DENGUE VIRAL INFECTION Measure petechiae on the antecubital

Carina H. Frayco area

Lab: Hct 0.45; platelet count 130
OUTLINE: What is your assessment? Dengue without warning
I. Present a case of dengue, course and management signs
II. Differentiate dengue form other acute viral infection Management: May send home with proper advise
III. Discuss the global burden of dengue and other
Do not give aspirin due to the risk of bleeding
common viral infection
IV. Updates on the dengue vaccine 24 hours later, the same patient developed abdominal
pain and was afebrile with HCT 0.54
Source: WHO 2009 Guidelines in the treatment, (hemoconcentration) -> dengue with warning signs
management, and prevention of Dengue (theres a PDF file o Management: admit and administer D5LRS
daw which you might want to download ;)) 5cc/kg/hour
Patients condition deteriorated. He became
hypotensive, tachycardic, and developed pleural
CASE: effusion (end-organ impairment)
A.D.G., 23 years old, male o Assessment: Severe dengue
From Quezon City 12 hours later, patient presented with severe
Consulted at the OPD abdominal pain and melena, hypotensive, normal
Pertinent History: hematocrit, platelet: 18,000
o First review the fluids, baka kulang yung
o Fever of 3 days duration intermittent, moderate
binibigay
to high grade, relieved by Paracetamol
o Transfuse blood: fresh whole blood since there is
o Accompanied by body malaise, headache and
already bleeding and there is liver dysfunction.
anorexia
FWB still has clotting factors which helps in the
o Recent history of dengue in the family
expansion of the intravascular volume.
(patients brother had dengue 1 week prior to
o Secondary dengue patient predisposed to
patients consultation)
severe dengue compared to primary dengue:
V/S: BP=110/70 CR=105bpm RR=24cpm T=39C
hyperimmune response aka antibody-dependent
o Wt: 55 kg enhancement (ADE) which enhances the
o Conscious, coherent, ambulatory entrance of the virus to the macrophages which
o (+) conjunctival injections are supposed to be the first line of protection ->
CBS, tachycardic, normal abdominal exam, full pulse, heightened response -> more vasculitis
flushed skin
(+) tourniquet test
o Presumptive test THE HISTORY
o How to do tourniquet test? Jin Dynasty (265-420 AD) -> water poison 1 st case
First, get the mean arterial pressure of probable dengue fever
(MAP) o Called water poison because the source of the
Inflate sphygmomanometer vector is from water
Aedes aegypti vector
 Increased globalization secondary to the slave trade CBC and PE (leucopenia):
WWII marked spread of dengue except for Hemoconcentrat
Severe form of the disease was first reported in the temperatur ion,
Philippines in 1953 e thrombocytopen
ia
Break-bone Fever Diagnostics Dengue IgM IgM, IgG
Dr. Benjamin Rush reported the outbreak of dengue NS1
fever. Complicati Dehydratio Bleeding, organ Fluid
In 1798 from Philadelphia which he called Break-bone ons n impairment overload
Disease (increased
SGPT, BUN, and
Crea)
Notes Peak of Must admit, Mounting of
fever saddle back all
reaching pattern of immunoglobu
40C, fever, onset of lins
viremia, vasculitis

*viremia: high level of virus in the blood responsible for the

production of TNF-a and other cytokines
*NS1 is part of the virus, a non-structural protein that you
detect, which is detected in the 1st 4 days of illness
Incubation Period: 4-7 DAYS *a negative NS1 does not rule out dengue if you took it
beyond the 4th day of illness
Phases of Dengue: *differential diagnoses for the febrile phase: any viral
Febrile Critical Phase Recovery infection, leptospirosis, infectious mononucleosis, HIV
Phase Phase (primary/acute retroviral syndrome; 1st 3-6 months of
Day of Day 1-3 Day 4-6 Day 7-10 infection)
Illness *always ask what day of illness the patient is in to be able to
Signs and Non- Hypotension, Altered deduce which phase the patient is in and know how to
Symptoms specific: pleural effusion, consciousnes manage it
*chikungunya rashes appear within the first 3-4 days of
Fever, ascites, GI s, seizures,
illness while in dengue, rashes appear during the recovery
headache, bleeding itching, slow
phase
bone-ache, heart rate *platelet in dengue: rapid decline
joint pain, *do not give diuretics in the critical phase unless you adjust
rashes, the fluids of the patient
abdominal *no drug of choice, management is mainly symptom-based
pain, *if at the first 4 days of illness you detected positive IgG this
diarrhea can be interpreted as a secondary dengue infection
Labs Normal Very low WBC *REMEMBER THE PHASES OF DENGUE
*discontinue fluids after the critical phase if the patient can
tolerate oral intake of fluids and has adequate urine output
 o Aches and pains
o Tourniquet test positive
o Leucopenia
o Any warning sign
Laboratory confirmed dengue
o Important when no sign of plasma leakage

2. Dengue with WARNING SIGNS

ABDOMINAL PAIN OR TENDERNESS
PERSISTENT VOMITING
CLINICAL FLUID ACCUMULATION
MUCOSAL BLEED
LETHARGY; RESTLESSNESS
LIVER ENLARGEMENT >2cm
Laboratory: increased in HCT concurrent with
rapid decrease in platelet count
Requiring strict observation and medical
intervention
Admit immediately

3. Severe Dengue
Criteria for Severe Dengue
1. Severe Plasma Leakage leading to:
a. Shock (DSS)
b. Fluid accumulation with respiratory distress
2. Severe bleeding as evaluated by clinician
3. Severe organ involvement
a. Liver: AST or ALT >=1000
b. CNS: Impaired consciousness
c. Heart and other organs

Outpatient Case: ORS (Ludans Method)

Body Weight (kg) ORS to be given
DENGUE CASE CLASSIFICATION BY SEVERITY > 3-10 kg 100 mL/kg/day
1. Probable Dengue > 10-20 kg 75 mL/kg/day
Live in/travel to dengue endemic area. Fever and 2 of > 20-30 kg 50-60 mL/kg/day
the following criteria: > 30-60 kg 40-50 mL/kg/day
o Nausea, vomiting
o Rash
 DENGUE GLOBAL BURDEN Region III 75
Incidence: 2.5 billion people Region V 3
Over 40% of the world population is at risk for dengue Region X 2
WHO estimates 50-100 million dengue infections Region I 2
worldwide every year Region II 2
Estimated 500,000 people with severe dengue require Region IVB 1
hospitalization per year Region VIII 1
~2.5% of those affected die Region IX 1
USA, SEA, Western Pacific: First reported cases in CAR 1
France and Croatia
South American countries: Honduras, Costa Rica, and
CHIKUNGUNYA, OUT OF AFRICA, AT OUR FRONT DOOR
Mexico
Aedes aegypti
Florida (US) Yunnan province of China
o Swahili, African dialect to be bent over
Increase cases in Singapore outbreaks in Laos
o Congo Africa buka-buka broken-broken
2008: >1.2 million cases in USA reported
Geographical distribution of chikungunya virus. CHIKV
2010: >2.3 million (based on official data submitted by
was largely restricted to Africa and Asia until
Member States successive waves of outbreaks beginning with an
2012: Outbreak in Madeira Islands, Portugal, 2000 epidemic in Kenya in 2004 swept across the globe
cases and other parts of Europe
2013: 2.35 million cases of dengue reported in USA DENGUE VS. CHIKUNGUNYA FEVER
alone (37687 severe dengue cases) Feature Chik Virus Dengue Virus
2014: cases in Cook Islands, Malaysia, Fiji and Infection Infection
Vanuatu, with DEN 3 affecting the Pacific Island Fever +++ ++
countries Arthralgia +++ +/-
Polyarthritis + -
Headache ++ ++
PHILIPPINES DENGUE CASES AND DEATHS PER YEAR Rash ++ (d 1-4) + (d 3-7)
Cases as of January 1 April 4, 2015 19,946 which Myalgia + ++
was 6.49% higher than in 2014 of the same month, Hemorrhage +/- ++
18,730 (+) only for
Deaths recorded from January 1 April 4, 2015 53 atypical
San Lazaro Hospital in 2014 chikungunya
o Age Range: 4 months 76 years old patients
o Mean Age: 33 years old Shock - +
o Pedia: 1,440 (64%) Lymphopenia +++ ++
o Adult: 813 (36%) Neutropenia + +++
Geographical Location: Thrombocytopeni + +++
NCR 1,882 a
Region IV 283 Hemoconcentratio - ++
 n Philippines during 2014: 21,420 confirmed cases, 110
*another vector for dengue is Aedes albopictus however, it is deaths
more associated with chikungunya 2015: 201 suspected cases of measles, 33 confirmed
cases and no deaths

Questions and Answers on Dengue Vaccines

to reduce dengue mortality by 50% and morbidity by 25%
by 2020 as targeted by the WHO

What is the current status of dengue vaccine

development?
Live attenuated tetravalent dengue vaccine developed
by Sanofi Pasteur (CYD-TDV) on phase III trial

What were the main objectives of the phase III study

of CYD-TDV in Latin America?
To assess the safety and efficacy of CYD-TDV in one
year after completion of the vaccination schedule of
three doses (6 months apart)
Evaluation of immunogenicity
P = 20,869 children (9 to 16 years), 5 countries in
Latin America
The study protocol a hospital-based follow-up period
of 4 additional years, currently ongoing

Clinical efficacy and safety of a novel tetravalent

dengue vaccine in healthy children in Asia: a phase 3,
randomized, observer-masked, placebo-controlled trial

Interpretations:
Dengue vaccine is efficacious, given as 3 injections
at months -, 6, and 12 to children aged 2-14 years
in endemic areas in Asia, and has a good safety
profile
Vaccination could reduce the incidence of
symptomatic infection and hospital admission and
*islands of white in a sea of red: Hermans rash has the potential to provide an important public
health benefit
CDC
WHO as of February 20, 2015: 58,010 suspected cases What are the plans for a WHO position on use of
of measles dengue vaccines?
 The WHO Strategic Advisory Group of Experts (SAGE) The global incidence of dengue has grown dramatically
on immunization will advise WHO on any in recent decades
recommended use of dengue vaccines Half of the worlds population is now at risk
Key issues: programmatic suitability and dose It is found in tropical and sub-tropical climates
scheduling worldwide
A formal WHO assessment of public health utility and Severe dengue leading cause of serious illness and
any recommendations for use will only be issued death among children in some Asian and Latin
following licensure of the vaccine by a functional American countries
National Regulatory Authority (NRA). No specific treatment for dengue/severe dengue, but
early detection and access to proper medical care
Take Home Message lowers fatality rates below 1%
Dengue is a mosquito-borne viral infection Dengue prevention and control solely depends on
It causes flu-like illness, and occasionally develops into effective vector control measure
a potentially lethal complication called severe dengue - end -