MANAGEMENT OF
DENGUE FEVER
PRESENTER : Dr.Mohan.T.Shenoy
CHAIRPERSON: Dr.Nisarga
REFERENCES
NELSON Textbook of Pediatrics 18th edition
MEHERBAN SINGH Pediatric Emergencies 4th edition
IAP Textbook of Pediatrics 4th edition
Textbook of Pediatric & Neonatal emergencies by SACHDEV
Textbook of pediatric infectious diseases By Ralph D. Feigin
Davidson's principles & practice of medicine
PARK’s Textbook of Preventive and Social medicine 20th edition
http://www.who.int/ctd/docs/dengue.pdf
http://www.cdc.gov/
Jornal de Pediatria - Vol. 83, No.2(Suppl), 2007 -Dengue and
dengue hemorrhagic fever – Singhi S et al.
Emerged among children in Southeast Asia during the 1950s.
Its severe forms (hemorrhagic fever and shock syndrome) may lead
to multisystem involvement and death.
Initial Warning
Signals When Patients Develop
• Disappearance of fever DSS:
• Drop in platelets • 3 to 6 days after onset of
• Increase in hematocrit symptoms
Special attention :High-risk dengue patients
Infants under 1 year of age
Overweight/obese patients
Massive bleeding
Use Paracetamol
Avoid Aspirin and NSAIDs
NCPAP
should be preferred if there is Acute respiratory failure
associated with DSS.
Domperidone
1 mg/kg/day in three divided doses in case of severe
vomiting for 1-2 days.
One single dose may be adequate
Antibiotic
Not necessary; it may lead to complications
FLUID MANAGEMENT
In young infants without shock-
N/2 saline in 5% dextrose
DOSE
10-20 mL/kg
Platelets or blood should NOT be transfused based upon
platelet count alone.
DOSE
DIC
Myocardial dysfunction incl. Cardiomyopathy
Hepatitis
Reye-like syndrome
Encephalitis
ARDS
Glomerulonephritis
Treatment of complications
Fluid overload
AVOID
Treatment
Hyponatremia
Hypocalcemia – 10% Ca gluconate 1 mL/kg/dose, slow IV push
every 6 hour
Seriously sick patients with bleeding & DIC have benefited from :
Nasal CPAP
Refractory shock
Vasopressin
Desmopressin 0.3 mcg/kg over 30 min 3-4 days
Prognosis
DF is a very incapacitating disease; however, its prognosis is favorable.
prolonged shock
massive bleeding
fluid overload and
acute liver failure with encephalopathy.
Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever: Guidelines for
Prevention and Control. PAHO: Washington, D.C., 1994: 69.
Convalescent confluent petechial rash
PERSONAL PROTECTION
The tetravalent live attenuated DEN vaccine trial has been done in
Thailand.
CATEGORY-A
(INDONESIA,MYANMAR,AND THAILAND)
CATEGORY-B
(INDIA,BANGALADESH,MALDIVES,AND SRILANKA)
CATEGORY-C
(BHUTAN, NEPAL)
CATEGORY-D
(DPR KOREA)
The Dengue Virus
Single stranded RNA virus
Positive sense
40 to 50 nanometers
Flavivirus
Four sero-sub types
Type 1 to 4
Susceptible hosts,
(population)
Viraemia & Fever: 5-7 days Source patients
During dengue epidemics, attack rates among susceptible
individuals are often 40-50%, but may reach 80-90%.
Population
24%
Infection
76%
DF DHF/DSS 0.8%
(non-DHF) 99.2%
survive Death
Rates in dengue model by Shepard et al. Vaccine. 2004, 22:1275-1280.
Clinical Features
Fever – biphasic/saddle-back type
Headache with retro-orbital pain
Muscle and joint pain
Nausea/vomiting
Rash
Hemorrhagic manifestations
Abdominal pain
Polyserositis
Undifferentiated Fever
DS Burke, et al. A prospective study of dengue infections in Bangkok. Am J Trop Med Hyg 1988;
38:172-80.
ERYTHEMATOUS FLUSH
Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever: Guidelines for
Prevention and Control. PAHO: Washington, D.C., 1994: 12.
Positive Tourniquet Test
Endemic areas -WHO criteria
2 clinical observations
+
1 laboratory finding
OR
Enhancing Ab
Serotype independent
Concentration dependent
Hyperendemic transmission
Virus serotype
Hydration status
Tourniquet test
Peripheral smear
Dot-Blot immunoassay
RT-PCR
Early detection of dengue infection when antibodies are
not yet detectable.
Epidemiological studies
Sensitivity of 50 %
Culture done in cell line derived from A. albopictus cell.
Can determine serotype of the infecting virus)
For research and epidemiological studies.
AND/OR
Bleeding, abdominal pain, vomiting, appetite, fluid intake, and urine output
Physical examination
Blood counts
Extrinsic Intrinsic
incubation incubation
period period
Viremia Viremia
0 5 8 12 16 20 24 28
DAYS
Illness Illness
Human #1 Human #2
Temperature, Virus Positivity and
Anti-Dengue IgM , by Fever Day
100
39.5
Percent Virus Positive
80
39.0 225
38.5 60
150
38.0 40
37.5 20 75
37.0
0 0
-4 -3 -2 -1 0 1 2 3 4 5 6
Fever Day
Mean Max. Temperature Virus Dengue IgM
Adapted from Figure 1 in Vaughn et al.,
J Infect Dis, 1997; 176:322-30.