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Understanding Expanded Dengue Syndrome: Clinical Aspects and Management Recommendations

Explore the clinical aspects and management strategies for Expanded Dengue Syndrome (EDS) as discussed by Professor Siripen Kalayanarooj, Director of WHO Collaborating Centre for Case Management of Dengue. Understand the classifications, manifestations, and clues to diagnose EDS for timely intervention.

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Understanding Expanded Dengue Syndrome: Clinical Aspects and Management Recommendations

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  1. What`s New in DHF:Clinical aspect Professor Siripen Kalayanarooj, Director, WHO Collaborating Centre for Case Management of Dengue/DHF/DSS, Queen Sirikit National Institute of Child Health.

  2. 1. Adults is more affected than Children

  3. 2. Expanded Dengue Syndrome or Unusual Manifestations of Dengue • Infant < 1 year old • Commonly found in adults • In newly outbreak countries • In endemic countries where there are limited laboratory facilities

  4. Expanded Dengue Syndrome(EDS) • Encephalopathy: confusion, seizure, coma • Liver failure • Renal failure • Cardiac involvement: myocarditis • Other organs involvement

  5. Causes of EDS • Prolonged shock: Liver, renal, respiratory and other organs (unrecognized at the very beginning) • Dengue infections in patients with underlying diseases: DM, HT, Heart diseases, Thalassemia, Liver and renal diseases, etc… • Co-infections with other microbial agents: • Dengue virus virulence: encephalitis, liver failure

  6. Clinical manifestations of EDS Mostly manifestations of DHF+ • Complications • Underlying diseases • Co-infections

  7. Clues to diagnose EDS Detection of plasma leakage (early when the patients present to the healthcare facilities): • Rising Hct ≥ 20% • Pleural effusion: clinical, CXR – right lateral decubitus, ultrasound • Ascites: clinical, ultrasound • Hypoalbuminemia: serum albumin ≤ 3.5 gm% in normal nutritional status Other evidence of DHF: • Thrombocytopenia especially when platelet count < 50,000 cells/cumm. • Clinical bleeding

  8. CXR – compare between 2 positions

  9. Early clinical diagnosis &Management Suspected EDS in patients with thrombocytopenia (platelet count ≤ 100,000 cells/cumm.) or clinical bleeding or shock with high fever (probably with encephalopathy) • Look for evidence of plasma leakage, if positive more likely to have DHF with complication: • DHF with superimposed bacterial infections • DHF with liver injury: hepatitis, liver dysfunction/ failure • DHF with concealed internal bleeding (mostly GI bleed)

  10. 3. Dengue Classifications 1975, 1986, 1997, 2011 2009

  11. Dengue Classification Original WHO Newly suggested WHO 1975, 1986,1997, 2011 • Undifferentiated febrile illness • Dengue Fever (DF) • Dengue hemorrhagic fever (DHF) • Dengue Shock Syndrome (DSS) • Expanded Dengue Syndrome (EDS) WHO TDR 2009 • Dengue (D) • Dengue ± Warning signs (D ± WS) • Severe Dengue (SD)

  12. Dengue virus infection 10,000 AsymptomaticSymptomatic Viral syndrome Dengue fever DHF 1,000 9,000 100 500 400 Plasma leakage • Expanded dengue syndrome • Prolonged shock: liver failure, • renal failure,…Encephalopathy… • Co-morbidities • 3. Co-infections • 4. True dengue infection - encephalitis DHF DSS 1-2

  13. Suspected dengue infections:Fever with any 2 of the followingsin dengue endemic area Original WHO Suggested New • Headache • Retro-orbital pain • Myalgia • Arthralgia/ bone pain • Rash • Bleeding manifestations (Tourniquet positive) • Leukopenia • Rising Hct 10-15% • Platelet ≤ 150,000 cels/cumm • Nausea/ vomiting • Rash • Aches and pain • Tourniquet positive • Leukopenia • Any warning signs Tourniquet positive + Leukopenia

  14. AT QSNICH OPD: Suspected dengue cases that need close observation Original Newly suggested Tourniquet positive + Leukopenia 1,500 cases Warning signs: nausea/vomiting and abdominal pain 30,000+ cases (20 times more workload)

  15. QSNICH: IPD (June – August 2009) Confirmed = 274/298 = 91.9% Kalayanarooj S. J Med Assoc Thai 2011; 94(3); s74-83.

  16. Different between the two classifications Original WHO Suggested New Emphasize on plasma leakage*and abnormal hemostasis (platelet count ≤ 100,000 cells/cumm): • Rising Hct ≥ 20% • Pleural effusion: PE, CXR(right lateral decubitus, ultrasound) • Ascites: PE, ultrasound • Hypoalbuminemia (Alb ≤ 3.5 gm%) Emphasize on warning signs*: • Abdominal pain or tenderness • Persistent vomiting • Clinical fluid accumulation • Mucosal bleed • Lethargy, restlessness • Liver > 2 cm • Lab.: increase in Hct concurrent with rapid decrease in Platelet count *Need close monitoring

  17. Natural course of DHF Day 1 2 3 4 5 6 7 8 9 Shock Fever Pleural effusion, Ascites Hematocrit Plasma leakage Stop leakage Reabsorption Fluid overload IV fluid: NSS, DAR, DLR Colloid: 10%Dextran, 10%Haes-steril M+5% Deficit (= 4,600 ml in adult) WBC Tourniquet test + WBC 6,000-9,000 ≤5,000 Platelet count 200,000 ≤100,000 <50,000 Hct 35 38 45 (rising 20%) Albumin ≤3.5 gm% Cholesterol ≤100 mg% Professor Siripen Kalayanarooj

  18. Early diagnosis by CBC:Guide for management BP = 90/70 mmHg, P 118/min AST/AL:T = 62/59 A 20-year-old woman Good consciousness

  19. Compare between 2 classifications Plasma leakage Warning signs • Follow up platelet and frequent Hct (at least q 6 hours) at critical period • Can prevent shock and severe cases with complications of organs failure • Follow warning signs which are non-specific • Shock cannot be prevented. Organs failure as a consequence of prolonged shock are detected late with overt manifestations and poor prognosis

  20. Lahore Experienced (Sep.-Nov. 11) • Total suspected cases : 600,000+ cases • Confirmed 20,000 cases (< 4%) • At the peak: 4,000-6,000 patients/day • Admission 500-600 cases/day • Death 10-15 cases per day

  21. Multi-country study: 18 countriesValidation study of the newly suggested classification Barniol J et al: BMC Infectious Disease 2011,11: 106

  22. Original and Newly suggested WHO Classification for Dengue Severity: 2005-2010 (total 494 patients) DHF+DSS = 152 patients DW+SD = 467 patients Narvaez F et al: PlosNTD 2011, 5: e1397.

  23. Advantages Original WHO Suggested new • Proven in reducing CFR • Can prevent shock so less severe cases and less complications • No need for confirmed dengue laboratories (PCR, NS1Ag, IgM/IgG tests): diagnosis DHF/DSS by clinical criteria correct > 90% • Easy and friendly use • Use only clinical especially warning signs. • No need for any laboratory tests to follow up: CBC • Increase number of cases report so may be more effective control?

  24. Disadvantages Original WHO Suggested new • Need follow up of laboratory test especially CBC and frequent Hct monitoring • Need close monitoring especially during 24-48 hours of critical period of plasma leakage • More workload to healthcare personnel, at least 20 times at OPD and 2 times for IPD • More complication of fluid overload (admit and observe early with IV fluid infusion) • More severe cases with EDS • Need dengue confirm labs. except those with shock, with complication of fluid overload • Increase in CFR

  25. 4. IV fluid management in shock cases Original WHO Newly suggested • 10 ml/kg/hr in children or 300-500 ml/hr in adult • 20 ml/kg in 20 mins. and can repeat another 2 times

  26. 4. IV fluid management in non-shock (compensated shock) cases Original WHO Newly suggested • 1.5 ml/kg/hr in children or M/2 in early and adjust rate accordingly to clinical, vital signs, Hct and urine output • 5-7 ml/kg/hr

  27. 4. Others management Original WHO Newly suggested • Colloidal solution: only plasma expander (hyper-oncotic) - 10% Dextran-40 in NSS • No platelet prophylaxis except in adults with underlying HT and Plt < 10,000 cells/cumm. • Any colloidal solution including FFP • Platelet prophylaxis

  28. Hotline DHF:089-2045522 – M.D.089-2042255 – GN.siripenk@gmail.com

  29. Thank you !!!

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