My presentation on Dengue syndrome, presented on 08/10/2023. Venue : Satkhira Medical College Exam Hall.

1. Dengue Syndrome
Dr. Sanjoy Kumar Ray
MCPS (Medicine)
MO, Satkhira Medical College Hospital.
Welcome to monthly seminar on

2. Acknowledgement
 Press Release, MIS, DGHS
 National Guideline for dengue syndrome
 WHO Guideline for Dengue management
 E- Sources:
 htip:// www.mohfw.gov.bd
 htip:// www.who.int/tdr
 htip:// www.searo.who.int/dengue
 hhp://www.cdc.gov

3. Contents:
A. Introduction and Epidemiology
B. Clinical manifestation: Spectrum of disease
C. Investigation
D. Management
E. Dengue Prevention and Control

4. A. Introduction & Epidemiology

5. Dengue Virus
 Four dengue virus serotypes: DENV-1, DENV-2, DENV-3, and DENV-4.
 DENV-2 - dominant type, but also detected some DENV-1, DENV-3
 Infection with a particular serotypes confers lifelong immunity to that
serotype.
 They elicit cross protection for only few months.
 Secondary infection with dengue serotype 2 or multiple infection with
different serotypes enhance chances of occurring more severe form of
diseases.

6. Vectors

7. Epidemiological review

8. Epidemiological review

9. Epidemiological review

10. Monthly Dengue case 2023

11. Dengue case last 5 years

12. B. Clinical Presentation: Spectrum of Disease

13. Natural course of dengue infection:

14. Differential Diagnosis

15. Clinical Presentation of Dengue
1. Dengue fever
2. Dengue haemorrhagic fever
3. Dengue shock syndrome
4. Expanded dengue syndrome

16. 1. Dengue fever: Presentation
 Headache, Myalgia, Rash
 Arthralgia / bone pain (break-bone fever)
 GIT manifestations: Nausea, vomiting, diarrhea
 Hemorrhagic manifestations: mild
 Leukopenia (WBC <5,000 cells/mm3)
 Platelet count ≤150,000 cells/mm3
 Rising Hct. 5-10%

17. 1. Dengue fever: Diagnosis
 Tourniquet test positive + WBC ≤ 5,000 cells/cmm
 positive predictive value = 83%

18. Generalised flushing of skin blanching
with pressure appears with or without
morbilliform erythematous eruptions
and islands of pallid areas

19. 2. Dengue Hemorrhagic Fever
Clinical
 High, continuous fever 2-7 days.
 Haemorrhagic manifestations:
1. tourniquet test positive,
2. petechiae, epistaxis,
haematemesis etc.
 Liver enlargement ±
 Shock ±
Laboratory
 Evidence of plasma leakage:
1. Circulatory failure:
2. Fluid accumulation
3. Rising Hct. >20% from baseline
4. Hypoalbuminemia ( <3.5 gm% )
 Platelet count <100,000 cells/mm3.

20. Natural
Course of

21. 3. Dengue Shock Syndrome (DSS):
 Cool extremities, delayed CRFT, lethargy, restlessness
 Tachypnoea or Kussmaul’s breathing
 Tachycardia, weak pulse
 Narrow PP: ≤ 20 mmHg with high DBP, e.g. 100/80 mmHg
 Hypotension by age, defined as
1. SBP < 80 mmHg for those aged <5 years or
2. SBP < 80 to 90 mmHg for older children and adults

22. 4. Expanded dengue syndrome
 Unusual manifestations
 Severe organ involvement: liver, kidneys, brain or heart
 Reported in DHF and in DF who do not have evidence of
plasma leakage.
 It may be associated with
 co-infections, co-morbidities or
 complications of prolonged shock.

23. C. Investigation

24. Investigation: for diagnosis
 1 to 5 days of fever:
 CBC, NS1 antigen, SGOT and SGPT,
 RT-PCR- confirm diagnosis
 After day7 :
 IgM and IgG Antibodies [ Rapid test, ELISA]

25. Investigation: for follow up
 CBC:
on 1st afebrile day
should be done daily if DHF suspected
 Haematocrit:
more important for Mx than the thrombocytopenia
In severe dengue with shock hourly Hct is crucial for Mx

26. D. Management

27. WHO Dengue case classification by severity
Group A
 Dengue without
warning signs:
 Send home
Group B
 Dengue with
warning signs:
 Referred for in-
hospital care.
Group C
 Severe dengue:
 Require
emergency
management.

28. Dengue case classification by severity

31. Adequate bed rest, fluid intake
Fever:Tepid sponging, paracetamol
Avoid Aspirin, NSAIDs, Steroids, Antibiotics
Immediate hospitalization, if
worsening of the situation or any warning sign
no urine output for 4–6 hours
 Absence of warning signs
 Physical examination:
1. Haemodynamically stable
2. No sign of fluid accumulation
 Investigation: Stable serial Hct.
 No other criteria for admission. i.e-
 co-morbidities, pregnancy, social factors
Group-A Patient: Home Management

32. Group-B Patient: Hospital Management
 Without shock

33. Group-B Patient: without shock
Duration of
administrator
Indication Fluid type
Total fluid
volume
Rate of
administration
Fluid Management

34.  Crystalloids
1. 0.9% NaCl (isotonic normal saline solution) (Preferable)
2. Hartman solution (Preferable)
3. 0.45% HS normal saline solution (For children <6 months)
4. 5% dextrose in Ringer's lactate solution (5%DRL)
 Colloids
1. Plasmasol, Dextran 40, Human Albumin
2. Plasma, Hemaceel
3. Blood & Blood Components
Group-B Patient: IV Fluid
 Obtain a reference haematocrit before IV fluid therapy begins.
 Indications for IV fluid:
 If patient cannot have adequate oral fluid intake or is vomiting.
 When HcT continues to rise 10%–20% despite oral rehydration.
 Impending shock/shock.

35.  Both oral and IV, in critical phase (48 hours)
 M+5% (Maintenance + 5% deficit).
 5% deficit = 50 ml/kg up to 50kg
 Maintenance = ??
 .
Group-B Patient: Fluid calculation

36. Group-B Patient: Rate of administrator

37. Group-B Patient: Rate of administrator

38. Group-C Patients: Severe Dengue
Plasma Leakage
Haemorrhage
Compensated shock
Decompensated shock
Expanded Dengue Syndrome
Metabolic abnormalitis

39. Group-C:
Compensated
shock

40. Group-C: Compensated shock

41. Group-C:
Decompensated
shock

42. Steroids in Dengue
 There is no specific recommendation of steroids
 But steroid has been used in Dengue Encephalopathy and
Hemophagocytic Syndrome empirically with anecdotal benefits.

43. E. Dengue Prevention and Control

44. Prevention
 Integrated vector management (IVM)
 Household level actions
 Community level actions
 Institutional level action
 Dengue Vaccine

46. Dengue Vaccine
 Dengue vaccine: Dengvaxia (CYD-TDV):
 first dengue vaccine, 2015
 Live attenuated tetravalent vaccine (LATV)
 Age: 9 -45 years
 Total 3 doses: 0, 6, 12 month schedule
 For dengue seropositive persons living in endemic area
 Licensed for 20 countries

47. Dengue Vaccine candidates:
 Two other vaccine candidates are under phase III trails
1. TAK – 003
2. TV003/TV005

48. Dengue Vaccine candidates:

49. Dengue Vaccine in Bangladesh
 Phase III trail by ICDDR,B &University of Vermont (UVM)
 Vaccine candidate: TV005
 Seronegative
 Single dose,
 Booster  at 6/12 month

50. Dengue Vaccine in Bangladesh

51. Pearls