Gatoet Ismanoe

Division of Tropical Medicine & Infectious Diseases

Department Of Internal Medicine Brawijaya Medical Faculty
Saiful Anwar Teaching Hospital Malang
Virus DEN Sel Target
Monosit
Makrofag
Sel Kupffer

Komplemen

Pelebaran celah Endotel

Interferon  Pe Permeabilitas
Hiperaktifitas
Interferon  komplemen

Pe Sekresi Histamin
Virus DEN

Ensim PLA 2

Makrofag
Metabolisme
As Arakhidonat

Jalur Siklooksigenase

Leokotrien
Membuka Celah
Protasiklin
Endotel kapiler
Tromboksan
Prostaglandin E-2
Virus DEN
Aktifasi Gen
NF-kB

Makrofag
Produksi & Sekresi
Sitokin Proinflamatori

IL-I  Malfungsi Endotel

IL-I 6
TNF  -> Destruksi Endotel

Plasma Leakage
Virus DEN

Makrofag
Sintesis NO

Pe Kelenturan
Dinding Kapiler
ROS

Plasma Leakage
Transmission Cycle
NOISAKRAN AND PERNG
 Clinical manifestation
• Asymptomatic
• Dengue fever
• Dengue hemorrhagic
fever
• Dengue shock syndrome
Risk Factors For Dengue
Haemorrhagic Fever
Natural Course of DHF

• Fever 2 – 7 Days
• Critical Period 24 – 48 hrs
Plasma leakage
Abnormal hemostasis
• Convalescence 3 – 7 Days
 Dengue fever
 Acute febrile illness with two or more of the following
– Headache, retro-orbital pain, myalgia,
arthralgia, rash, hemorrhagic manifestation,
leukopenia
 Lab for confirmation
– Isolation of dengue virus, fourfold rising in
reciprocal IgG or IgM, PCR (genomic
sequence), immunostaining (dengue
antigen)
Dengue hemorrhagic fever
• Fever (last 2-7 days), occasionally biphasic
• Hemorrhagic tendency
– Tourniquet test, petechiae, bleeding from mucosa
• Thrombocytopenia (< 100,000 cell/mm3)
• Evidence of plasma leakage
– Hct increase >20%, Hct drop >20% after
volume replacement, pleural effusion, ascites,
hypoproteinaemia
Dengue shock syndrome

 Evidence of circulatory failure

 Narrow pulse pressure < 20
mmHg
 Hypotension
 Rapid and weak pulse
 Cold, calmy skin, restlessness
Case Definition for DHF I
 Fever, or history of acute fever, lasting 2-7 days,
occasionally biphasic
 Haemorrhagic tendencies, evidenced by at least one
of the following :
 A positive tourniquet test
 Petechiae, ecchymoses or purpura
 Bleeding from the mucosa,
gastrointestinal tract, injection site or
other locations
 Haematemesis or melena
Case Definition for DHF II
 Thrombocytopenia ( 100.000 cells/mm3 or less)
 Evidence of plasma leakage due to increased
vascular permeability, manifested by at least one of
the following :
 A rise in the haematocrite equal to or greater than 20%
above average for age, sex and population
 A drop in the haematocrite following volume-
replacement treatment equal to or greater than 20% of
baseline
 Signs of plasma leakage such as pleural effusion, ascites
and hypoproteinaemia
Case Definition for DSS
All of the above four criteria for the DHF
must be present, plus evidence of
circulatory failure manifested by :
 Rapid and weak pulse, and
 Narrow pulse pressure (<20 mmHg)
Or Manifested by :
- Hypotension for age, and
- Cold, clammy skin and restlessness
Dengue Diagnosis
Virus isolation Hemagglutination Inhibition
Mosquito inoculation Plaque Reduction Neutraliza
(intrathoracic) IgM and IgG ELISA
Toxorhynchites splendens Rapid tests: Dot blot, Imm
Mosquito cell culture Dipstick, Immunochromatog
C6/36 (Aedes albopictus)
Molecular techniques Anti-dengue
Polymerase chain reaction(PCR) IgM
Taqman
Manifestations :
NS1 Ag Fever
Shock
Viremia Hemorrhage
Day of Fever 2 4 6 8 10 12 14
Days after infection
Sensitivity in the febrile phase
(First few days of fever)
• PCR: >95% - expensive, not available
in most places
• ELISA : 60% on the day of shock
30-40% one day before shock 100% one
day after shock
• NS1Ag: 60-70%
Early Diagnosis :simple clinical & lab.

• Tourniquet test
• CBC PPV = 70-80%
Tourniquet test positive + leucopenia*
= Dengue infection
*Leucopenia = wbc 5,000 cells/cumm
• At least day 3 of fever
• CBC everyday if possible
• Close follow up until 24 hours of defervescence
Tourniquet Test
 Fever day 1
50%
 Fever day 2 70%
 Fever day 3 > 90%
False negative TT
• Obese patients
• Thin patients
• Not good technique
• During shock
 Prolonged shock
• > 10 hours untreated - Death!!!
• > 4 hours untreated
 Liver failure- prognosis 50%

 Liver + Renal failure - prognosis10%

 3 organs failure (+respiratory

 failure) – Prognosis is a miracle!!!

THANK YOU...