HARI MUKTI U

ICU & NICU Department

HERMINA mother and child Hospital
Jakarta
MANIFESTATION OF DENGUE
INFECTION


Symptomatic


Symptomatic
MANIFESTATION OF DENGUE
INFECTION
SYMPTOMATIC :
∗ Undifferentiated Fever
∗ Dengue Fever :
− Without haemorrhage
− With unusual haemorrhage
∗ Dengue Haemorrhagic Fever
− No shock
− DSS
 PATHOGENESIS OF DENGUE
FEVER AND SHOCK
The pathogenesis of DF/DHF is incompletely
understood, but epidemiologic studies
suggest that it is usually associated with
second infections with dengue type 1-4.
Dengue virus is present in the blood in the
early acute phase only, generally for 1-5
days.
The incubation periode varies between 3-10
days, with an average 4-6 days.
 MANIFESTATION OF DENGUE
INFECTION
The major pathophysiological abnormality seen in
DHF/DSS is an acute increase in vascular
permeability leading to loss of plasma from the
vascular compartement.
There is a loss of plasma of more than 20 % in
severe cases.
No destructive or inflammatory vascular lessions are
observed, suggesting that transient, functional
vascular changes due to short-acting mediators
occur.
Plasma leakage can lead to shock, which, if
uncoreccted, leads to tissue hypoxia, metabolic
acidosis and death.
 MANIFESTATION OF DENGUE
INFECTION

The haemostatic changes in DHF include 3

components :
 Vascular changes
 Thrombocytopenia
 Coagulation disorders
Recogition of Dengue Fever / Dengue Haemorrhagic Fever

Pointer to the clinical diagnosis of dengue infection

5. High continuous fever of 3 days or more

6. Headache, backache, retro-orbital pain
7. Abdominal pain, vomiting, loose stools
8. Petechial haemorrhage and / or spontaneous bleeding
9. Rash – generalized flushing/maculopapular/confluent rash
with small islands or normal skin
10. Hepatomegaly
11. Fall in platelet caount that precedes or occurs
simultaneously with a rise in Hct
12. Normal WBC or Leucopenia with relative lymphocytosis
13. Normal ESR (< 20 mm/hr)
14. Shock
 CLASSICAL DF
Is an acute febrile illness of 2-7 days duration
(sometimes with two peaks) with two or
more of the following manifestations :
• Headache
• Rertro-orbital pain
• Myalgia/arthralgia
• Rash
• Haemorrhagic manifestation (petechiae and
positive tourniquet test)
• leucopenia
 DHF
Is probable case of dengue and
2. Haemorrhagic tendency evidenced by one or more of
following :
– Positive tourniquet test
– Petechiae, ecchymosis or purpura
– Bleeding from mucosa, injection sites, or other sites
– Haematemesis or melaena
– thrombocytopenia
3. Evidence of plasma leakage due to increased capillary
permeability manifested by one or more of the following :
• A >20 % rise in haematocrit for age and sex
• A <20 % drop in Hct following treatmentwith fluids as compared to
baseline
• Sign of plasma leakage (Pleural effusion, ascites or
hypoproteinaemia)
 DSS

All the above criteria of DHF plus signs of

circulatory failure manifested by :
2. Rapid and weak pulse
3. Narrow pulse pressure ( < or equal to
20 mmHg)
4. Hypotension for age
5. Cold and clammy skin and restlessnes
 DISEASE COURSE
It is important to differentiate DF to DHF, as some
cases of DHF may progress to DSS.
DF/DHF has an unpredictable course. Most patients
have a febrile phase lasting 2-7 days. This is
followed by a critical phase which is of about 2-3
days duration.
During this phase, the patient is afebrile, and is at risk
of developing DHF/DSS which may prove fatal if
prompt and appropriate treatment is not provided.
Since haemorrhage and or shock can occur rapidly,
arrangements for rapid and appropriate treatment
should be always available.
 GRADING THE SEVERITY OF
DENGUE INFECTION
It is impoprtant to classify the severity of
dengue infection for optimal treatment.
DF/DHF SYMPTOMS LABORATORY
DF fever with two Leukopenia
or more of the occasionally,
following signs Thrombocytopenia
: headache, may be present,
retro-orbital pain, No evidence of
myalgia, arthralgia plasma loss
 GRADING THE SEVERITY OF
DENGUE INFECTION
DF/DHF SYMPTOMS LABORATORY
DHF I Above signs plus Thrombocytopenia
positive tourniquet test < 100.000,
Hct rise > 20 %

DHF II Above signs plus Thrombocytopenia

spontaneous bleeding < 100.000,
Hct rise > 20 %
 GRADING THE SEVERITY OF
DENGUE INFECTION

DF/DHF SYMPTOMS LABORATORY

DHF III Above signs plus Thrombocytopenia
circulatory failure (weak < 100.000,
pulse, hypotension, Hct > 20 %
Restlessness)

DHF IV Profound shock with Thrombocytopenia

Undetectable BP and < 100.000,
Pulse Hct rise > 20 %
 TREATMENT OF DENGUE INFECTIONS
Criteria for admission for suspected dengue fever
(any of the following ):
• Restlessness or lethargy
• Cold extremities or circumoral cyanosis
• Bleeding in any form
• Oliguria or reluctance to drink fluids
• Rapid and weak pulse
• Capilarry refill time > 2 seconds
• Narrowing of pulse pressure (< 20 mmHg) or hypotension
• Hct of 40, or rising Hct
• Platelet count of < 100.000/µL
• Acute abdominal pain
• Evidence of plasma leakage, e.g. pleural effusion, ascites
 TREATMENT OF DENGUE
INFECTIONS
• Febrile Phase
In the early febrile phase, it is not possible to
distinguish DF from DHF. Their treatments
during the febrile phase are mainly
symptomatic and supportive :
– Rest
– Antipyretics (paracetamol) for fever > 39 0 C
– No aspirin or Brufen
– No antibiotics is necessery
 TREATMENT OF DENGUE
INFECTIONS
– ORT or IV therapy may be required for patients with
moderate dehydration caused by vomiting and high
temperature
– Food should be given according to appetite

Observed for complications for at least 2 days after

recovery from fever. Life threatening
complications often occur during this phase .
If no evidence of complications and afebrile for 2-3
days, no further observation is necessery
 TREATMENT OF DENGUE
INFECTIONS
• Afebrile Phase
Dengue Fever
Constitutional symptoms in patients with DF
after the fall of fever are as during the
febrile stage.
Most patients will recover without
complication.
Check platelet count and Hct accordingly
and provide fluids and electrolyte therapy.
TREATMENT OF DHF GRADE I AND II

The only difference between the DF and DHF

grade I is the presence of thrombocytopenia and
a rise in HCT (>20%).
All cases are to be admitted. Check Hct and
Platelet count immediately on admission and
daily subsequently.
Children with DHF grade I do not usually require IV
fluid and ORT is sufficient. IV fluid may be
needed when the patient is vomiting persistently
or severely, or refusing to accept oral fluids.
TREATMENT OF DHF GRADE I AND II

A reduction in the platelet count to ≤

100.000/µL or less than usually precedes
a rise in Hct. A rise in Hct of 20 % or more
reflects a significant plasma loss and
indicates the needed for IV fluid therapy.
Early volume replacement of lost plasma
with crystalloid solution can reduce the
severity of the disease and prevent shock.
IV fluid therapy before leakage is not
recommended.
TREATMENT OF DHF GRADE I AND II

If rise of Hct > 20% : initiate IV therapy 6 ml/Kg/h

(for 3 hours). Check Hct/Vital signs/urine output
after 3 hours.
In case of improvement, reduce IV therapy to 3
ml/kg/h (for 3 hours). If further improvement,
continue IV therapy at 3 ml/kg/h (6-12 hours)
and then discontinue IV therapy.
In mild or moderat cases of DHF grade II, IV
therapy may be given for a period of 12-24
hours.
Patients should be monitored an hourly basis.
Based on periodic Hct/platelet count
determinations, vital signs, and urine output, the
treatment should be reviewed and revised.
TREATMENT OF DHF GRADE III AND IV

This is an emergency, and every minute

count. All cases of severe DHF and DSS
should ideally be maneged in a high
dependency unit.
During the afebrile phase of DHF grade IV,
vital signs are unstable. The patient, in the
early stage of shock, has acute abdominal
pain, restleness, cold and clammy skin,
rapid and weak pulse.
TREATMENT OF DHF GRADE III AND IV

Immediately after hospitalization, the Hct, platelet

count and vital signs should be examined to
assess the patient’s condition and IV fluid
therapy should be started. The patient requires
regular and susteined monitoring.
If the patient has already received about 1.000 ml
of IV fluid and the vital signs are still not stable,
the Hct should be repeated and :
– If the Hct is increasing, IV fluid should be changed to
colloidal solution, or
– If the Hct is decreasing, fresh whole blood transfusion
10ml/Kg/dose should given
TREATMENT OF DHF GRADE III AND IV
In case of continued or profound shock when pulse
and BP are undetectable, the patient should be
given colloidal fluid following the initial fluid
bolus.
In the case persistent shock when, after initial fluid
replacement and resuscitation with plasma or
plasma expanders, the Hct continues to decline,
internal bleeding should be suspected. It may be
difficult to recognize and estimate the degree of
internal blood loss in the presence of
haemoconcentration. Fresh whole blood,
100ml/kgBw at one time can be given.
Oxygen should be given to all patients in shock.
 TREATMENT OF DHF GRADE III AND IV

Blood transfusion
• Blood transfusion is indicated in significant clinical
bleeding, most often haematemesis and malaena.
• Persistent shock with rapidly declining Hct level
despite adequte volume replacement indicates
significant clinical bleeding which requires prompt
treatment with blood transfusion.
• Blood products like fresh frozen plasma, platelet
concentrate and cryoprecipitate may be indicated
in some cases, especially when consumptive
coagulopathy causes significant bleeding.
• Platelet concentrate is required if the platelet
count is < 50.000µ/L with bleeding. In the
absence of bleeding, prophylactic platelet
concentrate is indicated when the platelet count
is less than 10.000 to 20.000 µ/L
• In the presence of disseminated intravascular
coagulation (DIC), supportive therapy consisting
of maintaining circulatory volume, correcting
acidosis with sodium bicarbonate and hypoxia
with oxygen are required in addition to the use of
blood products. Cryoprecipitate (1 unit/5Kgbw)
followed by platelets (4 unit/m2 or 10-20 ml/Kg)
within 1h and fresh frozen plasma (FFP 10-20
ml/Kg). Frequent clinical assessment and
regular coagulation profile (PT, aPTT,
Fibrinogen, Platelet and FDP) are mandatory as
indicated
 LABORATORY DIAGNOSIS
Thera are 3 approaches in the laboratory
diagnosis of dengue infection :
Serology
Virus Isolation
Detection of Dengue Ribonucleic Acid