occurs in nonimmune, nonindigenous adults and children. Symptoms begin after a 5- to 10-day incubation period. DHF/DSS usually occurs during a second dengue infection in persons with preexisting actively or passively (maternally) acquired immunity to a heterologous dengue virus serotype. Illness begins abruptly with a minor stage of 2-4 days' duration followed by rapid deterioration. Increased vascular permeability, bleeding, and possible DIC may be mediated by circulating dengue antigen-antibody complexes, activation of complement, and release of vasoactive amines. In the process of immune elimination of infected cells, proteases and lymphokines may be released and activate complement coagulation cascades and vascular permeability factors.

Deterrence/Prevention

Reduce A aegypti vector populations.3 Reduce exposure to A aegypti. o Use insect repellent. o Sleep under a mosquito net in affected areas. o Wear protective clothing. Vaccines against all 4 serotypes are currently under development. While this is challenging due to the complex immune response, vaccines may ultimately be the most effective control strategy, since vector control programs have been largely unsuccessful and of only short-term local benefit.4,5

Prevention
By Mayo Clinic staff A dengue fever vaccine is in development but isn't generally available. If you're living or traveling in an area where dengue fever is known to be, the best way to avoid dengue fever is to avoid being bitten by mosquitoes that carry the disease. To reduce your risk of mosquito bites, minimize your exposure to mosquitoes:

Schedule outdoor activities for times when mosquitoes are less prevalent. Avoid being outdoors at dawn, dusk and early evening, when more mosquitoes are buzzing about. Wear long-sleeved shirts, long pants, socks and shoes when you go into mosquito-infested areas. Stay in air-conditioned or well-screened housing. Patch screens if necessary, especially where there will be nighttime exposure. Apply permethrin-containing mosquito repellent to your clothing, shoes, and camping gear and bed netting. You can also buy clothing made with permethrin already in it.

Use repellent with a 10 to 30 percent concentration of DEET on your skin. Choose the concentration based on the hours of protection you need a 10 percent concentration of DEET is effective for about two hours; higher concentrations last longer. However, chemical repellents can be toxic, so use only the amount needed for the time you'll be outdoors.

Don't use DEET on the hands of young children or on infants under 2 months of age. Instead, cover your infant's stroller or playpen with mosquito netting when outside. According to the Centers for Disease Control and Prevention, oil of lemon eucalyptus, a more natural product, offers the same protection as DEET when used in similar concentrations. Meedica Patients present with: flu-like myalgia, maculopapular or petechial rash, sudden onset fever, postorbital pain, nausea, vomiting and possible signs of hemorrhage or vascular permeability. Disease is often less severe in infants as maternal antibodies may offer transient protection but overall causes higher morbidity and mortality in children under age 15. Fever may have a characteristic saddleback appearance during the acute phase of infection (5 or fewer days after onset). Fever will resolve after a sudden onset and then reappear in a few days. Consider dengue fever the causative agent of such symptoms in endemic regions during rainy seasons and periods of mosquito activity. Due to an incubation period of 3 to 14 days, suspect travelers of dengue infection if the onset of fever occurs less than 2 weeks after travel to an endemic region. Dengue virus has an incubation period of 3 to 14 days, followed by an acute phase lasting approximately 5 days with fever, rash and potential development of more severe forms of the illness. Convalescence lasts up to 3 weeks from onset and is often accompanied by fatigue and depression in adults. Diagnostic medical management of dengue fever requires collection of two or more blood draws. Draw the first sample upon presentation (during the acute phase) and a second sample during convalescence (6 to 21 days after onset). Use acute phase samples to check CBC, albumin levels, liver function, viral isolation and serology. Send convalescent samples for serology study by ELISA. Base medical management of dengue hemorrhagic fever on empirical clinical findings; physicians rarely receive dengue infection confirmation through viral isolation or serology during acute the acute phase of infection. Differential diagnosis requires consideration of influenza, malaria, measles, rubella, leptospirosis, meningococcemia, typhoid fever, bacterial sepsis and other viral hemorrhagic fevers. Blood pressure may be elevated on exam due to dehydration and compromised vascular permeability. Signs of hemorrhage include petechiae and bleeding from various orifices (vaginal, nasal, oral, anal, aural). According to the Centers for Disease Control, you can perform a

tourniquet test by inflating the blood pressure cuff "midway between systolic and diastolic pressure for 5 minutes." Twenty of more petechiae per square inch indicate a positive result. Patients may exhibit mildly to moderately elevated liver enzymes, specifically aspartame aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transpeptidase (GGT). Bilirubin and alkaline phosphotase may also show elevations.

Warning
Dengue fever patients exhibiting neurological symptoms such as seizures, confusion and lowered consciousness are at higher risk for subsequent development of dengue hemorrhagic fever (DHF). Watch for signs of impending circulatory failure and shock in patients with dengue hemorrhagic fever (DHF). Danger signs include intense sustained abdominal pain, repeated vomiting, rapid onset of hypothermia following fever and altered mental status.

Considerations
In the medical management of a suspected dengue fever fatality, request collection of fresh tissue samples from the heart, liver, kidney, lungs, intestines, spleen, lymph nodes, brain and skin (from an area exhibiting petechiae) for use in viral isolation and immunohistochemistry. Samples fixed in formalin are not suitable for viral isolation.

Expert Insight
The four flavivirus strains (DEN-1, DEN-2, DEN-3, DEN-4) causing dengue fever do not confer cross-immunity. A prior history of dengue fever infection does not preclude a current case of dengue fever. Co-infection with multiple strains is a distinct possible in endemic regions. Infection or co-infection with hepatitis B or hepatitis C may also lead to similar liver function test results. http://www.ehow.com/about_4645028_medical-management-dengue-hemorrhagicfever.html