Dengue Fever Clinical

1. Clinical
management of
Dengue Syndrome
DR.H.M.NAZMUL AHSAN
FCPS(Medicine)
Associate Prof. Medicine
Shaheed Suhrawardy Medical college

3. Dengue Facts
 Arbo-viral disease
 Virus-Genus: Flavivirus
 Four serotypes: Den 1, Den 2, Den 3, Den 4. Infection
with one serotype confers life long immunity to that
serotype and cross immunity to other serotypes for 2-3
months only.
 All four serotypes are associated with epidemic and
DHF.

4. Pathophysiology and cytokine
 The pathogenesis of severe disease is not well
understood. Various mechanisms of severe disease have
been suggested, including:
(a) Antibody-dependent enhancement or ADE,
(b) Complement activation by virus-antibody complexes
and
(c) T-cell mediated immunopathology
(d) Cytokine abundance.
 Dengue infected monocytes act as antigen presenting
cells (APCs) to induce release of lymphokines and other
factors from activated T cells. Tumour Necrosis Factor-
,Interleukin(IL) IL-1, IL-2, IL-6, IL-8, Interferon (IFN)-,
RANTES etc. are the cytokines that are released from
these cells.
 These cytokines along with complement breakdown

5. Severe Dengue:
immunopathogenesis
Mo
Mo
CD4
CD8
Ab’s Monocytes T cells(Serotype
Complement Macrophages cross reactive
memory T-cells)
IFN
C3a C5a TNF, IL-1, PAF IL-2, TNF, IL-6
IL-6 IFN
 FcR, MHC I and II
Complement
activation
Capillary leak syndrome  DHF
Vascular endothelial cells
Lysis
Dengue virus
Capillary leakage
viraemia
IgM
IgG
0 1 2 3 4 5 6
days
Inflammatory
host response
A patient with secondary dengue

6.  The pathogenesis of dengue involves a complex
interaction
between virus and host factors, and remains
incompletely Understood
 The immune system plays a key role in disease
pathogenesis
 Non-neutralising cross-reactive antibodies elicited
in a primary infection bind virus in a secondary
infection and then have a greater ability to infect
Fc-receptor bearing cells. This is called antibody-
dependent enhancement (ADE), and potentially
leads to an increased viral biomass, and
therefore more chance of developing severe
disease
In addition, there is evidence that ADE

7.  The cellular immune response is also involved
with the
clearance of dengue virus from the host, and is
thought to
play a role in the development of severe disease
 The proliferation of activated memory T cells
and the production of pro-inflammatory cytokines
are thought
to contribute to the development of plasma leak
observed
in dengue.
 In addition, the level of T cell activation is
proposed to correlate with disease severity. It has
been demonstrated that the T cells produced in

8. Pathophysiology of DF/DHF
8

9. 9

10. Causesof bleeding in DF/DHF

11. Causes of Thrombocytopenia

12. Clinical presentations,Case Definitions,
classifications and Severity Grading of
Dengue syndrome

13. Clinical Presentations(Dengue
Syndrome)
 Majority patients infected with dengue virus
remain asymptomatic.
 Others, develop a febrile illness and the
manifestations of which are similar and
overlapping .They are grouped into 'Dengue
Syndromes' which encompass the following:
 Undifferentiated fever
 DF
 DHF
 Expanded dengue syndrome (rare)

15. Case definitions
Case definitions are developed as aid tools for
Early
diagnosis and prompt treatment, Epidemiological
Surveillance and reporting.
Purpose:
 For uniformity in clinical case management at
both outpatient and inpatient setups.
 For uniform reporting of the cases to
designated appropriate health authority.

16. Case Definitions for Clinical
Management:(Old)
1.Dengue Fever
2.Dengue Haemorrhagic Fever
3.Dengue Shock Syndrome
4.Expanded dengue syndrome
Case Definitions For Reporting
1.Suspected: Clinically diagnosed as per ‘Clinical Case
Definition’
2.Probable: Clinical Diagnosis+ Positive serology
3.Confirmed: When case is confirmed by Virus
isolation or antigen detection

17. New Revised case classification for
clinical management by severity
1.Dengue without warning signs: GroupA
(May be send home)
2.Dengue with warning signs: GroupB
(Referred for in hospital care)
3.Severe dengue: GroupC
(Require emergency treatment)

19. Natural course of dengue
infection
3 Phases
A. Febrile Phase(2-7days)
B. Afebrile/Critical Phase(2-
3days)
C. Convalescent/Recovery
Phase
(7-10days) 19

20. 20

21. Case Definitions

22. Dengue Fever
Dengue Fever
Suspected Dengue:
Acute febrile illness of 2 to 7 days duration with 2 or more of the
following:
• headache,
• retro-orbital pain,
• myalgia,
• arthralgia/bone pain,
• rash,
• haemorrhagic manifestations( Unusual hemorrhage)
• leucopenia (wbc ≤5000 cells/mm3),
• thrombocytopenia (platelet count <150 000 cells/mm3),
• rising haematocrit (5 – 10%);
And
•High index of suspicion based on Period, Population & Place
And
•Absence of convincing evidence of any other febrile illness

23. Fever
 Sudden onset, high grade, continued.
 The body temperature is usually between 39 °C
and 40 °C (102° F to 104° F).
 The fever may be biphasic, lasting 2–7 days in
the majority of cases.

24. Rash
 first 2 to 3 days - Diffuse flushing or fleeting eruptions
may be seen on the face, neck and chest
 third and fourth day- a conspicuous rash that may
be maculopapular or rubelliform
 afebrile period or defervescence - Some patients
have a confluent erythematous or petechial rash with
small areas of normal skin, described as “islets of
white in the sea of red” may appear over the dorsum
of the feet, on the legs and on the hands and arms.
Skin itching may be observed.

25. 25

26. 26

27. Probable Dengue: Suspected dengue + Positive Serology
Suspected dengue and at least one of following:
• supportive serology on single serum sample: IgG titre ≥1280 with
haemagglutination inhibition test/ enzyme-linked immunosorbent
assay, or testing positive in IgM antibody test.
Confirmed dengue: Suspected dengue + Virus isolation
or Antigen detection
Probable case with at least one of the following:
• isolation of dengue virus from serum, CSF or autopsy samples.
• fourfold or greater increase in serum IgG (by haemagglutination
inhibition test) or increase in IgM antibody specific to dengue virus
in paired sera.
• detection of dengue virus or antigen in tissue, serum or
cerebrospinal fluid by immunohistochemistry, immunofluorescence
or enzyme-linked immunosorbent assay.
• detection of dengue virus genomic sequences by reverse

28. Dengue Haemorrhagic Fever
Suspected DHF:
All of following:
 Acute onset of fever of two to seven days duration.
 Haemorrhagic manifestations, shown by any of the following:
 positive tourniquet test,
 petechiae, ecchymoses or purpura, or
 bleeding from mucosa, gastrointestinal tract, injection sites, or other
locations.
 Platelet count ≤100 000 cells/mm3
 Objective evidence of plasma leakage due to increased vascular
permeability shown by any of the following:
 Rising haematocrit/haemoconcentration ≥20% from baseline or
decrease in convalescence, or
 pleural effusion, ascites or
 hypoproteinaemia/ albuminaemia.
And
•High index of suspicion based on Period, Population & Place
And
•Absence of convincing evidence of any other febrile illness

30. Evidence of Plasma Leakage
Rise in HCT
 20% = children 35  42 adults 40  48
Circulatory failure
Fluid accumulation – Ascites,
Pleural effusions
Albumin < 3.5 gr/dl
Cholesterol < 100 mg%

32. Probable DHF: Suspected DHF +Positive serology
Suspected dengue and at least one of following:
• supportive serology on single serum sample: IgG titre ≥1280 with
haemagglutination inhibition test/ enzyme-linked immunosorbent
assay, or testing positive in IgM antibody test
Confirmed DHF: Suspected DHF+ Virus isolation or Antigen
detection
Probable case with at least one of the following:
• isolation of dengue virus from serum, CSF or autopsy samples.
• fourfold or greater increase in serum IgG (by haemagglutination
inhibition test) or increase in IgM antibody specific to dengue virus
in paired sera.
• detection of dengue virus or antigen in tissue, serum or
cerebrospinal fluid by immunohistochemistry, immunofluorescence
or enzyme-linked immunosorbent assay.
• detection of dengue virus genomic sequences by reverse
transcription-polymerase chain reaction.

33. Dengue Shock Syndrome
Criteria for dengue haemorrhagic fever as before with
signs of shock including:
 Tachycardia, weak pulse, cool extremities, delayed
capillary refill, lethargy or restlessness, which may be a
sign of reduced brain perfusion.
 Narrow pulse pressure: Pulse pressure ≤20 mmHg with
increased diastolic pressure, e.g. 100/80 mmHg.
 Hypotension by age, defined as systolic pressure <80
mmHg for those aged <5 years or 80 to 90 mmHg for older
children and adults.

34. 34

35. Expanded dengue syndrome
 Unusual manifestations with severe organ
involvement such as liver, kidneys, brain or
heart associated with dengue infection have
been increasingly reported in DHF and also in DF
who do not have evidence of plasma leakage.
 These unusual manifestations may be associated
with coinfections, comorbidities or
complications of prolonged shock.
 Exhaustive investigations should be done in
these cases.

36. Expanded dengue syndrome

37. Expanded dengue syndrome

38. Severity progression
Warning signs
few hrs
Compensated shock
few hrs
Decompensated shok/Hypotensive shock
few min
Cardiorespiratory collapse and cardiac arrest

39. Differential diagnosis
39

40. Differential diagnosis
40

41. Difference Between
Chikungunya and Dengue
Chikungunya Dengue
Fever (>39°C) +++ ++
Arthralgia +++ +/-
Arthritis + -
Headache ++ ++
Rash ++ +
Myalgia + ++
Hemorrhage +/- ++
Shock - +
Lymphopenia +++ ++
Neutropenia + +
Thrombocytopeni
a
+ +++
Hemoconcentratio
n
- ++

42. Lab Investigations for
Diagnosis and Management

43. Early laboratory confirmation of clinical
diagnosis is important because some
patients progress within a short period
from mild to severe disease and
sometimes to death. Early intervention
may be life-saving.

44. Laboratory Investigations
 Complete Blood Counts
 Hematocrit
 Platelet Count
 Immunological Tests : NS1Antigen,Anti
Dengue IgM and IgG
 SGOT, SGPT
 Blood urea, serum creatinine,
 serum electrolyte, serum calcium
 Serum Albumin
 Blood gas analysis, lactate (if
available)
 Chest X-Ray
 USG of Abdomen

45. Time and frequency of doing
investigations
 1 to 5 days of fever : CBC, NS1 antigen, SGOT and
SGPT(Not mandatory but helpful)
 After day5 (But sensitivity more after day7) : IgM and
IgG Antibodies
 Tests should be done during first consultation to get the
baseline characteristics like Haematocrit and Complete
blood count.
 Follow up testing may be done on 1st afebrile day, but
should be done daily once DHF is suspected.
 A regular haematocrit is more important for
management than the thrombocytopenia. Even in
severe dengue especially with shock) hourly haematocrit is
crucial for management.

49. 49

50. 50

51. 51

52. Approach to management of a patient with Dengue
Fever
52

53. 53

54. 54

55. Step I—Overall assessment
History
The history should include:
– date of onset of fever/illness;
– quantity of oral intake;
– assessment for warning signs ;
– diarrhea;
– change in mental state/seizure/dizziness;
– urine output (frequency, volume and time of last
voiding);
– other important relevant histories, such as family or
neighborhood dengue,
– co-existing conditions (e.g. infancy, pregnancy,
obesity, diabetes mellitus, hypertension), 55

56. Physical examination
The physical examination should include:
– assessment of mental state;
– assessment of hydration status;
– assessment of hemodynamic status
– checking for tachypnoea/acidotic breathing/pleural
effusion;
– checking for abdominal pain,
tenderness/hepatomegaly/ascites;
– examination for rash and bleeding manifestations;
– tourniquet test (repeat if previously negative or if
there is no bleeding manifestation). 56

57. Investigations:
1. CBC , PLATELET COUNT, HCT
2. ELECTROLYTES, UREA&CREATININE, BLOOD SUGAR
3. SGPT,SGOT
4. IMMUNOLOGICAL TESTS FOR DENGUE
5. BLOOD GROUP
6. OTHERS-
S.ALBUMIN,S.CALCIUM,,BICARBONATE,LACTATES,CHOLESTEROL
57

58. Step II—Diagnosis, assessment of
disease phase and severity
On the basis of evaluations of the history, physical
examination and investigations :
Confirm the diagnosis as dengue syndrome
Assess the phase (febrile, critical or recovery)
Presence of warning signs
The hydration and hemodynamic status
Needs for admission and/or referral to
emergency department.

59. Hospital Admission Criteria
Warning signs
Any of the warning signs if present.
59

60. Hospital Admission Criteria
60

61. STEP ΙΙΙ:
1.Disease notification
2.Management
Depending on the clinical manifestations and other
Circumstances:
Patients may be sent home (Group A): Mild Dengue
Referred for in-hospital management or (Group
B):Moderate Dengue
Require emergency treatment and urgent referral
(Group C): Severe Dengue
61

62. GROUP - A

63. Group- A (Mild Dengue): Send home with
advice
Dengue fever –
1.Without complications like bleeding,hypotension or organ
involvement
2.Without evidence of plasma leakage(clinical and
laboratory)
3.Without co-morbidities or high risk group patients
4.With near normal blood count and hematocrit

64. Home care for dengue
(OPD care - Group A)
 Home care card for dengue(Treatment and advice)
 Adequate bed rest
 Adequate fluid intake (Around 2500 ml or 8-10 glasses for average-sized adults
or accordingly in children, around 50ml/kg)
 Milk, fruit juice (caution with diabetes patient) and isotonic electrolyte solution
(ORS) and barley/rice water, cocoanut water
 Plain water alone may cause electrolyte imbalance.
 Take paracetamol (not more than 8tabs (4 Gm) per day for adults and
accordingly in children(10-15mg/kg)
 Tepid sponging with lukewarm water or shower with lukewarm water
 Keep the patiet under mosquito net during febrile phase.
 Avoid all NSAIDS and steroids
 Withhold temporarily Aspirin, clopidogrel,dipyridamole,warfarin in cardiac
patients who take for long term
64

65. Home care for dengue
Approach the hospital early if (Home warning sign )
No clinical improvement or worsening of the situation just before or during
the transition to afebrile phase or as the disease progresses
Bleeding
− red spots or patches on the skin
− bleeding from nose or gums
− vomiting blood
− black-coloured stools, heavy menstruation/vaginal bleeding
Frequent vomiting
Severe abdominal pain
Drowsiness, mental confusion or seizures
Pale, cold or clammy hands and feet
Difficulty in breathing
Less or no urine output for 4-6 hours. 65

66. GROUP- B

67. Group-B (Moderate Dengue): Close
monitoring and possible
hospitalization
Dengue fever -
1. With warning sign and symptoms
2. With High risk and co-morbid conditions
3. Social circumstances- living alone, living far from
hospital facility
4. Dengue hemorrhagic fever with minor bleeding
5.Increasing hematocrit or rapidly decreasing platelet
count

68. Warning signs

69.  Social reasons
-Living alone
-Living far from hospital
 High risk groups and co-morbid conditions:
-Pregnancy, infancy and old age -Renal failure
-obesity -Chronic hemolytic
disease
-DM -Autoimmune
disease
-HTN
-Heart failure

70. Intravenous Fluid therapy in DHF
during the critical period:
Indications for I/V fluid
 When the patient cannot have adequate oral fluid intake or
vomiting
 When HCT continues to rise 10%- 20% despite oral
rehydration
 Impending shock/Shock

71. Signs and symptoms of Impending shock
Symptoms
 Sweating
 Abdominal pain
 Restlessness
 Altered consciousness level
Signs
 Cold extremities
 Prolonged capillary refilling time>2Seconds
 Unexplained tachycardia
 Increasing diastolic pressure
 Narrrow pulse pressure

72. Fluid requirement
 The fluid requirement, both oral and intravenous, in
critical phase (48 hours) is calculated as M+5%
(maintenance + 5% deficit).
 5% deficit is calculated as 50 ml/kg up to 50kg
Calculations for normal maintenance of intravenous
fluid Infusion:

74. *For overweight/obese patients calculate
normal maintenance fluid based on ideal body
weight (IBW), using the
following formula:
 Female: 45.5 kg + 0.91(height–152.4) cm
 Male: 50.0 kg + 0.91(height–152.4).cm

75. 75

76. 76

77. Calculation of total fluid quota for the critical
period
M (Maintenance) =
100ml/kg for first 10 kg
+50 ml/kg for next 10 kg
+20 ml/kg for balance weight
5% of body weight = 50ml x body weight (kg)
E.g. Body weight 22 kg
(This is the ideal or actual body weight, whichever is smaller)
M = 100 x 10 + 50 x 10 + 20 x 2 =1540 ml
5% = 50 x 22 =1100 ml
M + 5% = 1540 + 1100 =2640 ml

78. Example of fluid calculation for a 65 kg person (maximum
body weight for fluid calculation is 50 kg)
- For the 1st 10 kg - 100 ml/kg = 1000 ml
- For the 2nd 10 kg - 50 ml/kg = 500 ml
- From 20 kg and above up to 50 kg -20 ml/kg = 600 ml
- 5% deficit is calculated as 50 ml/kg up to 50 kg = 2500 ml
Therefore the maximum fluid requirement for an average adult for
the entire phase of critical 48 hours is 4600 ml.
If the body weight is less than 50 kg, calculation should be done according to
the ideal body weight or actual body weight whichever is less.

79.  The fluid quota is aimed at giving just adequate amount of fluid
without causing fluid overload (to maintain perfusion to vital
organs).
 Once the fluid quota is exceeded chances of fluid overload is
high.
 All patients will not need the full quota of M+ 5% fluid and
many may need less than this, as the rate, peak and the duration
of leaking are variable from patient to patient.

81. The following fluids are recommended both crystalloids and
colloids
Crystalloids
 0.9% Nacl (isotonic normal saline solution) (0.9%NS)
 0.45% half strength normal saline solution (0.45%NS) (For
children)
 5% dextrose in lactated Ringer's solution (5%DRL)
 5% dextrose in acetated Ringer's solution (5%DRA)
 Hartman solution
Colloids
 Dextran-based:Dextran 40,Dextran70
 Starch based(6% Hetastarch) : Voluven, Plasmasol
 Hemaceel
 Plasma
 Blood & Blood Components

82. Duration of IV fluid therapy
 The duration of intravenous fluid therapy should
not exceed 24 to 48 hours for those with shock.
 However, for those patients who do not have
shock, the duration of intravenous fluid therapy
may have to be longer but not more than 60 to 72
hours. This is because the latter group of patients
has just entered the plasma leakage period
while shock patients have experienced a longer
duration of plasma leakage before intravenous
therapy is begun.

83. IV Fluid for
Non shock Dengue patients

84. 84

85. 85

86. 86

87. Severe Dengue
(Group C – Emergency care)
87

88. 88

89. IV Fluid for
Compensated shock

90. 90

91. Rate of infusion in Dengue Shock
Syndrome grade ΙΙΙ(Compensated
Shock)
91

92. Rate of infusion in Dengue Shock
Syndrome grade ΙΙΙ(Compensated
Shock)
92

93. 93

94. IV Fluid for
Decompensated
shock

95. 95

96. When to stop intravenous fluid
therapy
 Cessation of plasma leakage;
 Stable BP, pulse and peripheral perfusion;
 Hematocrit decreases in the presence of a good
pulse volume;
 Apyrexia (without the use of antipyretics) for more
than 24–48 hours;
 Resolving bowel/abdominal symptoms;
 Improving urine output.
Continuing intravenous fluid therapy beyond the
48 hours of the critical phase will put the patient
at risk of pulmonary

97. Convalescent phase (recovery phase)
 This starts after the end of the critical phase and usually lasts
2-5 days.
 There will be reabsorption of extravasated fluid during this
period.
Indicators that the patient has reached convalescent
phase:
 Improved general well-being and improved appetite
 Appearance of convalescent rash (typically appears as white
patches in a red background)
 Generalized itching
 Hamodynamic stability
 Bradycardia
 Diuresis
 Stabilization of Haematocrit (HCT may even be lower than

98. Complications of Dengue
Fever
 Haemorrhagic complications
 Fluid overload
 Ascites, Pleural effusion, Pulmonary aedema
• Metabolic acidosis and electrolyte imbalance
• Severe shock
• Acute Respiratory Distress Syndrome
• Hyperglycaemia and hypoglycaemia
• Nosocomial infections
• Mycocarditis
• Hepatitis
98

99. Indications for Blood
Transfusions
 Overt bleeding ( more than 10% or 6-8ml/kg)
 Significant drop of HCT < 40 ( < 45 for males) after
fluid resuscitation
 Hypotensive shock + low/normal HCT
 Persistent or worsening metabolic acidosis
 Refractory shock after fluid 40-60 ml/kg
Dose of whole fresh blood: 10 ml/kg/dose at a time.
only 10-15% patients need blood
Circulatory failure with high HCT should be managed
with colloids ( + Lasix if fluid overloaded) before

100. To decide on platelet transfusion
To recognize the beginning of
critical stage -
As a prognostic indicator-
Why do you do platelet counts ?
(Answer this MCQ)

101. To decide on platelet transfusion -
X
To recognize the beginning of
critical stage -
As a prognostic indicator-
Why do you do platelet counts ?

102. concentrate
It has been observed that there is very limited role of
platelet transfusion. In most of the situation fresh whole
blood transfusion is suffice. However it may be
required in some special situation. The indication of
which may be as follows:
-Platelet count ≤ 10000 /mm3
If platelet concentrate is not available fresh whole
blood may be transfused as per guidelines given under
DHF management.

103. Discharging Criteria

104. Out break Observation - 2018
 Less rash
 Fever persists longer duration
 More Leucopenia
 High AST
 Tourniquet test +ve early
 Diarrhea
 Pharyngeal congestion
 Myocarditis

105. Out break Observation - 2019
 Very less Rash .( more convalescent rash)
 Fever persists longer duration ( > 5 days )
 More Leucopenia ( as low as 1430/mm3)
 High AST ( 7123 IU )
 High Lipase level
 Tourniquet test +ve early ( even during febrile period) but
less common
 Diarrhea ( Very common )
 Abdominal pain
 Persisting vomiting
 Expanded Dengue with Organopathy ( Very frequent)
 Myocarditis ( very often )

106. Special observations 2019
 Ascites ( before critical phase)
 Pleural effusion (Invariably in right side)
 Encephalopathy
 Isolated cranial nerve palsy
 Acute renal failure
 Splenomegaly
 Pneumonitis
 Pancreatitis
 Pharyngeal congestion
 GBS like feature ( hypokalamia must be ruled out due to
vomiting)

107. Dengue in Pregnancy and labor
 Admission is required and close follow up
with CBC daily is very important
 A multi-disciplinary team consisting of
obstetricians, physician,anaesthetist and the
paediatrician should get involved in the
management.
 When a Suspected dengue (febrile patient) is first
seen, look for warning signs and admit if any one
is found..
 The signs, symptoms and lab investigations
may be confused with other complications of
pregnancy such as toxaemia and HELLP
syndrome (Haemolysis, Elevated Liver

108. Complication:
 Premature fetal loss or vertical transmission in Dengue
infection may be one of the grave fetal complications in
pregnancy.
 The vertical transmission in fetus is evidenced by fever,
thrombocytopenia, raised liver enzymes, gastric bleeding,
pleural effusion, conva lescent rash and Dengue-specific
IgM (+).
 The important maternal complications include
thrombocytopenia,
raised liver enzymes, febrile illness, gum bleeding and
bilateral pleural
effusions.

109. The normal physiological changes in pregnancy make the
diagnosis and assessment of plasma leakage difficult.
Therefore, the following baseline parameters should be noted as
early as possible on the first day of illness. Subsequent
management will be based on the changes of baseline levels.
 Pulse, blood pressure (BP), pulse pressure.
(Baseline BP is often lower and pulse pressure wider
& heart rate may be higher)
 CBC - (Haemoglobin, HCT & platelet count may be
lower than in nonpregnant patient)
 SGOT/SGPT
 Clinical detection of pleural effusion and ascites may
be difficult due to the presence of gravid uterus. Use
of Ultra Sound is advisable

110.  Generally the presentation and clinical course of
dengue in pregnant women is similar to that in
non-pregnant individuals.
 The fluid volume for the critical period(M+5%) for
a pregnant mother should be calculated ( based
on the weight prior to pregnancy)

111. patients with DF/DHF close to
delivery
 Risk of bleeding is at its highest during the period of
plasma leakage (critical phase). Therefore,Unless to
save mothers life, avoid Lower uterine segment
Caesarean Section (LUCS) or induction of labour
during the Critical (plasma leakage) phase.
 Obstetric procedures (such as amniocentesis or
external cephalic version) should be avoided during
the illness.
 If obstetric procedures are to be undertaken,
Maintain the platelet count above 50,000/mm3
Single donor platelet transfusion is preferred, if
available(apheretic platelet)
111

112.  If patient goes into spontaneous labour during
critical phase take steps to prevent vaginal tears
by performing an episiotomy.
 In a case of fetal compromise priority should be
given to the mother’s life and decision making
should involve the multidisciplinary team.
 Counseling the family on the probable outcome is
essential.

113. Dengue in infants and children
Infants who develop primary dengue infection may
have a simple fever indistinguishable from other viral
infections.
 It may have a wide range of clinical
presentations.Maculo-papular rashes (blanching
erythema) may accompany the fever or may appear
during defervescence.
 Upper respiratory (such as cough, rhinitis or injected
pharynx and) and gastrointestinal symptoms (loose
stool mimicking acute gastro-enteritis) are common.
 This may present with seizures mimicking febrile
convulsions or aseptic meningitis.

114.  Septicaemia should always be considered in a febrile
neonate.
 Splenomegaly has been observed in young infants
(especially
under six months) clinically or by radiological
examination (Ultra sound scan)
 Infants have less respiratory reserves, and are more
susceptible to liver impairment (tender hepatomegaly)
and electrolyte imbalance leading to hyponatremia.
 DHF in infancy may not have leucopenia. Often Total
WBC is > 10,000 (may be even 18-19 x 103).
 During latter part of infancy, infants have lower HCT
due to physiological and iron deficiency anaemia

115. Key points
Infants may have a shorter duration of
plasma leakage (lasts for < 24 Hours - may
be as short as 6 – 12 hours) and usually
respond quickly to fluid resuscitation.

116. Do and don’t of Dengue Fever
Good Practice Bad Practice
1 Administration of Paracetomal for
high fever and myalgia.
Sending patients with non-severe
dengue home with no follow-up and
inadequate instructions
2 Clinical assessment of the
haemodynamic status before and
after each fluid bolus
Administration of acetylsalicylic acid
(aspirin) or ibuprofen
3 Give intravenous fluids for repeated
vomiting or a high rapidly rising
haematocrit
No clinical assessment of patient
with respect to fluid therapy
4 Use the isotonic intravenous fluids
for severe dengue
Administration of intravenous fluids
to any patient with non-severe
dengue
5 Avoid intramuscular injections Giving intramuscular injections to
dengue patients
6 Tight Glycemic control Not monitoring blood glucose
116

117.  Each Patient is a Book
 Each Day is a Learning Opportunity
 CME has More Relevance
Now Than Ever
Together We Learn Better

118. THANK YOU