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DENGUE IN CHILDREN

  1. 1. DENGUE IN CHILDREN -Dr.Apoorva.E PG,DCMS
  2. 2. EPIDEMIOLOGY • Dengue is the most rapidly spreading mosquito-borne viral disease in the world • Increase in incidence by over 30-fold in the last 50 years • Currently endemic in all continents except Europe
  3. 3. ETIOLOGY THE VIRUS • DEN- family flaviviridae genus flavivirus • Has four distinct serotypes (DEN1 – 4) • DEN-2 and DEN-3 cause severe disease • Cleaved by host and viral proteases into 3 structural proteins and 7 nonstructural proteins(NS)
  4. 4. THE VECTOR • Transmitted by infected Aedes mosquitoes • Highly urbanized, fresh water, day feeding mosquito
  5. 5. THE HOST • Humans are the primary host of the virus • Severity depends upon factors like gender,secondary infection,age and chronic diseases (sickle cell anemia, asthma , DM) • Vertical transmission and through infected blood products +
  6. 6. PATHOGENESIS
  7. 7. Capillary damage Fluid leaks into extravascular spaces Hemoconcentration Hypovolemia Increased cardiac work Tissue hypoxia,metabolic acidosis
  8. 8. THROMBOCYTOPENIA + LIVER DAMAGE + DIC DENGUE HAEMORRHAGIC FEVER
  9. 9. A N T I B O D Y D E P E N D E N T E N H A N C E M E N T
  10. 10. • Specific antibodies start appearing around day 5 of illness. • Infection with one serotype gives lifelong immunity to that type, but only short term protection against the other three. • Secondary infection with DEN-2, DEN-3 is associated with dengue haemorrhagic fever.
  11. 11. CLINICAL MANIFESTATIONS • Multisystem disease with a wide clinical spectrum • Incubation period – 4 to 10 days • Illness begins abruptly following the IP,divided into three phases FEBRILE CRITICAL RECOVERY
  12. 12. FEBRILE PHASE • High grade fever lasting for 2-7 days • Accompanied by facial flushing,rash,myalgia,arthralgia,headache, nausea,vomiting,anorexia,sore throat,injected pharynx and conjunctiva. • Petechiae,epistaxis,gum bleed may be seen.
  13. 13. CRITICAL PHASE • Usually occurs on days 3-6 of the illness • Lasts for 24-48 hours • Progressive leukopenia,increasing hematocrit levels,decrease in platelet count precede plasma leakage Ascites Pleural effusion Shock
  14. 14. • Prolonged shock leads to DIC which leads to severe haemorrhage -Decrease in hematocrit -GI bleeding usually • Organ hypoperfusion can lead to hepatitis,myocarditis,encephalitis
  15. 15. RECOVERY PHASE • Reabsorption of the fluid from extravascular compartment occurs • General well-being improves,appetite returns,hemodynamic status stabilizes,urine output becomes normal,GI symptoms abate • Generalized pruritus,bradycardia ++
  16. 16. CLINICAL PROBLEMS ENCOUNTERED DURING DIFFERENT PHASES
  17. 17. DENGUE CASE PROBABLE DENGUE (live in/travel to endemic area+fever+any of the following two criteria : rash,nausea/vomiting,aches,positive tourniquet test,leukopenia,any warning sign) WARNING SIGNS NEGATIVE POSITIVE DENGUE WITH SEVERE WARNING SIGNS DENGUE DENGUE WITHOUT WARNING SIGNS
  18. 18. WARNING SIGNS
  19. 19. SEVERE DENGUE FEVER OF 2-7 DAYS PLUS ANY OF THE FOLLOWING FEATURES : 1.EVIDENCE OF PLASMA LEAKAGE 2.SIGNIFICANT BLEEDING 3.ALTERED LEVEL OF CONSCIOUSNESS 4.SEVERE GI INVOLVEMENT 5.SEVERE ORGAN INVOLVEMENT
  20. 20. DENGUE SHOCK SYNDROME COMPENSATED DECOMPENSATED SHOCK SHOCK (pulse pressure<20mmHg, cold clammy extremities, feeble rapid pulse)
  21. 21. DENGUE HAEMORRHAGIC FEVER
  22. 22. GRADING OF DENGUE FEVER
  23. 23. MANAGEMENT • HISTORY – Time of fever onset,associated symptoms,warning signs,urine output,family or neighbourhood dengue • PHYSICAL EXAMINATION – Assess hydration,hemodynamic status,tender abdomen,ascites,hepatomegaly,pleural efffusion,bleeding manifestations,mental state,tourniquet test
  24. 24. • INVESTIGATIONS – CBP with HCT,other organ function tests as indicated(USG,CXR,LFT,RFT,PT APTT INR,BLOOD GLUCOSE,SERUM ELECTROLYTES,ABG) • SPECIFIC DIAGNOSTIC TESTS – NS1 Ag detection IgM IgG detection Viral isolation PCR to detect viral genome
  25. 25. DENGUE WITHOUT WARNING SIGNS - TREATMENT
  26. 26. DENGUE WITH WARNING SIGNS - TREATMENT
  27. 27. SEVERE DENGUE(COMPENSATED SHOCK) - TREATMENT
  28. 28. HYPOTENSIVE SHOCK - TREATMENT
  29. 29. DISCHARGE CRITERIA • No fever for 48hours • Improvement in general well- being,appetite,U/O,hemodynamic status • Increasing platelet count • Stable HCT without IVF
  30. 30. D/D • CONDITIONS THAT MIMIC FEBRILE PHASE : Influenza, measles, chikungunya, scarlet fever, meningococcal infection, drug reactions, G.E
  31. 31. • CONDITIONS THAT MIMIC CRITICAL PHASE : Acute GE, malaria, viral hepatitis, acute abdomen, DKA, lactic acidosis, acute leukemia, platelet disorders, leptospirosis
  32. 32. THANK YOU !

Editor's Notes

  • acute mosquito transmitted disease characterized by
    fever, headache, muscle, joint pains, rash, nausea and vomiting.
  • Global case load of about 50 million annually ……endemic in all states except extreme north and the north east….cyclical trends with high epidemic years and non epidemic years
  • Dengue fever virus is an ss rna virus…transmitted by arthropods hence also called arbovirus….asian genotypes ….viralgenome cleaved into capsid membrane envelope
  • Prinicpally aedes aegyptyi..also albopictus polynesiensis scutellaris(stegomyia family)……….good vector coz its highly anthropophilic(close proximity to humans)
  • Mechanism explain….extrinsic ip of 8-12 days females-more severe
  •  vasculopathy causing dss,coagulopathy causing dhf…mannose lectin receptors…..
  • Electrolytes ,small proteins and sometimes rbcs
  • ACT SYNERGISTICALLY
  • ENHANCING ANTIBODIES ARE CONCENTRATION DEPENDENT AND SEROTYPE INDEPEMNDENT
  • Coincident with the disappearance of virus and antigens
  • Difficult to differentiate between dengue and non dengue fever in this phase.Positive tourniquet test during this phase increases probability of dengue
  • Around the time of defervescence
  • GI BLEEDING USUALLY
  • Over 48 to 72 hours…no excess iv fluids .islets of white in sea of red rash
  • CNS , GI MANIFESTATIONS
  • SHOULD BE CONSIDERED WHEN THE PERSON IS FROM AN AREA AT DENGUE RISK
  • ACC TO NVBDCP……..DHF GRADE 3 AND 4 IS DSS
  • TO ESTABLISH BASELINE HCT…&amp;gt;20% rise……as early as day 1….igm varies….at around 5 days……nvbdcp using macelisa…HEMAGG INHIBITION METHOD
  • MONITOR PERIPHERAL PERFUSION,VITALS,URINE OUTPUT,HCT,BLOOD GLUCOSE,OTHER ORGAN FUNCTIONS
  • GROUP CRITERIA INCLUDE
  • 5-10 ML OF PACKED CELLS./10-20 ML OF FRESH WHOLE BLOOD…………correct the electrolyte dist,acid base imbalances
  • Acute hiv seroconversion
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