Dengue Divya Bappanad Karapitya HospitalGalle, Sri Lanka

Initial Presentation•HPI: 18 yo Sri Lankan male in USOH until

developed fever, myalgias and vomiting x 3 days. On basketball team and day prior to fever participated in game with no complaints.

•PMH: none•Medications: none• Immunizations: up to date•SH: student, lives with mother in nearby

community outside Galle, + electricity and running water, no siblings, no recent travel.

Physical Exam•Vitals: T 40C BP 110/80 supine 90/70

standing HR 96 RR 16 SpO2 not available•Gen: Alert, Ill appearing•HEENT: PERRLA, EOMI, + conjunctival

injection, OP clear, MM dry•Neck: No LAD•CV: RRR, no m/g/r•Lungs: CTAB, no w/r/r•Ab: +BS, soft, NT, ND, no HSM•Ext: No edema•Skin: No petechia

Studies

•WBC 5.2 86% N, 12% L and 1.2% M, Hgb 14 and Platelets 16,000

•Dengue IgM + and IgG +•CXR: clear

Continued Clinical Course

•Day 2 Coffee ground emesis▫Transfused FFP, plts and has transfusion rx

•Day 3 Increased work of breathing▫Transferred to ICU and intubated▫Abx, plts and steroids

•Day 4 Hypotension, decreased urine output with worsening hypoxia▫Started on pressors

Progressive Deterioration

•Day 6 Abdominal compartment syndrome▫Paracentesis with 1.5 L removed

•Day 7 Worsening hypotension, decreased urine output and difficulty ventilating

•Day 10▫Withdrawal of ventilatory support

Dengue Epidemiology• Incidence

▫2.5 billion people in over 100 endemic countries▫50 million people infected annually with 500,000

cases of DHF and approx 20,000 deaths ▫Wide spectrum of illness although most

subclinical or asymptomatic

• Dengue virus▫Flavivirus: Single Stranded RNA virus▫Serotypes: DEN-1 to DEN-4▫DEN-2 and DEN-3 severe disease with secondary

dengue infections

Epidemiology

•Vector▫Mosquito▫Primarily Aedes Aegypti

Aedes albopictus, Aedes polynesiensis and other Aedes species also

▫Most female Ae. aegypti appear to spend lifetime in or around the houses where they emerge as adults.

▫Suggest people rather than mosquitoes, rapidly move the virus within and between communities

Clinical Progression

•Critical phase▫3-7 days▫Temperature defervescence with possible

increased capillary permeability and increasing hematocrit

▫If no change in capillary permeability will improve and “non-severe dengue”

▫If fail to defervesce and develop leakage concerning for development shock

Clinical Progression

•Recovery phase▫2-3 days▫Reabsorption of extravascular fluid▫Bradycardia and ECG changes common▫Hemodynamics stabilize, auto diuresis

begins and patient clinically improves

Severe Dengue( Dengue Hemorrhagic Fever or Dengue Shock Syndrome)• Fever of 2–7 days plus :

▫ Evidence of plasma leakage, such as: high or rising hematocrit; pleural effusions or ascites;

circulatory compromise or shock

▫ Significant bleeding.

▫ Altered level of consciousness (lethargy or restlessness, coma, convulsions).

▫ Severe gastrointestinal involvement (persistent vomiting, increasing or intense abdominal pain, jaundice).

▫ Severe organ impairment (acute liver failure, acute renal failure, encephalopathy or encephalitis, or other unusual manifestations, cardiomyopathy) or other unusual manifestations.

Diagnosis

•Clinical diagnosis▫Live and travel in endemic area and fever +

2 Anorexia and nausea Rash Myalgias/arthralgias Leukopenia Tourniquet test + Signs of severe dengue

Serologic Diagnosis

•Decreasing wbc▫1st serologic abnormality

•Dengue IgM and IgG▫tests viral specific antibodies▫76% sensitive for primary infection and

88% for secondary infection▫88%-99% specificity

Treatment

•Supportive•WHO management algorithm for fluid

resuscitation•Transfusion•Oxygen•ICU monitering

Prognosis

•Dengue fever < 1% mortality•Dengue hemorrhagic fever approx 2.5%

mortality▫Primarily children

•Dengue shock up to 47% mortality

Recurrent infection

•Active infection protected from illness from different serotype for 2-3 months, but not long term

•Infection by one serotype confirms lifelong immunity to that serotype

•No immunization currently available

Bibliography

• Dengue: guidelines for diagnosis, treatment, prevention and control. Second edition. Geneva: World Health Organization. 2009. Accessed at http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf

• Singhi S, Kissoon N, Bansal A. Dengue and dengue hemorrhagic fever: management issues in an intensive care unit. J Pediatr (Rio J). 2007; 83(2 Suppl):S22-35.