SlideShare uma empresa Scribd logo
1 de 61
Dengue Fever
Dinoosh De Livera, 6th Year
Foreign Students’ Training Faculty
Vitebsk State Medical University
Department of Infectious Diseases
Tropical Diseases
Contents
1. What is ‘’Dengue’’ ?
2. Epidemiology
3. Vector
4. Virus
5. Pathogenesis of the disease
6. Classification
7. Clinical signs & symptoms
8. Diagnosis
9. Main principles of Management & Complications
10. Prevention
(1)What is Dengue?
A vector-borne disease: Transmitted by Aedes aegypti, Aedes albopictus & Aedes polynesiensis.
Breeds in relatively fresh water, Day time biting, Limited flight range, Urbanized populations most affected.
Dengue virus, Genus Flavivirus, Family Flaviviridae, Four serotypes (1-4).
The most rapidly spreading mosquito-borne viral disease in the world.
Incubation period : 4-7 days (range 3-14)
Primary Dengue Infection – Self Limited
May also progress to severe dengue (DHF/DSS)
(normally children, elderly & immunocompromised)
(2) Epidemiology:
World Situation:
Most common arboviral disease worldwide
75% of global disease burden in Asia-Pacific region
Yearly 50 to 100 million infections
500,000 DHF cases
22,000 deaths, mostly among children.
“In the last 50 years, 30 fold rise 2.5 billion or 40% of the world, live in dengue
endemic countries.” - WHO (2009).Dengue: guidelines for diagnosis, treatment, prevention and control -- New edition
Reasons for incidence increase by 30-fold in last 50 years :
Inadequate closed drainage
Insecticide resistance in mosquito
vector population
Can also be considered reasons
for increased incidence.
Dengue
(2) Epidemiology continued...
Sri Lankan Situation:
First serologically confirmed case - 1962
First documented dengue outbreak - 1965- 1966
First epidemic of DHF/ Dengue Shock Syndrome -
1989 – 1990.
Year 2014, 46584 suspected dengue cases
55.26% of dengue cases from the Western province.
Dengue
Dengue
(3) Vector:
Biological vector – Female Mosquitoes
In Sri Lanka: Aedes albopictus and Aedes aegypti
Aedes aegypti is the main species.
(4) Virus-
Genus – Flavi virus
Family – Flaviviridae
Virus – Dengue virus (DEN)
Serotypes – 4 serotypes:
DEN 1 to 4
Dengue
Pathogenesis:
1.The virus is inoculated into humans with the mosquito saliva.
2.The virus localizes and replicates in various target organs, for example, local lymph nodes and the liver.
3.The virus is then released from these tissues and spreads through the blood to infect white blood cells and
other lymphatic tissues.
4.The virus is then released from these tissues and circulates in the blood. This secondary viremia is
responsible for the signs and symptoms of dengue fever
1) Primary dengue infection: First time viral infection, with any of the 4 virus types.
2) Secondary dengue infection: Any dengue infection, except the primary infection virus type. (NOT
necessarily the ‘’second’’ dengue infection)
Pathogenesis of Secondary infection:
Primary Infection - host develops a Life-long protective immunity to the homologous (same) serotype
Secondary Infection (caused by other 3 serotype) - host shows only partial and transient protection. High
risk of Dengue Hemorragic Fever development.
“Antibody dependent enhancement mechanism”
Infection by virus of another serotype
Production of non-neutralizing antibodies
Facilitate entry of virus to monocytes
Dengue virus never spreads from person to person directly. It is transmitted only by
the bite of an infected mosquito.
Moreover , the time between the bite of a mosquito carrying dengue virus and the start
of symptoms averages (INCUBATION PERIOD) 4 to 6 days, with a range of 1 to 7
days . And an infected person can be a source of dengue virus for mosquitos for about
6 days
Risk Factors for development of DHF/DSS:
(Harrison’s textbook of internal medicine, 17th edition,2008)
Presence of enhancing and non neutralising antibodies
Age : susceptibility to DHF/DSS drops significantly after 12 yrs of age
Sex : females more often affected than males
Race : Caucasians more often affected than blacks
Nutritional status : malnutrition is protective
Sequence of infection : example, serotype 1 followed by serotype 2 is more dangerous than serotype 4 followed
by serotype 2
Infecting serotype : type 2 more dangerous than others
Infecting genotype : Asian type 2 causes DHF/DSS while American type is not responsible for the illness
Pathogenesis of DSS (Dengue Shock Syndrome):
Pathogenesis of Bleeding in DSS:
Vasculopathy
Thrombocytopenia (due to virus induced reduction in hematopoeitic progenitor cell
growth and a subsequent decrease in thrombopoeisis)
Platelet dysfunction (due to interaction of virus with platelets through IgM
antiplatelet antibody)
Disseminated intravascular clotting (d-dimer, a marker for DIC is significantly
correlated with dengue disease severity)
Dengue
Dengue
Earlier(in 2005), WHO grouped symptomatic dengue virus infection into 3
categories:
1. Undifferentiated fever
2. Dengue fever
3. Dengue hemorrhagic fever
(which was further classified into four severity grades)
Currently, the classification into DF/DHF/DSS continues to be widely used
WHO (Old Classification):
According to WHO, “dengue is one disease entity with different clinical
presentations and often with unpredictable clinical evolution and outcome”;
The classification into levels of severity has a high potential for being of practical
use in the clinicians’ decision as to where and how intensively the patient should be
observed and treated (i.e. triage, which is particularly useful in outbreaks)
Hence, the rationale for following case classification of dengue (New Classification)
WHO (New Classification)
Clinical manifestations of DHF:
1. Undifferentiated fever
2. Classic dengue fever
3. Dengue hemorrhagic fever
4. Dengue shock syndrome
Criteria for Diagnosis:
1. Fever, or recent history of acute fever
2. Hemorrhagic manifestations
3. Low platelet count (100,000/mm3 or less)
4. Objective evidence of “leaky capillaries:”
● elevated hematocrit (20% or more over
● baseline)
● low albumin
● pleural or other effusions
Hemorrhagic manifestations:
● Skin hemorrhages: petechiae,
purpura,
● ecchymoses
● Gingival bleeding
● Nasal bleeding
● Gastro-intestinal bleeding:
● hematemesis, melena, hematochezia
● Hematuria
● Increased menstrual flow
Classical Presentation:
Sudden onset of fever, headache, retro-orbital pain, and back pain
Severe myalgia (hence the colloquial designation “break bone fever”)
Macular rash on the first day
Adenopathy, palatal vesicles, scleral injection
Epistaxis and scattered petechiae may be seen and pre-existing gastrointestinal lesions
may bleed
At the time of defervescence, a maculopapular rash may be seen (beginning on the trunk
and spreading to the extremities and face) along with mild grade fever (hence the
designation “biphasic fever”)
Dengue Fever (DF):
2 – 7 days of illness + high grade fever
Headache
Retro – orbital pain
Myalgia
Arthralgia
Rash & haemorrhagic manifestations
Positive tourniquet test
Petechiae
1) Classic Dengue – Break Bone fever
● Incubation period is 4 – 6 days ( range 3 -14)
● Abrupt onset of fever, chills, headache, retro orbital
● pain and backache
● Fever is 39 – 40◦ C; remission of 2days followed by
● Second febrile phase for 1 -2 d.
● Biphasic curve or saddle back fever.
● Fever lasts for 5- 7 days
● Transient generalized erythematous rash – first 24 – 48hrs. This morbilliform rash appears on trunk,
spreads to face and limbs sparing palms and soles. It lasts for 1- 5 days.
● Generalised myalgias, arthralgia and constitutional symptoms like anorexia, nausea, vomiting and
dysgeusia
● Relative bradycardia and generalised lymphadenopathy
● Marked leucopenia and thrombocytopenia.
● ↓ Platelets is due to impaired megakaryocyte production & ↑ platelet destruction.
Signs & Symptoms of DHF:
Signs & symptoms + Plasma leakage
Criteria (4)
1. Fever or h/o fever lasting 2-7 days
2. Hemorrhagic tendency
● +ve tourniquet test
● Petechae, ecchymosis, purpura
● Bleeding per mucosa, GIT , etc.
● Hematemesis, Malena
1. Thrombocytopenia, Platelets < 100,000/mm3
2. Plasma leakage
● rise in hematocrit > 20%
● fall in hematocrit > 20% after i/v fluids
● Pleural effusion, ascites, hypoalbuminemia.
Dengue haemorrhagic fever is a dynamic disease:
1. Febrile phase
2. Critical phase
3. Convalescent phase
DSS symptomatology according to phases &
1. Leaky phase : -
a. Circulatory failure
b. Oliguria
c. Postural hypotension
2. Congestive phase :
a. Fast and bounding pulse
b. Wider pulse pressure
c. Improved urinary output
3. Convalescence:
a. Bradycardia
b. Arrhythmia
c. Confluent petechial rash
Definition of DSS - Dengue Shock Syndrome (WHO, 2005)
DHF (following must all be present )
● Fever
● Hemorrhagic tendencies
● Thrombocytopenia
● Plasma leakage
plus
EVIDENCE OF CIRCULATORY FAILURE (manifested as)
● Narrow pulse pressure / hypotension for age
● Rapid and weak pulse
● Cold clammy extremities
Grading of severity of DSS & DHF:
Grade I : fever & constitutional signs and symptoms plus haemorrhagic
manifestation (positive TT and/or easy bruising)
Grade II : grade I plus spontaneous bleeding
Grade III : grade II plus circulatory failure
Grade IV : grade III plus shock with undetectable blood pressure or pulse.
(Grades III and IV define DSS)
(8) Diagnosis & Work-up of Dengue patient:
1) Laboratory diagnosis
● Virus isolation (cultured mosquito cells / mammalian cells - “Gold Standard” - low sensitivity & long
duration)
● Genome detection (RT-PCR, NASBA Assay)
● Antigen detection (E/M Antigen, NS I Antigen)
● Serological diagnosis (IgM & IgG Antibody detection)
2) Supportive investigations
● Tourniquette test
● Hematocrit & platelet count
● Time bound relationship between rise in hematocrit & fall in platelets: Represents pathophysiological
hallmark of disease: capillary permeability & abnormal haemostasis
● Fall in hematocrit during shock
● Progressive leukopenia
● Chest X-Rays
Interpretation of Diagnostic tests:
Interpretation of Dengue Serology:
IgM IgG Interpretation
Negative Negative Early sample/not dengue
Negative Positive (low titre) Past dengue infection
Negative Positive (high titre) Secondary dengue infection
Positive Negative Primary dengue infection
Positive Positive (low titre) Recent primary dengue infection
Positive Positive (high titre) Secondary dengue infection
Markers for Severe Disease:
Increased urinary levels of heparan sulphate
Increased plasma levels of pentraxin 3
Decreased serum albumin
Increased levels of vascular endothelial growth factor (VEGF)
Increased levels of soluble vascular cell adhesion molecule – 1 (VCAM-1)
Differential Diagnosis:
Dengue-like diseases [including Chikungunya fever , West Nile fever (with rash) &
Colorado tick fever, sandfly fever, Rift Valley fever, and Ross River fever (without
rash)]
Early stages of malaria
Mild yellow fever
Viral hepatitis
Leptospirosis
Viral respiratory and influenza like diseases
(9) Main principles of Management:
Out-patient Management:
● Advise bed rest
● Encourage plenty of oral fluid intake (of oral rehydration solution (ORS), fruit
juice and other fluids containing electrolytes and sugar), avoid plain water.
● Give paracetamol for high fever if the patient is uncomfortable (10-15mg/kg/dose)
● Inform the patient about the warning signs
● Anti-emetics and H2 RB.
● NO NSAIDs or STEROIDs
● Review with FBC , 1st after 3 days of onset
● Advice to return immediately for review if Indications for hospitalization (Next
slide)
Indications for hospitalization:
● Suspect severe dengue and the need for hospitalisation when patient develops :
● Feeling of giddiness
● Cooler extremities compared to trunk & extremities
● Oliguria with dark urine
● Right hypochondriac pain or severe abdominal pain
● Bleeding from any site
● Persistent vomiting
● Lethatgy or irritability/restlessness
also
● Infants
● Obese
● Major co-morbidities
● Adverse social circumstances
Inward management:
1. Febrile phase
2. Critical phase
3. Convalescent phase
Clinical Markers of Dengue:
● Continuous fever
● Characteristic myalgia ( retro orbital &
● interscapular)
● Palatal petechiae
● Conjunctival suffusion
● Magenta colored tongue
● Maculopapular rash
● Facial flush
● Hypotention
● Hemorrhage
1. Febrile Phase Management:
In DF & DHF ; lasts for 2-7 days
Total WBC count: initially high or normal drops < 5000/mm3
Platelet count: Initially normal drops < 100,000/mm3 in 50% DF & 100% DHF
Tender hepatomegaly DHF > DF
Erythematous/ maculo-papular rash
DHF < DF
1. Febrile Phase Management continued..
1) Adequate fluid intake: Total fluid requirement depends on degree of dehydration (Oral + IV)
● Infants <6 months – 5% dextrose in N/2
● Others – normal saline
2) Adequate physical rest
3) Paracetamol 10-15mg/kg/dose (max 60mg/kg/day)
4) NO all NAIDSs & STEROIDs
5) Monitoring (According to dengue guidlines - Annexure iii)
Dengue
Dengue
2. Critical Phase Management: Annexure IV & V
Dengue
Indicators for end of Critical Phase:
Stable vital signs
HCT becomes normal
Clinically improvement
Diuresis
3. Convalescent Phase Management:
Lasts for 2-5 days
Steps in Management:
1. Change over to hypotonic fluid
2. Decrease infusion rate to 3-5 ml/kg BW/hr
3. Diuretics & digitalisation needed in patients with cardiac overload due to regurgitant fluid
Reabsorption of the extravasated fluid.
Complications
1. Fluid overload
2. Hypocalaemia
3. Nosocomial infections
Adjunct therapy:
Platelet transfusion
Recombinant factor vii
Inotropic drugs
Steroids & IV immunoglobulins
Fresh frozen plasma (FFP)
Furosemide
Dos & Dont’s:Dos:
1. Avoid IM injections
2. Administer paracetamol for high fever
3. Use isotonic intravenous fluids for severe dengue
4. Give intravenous fluid volume just sufficient to maintain effective circulation
during period of plasma leakage for severe dengue
5. Tight glycemic control
Dont’s:
1. Administer aspirin or ibuprofen for fever
2. Use hypotonic intravenous fluids for severe dengue
3. Excessive or prolonged intravenous fluid during severe dengue
4. Unaware of effect of hyperglycemia on osmotic diuresis and hypovolemia
Primary causes of death in DHF:
Prolonged shock
1. >4 hrs organ failure
2. Liver failure 50% prognosis
3. Liver + Renal 10% prognosis
4. 3 organs(+ respiratory) very bad
Fluid overload
Features :-
1. Early- puffy eye lids, distended abdomen
2. (ascites), tachypnoea, mild dyspnoea
3. Late – Respiratory distress, SOB, &
4. wheezing
Patients with high risk for Complications:
1. Infants
2. Obese
3. Bleeding
4. Encephalopathy
5. Underline diseases
6. Pregnancy
Complications according to stage:
1- Febrile phase - Dehydration
2- Critical phase - Shock from plasma leakage: severe haemorrhage / organ impairment = DSS
3- Recovery phase - Hypervolaemia
Other Complications & Management:
A – Acidosis: NaHCO3 1ml/kg slow bolus (max 50ml) Diluted in equal volume of Normal Saline
B – Bleeding: Use Packed Red Cells 5ml/kg once
C – Calcium (hypocalcaemia): 1ml/kg of 10% Ca Gluconate,(max 10ml) Slow IV bolus over 15-20 mins,
Diluted in equal volume of NS Repeat 6 hourly,
S – Sugar (hypoglycaemia): Dextrose saline (0.9% NaCl with 5% Dextrose): Add 50ml 50% Dextrose to
450ml of 0.9% NaCl.
Hyponatremia: 3% NaCl is 3-5ml/kg Slow IV Through a larger vein; mostly a central vein
Encephalopathy: Mainly - Hepatic encephalopathy
Prognosis:Poor prognostic indicators include :
1. Early & profound shock with no detectable diastolic pressure or unrecordable BP
2. Delayed admission to hospital
3. DSS with gastrointestinal hemorrhage
Causes of death in a case of DHF/DSS :
1. Failing to recognise that a patient is in shock
2. Hemorrhages
3. Failing to recognise that patient has entered congestive phase
Sequelae:
1. Bradycardia & ventricular extra-systoles during convalescent stage
2. Profound asthenia with or without mental depression
Criteria that should be met before discharge:
No fever 24 hrs, without antipyretics
At least 2 days after recovery from shock
Generally good & Increasing appetite
Normal HCT for age. [baseline around 38-40% when not known]
No distress from pleural effusion or ascites
Rising platelet count & >50,000/mm3
No other complication
Signs of Recovery:
Stable pulse, BP & breathing rate
Normal temperature
No evidence of external/internal bleeding
Return of appetite
No vomiting
Good urinary output
Stable hematocrit
Convalescent confluent petechial rash
(10) Control and Prevention:
1. Vector Control (Insecticides, destroying breeding sites and larvae)
2. Individual Measures (Mosquito repellants & sprays, avoiding high risk areas,
using mosquito nets at night & wearing clothes that cover body)
3. Immunization (Sanofi Dengvaxia for all 4 serotypes)
Vector Control Methods:
1. Chemical Control
● Larvicides (organophosphorus compounds – fenthion ,abate) may be used to kill immature aquatic
stages
● Ultra-low volume fumigation ineffective against adult mosquitoes
● Mosquitoes may have resistance to commercial aerosol sprays
2. Biological control
● Largely experimental
● Option: place fish in containers to eat larvae
3. Environmental control
● Elimination of larval habitats
● Most likely method to be effective in the long term
Thank you for your
attention :)

Mais conteúdo relacionado

Mais procurados (20)

DENGUE FEVER.pptx
DENGUE FEVER.pptxDENGUE FEVER.pptx
DENGUE FEVER.pptx
 
Dengue diagnosis, treatment, prevention and control
Dengue diagnosis, treatment, prevention and controlDengue diagnosis, treatment, prevention and control
Dengue diagnosis, treatment, prevention and control
 
Dengue Fever
Dengue FeverDengue Fever
Dengue Fever
 
Lab diagnosis of Dengue
Lab diagnosis of DengueLab diagnosis of Dengue
Lab diagnosis of Dengue
 
Chikhungunya
ChikhungunyaChikhungunya
Chikhungunya
 
Dengue fever presentation
Dengue fever presentationDengue fever presentation
Dengue fever presentation
 
Dengue ppt
Dengue pptDengue ppt
Dengue ppt
 
Chikungunya
Chikungunya Chikungunya
Chikungunya
 
Dengue Fever 2019
Dengue Fever 2019Dengue Fever 2019
Dengue Fever 2019
 
Dengue
Dengue Dengue
Dengue
 
yellow fever.pptx
yellow fever.pptxyellow fever.pptx
yellow fever.pptx
 
Dengue final pdf
Dengue final pdfDengue final pdf
Dengue final pdf
 
Dengue fever
Dengue feverDengue fever
Dengue fever
 
Dengue fever recent advances
Dengue fever recent advancesDengue fever recent advances
Dengue fever recent advances
 
Dengue fever ppt
Dengue fever pptDengue fever ppt
Dengue fever ppt
 
Ebola virus disease
Ebola virus diseaseEbola virus disease
Ebola virus disease
 
Dengue fever slide
Dengue fever slideDengue fever slide
Dengue fever slide
 
Dengue
DengueDengue
Dengue
 
Dengue fever final
Dengue fever finalDengue fever final
Dengue fever final
 
Cholera and other vibrios
Cholera and other vibriosCholera and other vibrios
Cholera and other vibrios
 

Semelhante a Dengue

Semelhante a Dengue (20)

Dengue illnesses praman
Dengue illnesses pramanDengue illnesses praman
Dengue illnesses praman
 
DENGUE.pptx
DENGUE.pptxDENGUE.pptx
DENGUE.pptx
 
Dengue & It's Management in Bangladesh
Dengue & It's Management in BangladeshDengue & It's Management in Bangladesh
Dengue & It's Management in Bangladesh
 
Dengue Fever(2),09
Dengue Fever(2),09Dengue Fever(2),09
Dengue Fever(2),09
 
Dengue Fever.ppt
Dengue Fever.pptDengue Fever.ppt
Dengue Fever.ppt
 
Chapter 1 dengue fever in general
Chapter 1 dengue fever in generalChapter 1 dengue fever in general
Chapter 1 dengue fever in general
 
Dengue
DengueDengue
Dengue
 
DENGUE.pptx
DENGUE.pptxDENGUE.pptx
DENGUE.pptx
 
debgue file.pptx
debgue file.pptxdebgue file.pptx
debgue file.pptx
 
Dengue fever
Dengue fever Dengue fever
Dengue fever
 
Dengue Hemorrhagic Fever and DSS
Dengue Hemorrhagic Fever and DSSDengue Hemorrhagic Fever and DSS
Dengue Hemorrhagic Fever and DSS
 
Dengue fever
Dengue feverDengue fever
Dengue fever
 
Dengue fever ppt [autosaved]
Dengue fever ppt [autosaved]Dengue fever ppt [autosaved]
Dengue fever ppt [autosaved]
 
YELLOW-FEVER Shubham.pptx ism collage workshop
YELLOW-FEVER Shubham.pptx ism collage workshopYELLOW-FEVER Shubham.pptx ism collage workshop
YELLOW-FEVER Shubham.pptx ism collage workshop
 
Degue fever
Degue feverDegue fever
Degue fever
 
Dengue Fever – Newer Insights.pptx
Dengue Fever – Newer Insights.pptxDengue Fever – Newer Insights.pptx
Dengue Fever – Newer Insights.pptx
 
Dengue
DengueDengue
Dengue
 
Dengue
DengueDengue
Dengue
 
Dengue
DengueDengue
Dengue
 
The dengue syndrome_Vighnesh D
The dengue syndrome_Vighnesh DThe dengue syndrome_Vighnesh D
The dengue syndrome_Vighnesh D
 

Mais de Dinoosh De Livera

IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)
IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)
IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)Dinoosh De Livera
 
IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)
IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)
IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)Dinoosh De Livera
 
Lightning strike: main signs and emergency management
Lightning strike:  main signs and emergency managementLightning strike:  main signs and emergency management
Lightning strike: main signs and emergency managementDinoosh De Livera
 
Tuberculosis (Phthisiopulmonology)
Tuberculosis (Phthisiopulmonology)Tuberculosis (Phthisiopulmonology)
Tuberculosis (Phthisiopulmonology)Dinoosh De Livera
 
Respiratory medicine (pulmonology) notes
Respiratory medicine (pulmonology) notesRespiratory medicine (pulmonology) notes
Respiratory medicine (pulmonology) notesDinoosh De Livera
 
Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...
Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...
Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...Dinoosh De Livera
 
Endocrine disease of the Adrenal, Pituitary glands
Endocrine disease of the Adrenal, Pituitary glandsEndocrine disease of the Adrenal, Pituitary glands
Endocrine disease of the Adrenal, Pituitary glandsDinoosh De Livera
 
Diseases of the Thyroid gland
Diseases of the Thyroid glandDiseases of the Thyroid gland
Diseases of the Thyroid glandDinoosh De Livera
 
Diabetes mellitus - Endocrinology
Diabetes mellitus - EndocrinologyDiabetes mellitus - Endocrinology
Diabetes mellitus - EndocrinologyDinoosh De Livera
 

Mais de Dinoosh De Livera (20)

Porphyria
Porphyria  Porphyria
Porphyria
 
IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)
IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)
IELTS ACADEMIC - WRITING - PART 1 (LINE GRAPHS)
 
IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)
IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)
IELTS UKVI ACADEMIC - WRITING PART 2 (NOTES)
 
Lightning strike: main signs and emergency management
Lightning strike:  main signs and emergency managementLightning strike:  main signs and emergency management
Lightning strike: main signs and emergency management
 
Tuberculosis (Phthisiopulmonology)
Tuberculosis (Phthisiopulmonology)Tuberculosis (Phthisiopulmonology)
Tuberculosis (Phthisiopulmonology)
 
Respiratory medicine (pulmonology) notes
Respiratory medicine (pulmonology) notesRespiratory medicine (pulmonology) notes
Respiratory medicine (pulmonology) notes
 
Allergology
AllergologyAllergology
Allergology
 
Hematology notes
Hematology notesHematology notes
Hematology notes
 
Rheumatological diseases
Rheumatological diseases Rheumatological diseases
Rheumatological diseases
 
Diseases of the Kidney
Diseases of the KidneyDiseases of the Kidney
Diseases of the Kidney
 
Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...
Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...
Surgical diseases of endocrine glands (insulinoma, pheochromocytoma, hyperpar...
 
Endocrine disease of the Adrenal, Pituitary glands
Endocrine disease of the Adrenal, Pituitary glandsEndocrine disease of the Adrenal, Pituitary glands
Endocrine disease of the Adrenal, Pituitary glands
 
ECG Basics
ECG BasicsECG Basics
ECG Basics
 
Diseases of the Thyroid gland
Diseases of the Thyroid glandDiseases of the Thyroid gland
Diseases of the Thyroid gland
 
Diabetes mellitus 2
Diabetes mellitus 2Diabetes mellitus 2
Diabetes mellitus 2
 
Diabetes mellitus - Endocrinology
Diabetes mellitus - EndocrinologyDiabetes mellitus - Endocrinology
Diabetes mellitus - Endocrinology
 
Liver diseases
Liver diseasesLiver diseases
Liver diseases
 
Intestinal diseases
Intestinal diseasesIntestinal diseases
Intestinal diseases
 
Gastric Diseases
Gastric DiseasesGastric Diseases
Gastric Diseases
 
Esophageal Diseases
Esophageal DiseasesEsophageal Diseases
Esophageal Diseases
 

Último

BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 

Último (20)

BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 

Dengue

  • 1. Dengue Fever Dinoosh De Livera, 6th Year Foreign Students’ Training Faculty Vitebsk State Medical University Department of Infectious Diseases Tropical Diseases
  • 2. Contents 1. What is ‘’Dengue’’ ? 2. Epidemiology 3. Vector 4. Virus 5. Pathogenesis of the disease 6. Classification 7. Clinical signs & symptoms 8. Diagnosis 9. Main principles of Management & Complications 10. Prevention
  • 3. (1)What is Dengue? A vector-borne disease: Transmitted by Aedes aegypti, Aedes albopictus & Aedes polynesiensis. Breeds in relatively fresh water, Day time biting, Limited flight range, Urbanized populations most affected. Dengue virus, Genus Flavivirus, Family Flaviviridae, Four serotypes (1-4). The most rapidly spreading mosquito-borne viral disease in the world. Incubation period : 4-7 days (range 3-14) Primary Dengue Infection – Self Limited May also progress to severe dengue (DHF/DSS) (normally children, elderly & immunocompromised)
  • 4. (2) Epidemiology: World Situation: Most common arboviral disease worldwide 75% of global disease burden in Asia-Pacific region Yearly 50 to 100 million infections 500,000 DHF cases 22,000 deaths, mostly among children. “In the last 50 years, 30 fold rise 2.5 billion or 40% of the world, live in dengue endemic countries.” - WHO (2009).Dengue: guidelines for diagnosis, treatment, prevention and control -- New edition
  • 5. Reasons for incidence increase by 30-fold in last 50 years : Inadequate closed drainage Insecticide resistance in mosquito vector population Can also be considered reasons for increased incidence.
  • 7. (2) Epidemiology continued... Sri Lankan Situation: First serologically confirmed case - 1962 First documented dengue outbreak - 1965- 1966 First epidemic of DHF/ Dengue Shock Syndrome - 1989 – 1990. Year 2014, 46584 suspected dengue cases 55.26% of dengue cases from the Western province.
  • 10. (3) Vector: Biological vector – Female Mosquitoes In Sri Lanka: Aedes albopictus and Aedes aegypti Aedes aegypti is the main species.
  • 11. (4) Virus- Genus – Flavi virus Family – Flaviviridae Virus – Dengue virus (DEN) Serotypes – 4 serotypes: DEN 1 to 4
  • 13. Pathogenesis: 1.The virus is inoculated into humans with the mosquito saliva. 2.The virus localizes and replicates in various target organs, for example, local lymph nodes and the liver. 3.The virus is then released from these tissues and spreads through the blood to infect white blood cells and other lymphatic tissues. 4.The virus is then released from these tissues and circulates in the blood. This secondary viremia is responsible for the signs and symptoms of dengue fever 1) Primary dengue infection: First time viral infection, with any of the 4 virus types. 2) Secondary dengue infection: Any dengue infection, except the primary infection virus type. (NOT necessarily the ‘’second’’ dengue infection)
  • 14. Pathogenesis of Secondary infection: Primary Infection - host develops a Life-long protective immunity to the homologous (same) serotype Secondary Infection (caused by other 3 serotype) - host shows only partial and transient protection. High risk of Dengue Hemorragic Fever development. “Antibody dependent enhancement mechanism” Infection by virus of another serotype Production of non-neutralizing antibodies Facilitate entry of virus to monocytes
  • 15. Dengue virus never spreads from person to person directly. It is transmitted only by the bite of an infected mosquito.
  • 16. Moreover , the time between the bite of a mosquito carrying dengue virus and the start of symptoms averages (INCUBATION PERIOD) 4 to 6 days, with a range of 1 to 7 days . And an infected person can be a source of dengue virus for mosquitos for about 6 days
  • 17. Risk Factors for development of DHF/DSS: (Harrison’s textbook of internal medicine, 17th edition,2008) Presence of enhancing and non neutralising antibodies Age : susceptibility to DHF/DSS drops significantly after 12 yrs of age Sex : females more often affected than males Race : Caucasians more often affected than blacks Nutritional status : malnutrition is protective Sequence of infection : example, serotype 1 followed by serotype 2 is more dangerous than serotype 4 followed by serotype 2 Infecting serotype : type 2 more dangerous than others Infecting genotype : Asian type 2 causes DHF/DSS while American type is not responsible for the illness
  • 18. Pathogenesis of DSS (Dengue Shock Syndrome):
  • 19. Pathogenesis of Bleeding in DSS: Vasculopathy Thrombocytopenia (due to virus induced reduction in hematopoeitic progenitor cell growth and a subsequent decrease in thrombopoeisis) Platelet dysfunction (due to interaction of virus with platelets through IgM antiplatelet antibody) Disseminated intravascular clotting (d-dimer, a marker for DIC is significantly correlated with dengue disease severity)
  • 22. Earlier(in 2005), WHO grouped symptomatic dengue virus infection into 3 categories: 1. Undifferentiated fever 2. Dengue fever 3. Dengue hemorrhagic fever (which was further classified into four severity grades) Currently, the classification into DF/DHF/DSS continues to be widely used
  • 24. According to WHO, “dengue is one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcome”; The classification into levels of severity has a high potential for being of practical use in the clinicians’ decision as to where and how intensively the patient should be observed and treated (i.e. triage, which is particularly useful in outbreaks) Hence, the rationale for following case classification of dengue (New Classification)
  • 26. Clinical manifestations of DHF: 1. Undifferentiated fever 2. Classic dengue fever 3. Dengue hemorrhagic fever 4. Dengue shock syndrome Criteria for Diagnosis: 1. Fever, or recent history of acute fever 2. Hemorrhagic manifestations 3. Low platelet count (100,000/mm3 or less) 4. Objective evidence of “leaky capillaries:” ● elevated hematocrit (20% or more over ● baseline) ● low albumin ● pleural or other effusions Hemorrhagic manifestations: ● Skin hemorrhages: petechiae, purpura, ● ecchymoses ● Gingival bleeding ● Nasal bleeding ● Gastro-intestinal bleeding: ● hematemesis, melena, hematochezia ● Hematuria ● Increased menstrual flow
  • 27. Classical Presentation: Sudden onset of fever, headache, retro-orbital pain, and back pain Severe myalgia (hence the colloquial designation “break bone fever”) Macular rash on the first day Adenopathy, palatal vesicles, scleral injection Epistaxis and scattered petechiae may be seen and pre-existing gastrointestinal lesions may bleed At the time of defervescence, a maculopapular rash may be seen (beginning on the trunk and spreading to the extremities and face) along with mild grade fever (hence the designation “biphasic fever”)
  • 28. Dengue Fever (DF): 2 – 7 days of illness + high grade fever Headache Retro – orbital pain Myalgia Arthralgia Rash & haemorrhagic manifestations Positive tourniquet test Petechiae
  • 29. 1) Classic Dengue – Break Bone fever ● Incubation period is 4 – 6 days ( range 3 -14) ● Abrupt onset of fever, chills, headache, retro orbital ● pain and backache ● Fever is 39 – 40◦ C; remission of 2days followed by ● Second febrile phase for 1 -2 d. ● Biphasic curve or saddle back fever. ● Fever lasts for 5- 7 days ● Transient generalized erythematous rash – first 24 – 48hrs. This morbilliform rash appears on trunk, spreads to face and limbs sparing palms and soles. It lasts for 1- 5 days. ● Generalised myalgias, arthralgia and constitutional symptoms like anorexia, nausea, vomiting and dysgeusia ● Relative bradycardia and generalised lymphadenopathy ● Marked leucopenia and thrombocytopenia. ● ↓ Platelets is due to impaired megakaryocyte production & ↑ platelet destruction.
  • 30. Signs & Symptoms of DHF: Signs & symptoms + Plasma leakage Criteria (4) 1. Fever or h/o fever lasting 2-7 days 2. Hemorrhagic tendency ● +ve tourniquet test ● Petechae, ecchymosis, purpura ● Bleeding per mucosa, GIT , etc. ● Hematemesis, Malena 1. Thrombocytopenia, Platelets < 100,000/mm3 2. Plasma leakage ● rise in hematocrit > 20% ● fall in hematocrit > 20% after i/v fluids ● Pleural effusion, ascites, hypoalbuminemia.
  • 31. Dengue haemorrhagic fever is a dynamic disease: 1. Febrile phase 2. Critical phase 3. Convalescent phase
  • 32. DSS symptomatology according to phases & 1. Leaky phase : - a. Circulatory failure b. Oliguria c. Postural hypotension 2. Congestive phase : a. Fast and bounding pulse b. Wider pulse pressure c. Improved urinary output 3. Convalescence: a. Bradycardia b. Arrhythmia c. Confluent petechial rash
  • 33. Definition of DSS - Dengue Shock Syndrome (WHO, 2005) DHF (following must all be present ) ● Fever ● Hemorrhagic tendencies ● Thrombocytopenia ● Plasma leakage plus EVIDENCE OF CIRCULATORY FAILURE (manifested as) ● Narrow pulse pressure / hypotension for age ● Rapid and weak pulse ● Cold clammy extremities
  • 34. Grading of severity of DSS & DHF: Grade I : fever & constitutional signs and symptoms plus haemorrhagic manifestation (positive TT and/or easy bruising) Grade II : grade I plus spontaneous bleeding Grade III : grade II plus circulatory failure Grade IV : grade III plus shock with undetectable blood pressure or pulse. (Grades III and IV define DSS)
  • 35. (8) Diagnosis & Work-up of Dengue patient: 1) Laboratory diagnosis ● Virus isolation (cultured mosquito cells / mammalian cells - “Gold Standard” - low sensitivity & long duration) ● Genome detection (RT-PCR, NASBA Assay) ● Antigen detection (E/M Antigen, NS I Antigen) ● Serological diagnosis (IgM & IgG Antibody detection) 2) Supportive investigations ● Tourniquette test ● Hematocrit & platelet count ● Time bound relationship between rise in hematocrit & fall in platelets: Represents pathophysiological hallmark of disease: capillary permeability & abnormal haemostasis ● Fall in hematocrit during shock ● Progressive leukopenia ● Chest X-Rays
  • 37. Interpretation of Dengue Serology: IgM IgG Interpretation Negative Negative Early sample/not dengue Negative Positive (low titre) Past dengue infection Negative Positive (high titre) Secondary dengue infection Positive Negative Primary dengue infection Positive Positive (low titre) Recent primary dengue infection Positive Positive (high titre) Secondary dengue infection
  • 38. Markers for Severe Disease: Increased urinary levels of heparan sulphate Increased plasma levels of pentraxin 3 Decreased serum albumin Increased levels of vascular endothelial growth factor (VEGF) Increased levels of soluble vascular cell adhesion molecule – 1 (VCAM-1)
  • 39. Differential Diagnosis: Dengue-like diseases [including Chikungunya fever , West Nile fever (with rash) & Colorado tick fever, sandfly fever, Rift Valley fever, and Ross River fever (without rash)] Early stages of malaria Mild yellow fever Viral hepatitis Leptospirosis Viral respiratory and influenza like diseases
  • 40. (9) Main principles of Management: Out-patient Management: ● Advise bed rest ● Encourage plenty of oral fluid intake (of oral rehydration solution (ORS), fruit juice and other fluids containing electrolytes and sugar), avoid plain water. ● Give paracetamol for high fever if the patient is uncomfortable (10-15mg/kg/dose) ● Inform the patient about the warning signs ● Anti-emetics and H2 RB. ● NO NSAIDs or STEROIDs ● Review with FBC , 1st after 3 days of onset ● Advice to return immediately for review if Indications for hospitalization (Next slide)
  • 41. Indications for hospitalization: ● Suspect severe dengue and the need for hospitalisation when patient develops : ● Feeling of giddiness ● Cooler extremities compared to trunk & extremities ● Oliguria with dark urine ● Right hypochondriac pain or severe abdominal pain ● Bleeding from any site ● Persistent vomiting ● Lethatgy or irritability/restlessness also ● Infants ● Obese ● Major co-morbidities ● Adverse social circumstances
  • 42. Inward management: 1. Febrile phase 2. Critical phase 3. Convalescent phase Clinical Markers of Dengue: ● Continuous fever ● Characteristic myalgia ( retro orbital & ● interscapular) ● Palatal petechiae ● Conjunctival suffusion ● Magenta colored tongue ● Maculopapular rash ● Facial flush ● Hypotention ● Hemorrhage
  • 43. 1. Febrile Phase Management: In DF & DHF ; lasts for 2-7 days Total WBC count: initially high or normal drops < 5000/mm3 Platelet count: Initially normal drops < 100,000/mm3 in 50% DF & 100% DHF Tender hepatomegaly DHF > DF Erythematous/ maculo-papular rash DHF < DF
  • 44. 1. Febrile Phase Management continued.. 1) Adequate fluid intake: Total fluid requirement depends on degree of dehydration (Oral + IV) ● Infants <6 months – 5% dextrose in N/2 ● Others – normal saline 2) Adequate physical rest 3) Paracetamol 10-15mg/kg/dose (max 60mg/kg/day) 4) NO all NAIDSs & STEROIDs 5) Monitoring (According to dengue guidlines - Annexure iii)
  • 47. 2. Critical Phase Management: Annexure IV & V
  • 49. Indicators for end of Critical Phase: Stable vital signs HCT becomes normal Clinically improvement Diuresis
  • 50. 3. Convalescent Phase Management: Lasts for 2-5 days Steps in Management: 1. Change over to hypotonic fluid 2. Decrease infusion rate to 3-5 ml/kg BW/hr 3. Diuretics & digitalisation needed in patients with cardiac overload due to regurgitant fluid Reabsorption of the extravasated fluid. Complications 1. Fluid overload 2. Hypocalaemia 3. Nosocomial infections
  • 51. Adjunct therapy: Platelet transfusion Recombinant factor vii Inotropic drugs Steroids & IV immunoglobulins Fresh frozen plasma (FFP) Furosemide
  • 52. Dos & Dont’s:Dos: 1. Avoid IM injections 2. Administer paracetamol for high fever 3. Use isotonic intravenous fluids for severe dengue 4. Give intravenous fluid volume just sufficient to maintain effective circulation during period of plasma leakage for severe dengue 5. Tight glycemic control Dont’s: 1. Administer aspirin or ibuprofen for fever 2. Use hypotonic intravenous fluids for severe dengue 3. Excessive or prolonged intravenous fluid during severe dengue 4. Unaware of effect of hyperglycemia on osmotic diuresis and hypovolemia
  • 53. Primary causes of death in DHF: Prolonged shock 1. >4 hrs organ failure 2. Liver failure 50% prognosis 3. Liver + Renal 10% prognosis 4. 3 organs(+ respiratory) very bad Fluid overload Features :- 1. Early- puffy eye lids, distended abdomen 2. (ascites), tachypnoea, mild dyspnoea 3. Late – Respiratory distress, SOB, & 4. wheezing
  • 54. Patients with high risk for Complications: 1. Infants 2. Obese 3. Bleeding 4. Encephalopathy 5. Underline diseases 6. Pregnancy Complications according to stage: 1- Febrile phase - Dehydration 2- Critical phase - Shock from plasma leakage: severe haemorrhage / organ impairment = DSS 3- Recovery phase - Hypervolaemia
  • 55. Other Complications & Management: A – Acidosis: NaHCO3 1ml/kg slow bolus (max 50ml) Diluted in equal volume of Normal Saline B – Bleeding: Use Packed Red Cells 5ml/kg once C – Calcium (hypocalcaemia): 1ml/kg of 10% Ca Gluconate,(max 10ml) Slow IV bolus over 15-20 mins, Diluted in equal volume of NS Repeat 6 hourly, S – Sugar (hypoglycaemia): Dextrose saline (0.9% NaCl with 5% Dextrose): Add 50ml 50% Dextrose to 450ml of 0.9% NaCl. Hyponatremia: 3% NaCl is 3-5ml/kg Slow IV Through a larger vein; mostly a central vein Encephalopathy: Mainly - Hepatic encephalopathy
  • 56. Prognosis:Poor prognostic indicators include : 1. Early & profound shock with no detectable diastolic pressure or unrecordable BP 2. Delayed admission to hospital 3. DSS with gastrointestinal hemorrhage Causes of death in a case of DHF/DSS : 1. Failing to recognise that a patient is in shock 2. Hemorrhages 3. Failing to recognise that patient has entered congestive phase Sequelae: 1. Bradycardia & ventricular extra-systoles during convalescent stage 2. Profound asthenia with or without mental depression
  • 57. Criteria that should be met before discharge: No fever 24 hrs, without antipyretics At least 2 days after recovery from shock Generally good & Increasing appetite Normal HCT for age. [baseline around 38-40% when not known] No distress from pleural effusion or ascites Rising platelet count & >50,000/mm3 No other complication
  • 58. Signs of Recovery: Stable pulse, BP & breathing rate Normal temperature No evidence of external/internal bleeding Return of appetite No vomiting Good urinary output Stable hematocrit Convalescent confluent petechial rash
  • 59. (10) Control and Prevention: 1. Vector Control (Insecticides, destroying breeding sites and larvae) 2. Individual Measures (Mosquito repellants & sprays, avoiding high risk areas, using mosquito nets at night & wearing clothes that cover body) 3. Immunization (Sanofi Dengvaxia for all 4 serotypes)
  • 60. Vector Control Methods: 1. Chemical Control ● Larvicides (organophosphorus compounds – fenthion ,abate) may be used to kill immature aquatic stages ● Ultra-low volume fumigation ineffective against adult mosquitoes ● Mosquitoes may have resistance to commercial aerosol sprays 2. Biological control ● Largely experimental ● Option: place fish in containers to eat larvae 3. Environmental control ● Elimination of larval habitats ● Most likely method to be effective in the long term
  • 61. Thank you for your attention :)