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PUBLIC ENEMY NO. 1
Dengue Haemorrhagic Fever
Dr. SOMESH MEHROTRA
Critical care Specialist
Siddhi Vinayak HospitalBareilly , UP, india
9837000048
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To fight- you should know the enemy inside out
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Four lives of Dengue virus Family flaviviridae .
has four serovars.den1-den2,den3and den4
Infection with one serotype confers long term immunity tothat serotpt only
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Efficient vector susceptible to Dengue virus.
Bites many human for a single meal in day time.
Urban dweller
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Global problem
Recognized in the Philippines in 1953.
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Transmission of Dengue Viruses
Viruses are transmitted from humans to
mosquitoes to humans
Next generation of mosquitoes
Human are the main amplifying hosts
Monkeys can also be reservoirs
The virus circulates in the blood approx.
at the time of fever
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OUT BREAK
-PART I
(Two important epidemiological patterns)
DHF/DSS in where multiple dengue
serotypes are endemic.
Sporadic cases or small outbreaks in urban
areas that steadily.increase in size
Pattern of epidemic activity every 2-5 years.
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OUT BREAKPART - II
A second pattern
Low endemicity
Multiple Dengue serotypes
Relatively low rates of infections
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Pathology
At autopsy Frequency of Hemorrhage
Skin and subcutaneous tissue
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Liver
There is focal necrosis of hepatic cells,
swelling.
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Kidney
Immune-complex type of
glomerulonephritis which resolves
completely in 3 weeks Perivascular Oedema
Sderum complement, immunoglobulin and
fibrinogen.
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Bone marrow
Depression of all haematopoietic cells was
observed, which would rapidly improve as
fever subsided.
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Pathogenesis of DHF/DSS
Vascular permeability. Disorder in haemostasis
(Haemoconcentration, ( Vascular changes,
low pulse pressure. Thrombocytopenia andSign of shock.) coagulopathy.)
of the complement system of C3 and C5 levels.
Platelet defects both qualitative and quantitative.
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Secondary Infections
Enhancement of virus replication in
macrophages by heterotypic antibodies.
Cross-reactive but not neutralizing
antibodies.
Cross-reactive CD4+ and CD8 + cytotoxic
lymphocytes.
Cross Reaction
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Case Definitions
Probable Dengue Fever
An acute febrile illness with two or more of the following :
headache
retro-orbital pain myalgia rash
heamorrhagic manifestations
leukopenia
and
supportive serology : antibody titre >1280, a comparable IgG ELISA titre, or a positiveIgM antibody test
Or occurrence at the same location and time as other confirmed cases of dengue
fever.
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Case Difination
Confirmed dengue fever Isolation of the dengue virus from serum or autopsy; or
A fourfold or greater change in rciprocal IgG or IgM antibody titresto one or more dengue virus antigens in paried serum samples; or
Dengue virus antigen in autopsy tissue, serum or C.S.F. samples byimmunohistochemistry, immunofluorescence or ELISA; or
Dengue virus genomic sequences in autopsy tissue serum or C.S.F.
samples by PCR.
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Case definition
Dengue haemorrhagic feverAll of the following must be present
Fever, or history of acute fever, lasting 2-7 days occasionally biphasic.
Haemorrhagic tendencies(at least one of--)
Tourniquest test
1. Petechiae, ecchymoses,purpura2. Bleeding-mucosa,git,injection site
3. Haemetemesis, malena
Thrombocytopenia (100000 cells per mm3 or less).
Evidence of plasma leakage due to increased vascular permeability,manifested by at least one of the following.
1. A rise in PCV equal to or greater then.2. A drop in the haematocrit following volume-replacement treatmentequal to or greater than 20% of baseline;
3. Signs of plasma leakage such as pleural effusion, ascities andhypoproteinaemia.
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Case Definition for Dengue
Shock SyndromeAll four points of DHF and ;
Rapid and weak pulse.
Narrow pulse pressure(< 20mm Hg
(2.7KPa))
or manifested by :
Hypotension for age.
Cold, clammy skin and restlessness.
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Drugs for dengue
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Grading severity of DHF
Grade I : Fever + non-specific cc + tourniquet test and/or easybruising.
Grade II: Spontaneous bleeding.
..DSS..
Grade III : Circulatory failure i.e. a rapid, week pulse and narrowingof pulse pressure or hypotension, + cold, clammy skin andrestlessness.
Grade IV: Profound shock with undetectable blood pressure or pulse.
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Indications for hospitalization
for bolus intravenous fluid therapy may be
necessary where significant dehydration
(>10% of normal body weight) hasoccurred and rapid volume expansion is
needed. Signs of significant dehydration
include :
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Tachychardia
Ivreased capillary refill time (>2s)
Cool, mottled or pale skin
Diminished peripheral pulses
Changes in metal status
Oliguria
Sudden rise in haematocrit or continuously elevated
haematocrit despite administration of fluids
Narrowing of pulse pressure (
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DHF-treatment
# ORS
Hyperpyrexia
Day of judgment;is the day of
defervescence
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DSS- continued replacement
Plasma loss may continue for 24-48 hrs
CVP measurement
Reabsorption of extravasated plasma=pcv
falls
Blood transfusion
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Unusual manifestations of
dengue haemorrhagic fever Acute hepatic failure
Maintainance of consciousness even in
presence of severe shock
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Criteria for discharging inpatients
Absence of fever for at least 24 hours.
Return of appetite.
Visible clinical improvement. Good urine out put.
Stable haematocrit.
Passing of at least 2 days after recovery from
shock.
No respiratory distress from pleural effusion orascites.
Platelet count of more then 1 lakh per mm
3
.
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Chikungunya; that which bends up Is the little sister clinically
Joint pains are the major feature of both acute andchronic phase
Ankle & wrist Intense pain caused by the pressure on wrist is
diagnostic Lymphopenia, thrombocytopenia,hepatitis
High viremia causes direct man to mantransmission
World wide 2 million cases
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. Perils of platelet transfusion
Nu. & condition of pl.extract.
Fever, spelnomeghaly,drugs,DIC, Alloimmunization-from wbc,rbcs in
pl.extractirradation by ultraviolet B helps
TRAP study-apherisis ???#
Refractoriness
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