National guideline of Dengue Fever

1. DR. FATEMA

2. INTRODUCTION

3.  Dengue is the fastest emerging arboviral infection.
 It is a major public health concern throughout the
tropical and sub tropical regions of the world.
 Almost half the world population lives in countries
where dengue is endemic.
 Bangladesh has experienced the first visible
outbreak of dengue/DHF in 2000.

4. EPIDEMIOLOGY

5.  The epidemiology of dengue is an intricate
phenomenon which depends upon a complex
relationship between epidemiological factors
 Host: man and mosquito
 Agent: virus .Categorized under the genus
flavivirus. There are four serotypes
DENV-1
DENV -2
DENV-3
DENV-4
 Environment: Abiotic and biotic factors.

6. PATHOPHYSIOLOGY

9. Many patients infected with dengue virus remain
asymptomatic. Others, after an incubation period of
4-7(range 3-14) days, develop a febrile illness the
manifestations of which are similar and overlapping
in nature grouped into ‘Dengue Syndromes’ which
encompass the following:
 Undifferentiated fever
 Dengue fever
 Dengue hemorrhagic fever
 Expanded dengue syndrome

10. Manifestations of dengue virus infection

11. Dengue fever
Fever:
The body temperature is usually between 102⁰F-
104⁰F and the fever maybe biphasic, lasting 2-7
days in majority of patients.
Rash:
First 2-3 days: Diffuse flushing or fleeting eruption
maybe seen on face, neck and chest
Third and fourth day: A conspicuous rash that maybe
maculopapular or rubelliform
Afebrile period: Petechiae surrounding scattered pale,
round areas of normal skin

12. Other features:
 Retro orbital pain
 Photophobia
 Backache and pain in the muscles and joints
 Anorexia, altered taste sensation, constipation,
colicky pain and abdominal tenderness

13. Dengue hemorrhagic fever:
 More common in children less than 15 years of age
and in association with repeated infection
 It is characterized by acute onset of high grade fever
and associated with signs and symptoms similar to
the DF in early febrile phase.
 There are common hemorrhagic diathesis such as
positive tourniquet test, petechiae, easy bruising
and/or GI hemorrhage in severe case
 The cut off point of DF and DHF is the evidence of
plasma leakage which is invariably present in latter

14. There are three phases:
1) Febrile phase:
 High fever
 Facial flushing
 Myalgia/arthralgia
 Sore throat, injected pharynx, conjunctival injection
 Mild hemorrhagic manifestation
 Leucopenia and thrombocytopenia are common in
late phase

15. 2) Critical phase:
 It is heralded by the onset of plasma leakage.
Plasma leakage lasts for 24-48 hours
 This usually occurs towards the late febrile phase,
often after the 3rd day of fever, usually around the 5th
and 6th day of illness with defervescence
 A 20% rise of hematocrit from the baseline is
indicative of significant plasma leakage

16.  A rise in hematocrit less than 20% can be found
in patients who received excess oral/IV fluids or
in patients with bleeding
 Other evidences of plasma leakage are:
- a decrease in S. albumin
- non fasting S. cholesterol <100mg/dl
- pleural effusion/ascitis

17. 3) Convalescent phase:
This starts after the end of critical phase and usually
lasts for 2-5 days. Features which would suggest
that the patient has reached the convalescent
phase are:
 Improved general wellbeing and apetite
 Appearance of convalescent rash
 Generalized itching
 Hemodynamic stability
 Bradycardia
 Diuresis
 Stabilization of hematocrit
 Rise in WBC count followed by a rise in platelet
count

18. Dengue shock syndrome:
There is features of DHF plus signs of circulatory
failure, manifested by:
 Rapid and weak pulse
 Narrow pulse pressure
 Hypotension for age
 Cold clammy skin
 Restlessness

19. Expanded dengue syndrome:
 There is sometimes unusual manifestations such as
involvement of liver, kidney, brain or heart with or
without evidence of fluid leakage.
 These are mostly a result of prolonged shock leading
to organ failure

21. Warning signs:
No clinical improvement or worsening just before or
during the transition to afebrile phase or as the disease
progress
 Persistent vomiting
 Severe abdominal pain
 Lethargy or restlessness, sudden behavioral change
 Bleeding: epistaxis, black stool, hematemesis,
hematuria
 Pale, cold, clammy hand and feet
 Less or no urine output for 4-6 hours
 Liver enlargement >2cm
 Hematocrit >20%

22. LABORATORY
INVESTIGATIONS

23. 1) CBC:
 Leucopenia (TLC <5000 cells/cumm)
 Thrombocytopenia (Platelet <150000 cells/cumm)
 Hct: Rising of Hct 20% from baseline
2) S. AST and S. ALT:
 These levels are frequently higher elevated in DF
 Levels are significantly higher(5 to 15 times) in
patients with DHF
3) Other findings:
Hypoproteinemia/Hypoalbuminaemia,
Hyponatremia,Albuminuria
4)Chest X ray or USG

24. 5) Detection of antigen:
 NS1 antigen on first day of illness rapid test: positive
within minutes of starting symptoms
 ELISA NS1 antigen: positive on first day of illness.
Becomes negative from day 4-5 of illness
6) Detection of antibody:
 Anti dengue IgM antibodies can be detected 3-6 days
after the onset of fever
 It can be detected in low level upto 1-3 months after
fever
7)Others: Dengue virus isolation from serum,plsma and
leucocytes and nucleic acid detection by RT-PCR.

26. Triage assessment and
management
 Triage has to be performed by a trained and
competent person to divide the patients into
three groups:
 the patients who are stable and can go home
 the patients who will report every day with
platelet count and HCT
 the patients who will be admitted in the
hospital immediately

27. Management of patient who do not
need admission
 Ensure adequate oral fluid intake of
around 2500 ml for 24 hours
 Adequate physical rest
 Tepid sponging for fever
 Paracetamol 6 hourly

28.  Avoid all NSAIDS and steroids
 Withhold aspirin, clopidogrel, dipyridamol in
patients who take these on long term basis
 First CBC should be done on arrival to
physician and daily platelet and HCT if
initial platelet count is less than 1500000
and NS1 antigen

29. Criteria for admission:

32. Volume replacement DHF-Non shock:
 In general, the fluid allowance (oral+IV) is about
maintenance (for one day) + 5% deficit (oral+ IV),
to be administered over 48 hours
• Normal maintenance fluid per hour can be
calculated on the basis of following formula:
4mlkghr for first 10kg body weight+
2mlkghr for next 10kg body weight+
1mlkghr for subsequent kg body weight
5% deficit is calculated as 50ml/kg up to 50 kg

34. DHF grades 3 and 4
management

37. Signs of recovery
 Stable pulse, blood pressure and breathing
rate.
 Normal temperature.
 No evidence of external or internal bleeding.
 Return of appetite.
 No vomiting, no abdominal pain.
 Good urinary output.
 Stable heamatocrit at baseline level.
 Convalescent confluent petechiae rash or
itching, especially on the extremities.

38. Discharge criteria
 No fever for at least 24 hours without the
usage of antipyretic drugs
 At least two days have lapsed after recovery
from shock
 Good general condition with improving
appetite
 Normal HCT at baseline value or around 38-
40% when baseline value is not known
 No distress from pleural effusions
 No ascites
 Platelet count has risen above 50000/mm3
 No other complications

39. THANK YOU