Diagnosis dan tatalaksana

Demam Berdarah Dengue

Dr. Prawitasari E, SpPD

Budiriyanto 1
 PENDAHULUAN
• DBD merupakan salah satu penyakit
menular yang dapat menimbulkan wabah.
• masalah kesehatan di Indonesia
• menimbulkan kekuatiran karena perjalanan
penyakitnya yang cepat dan dapat
menyebabkan kematian dalam waktu
singkat.
 Case fatality Rate DHF di ASEAN

7
Filipina
6
Vietnam
5 Thailand
4 Indonesia
Myanmar
3 Kamboja
2 Malaysia
Singapore
1
Laos
0
CFR
Halstead, 1997
Budiriyanto 3
 PENYEBAB DBD
Penyebab DBD adalah virus dengue yang sampai saat ini
dikenal dengan 4 serotipe :
1. Dengue – 1
2. Dengue – 2
3. Dengue – 3
4. Dengue – 4
Setiap serotipe cukup berbeda  tidak ada proteksi
silang dan wabah yang disebabkan beberapa serotipe
dapat terjadi.
INFEKSI DENGUE
• Masa Inkubasi biasanya 4 – 7 hari (3 – 15 hari)
• Manifestasi klinis :
 Bentuk Abortif  asimptomatik
 Demam Dengue ( DF )demam tinggi selama 4 – 7 hari
nyeri-nyeri pada tulang, diikuti dengan munculnya bintik-
bintik atau bercak-bercak pendarahan dibawah kulit.
 Dengue Haemorhagig Fever ( DBD/DHF ), = gejala Demam
dengue + gejala pendarahan/hemokonsetrasi
 Dengue Syok Sindrom ( DSS ), =DBD + syok/presyok.
 Infeksi Virus Dengue
Phenomena Gunung Es
5 Demam Berdarah Dengue
15 Demam Dengue
100

80

% 60 Asimptomatik
80
40

20

0
Gunung Es 6
Gejala Klinis Demam Dengue
Demam akut 2 -7 hari, disertai :

• Nyeri kepala
• Nyeri perut /mual/muntah
• Nyeri otot / sendi
• Muka kemerahan
• Petechiae
• Uji RL (+ )
• Lekopenia
Budiriyanto 7
 Kecenderungan perdarahan

 UJI RL (+)
 Petechiae / echymosis
 Epistaxis , perdarahan gusi
 Perdarahan tempat injeksi
 Hematemesis
 Melena

Budiriyanto 8
 Uji Tourniquet

• Pasang Manset ( Lebar 1/2 lengan atas )

• Tekanan darah antara sistolik- diastolik : 5’
• Volar / fossa cubiti
• Uji (+) : ≥10 pada diameter 2,8 cm.

Budiriyanto 9
 Derajat Infeksi Dengue
Derajat Klin is La borat orium

DD Dem am +2 >;ny eri Lekosit <,

k p l, perut / m ua l/ Trom b osit <
m un t a h ,ny eri ot ot
DBD I UJI RL (+) Tr<1 0 0 .0 0 0 .
Ht > 2 0 %
DBD II Perda ra ha n Idem
sp ont an
DBD III Gag a l sirk ula si Idem

DBD IV Profoun d Sy ok Idem

Budiriyanto 10
 Perjalanan penyakit DBD

DD DBD I DBD II DBD III DBD IV

Fase
akut
Fase
Akut
Fase
Kritis
Fase
Kritis

Fase
Fase
Konv
Konvalescense

alense
Budiriyanto 11
 Kebocoran plasma pada DBD

 Hematokrit > 20%

 Hematokrit  ( > 20% dari baseline )
 Tanda kebocoran plasma
- Efusi pleura
- Asites
- Edema
- Hipoprotein
Budiriyanto 12
Manifestasi Demam Dengue & DBD
DD DBD DD DBD
Nyeri kepala ++ + Obstipasi O +
Muntah +++ ++ Uji RL + ++
Mual + + Petekiae +++ +++
Nyeri otot + + Perdrh G.I 0 +
Diare ++ + Hepatomegali ++ ++
Batuk + + Nyeri perut + +++
Pilek + + Trombositopen
Kejang + + ia ++ +++
Kesadaran << 0 ++ Syok
lemah 0 + 0 +++

Budiriyanto 13
 Diagnosis DBD
 Kriteria WHO 2011
 Sitologi
 Serologi
 USG

Budiriyanto 14
 Sindrom Syok Dengue
 Kegagalan sirkulasi
 Nadi cepat dan lemah
 Tekanan nadi sempit ( < 20 mmHg )
 Hipotensi
 Kulit dingin dan lembab
 Diuresis ( < 1 cc/Kg/BB
 Lemah / kesadaran 
Budiriyanto 15
 Kriteria WHO

Klinis :
 Demam 2-7 hari
 Perdarahan : Uji RL/perdarahan spontan
 Pembesaran hati
 Syok

Laboratorium :
 Trombositopenia ( < 100.000 )
 Hemokonsentrasi ( > 20% )
( 2 Klinis + AT& Ht > )
Budiriyanto 16
Pemeriksaan Penunjang DBD

 Lekosit, Trombosit
 Ht, Hb
 Prot Plasma, Albumin
 Transaminase
 Faal koagulasi
 Uji diagnosis
 Foto Thorax, USG
Budiriyanto 17
 Pemeriksaan Serologis

* Hemaglutinasi inhibisi
* Komplemen fiksasi
* Netralisasi
* Ig M Elisa ( Ig M Dengue Blot )
* Ig G Elisa ( Ig M Dengue Blot )

Budiriyanto 18
Tatalaksana T e rs a n g k a D B D

A d a k e d a ru ra ta n T id a k a d a k e d a r u r a t a n

B a w a R S b l tr < 1 0 0 .0 0 0 R L (+ ) R L (-)

Tr < 100000 Tr > 100000 r a w a t ja la n

R a w a t in a p R a w a t ja la n
Budiriyanto 19
DBD tanpa syok

DBD SYOK (-), Perdarahan (-)

Hb, Ht N/Naik
Trombosit > 100.000

Evaluasi 24 jam

Hb, Ht N Hb Ht N/Naik Hb Ht N/Naik Klinis memburuk, TD ↓,

Stabil 24 jam Tr >100.000 Tr <100.000 Nadi↑, Diuresis ↓

Berikan Cairan Kristaloid Berikan Cairan Kristaloid

Berikan Cairan Kristaloid Pertimbangkan koloid

Evaluasi/24 jam Evaluasi/12 jam

Pulang
Baik/stabil
21
The Dengue Guidelines
2011
 Diagnosis
Diagnosis Classification
Classificationgnosis
Diagnosis Classification
Diagnosis Classification
1997 2009 2011
Dengue fever Dengue without warning Dengue fever
signs
DHF grade I Dengue with warning DHF grade I
signs
DHF grade II DHF grade II
DHF grade III Severe dengue DHF grade III
( severe plasma leakage,
severe hemorrhage,
severe organ involvement)
DHF grade IV DHF grade IV
* Expanded dengue
syndrome
Adult management Adult management
 Grade Sign and Symptomps Laboratory

DF DHF without plasma leakage

DHF I Fever with non-specific constitutional symptoms; Thrombocytopenia
the only hemorrhagic manifestation is a positive (platelet count 
tourniquet test &/or easy bruising 100,000/L)
evidence of plasma leakage

II DHF grade I plus spontaneous bleeding

III Circulatory failure manifested by a rapid, weak

pulse, narrowing of pulse pressure, or
hypotension, cold & clammy skin, restlessness

IV Profound shock with undetectable blood pressure

 Dengue with warning signs
Warning signs
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation
• Mucosal bleed
• Lethargy, restlessness
• Liver enlargement >2 cm
• Increase in HCT concurrent with rapid
decrease in platelet count
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 Severe Dengue
• Severe plasma leakage leading to:
• Shock (DSS)
• Fluid accumulation with respiratory distress
• Severe bleeding as evaluated by clinician
• Severe organ involvement
– Liver: AST or ALT ≥ 1000
– CNS: Impaired consciousness
– Heart and other organs
WHO classification of Dengue infections and grading of severity of DHF (2011)

DF/
DHF Grade Signs and Symptoms Laboratory
DF Fever with two of the following: • Leucopenia (WBC <5000 cells/mm3)
•Headache • Thrombocytopenia <150.000
•Retro-orbital pain cells/mm3)
•Myalgia • Rising Hct (5-10%)
•Athralgia/bone pain • No evidence of plasma loss
•Rash
•Haemorrhagic manifestations
•No evidence of plasma leakage

DHF I Fever and haemorrhagic manifestation Thrombocytopenia <100.000 cells/mm3

(positive tourniquet test) and evidence of Hct rise >20%
plasma leakage
DHF II As in Grade I plus spontaneous bleeding Thrombocytopenia <100.000 cells/mm3
Hct rise >20%
*DHF III As in Grade I or II plus circulatory failure Thrombocytopenia <100.000 cells/mm3
Hct rise >20%
*DHF IV As in Grade III plus profound shock with Thrombocytopenia <100.000 cells/mm3
undetectable bloodpressure and pulse Hct rise >20%

*DHF III and IV are DSS

 Discharge criteria
Criteria 1997 2009 2011
Absence of fever 24 hours 48 hours 24 hours
without the use without the
of anti-fever use of anti-
therapy fever therapy
Clinical improvement + + (general well-being, appetite, +
hemodynamic status, urine output,
no respiratory distress)
Return of appetite + - +
Good urine output + - +
Stable hematocrit + + (without intravenous fluids) +
Elapse from shock At least 2 days - At least 2-3
recovery days
No respiratory + - +
distress
Platelet count > 50,000/L Increasing trend > 50,000/L
 Signs of Significant Dehydration
- Tachychardia
- Increased capillary refill time (>2 second)
- Cool, mottled or pale skin
- Diminished peripheral pulses
- Changes in mental status
- Oliguria
- Sudden rise in haematocrit or continously elevated
haematocrit despite administration of fluids
- Narrowing of pulse pressure (< 20 mmHg)
- Hypotension (a late finding representing
uncorrected shock)
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 Warning signs (2011)
• No clinical improvement or worsening of the situation just
before or during the
• Transition to afebrile phase or as the disease progresses.
• Persistent vomiting, not drinking.
• Severe abdominal pain.
• Lethargy and/or restlessness, sudden behavioural changes.
• Bleeding: Epistaxis, black stool, haematemesis, excessive
menstrual bleeding, darkcoloured urine (haemoglobinuria) or
haematuria.
• Giddiness.
• Pale, cold and clammy hands and feet.
• Less/no urine output for 4–6 hours.

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 High-risk patients (2011)
• infants and the elderly,
• obesity,
• pregnant women,
• peptic ulcer disease,
• women who have menstruation or abnormal vaginal bleeding,
• haemolytic diseases such as glucose-6-phosphatase dehydrogenase (G-
6PD) deficiency,
• thalassemia and other haemoglobinopathies,
• congenital heart disease,
• chronic diseases such as diabetes mellitus, hypertension, asthma, ischaemic
heart disease,
• chronic renal failure, liver cirrhosis,
• patients on steroid or NSAID treatment, and
• others
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