Joel Vasanth Peter
Outline
History
Introduction
Mechanism of Action
Signs and Symptoms
Clinical Course
Complications
Laboratory investigations
Management
Differential diagnosis
Prevention
Vaccine
Conclusion
History
International Anti-Dengue Day is observed every
year on 15 June.
The first record of a case of probable dengue fever is
in a Chinese medical encyclopedia from the Jin
Dynasty (265–420 AD) which referred to a "water
poison" associated with flying insects.
Introduction
It is a mosquito borne tropical disease that is caused
by the dengue virus.
Introduction
Common in the tropics, up to the 35th latitude.
80% of all cases are either asymptomatic or have only
mild symptoms.
5% of all cases can be life threatening without
intervention
Introduction
It is an RNA virus.
There are 5 types of Dengue virus
(DENV1-4) and a recently
discovered one in 2013.
It is transmitted by the female
Aedes aegypti.
It can also be transmitted through
blood products and organ
donation.
Vertical transmission has also
been reported.
Mechanism of Action
Signs and Symptoms
Signs and Symptoms
Typically the signs and symptoms start between 3-14
days after incubation.
Most commonly it is between 2-7 days.
The symptoms is similar to a common cold and acute
gastroenteritis.
The symptoms of dengue are more severe in those
with co-morbidities and also with previous infection
of dengue with other viral strains.
Signs and Symptoms
A probable diagnosis of Dengue can be made if there is fever
along with any 2 of the following symptoms.
Nausea
Vomiting
Rash
Generalised pain/ Malaise
Low WBC count
Positive tourniquet test
Or any of the warning symptoms
Signs and Symptoms
The dengue rash is a rash
described as "islands of
white in a sea of red" has
also been observed.
Another rash may occur
with either a
maculopapular or a
vasculitic appearance,
which is followed by
peeling of the skin.
Signs and Symptoms
Tourniquet test: The tourniquet test, which is
particularly useful in settings where no laboratory
investigations are readily available, involves the
application of a blood pressure cuff at between the
diastolic and systolic pressure for five minutes,
followed by the counting of any petechial
hemorrhages. a higher number makes a diagnosis of
dengue more likely with the cut off being more than
10 to 20 per inch squared.
Signs and Symptoms
Warning signs
Worsening abdominal pain
On-going vomiting
Enlarged liver
Mucosal bleeding
High haematocrit but low platelets
Lethargy/Restlessness
Pleural effusion/Ascites
Clinical course
There are 3 courses of Dengue
The Febrile phase
The Critical phase
The Recovery phase
Clinical Course
Febrile phase
There is fever that can be greater than 104F. The
fever is of a biphasic nature. It breaks and then
returns for 1-2 days. It is also known as breakback
fever
There is also a rash that is present in 50%-80% of all
cases. It can occur on the 1st or 2nd day of fever.
Clinical course
Critical phase
Some individuals proceed to the critical phase. The fever
resolves. There is leakage of plasma from the blood vessels and
there is fluid shift into the body cavities.
It can accumulate as plural effusion or as ascites.
It also manifests as hypotension.
There can also be organ dysfunction and severe bleeding from
the GIT.
NSAIDs are contra-indicated in dengue as they can cause GI
bleeds.
5% of all cases proceed to Dengue Haemorrhagic syndrome and
Dengue Shocks syndrome.
Clinical Course
Recovery phase
There is reabsorption of the leaked fluid into the
blood stream.
This occurs in 2-3 days.
The patient can have bradycardia and severe itching.
A decreased level of consciousness can occur in 0.55-
6% of severe cases due to the inflammation of the
brain by the virus /due to fluid overload/
impairment vital organs such as the liver.
Clinical courses
Cases of Transverse myelitis and Guillain-burre
syndrome, Acute liver failure and infection of the
heart have been reported but are very rare.
In pregnancy having dengue can cause and increase
in the risk of miscarriage, low birth weight and
premature birth.
Complications
Dengue Haemorrhagic syndrome
Dengue shock syndrome
Dengue attacks the liver and the bone marrow.
It causes the dysfunction of the platelets due to
infection of the stromal cells.
There is increased capillary permeability which
causes decrease in the effective circulatory volume
and that causes hypotension. That causes organ
failure.
Complications
Dengue shock syndrome is present if the pulse
pressure is less than 20mmHg with peripheral
vascular collapse.
Dengue haemorrhagic fever involves bleeding
manifestations.
Laboratory
investigations
Thrombocytopenia
Elevated liver enzymes (moderately increased AST/ALT)
Hypoalbuminaemia
Increased Haematocrit
Deranged bleeding parameters
Metabolic acidosis
NS1 Antigen detection
Nucleic acid detection by PCR
IgG and IgM antibodies.
Dengue illness in children
Winsley Rose, J Ebor
Jacob, Debasis Das
Adhikari, Valsan Philip Verghese
Department of Child Health,
Christian Medical College,
Vellore, Tamil Nadu, India
Differential diagnosis
Malaria
Chikungunya
Leptospirosis
Viral haemorrhagic fever
Typhoid fever
Meningococcal disease
Measles
Influenza
Zika fever also has similar symptoms as dengue.
Prevention
The World Health Organization recommends an Integrated Vector
Control program consisting of five elements
Advocacy, social mobilization and legislation to ensure that
public health bodies and communities are strengthened;
Collaboration between the health and other sectors (public and
private);
An integrated approach to disease control to maximize use of
resources;
Evidence-based decision making to ensure any interventions
are targeted appropriately
Capacity-building to ensure an adequate response to the local
situation.
Prevention
The primary method of controlling A. aegypti is by
eliminating its habitats.
This is done by getting rid of open sources of water,
or if this is not possible by
adding insecticides or biological control agents to
these areas.
Mosquito netting
Insect repellent
Vaccine
In 2016 a partially effective vaccine for dengue
fever became commercially available.
It is based on a weakened combination of the yellow
fever virus and each of the four dengue serotypes.
Two studies of a vaccine found it was 60% effective
and prevented more than 80 to 90% of severe cases.
In 2017 the manufacturer recommended that the
vaccine only be used in people who have previously
had a dengue infection as otherwise there was
evidence it may worsen subsequent infections.
Conclusion
Early diagnosis
High level of clinical suspicion in endemic areas
Early intervention in severe dengue
Accurate active intervention, especially in children.
Thank you
