DENGUE FEVER

DEFINITION

Dengue Fever

acute fibrile illness syndrome caused by

arboviruses
characteristic: biphasic fever, myalgia,
arthralgia, leukopenia, rash &
lymphadenopathy.
A.k.a dengue / breakbone fever

Dengue
Hemorrhagic
Fever
(DHF/DSS)

Febrile disease caused by dengue viruses

Characteristic: abnormality in hemostasis,
protein & fluid leakage from capillaries &
shock ( severe case).
A.k.a infectious thrombocytopenic purpura

EPIDEMIOLOGY
Natural host: Human
Documented globally except at the Antartica
The 1st outbreak reported in 1780, in
Philadelphia, by Benjamin Rush.
Endemic in > 100 countries( Africa, America,
Eastern Mediterranian, SEA & Western Pacific)

2.5 billion people at risk, 50 million

infected worldwide per year

In SEA, among top ten causes of

death in children (1-14 years).
In Msia, 1st DF case found in 1902,
(Penang)
1st DHF in 1962 (Penang)

AETIOLOGY
Caused by 4 distinct but related viruses, DEN-

1/2/3/4- classified under Flaviviridae family

ssRNA viruses, enveloped and spherical (50 nm)
Infection by one type confer lifelong immunity
towards that type, but only partial towards other
type.
Evidence increase risk for DHF if there is sequential
infection

 Vector : Aedes aegypti (main), Aedes albopictus &

Culex quinquefasciatus
A.aegypti (day-time bitting mosquito)

-must be infective female

-prefer feeds on human (abundant around
human.
-breeds in clear water
-bitting activity reduced in low temperature
14C(transmission less in winter)

Transmission
Infected Human
-Source of viruses.
-Viremia for about 2-7 days.

Non infected human

-get infection by bitting.

Mosquitoes
- female,acquired
viruses from human
-transmitted during
feeding, life-long

Classification
Dengue

Dengue Fever

Dengue
Hemorrhagic
Fever
( DHF/DSS)

Clinical Manifestation
Dengue Fever
- 1 Infection with DEN-2 and DEN-4 are thought to be

inapparent, regardless of age

- 1 infection with DEN-1 & DEN-3 in adult produces
biphasic fever and rash.
- Manifestation varies,

in infant & young child asymptomatic to 1-5 days

fever, rhinitis, mild cough, pharyngeal inflammation
In classic dengue fever
- after incubation 2-7 d, rapid & sudden onset of fever

 Accompanied by frontal or retro-orbital headache

Back pain (precedes fever,occassionally)
Macular rash (transient, generalized,in first 2 days of

fever)
Pulse rate is slow ( in proportion to fever)
Myalgia ( increase in severity)
Nausea & vomiting (on 2-6 D of fever)
Generalized Lymphadenopathy , followed by of period of
Defervescence.
Generalized mobiliform, maculopapular rash(palm &
soles spare)- disappear in 1-5 D (Biphasic C curve)

 At any stage, petechiae,epistaxis & purpuric lesion occur

(not common)
After febrile stage, prolonged asthenia, bradycardia &
extrasystole note( common in adult)

Dengue Hemorrhagic Fever( DHF).

Fever of high grade &
continous for 2-7 Days

Hemorrhagic diathesis or
positive for tourniquet test
(except in shock)

Defination of DHF
( from WHO, must be
present):
Thrombocytopenia
( < 10^/ mm3)

Haemoconcentration (HCT
20% from baseline or
present plasma leakage).

~Other suggestive signs: hepatomegaly, circulatory

disturbance, hematocrite fall after fluid replacement

Clinical Manifestation
Dengue Hemorrhagic Fever (DHF/ DSS)
An acute vascular permeability syndrome followed with

abnormal in hemostasis.
Progression of illness is characteristics (in children).
In mild 1st phase: abrupt onset of fever, malaise,
cough, vomiting, headache & anorexia ( after 2-5 Days of
rapid deteroriation & physical collapse)
In 2nd phase: has clammy hand, cold, warm trunk.
Flush face & diaphoresis.
Restlessness, irritated, complained of mid-epigastric
pain.
Peripheral cyanosis may occur.

 Scattered petechiae on forehead, extremities, spontenous

ecchymoses, easy bruising and bleeding at site of

venupuncture( common findings).
Respiration is rapid & often laboured.
The pulse pressure is usually narrow (20 mmHg),
systole & diastolic pressure may be low or unobtainable.
Liver become tender ( 2-3 fingerbeadth below costal
margin, firm & nontender)
Bilateral or unilateral pleural effusion (radiograph)
After 2-3 Days of crisis, convalescence is rapid in
children who recovered.
Temperature may return to normal during or before
shock.

PATHOGENESIS
Infection by mosquitoes
bites,transmission of virus into host.
Dengue viruses infect & replicate in
I/cutaneous Langehans cell & in tissue
explant
Eventually, it targets liver parenchymal cell
(apoptosis, but not become replicate host)
In late infection,virus found in
circulating B-lymphocytes (viremia)

Infected cells are attacked by activated Tlymphocytes

Released of vasoactive cytokines (by
lymphocytes) will caused vascular
permeability.
Early in acute phase of 2 virus infection,
rapid activation of complement syst. occur.
But, during shock, complement substances
are depressed.TNF,IL-2 & IF- contribute it
(recent studies).
Capillary damage allowed blood component
to leak into i/vascular space, lead to
hypovolumia,hyponatremia,tissue hypoxia,
high in HCT & cardiac work
On micrscopic exam.maturation arrest of megakaryocytes in BM( D/t vasoactive
amines )

Diagnosis
Dengue Fever

DHF / DSS

Base on geographical
distribution.
Activities of patient
before onset of
illness.

Thrombocytopenia
(<10^4/mm3)
Hemoconcentration
(20% of normal
value)
Pleura or peritoneal
effusion
(pathognomonic)

WHO Grading of DHF/DSS

Grade 1

Grade 2

-Fever with
constitutional
symptoms.
-Positive Hess
test

-Spontenous

-Grade

Grade 3

-Circulatory
bleeding(skin failure (rapid
weak pulse,
other
narrow pulse
bleeds) in
pressure
addition to
manifestation <20mmHg,
but systolic
of Grade 1
BP still
normal.

Grade 4
-Profound
shock
(hypotension,
undetectable
BP & HR).

3 & 4 is Dengue Shock Syndrome (DSS).

-Thrombocytopenia & hemoconcentration differentiate Grade 1
& 2 of DHF from DF.

Investigation
Serology
Study

For etiology diagnosis.

Depend on antibodies titer
ELISA, Complement
fixation,Radioimmunoassay

Full Blood
Count (FBC)

Assess platelet level

Check for hematocrite level

Tourniquet
Assess for hemorrhagic tendency
Test(Hess
test)
Virus isolation

TREATMENT & MANAGEMENT

Dengue Fever:
Mostly supportive.
Antipyretic drugs or cold sponging (< 40C).

Fluid & electrolyte are given when necessary.

Aspirin is contraindicated ( avoid Reye Synd.)
DHF/DSS:
No antiviral given, only supportive measures.
Antipyretic to avoid convulsion .
Fluid intake is monitored (by mouth)

 Observe sign of shock in children.

Oral & parenteral fluid therapy for rehydration (to correct

metabolic aacidosis or dehydration).

Shock
Need admission.
obtainIV access. & resuscitate.
Monitor : vital signs, PCV, ABG, BP hourly until stable,

platelet count 6 hourly, BUSE & urine output.

Fluid maintenance- continue with .45%saline 5%
dextrose(1-2 maintenance)

 Electrolyte and metabolic disturbance.

-correction of hypoglycemia.
Transfusion of blood & blood products.
Monitor coagulation profile.
O2 supplement.
Vitamin K & H2 antagonist.

Prevention & Control

Environmental Methods
-Proper solid waste disposal.
-Improve water storage
practices

Vector Control
-Education

Chemical Methods
-appropriate
insecticides into larvae
habitat
-Space sprays
( machines, during
outbreaks)

Prognosis
Only 1/3 of DHF patient develop shock and

circulatory failure ( outpatient Tx is enough , bring

back when there are alarming signs) .
Early plasma, fluid & electrolyte replacement proved
to have favourable outcome( maintain circulation).
In DHF/DSS case, great care taken to reduce
invasive procedures while managing shock.
In children,
-in shock with unobtainable BP,
Has poor
-in shock but delayed admission,
prognosis
-in shock with GIT bleeding