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SALIENT FEATURES:

(+) High-grade fever


(+) Frontal headache
(+) Dizziness

CASE DISCUSSION:

BACKGROUND

Dengue is the most common arthropod-borne viral (arboviral) illness in humans


Transmitted by mosquitoes of the genus Aedes, which are widely distributed in subtropical and
tropical countries
Typically a self-limiting disease
Incubation period: 3-14 days (4-7 days)
Recovery: 7-10 days

EPIDEMIOLOGY

As of September 2015, a total of 92,807 dengue cases were reported nationwide. This figure is
23.5% higher compared to the same period last 2014 (75,117 cases)
A total of 269 deaths (0.3%) were reported in 2015 which is lower than in 2014 with 316 deaths
(0.4%)
Ages of the cases range from less than 1 month to 99 years old.
Majority of the cases were male. Most of the cases were from the 5-14 years age group
Most of the cases were reported from Cental Luzon of Region III (14,127 or 15.2%), CaLaBarZon or
Region IV-A (14,082 or 15.2%), and National Capital Region (10,385 or 11.2%)
UPDATE: A total of 33,760 dengue cases were reported nationwide from January 1 to May 6, 2017.
This number is 32% lower (49,565 cases) compared to the same period in 2016

ETIOLOGY
Dengue Virus 1-4 serotypes
Most common isolated serotypes in the Philippines; Den-1 and Den-2
Infection with one serotype does not protect against the others, and sequential infections put
people at greater risk for dengue hemorraghic fever (DHF) and dengue shock syndrome (DSS)

TRANSMISSION
Aedes aegypti and Aedes albopictus
A mosquito must feed on a person during a 5- day period when large amounts of virus are in the
blood.
The virus will require an additional 8-12 days incubation before it can then be transmitted to
another human.
The mosquito remains infected for the remainder of its life, which might be days or a few weeks.
Adult, female mosquitoes lay their eggs on the inner, wet walls of containers with water, above the
waterline.
Mosquitoes generally lay 100 eggs at a time.
Eggs are very hardy; they stick to the walls of a container and can survive drying out for up to 8
months.
Bowls, cups, fountains, tires, barrels, vases and any other container storing water makes for a great
nursery.
Male mosquitoes feed on nectar from flowers.
Female mosquitoes feed on humans and animals for food and to produce eggs.
Mosquitoes can fly 1 to 1.5 miles per hour.

SIGNS AND SYMPTOMS

Dengue Fever

Dengue fever presents in a nonspecific manner and may not be distinguishable from other viral or bacterial
illness. According to the Pan American Health Organization (PAHO), the clinical description of dengue fever
is an acute febrile illness of 2-7 days duration associated with 2 or more of the following:

Severe and generalized headache


Retro-orbital pain
Severe myalgias, especially of the lower back, arms, and legs
Arthralgias, usually of the knees and shoulders
Characteristic rash
Hemorrhagic manifestations
Leukopenia

Additional findings may include the following:


o Injected conjunctivae
o Facial flushing, a sensitive and specific predictor of dengue infection
o Inflamed pharynx
o Lymphadenopathy
o Nausea and vomiting
o Non-productive cough
o Tachycardia, bradycardia, and conduction defects

Up to half of patients with dengue fever develop a characteristic rash. The rash is variable and may be
maculopapular or macular. Petechiae and purpura may develop as hemorrhagic manifestations.
Hemorrhagic manifestations most commonly include petechiae and bleeding at venipuncture sites. A
tourniquet test is often positive. Other hemorrhagic manifestations include nasal or gingival bleeding,
melena, hematemesis, and menorrhagia.

Dengue Hemorrhagic Fever

Findings for dengue hemorrhagic fever are similar to those for dengue fever and include the following:
Biphasic fever curve
Hemorrhagic findings more pronounced than in dengue fever
Signs of peritoneal effusion, pleural effusion, or both

Minimal criteria for the diagnosis of dengue hemorrhagic fever, according to the World Health
Organization (WHO), are as follows:

Fever
Hemorrhagic manifestations (eg, hemoconcentration, thrombocytopenia, positive tourniquet test)
Circulatory failure, such as signs of vascular permeability (eg, hypoproteinemia, effusions)
Hepatomegaly

In addition, conjunctival injection develops in approximately one third of patients with dengue hemorrhagic
fever. Optic neuropathy has been reported and occasionally results in permanent and significant visual
impairment. Pharyngeal injection develops in almost 97% of patients with dengue hemorrhagic fever.
Generalized lymphadenopathy is observed.

Hepatomegaly is present more often in dengue shock syndrome than in milder cases. Hepatic transaminase
levels may be mildly to moderately elevated. Encephalopathy is a rare complication that may result from a
combination of cerebral edema, intracranial hemorrhage, anoxia, hyponatremia, and hepatic injury.

Dengue Shock Syndrome

Findings of dengue shock syndrome include the following:

Hypotension
Bradycardia (paradoxical) or tachycardia associated with hypovolemic shock
Hepatomegaly
Hypothermia
Narrow pulse pressure (< 20 mm Hg)
Signs of decreased peripheral perfusion

Undifferentiated Fever

May be the most common manifestation of dengue

Classic Dengue Fever


Fever
Headache
Muscle and joint pain
Nausea/vomiting
Rash
Haemorrhagic manifestations

Dengue Hemorrhagic Fever

Skin hemorrhages: (+) torniquet test (petechiae, purpura, ecchymoses)


Gingival bleeding
Nasal bleeding
Gastro-intestinal bleeding: hematemesis, melena, hematochezia
Hematuria
Increased menstrual flow
Dengue Shock Syndrome
4 criteria for DHF
o Fever, or recent history of acute fever ( 2- 7 days )
o Hemorrhagic manifestations
o Low platelet count (100,000/mm3 or less)
Objective evidence of leaky capillaries:
o elevated haematocrit (20% or more over baseline); any haematocrit > 40%; a drop in hct
>20% following volume replacement
o low albumin
o pleural or other effusions
Evidence of circulatory failure manifested indirectly by all of the following:
o Rapid and weak pulse
o Narrow pulse pressure ( 20 mm Hg) OR hypotension for age ( < 80 mmHg systolic < 5 yrs
and 90 mmHg systolic > 5 yrs.)
o Cold, clammy skin and altered mental status
Frank shock is direct evidence of circulatory failure

SUGGESTED DENGUE CASE CLASSIFICATION AND LEVELS OF SEVERITY (WHO 2009)


REVISED DENGUE CLASSIFICATION (DOH 2011)

DIAGNOSTICS
Tourniquet Test
The tourniquet test is part of the new WHO case definition for dengue. The test is a marker of
capillary fragility and it can be used as a triage tool to differentiate patients with acute
gastroenteritis, for example, from those with dengue. Even if a tourniquet test was previously done,
it should be repeated if
It was previously negative
There is no bleeding manifestation

How to do a Tourniquet Test


1. Take the patient's blood pressure and record it, for example, 100/70.
2. Inflate the cuff to a point midway between SBP and DBP and maintain for 5 minutes.
(100 + 70) 2 = 85 mm Hg
3. Reduce and wait 2 minutes.
4. Count petechiae below antecubital fossa. A positive test is 10 or more petechiae per 1
square inch.

Complete Blood Count Monitoring- Characteristic findings in dengue fever are thrombocytopenia
(platelet count < 100 x 109/L), and leukopenia.
A hematocrit level increase greater than 20% is a sign of hemoconcentration and precedes shock.
The hematocrit level should be monitored at least every 24 hours to facilitate early recognition of
dengue hemorrhagic fever and every 3-4 hours in severe cases of dengue hemorrhagic fever or
dengue shock syndrome.
Laboratory diagnosis method for confirming Dengue viral infection involves use of one or
combination of any of the following four different methods:
Microscopy and Staining
Culture
Serology
Detection of Antigen
Detection of Antibody
Molecular Diagnosis
Note: Early stages of the disease: After the onset of illness, virus can be detected in blood (serum,
plasma) or tissues; methods employed are; virus isolation, nucleic acid or antigen detection.
At the end of acute phase of infection: Serology is the method of choice.
Note: For virus culture, it is important to keep blood samples cooled or frozen to preserve the
viability of the virus during transport from the patient to the laboratory.

Fig 1: Comparison of Dengue virus diagnostic tests according to their accessibility and confidence
Microscopy and Staining: In this case, direct visualization of the virus in the sample (using electron
microscopy or via fluorescent staining technique) is not done in diagnostic laboratories.
Culture: Virus isolation in cell culture is difficult and is not the commonly used method in
diagnostic laboratories because it is demanding procedure (both in terms of infrastructure and
technical expertise). Virus may be recovered from serum, plasma and peripheral blood
mononuclear cells. Inoculation of a mosquito cell line with patient serum, coupled with nucleic acid
assays to identify the recovered virus is commonly used approach.
Fig
2: Approximate time-line of primary and secondary dengue virus infections and the
diagnostic methods that can be used to detect infection

Serological Test: Serological tests are the mainstay in the diagnosis of viral infections.
Detection of Viral Antigen: Dengue NS1 Antigen detection
useful for the diagnosis of acute dengue infections.
has been detected in the serum of DENV infected patients as early as 1 day post onset of symptoms
(DPO), and up to 18 DPO.
NS1 ELISA based antigen assay is commercially available
NS1 assay may also be useful for differential diagnostics between flaviviruses because of the
specificity of the assay
Detection of Anti-dengue antibodies in serum or other body fluids by ELISA or other rapid
tests. Various methods (IgM/IgG ELISA, Hemagglutination Inhibition Test, or Rapid diagnostic kits)
are available to detect Anti-Dengue Antibodies;IgM detection: Useful for the diagnosis of primary
Dengue infection and in distinguishing dengue from other flavivirus infections. IgM antibodies are
detectable in 99% of patients by day 10 after onset of illness.IgM levels peak about two weeks after
the onset of symptoms and then decline to undetectable levels over 23 months. Sensitivity: 65-
75% sensitive in single acute serum sample.
Fig 3: Rapid ICT
based Test for the diagnosis of Dengue Infection
IgG detection: Tests that detect IgG are useful in diagnosing secondary disease (IgG is the dominant
immunoglobulin type in secondary infection). The test is complicated by cross-reactivity of IgG
antibodies to heterologous flavivirus antigens (West Nile virus, tick-borne encephalitis virus, yellow
fever virus, Zika virus).
Note: To distinguish primary and secondary dengue infections, IgM/IgG antibody ratios are now
more commonly used than the haemagglutination-inhibition test (HI).
Molecular diagnosis: detection of viral RNA in plasma or serum or tissues using Nucleic Acid
Amplification Tests (NAAT). RT-PCR based methods for rapid identification and serotyping of
dengue virus in acute phase serum are available.

Fig 4: Summary of operating characteristics and comparative costs of dengue diagnostic methods

Interpretation of Dengue Diagnostic Tests:


Highly Suggestive Confirmed
One of the following: One of the following:
IgM + in a single serum sample PCR +
IgG + in a single serum sample with a HI Virus culture +
titre of 1280 or greater IgM seroconversion in paired sera
IgG seroconversion in paired sera or fourfold IgG
titer increase in paired sera
AST, ALT -mild-to-moderate elevation of aspartate aminotransferase and alanine aminotransferase
values. Enzyme levels begin to rise during the early stage and peak during the second week.
Clinically severe involvement was found to be idiosyncratic and infrequent but did contribute to
severe bleeding
PT, APTT -Prolonged prothrombin time and Prolonged activated partial thromboplastin time
FOBT
Urinalysis
Dengue Case Management
Classify patient
o Group A: Outpatient Management
o Group B: Inpatient Management
o Group C: Emergency Management
Signs of Recovery
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetite
No vomiting
Good urinary output
Stable hematocrit
Convalescent confluent petechiae rash

Criteria for Discharging Patients


Absence of fever for at least 24 hours without the use of anti-fever therapy
Return of appetite
Visible clinical improvement
Good urine output
Minimum of three days after recovery from shock
No respiratory distress from pleural effusion and no ascites
Platelet count of more than 50,000/mm3

Dengue Prevention and Control


Clothing: Reduce the amount of skin exposed by wearing long pants, long sleeved shirts, and socks,
tucking pant legs into shoes or socks, and wearing a hat.
Mosquito repellents: Use a repellent .
Mosquito traps and nets: Nets treated with insecticide are more effective, otherwise the mosquito
can bite through the net if the person is standing next to it. The insecticide will kill mosquitoes and
other insects, and it will repel insects from entering the room.
Door and window screens: Structural barriers, such as screens or netting, can keep mosquitos out.
Avoid scents: Heavily scented soaps and perfumes may attract mosquitos.
Camping gear: Treat clothes, shoes, and camping gear with permethrin, or purchase clothes that
have been pretreated.
Timing: Try to avoid being outside at dawn, dusk, and early evening.
Stagnant water: The Aedes mosquito breeds in clean, stagnant water. Checking for and removing
stagnant water can help reduce the risk.
To reduce the risk of mosquitoes breeding in stagnant water:

turn buckets and watering cans over and store them under shelter so that water cannot accumulate
remove excess water from plant pot plates
scrub containers to remove mosquito eggs
loosen soil from potted plants, to prevent puddles forming on the surface
make sure scupper drains are not blocked, and do not place potted plants and other objects over
them
use non-perforated gully traps, install anti-mosquito valves, and cover any traps that are rarely used
do not place receptacles under an air-conditioning unit
change the water in flower vases every second day and scrub and rinse the inside of the vase
prevent leaves from blocking anything that may result in the accumulation of puddles or stagnant
water

Dengue Prevention and Control in the Philippines

Practice 4s

Search & destroy mosquito breeding places


use Self-protection measures
Seek early consultation for fevers lasting more than 2 days
Say no to indiscriminate fogging

Space spraying/thermal fogging

destruction of flying mosquitoes by contact with insecticides in the air


Done when there is an impending outbreak
effective if done every week for (4) weeks
temporary in nature
requires lot of resources
The 4 oclock habit: stop, look and listen!

Stop means dropping everything and shifting current task for mosquito control. When the clock
strikes 4 p.m., look for the breeding sites of dengue-carrying mosquitoes and carry out systematic
search and destroy activities to eliminate them.
Listen entails heeding the instructions from local authorities, community leaders or work
supervisors for a synchronous implementation of the 4 oclock habit.

DENGVAXIA

1st dengue vaccine; FDA approved last Dec. 2015


Tetravalent (covers all 4 serotypes); Live attenuated
Protection from most extreme, potentially life- threatening form of disease (DHF)
Duration of protection: still unclear
Does not cover very young children
Administration: 3 doses scheduled w/ 6-month interval
60.8% ave. rate of effectiveness
Pediatric Infectious Disease Society of the Phil. (PIDSP):
- Encourages healthy individuals (9-45y/o) to be vaccinated
DOH: will spend P3.5 billion dengue immunization program (3,000 public school students in
areas w/ high incindence of dengue)

RECOMMENDATIONS:

Note: Since Dengue Fever is usually self-limiting disease management of this is geared towards
symptomatic treatment and palliative care. There is no specific antiviral treatment currently
available for dengue fever.

1. Group A : give ORS, paracetamol and bed rest


2. Group A ambulatory patients should be monitored daily for disease progression decreasing
WBC, increase Htc, decreasing Platelet, defervescence, warning signs until out of the critical
period
3. Supportive care with analgesics, fluid replacement, and bed rest is usually sufficient.
Paracetamol may be used to treat fever and relieve other symptoms.
4. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids should be
avoided.
5. Management of severe dengue requires careful attention to fluid management and proactive
treatment of hemorrhage.
6. Watch out for warning signs occur 37 days after the first symptoms in conjunction with a
decrease in temperature (below 38C/100F) and include: severe abdominal pain, persistent
vomiting, and rapid breathing, bleeding gums, fatigue, restlessness and blood in vomit. The
next 2448 hours of the critical stage can be lethal; proper medical care is needed to avoid
complications and risk of death.
7. Monitor for deteriorating status or signs of Severe Dengue such as:
- severe plasma leakage with shock and/or fluid accumulation with respiratory distress
- severe bleeding
- severe organ impairment
8. If patient recovers, advise patient to practice DOHs Aksyon Barangay KontraDengue program:
4S to avoid reinfection
- Search and destroy mosquito breeding places
- Use Self-protection measures
- Seek early consultation for fevers lasting more than 2 days
- Say YES to fogging when there is an impending outbreak
9. Dengue Vaccine