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Dengue

Dengue . Divya Bappanad Karapitya Hospital Galle, 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

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Dengue

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  1. Dengue Divya Bappanad Karapitya Hospital Galle, Sri Lanka

  2. 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.

  3. 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

  4. Studies • WBC 5.2 86% N, 12% L and 1.2% M, Hgb 14 and Platelets 16,000 • Dengue IgM + and IgG + • CXR: clear

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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.

  12. 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

  13. 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

  14. Treatment • Supportive • WHO management algorithm for fluid resuscitation • Transfusion • Oxygen • ICU monitering

  15. Prognosis • Dengue fever < 1% mortality • Dengue hemorrhagic fever approx 2.5% mortality • Primarily children • Dengue shock up to 47% mortality

  16. 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

  17. 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.

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