DENGUE FEVER
Dr Deepak G Bhosle
Professor
Department of Medicine
Bharati Vidyapeeth Medical College
& Bharati Hospital,Pun...
DENGUE IS ALSO KNOWN AS
 Philippine hemorrhagic fever
 Thai hemorrhagic fever
 Singapore hemorrhagic fever
 Onyong- Ny...
CAUSATIVE AGENT
 Dengue virus is a Arbovirus from the genus
Flavivirus
 Single stranded RNA virus
 Four species – Den 1...
ADES AEGYPTI MOSQUITO
 Lays its eggs in clean, stagnant water.
 One distinct physical feature – black and white
stripes ...
19-Sep-13
5
DeepakBhosle
19-Sep-13
6
DeepakBhosle
EPEDIOMOLOGY
 Rapid expansion of urbanization
 Inadequate closed drainage
 ↑ movement of human population within and
be...
CLINICAL FEATURES
 a) Classic Dengue – Break Bone fever
 Incubation period is 4 – 6 days ( range 3 -14)
 Abrupt onset o...
 Transient generalized erythematous rash – first 24 – 48
hrs. This morbilliform rash appears on trunk, spreads to
face an...
PETECHIA / PURPURA
19-Sep-13
10
DeepakBhosle
PETECHIA / PURPURA
19-Sep-13
11
DeepakBhosle
ECCHYMOSIS
19-Sep-13
12
DeepakBhosle
LARGE ECCHYMOSIS
19-Sep-13
13
DeepakBhosle
MORBILIFORM RASH
19-Sep-13
14
DeepakBhosle
b) Dengue Hemorrhagic fever
 Is defined as acute febrile illness with minor or major
bleeding, thrombocytopenia (platelet...
on upper arm to midway between systolic and diastoic BP
for 5 min. +ve test > 20 petechiae/ 2.5 cm square.
Also known as H...
TOURNIQUET TEST
19-Sep-13
17
DeepakBhosle
c) Dengue shock syndrome
 DSS is DHF with signs of circulatory failure
 Warning signs are intense, sustained abdominal p...
WHO case definitions
 Probable case – An acute febrile illness with 2 or more
of following – Headache, retro-orbital pain...
 Confirmed Case
Confirmation of the Dengue case is based on Lab
criteria. Virus isolation from serum or tissue samples.
O...
CRITERIA FOR DHF
(ALL 4 CRITERIA ARE REQUIRED)
 Fever or h/o fever lasting 2-7 days
 Hemorrhagic tendency
- a +ve tourni...
CRITERIA FOR DSS
 DSS requires all the DHF criteria in addition a
circulatory failure manifested by
- Rapid and weak puls...
LAB DIAGNOSIS
1. Culture of the virus from serum obtained during
febrile phase. Remains detectable in blood during
febrile...
3. Newer techniques like RT-PCR ( reverse transcriptase
polymerase chain reaction) are very sensitive & specific
for detec...
7. Leucopenia (↓ TLC) & neutropenia; towards the end of
febrile phase
8. Relative lymphocytosis
9. Deranged RFT & LFT & pr...
RAPID CARD TEST –USED IN PRACTICE
19-Sep-13
26
DeepakBhosle
DENGUERAPIDCARDTEST-USEDINPRACTISE
In practice in
a patient
with acute
febrile illness
with
thrombocyto
penia and a
positi...
RAPID CARD TEST
19-Sep-13
28
DeepakBhosle
RAPID CARD TEST
19-Sep-13
29
DeepakBhosle
RAPID CARD TEST
19-Sep-13
30
DeepakBhosle
DIFFERENTIAL DIAGNOSIS
 Any acute febrile illness with thrombocytopenia
1. Malaria
2. Leptospirosis
3. Infectious mononuc...
DENGUE AND MALARIA DIFFERENCES
Dengue(n=75) Malaria (n=75)
1. Continuous fever 80% 66%
2. Myalgia 96% 66%
3.Palatal petech...
CLINICAL MARKERS OF DENGUE
 Continuous fever
 Characteristic myalgia ( retro orbital &
interscapular)
 Palatal petechia...
TREATMENT
 Symptomatic - Paracetamol for fever & myalgia.
Aspirin, NSAIDS avoided due to risk of erosive
gastritis and bl...
TREATMENT 2
 Because patients have loss of plasma they must be
given isotonic solution or plasma expanders.
 Platelets a...
TREATMENT 3
 Besides bleeding other complications are ARDS,
renal failure, hepatic failure & encephalopathy.
19-Sep-13
36...
PREVENTION AND CONTROL
 It is by control of mosquitoes which live & breed in
stagnant water in and around the house.
 La...
PREVENTION AND CONTROL 2
 Vector control can be done by simple measures like
using insect repellants, indoor space spray
...
If you think education is
expensive ,Try Ignorance.
- Dereck Bok
dgbhosle@
gmail.com
19-Sep-13
39
DeepakBhosle
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Dengue fever- clinical features,investigations, diagnosis, treatment and prevention

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This presentation is for medical students and general practitioner It contains detailed account of epidemiology, causation, clinical features, investigations,diagnosis, treatment of dengue fever. contains pictures. useful latest and comprehensive information about Dengue. It also contains dengue case definitions of WHO.It also lists the complications of dengue. It enumerates the warning signs for more severe form of dengue fever. Includes risk factors for dengue shock syndrome and dengue hemorrhagic fever.It includes a list if clinical markers of dengue. Also details about the habits of the dengue vector , aedes aegypti mosquito

Published in: Health & Medicine, Technology

Dengue fever- clinical features,investigations, diagnosis, treatment and prevention

  1. 1. DENGUE FEVER Dr Deepak G Bhosle Professor Department of Medicine Bharati Vidyapeeth Medical College & Bharati Hospital,Pune 19-Sep-13 1 DeepakBhosle
  2. 2. DENGUE IS ALSO KNOWN AS  Philippine hemorrhagic fever  Thai hemorrhagic fever  Singapore hemorrhagic fever  Onyong- Nyang Fever  West Nile Fever  Dandy fever  Break Bone Fever  Dengue like Disease 19-Sep-13 2 DeepakBhosle
  3. 3. CAUSATIVE AGENT  Dengue virus is a Arbovirus from the genus Flavivirus  Single stranded RNA virus  Four species – Den 1,2,3,4  Infection with one serotype provides lifelong immunity for that species.  Transmitted by mosquito ,Aedes aegypti closely associated with human habitation. 19-Sep-13 3 DeepakBhosle
  4. 4. ADES AEGYPTI MOSQUITO  Lays its eggs in clean, stagnant water.  One distinct physical feature – black and white stripes on its body and legs – Tiger mosquito  Bites during the day.  On average, a female Aedes mosquito can lay about 300 eggs during her life span of 14 to 21 days.  Only the female Aedes mosquito feeds on blood. This is because they need the protein found in blood to produce eggs. Male mosquitoes feed only on plant nectar 19-Sep-13 4 DeepakBhosle
  5. 5. 19-Sep-13 5 DeepakBhosle
  6. 6. 19-Sep-13 6 DeepakBhosle
  7. 7. EPEDIOMOLOGY  Rapid expansion of urbanization  Inadequate closed drainage  ↑ movement of human population within and between countries  Insecticide resistance in mosquito vector population are few of the reasons for ↑ dengue transmission in recent years 19-Sep-13 7 DeepakBhosle
  8. 8. CLINICAL FEATURES  a) Classic Dengue – Break Bone fever  Incubation period is 4 – 6 days ( range 3 -14)  Abrupt onset of fever, chills, headache, retro orbital pain and backache  Fever is 39 – 40◦ C; remission of 2days followed by second febrile phase for 1 -2 d. Biphasic curve or saddle back fever. Fever lasts for 5- 7 days 19-Sep-13 8 DeepakBhosle
  9. 9.  Transient generalized erythematous rash – first 24 – 48 hrs. This morbilliform rash appears on trunk, spreads to face and limbs sparing palms and soles. It lasts for 1- 5 days.  Generalised myalgias, arthralgia and constitutional symptoms like anorexia, nausea, vomiting and dysgeusia may be +nt.  Relative bradycardia and generalised lymphadenopathy may be +nt.  Marked leucopenia and thrombocytopenia. ↓ Platelets is due to impaired megakaryocyte production & ↑ platelet destruction. 19-Sep-13 9 DeepakBhosle
  10. 10. PETECHIA / PURPURA 19-Sep-13 10 DeepakBhosle
  11. 11. PETECHIA / PURPURA 19-Sep-13 11 DeepakBhosle
  12. 12. ECCHYMOSIS 19-Sep-13 12 DeepakBhosle
  13. 13. LARGE ECCHYMOSIS 19-Sep-13 13 DeepakBhosle
  14. 14. MORBILIFORM RASH 19-Sep-13 14 DeepakBhosle
  15. 15. b) Dengue Hemorrhagic fever  Is defined as acute febrile illness with minor or major bleeding, thrombocytopenia (platelet ≤ 1.0 lakh/mm) & evidence of plasma leakage ->hemoconcentration (↑ hematocrit ) & pleural or other effusions ( serositis).  Primarily in children and young adults.  Susceptibility ↓ after 12 yrs of age.  DHF, DSS develops arround 3rd to 7th day  +ve Tournquet test – inflate the BP cuff 19-Sep-13 15 DeepakBhosle
  16. 16. on upper arm to midway between systolic and diastoic BP for 5 min. +ve test > 20 petechiae/ 2.5 cm square. Also known as Hess Test.  Petechiae, bruised skin ,S/c bleeding at venepuncture site seen in most cases.  Transudate due to excessive capillary leakage leads to pleural effusion & ascites.  Progressively ↓platelet count, ↑ hematocrit indicate probability of impending shock. 19-Sep-13 16 DeepakBhosle
  17. 17. TOURNIQUET TEST 19-Sep-13 17 DeepakBhosle
  18. 18. c) Dengue shock syndrome  DSS is DHF with signs of circulatory failure  Warning signs are intense, sustained abdominal pain, persistent vomiting, restlessness or lethargy & sudden change from fever to hypothermia with sweating and prostration.  Pt. may recover with i/v fluids, but shock may recur.  Once shock sets in ,mortality is high, 12 -44% 19-Sep-13 18 DeepakBhosle
  19. 19. WHO case definitions  Probable case – An acute febrile illness with 2 or more of following – Headache, retro-orbital pain, myalgia & arthralgia, nausea & vomiting, skin rash, hemorrhagic manifestations ; AND  supportive serology OR  occurrence at the same location & time as other confirmed cases of Dengue. 19-Sep-13 19 DeepakBhosle
  20. 20.  Confirmed Case Confirmation of the Dengue case is based on Lab criteria. Virus isolation from serum or tissue samples. OR Demonstration of 4 fold rise in IgG or IgM antibody titers in paired serum samples. OR Demonstration of Dengue antigen in tissue, CSF by immunocytochemistry or detection of genomic sequence by PCR. 19-Sep-13 20 DeepakBhosle
  21. 21. CRITERIA FOR DHF (ALL 4 CRITERIA ARE REQUIRED)  Fever or h/o fever lasting 2-7 days  Hemorrhagic tendency - a +ve tourniquet test - Petechae, ecchymosis, purpura - Bleeding per mucosa, GIT , etc. - Hematemesis, Malena  Thrombocytopenia, Platelets < 1.0 lakh/mm3  Plasma leakage - rise in hematocrit > 20% - fall in hematocrit > 20% after i/v fluids - Pleural effusion, ascites, hypoalbuminemia. 19-Sep-13 21 DeepakBhosle
  22. 22. CRITERIA FOR DSS  DSS requires all the DHF criteria in addition a circulatory failure manifested by - Rapid and weak pulse - Narrow pulse pressure ( < 20 mm Hg) - Hypotension, For age > 5yrs < 90 mm Hg for age < 5 yrs < 80 mm Hg - Cold dry skin, restlessness 19-Sep-13 22 DeepakBhosle
  23. 23. LAB DIAGNOSIS 1. Culture of the virus from serum obtained during febrile phase. Remains detectable in blood during febrile period. 2. Serologic diagnosis – by demonstrating a rise in antibody titer in paired sera drawn 7 to 14 days apart (This could be by any method like haemagglutination inhibition, complement fixation or, neutralizing anibodies) Rise in IgM antibody is more specific for recent infection; rising titer more specific. 19-Sep-13 23 DeepakBhosle
  24. 24. 3. Newer techniques like RT-PCR ( reverse transcriptase polymerase chain reaction) are very sensitive & specific for detecting viral RNA. 4. Thrombocytopenia & hemoconcentration 5. Drop in platelets to , 1.0lakh/mm3 is seen between 3rd to 8th day of illness 6. Hemoconcentration, with ↑ in hematocrit by 20% is definitive evidence of ↑ vascular permeability & plasma leakage 19-Sep-13 24 DeepakBhosle
  25. 25. 7. Leucopenia (↓ TLC) & neutropenia; towards the end of febrile phase 8. Relative lymphocytosis 9. Deranged RFT & LFT & prolonged PT is seen in severe cases of DHF 19-Sep-13 25 DeepakBhosle
  26. 26. RAPID CARD TEST –USED IN PRACTICE 19-Sep-13 26 DeepakBhosle
  27. 27. DENGUERAPIDCARDTEST-USEDINPRACTISE In practice in a patient with acute febrile illness with thrombocyto penia and a positive rapid card test for Dengue IgM antibody or Dengue NS1 antigen is taken as evidence of Dengue fever 19-Sep-13 27 DeepakBhosle
  28. 28. RAPID CARD TEST 19-Sep-13 28 DeepakBhosle
  29. 29. RAPID CARD TEST 19-Sep-13 29 DeepakBhosle
  30. 30. RAPID CARD TEST 19-Sep-13 30 DeepakBhosle
  31. 31. DIFFERENTIAL DIAGNOSIS  Any acute febrile illness with thrombocytopenia 1. Malaria 2. Leptospirosis 3. Infectious mononucleosis 4. Chickungunya 5. Viral hepatitis 6. Sepsis 7. Meningococcimeia 8. Influenza 9. Other hemorrhagic fever 19-Sep-13 31 DeepakBhosle
  32. 32. DENGUE AND MALARIA DIFFERENCES Dengue(n=75) Malaria (n=75) 1. Continuous fever 80% 66% 2. Myalgia 96% 66% 3.Palatal petechiae 78% 12% 4. Conjunctival suffusion 40% 7% 5. Magenta tongue 27% 0% 6. Maculopapular rash 26% 0% 7. Facial flush 20% 0% 8. Lymph nodes 26% 1% Hepatomegaly, Spleenomegaly, Jaundice and Hypotension were common for both. Adhikari Prabha; Dengue fever, Medicine Update, Vol 16,2006, API 19-Sep-13 32 DeepakBhosle
  33. 33. CLINICAL MARKERS OF DENGUE  Continuous fever  Characteristic myalgia ( retro orbital & interscapular)  Palatal petechiae  Conjunctival suffusion  Magenta colored tongue  Maculopapular rash  Facial flush  Hypotention  Hemorrhage Dengue feverAdhikari Prabha; Dengue fever, Medicine Update, Vol 16,2006, API 19-Sep-13 33 DeepakBhosle
  34. 34. TREATMENT  Symptomatic - Paracetamol for fever & myalgia. Aspirin, NSAIDS avoided due to risk of erosive gastritis and bleeding.  Rest  Oral rehydration  In DHF careful & repeated estimation of volume status & fluid replacement is corner-stone of management. Use isotonic i/v fluids. 19-Sep-13 34 DeepakBhosle
  35. 35. TREATMENT 2  Because patients have loss of plasma they must be given isotonic solution or plasma expanders.  Platelets are replaced if the count is less than 10000 /mm3 or clinical bleeding is +nt. It is better to give Single donor apheresis Platelets (SDAP) as compared to RDP to lower the risk of alloimmunization. 19-Sep-13 35 DeepakBhosle
  36. 36. TREATMENT 3  Besides bleeding other complications are ARDS, renal failure, hepatic failure & encephalopathy. 19-Sep-13 36 DeepakBhosle
  37. 37. PREVENTION AND CONTROL  It is by control of mosquitoes which live & breed in stagnant water in and around the house.  Lays eggs preferentially in jars, discarded containers, coconut shells, old tires etc.  Year round breeding  Tropical regions like India are its favorite zones.  How to prevent mosquito spread?  Do not allow empty vessels, coconut shells, plastic containers, flower pots, tires etc to collect rain water in them  Frequently (once in 2-3 days) empty all water storage containers  Cover your overhead tanks to prevent mosquitoes breeding in fresh water 19-Sep-13 37 DeepakBhosle
  38. 38. PREVENTION AND CONTROL 2  Vector control can be done by simple measures like using insect repellants, indoor space spray insecticides . How to prevent mosquito bites?  Screen your homes with mosquito screens like Netlon .  Wear full clothing – long sleeves  Apply mosquito repellents like Odomos, Goodnignt  Keep Dengue fever patient under mosquito net 19-Sep-13 38 DeepakBhosle
  39. 39. If you think education is expensive ,Try Ignorance. - Dereck Bok dgbhosle@ gmail.com 19-Sep-13 39 DeepakBhosle

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