1. DENGUE FEVER
Dengue is a self limiting acute mosquito transmitted disease characterized by fever, headache,
muscle, joint pains, rash, nausea and vomiting. Dengue Fever (DF) is caused by an arbovirus and
spread by Aedes mosquitoes. Some infections result in Dengue Haemorrhagic Fever (DHF) and
Dengue Shock Syndrome (DSS) which can be life threatening.
The clinical presentations depend on age, immune status of the host and the virus strain.
Case definitions by WHO:
Dengue Fever- An acute febrile illness of 2-7 days duration with two or more of the following
manifestations: Headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic manifestations.
Dengue Haemorrhagic Fever: A probable or confirmed case of dengue with haemorrhagic
tendencies (Positive tourniquet test, petechiae, ecchymoses or purpura, bleeding from mucosa,
gastrointestinal tract, injection sites or other sites, haematemesis or malena) and Thrombocytopenia
(<100,000 cells per cumm) and evidence of plasma leakage ( A rise in average haematocrit for age
and sex > 20%, a more than 20%drop in haematocrit following volume replacement compared to
baseline, pleural effusion, ascitis, hypoproteinaemia)
Dengue Shock Syndrome: All the criteria for DHF plus evidence of circulatory failure (rapid and weak
pulse and narrow pulse pressure (<20 mm Hg), hypotension for age, cold and clammy skin and
restlessness)
Case classification
Suspected: A case compatible with the clinical features
Probable: A case compatible with the clinical features with either Supportive serology or occurrence
at same location and time as other confirmed cases of dengue fever.
Confirmed: A case compatible with the clinical description that is laboratory Confirmed
Laboratory criteria for diagnosis (any one)
• Isolation of the dengue virus from serum, plasma, leucocytes.
• Demonstration of a fourfold or greater change in reciprocal IgG or IgM antibody titres to dengue
virus antigen in paired serum samples.
• Demonstration of dengue virus antigen in autopsy tissue by immunohistochemistry or
immunoflorescence or in serum samples by ELISA.
• Detection of viral genomic sequences in autopsy tissue, serum or CSF samples by polymerase
chain reaction (PCR).
CLASSICAL DENGUE FEVER:-
Abrupt onset of high grade fever, headache retro-orbital pain, photophobia, backache, myalgia
and arthralgia. Because of aches and pains dengue acquired an epithet of “Break bone fever”.
Transient maculopopular rash over face, trunk, axillae and palate occurs. Dengue facies -
suffused and swollen face, injected eyes, purplish lips, reddened mallar region and ear lobes –
patient assume a measly look – typical dengue erythematous flush. Fever lasts 3 to 7 days.

2. SYMPTOMS OF DHF
Typically DHF has 3 important findings- fever, bleeding tendency and hepatomegaly. Bleeding
manifestations are positive tourniquet test, bleeding at venepuncture sites, fine purpuric rash.
Liver 2 to 4 cm palpable and non tender. Critical stage is around defervescence which is often
accompanied by circulatory disturbances. Extravasation of plasma through leaky capillaries
results into haemoconcentration, hypovolemia and hypotension . Fluid which drips out
manifests as generalized oedema and effusions in serous cavities. Epistaxis, gingival and mild
gastro intestinal bleeding, haematuria and hypermenorrhoea, anorexia, nausea, vomiting vague
gerneralised abdominal pain.
SYMPTOMS OF SEVERE DHF
Leaky Phase- Profuse and continous leaking results in oliguria & postural hypotension. Skin
becomes cool blotchy and congested and circum oral cyanosis, fast and thready pulse, inperceptible
lower limb pulses, in extreme case unrecordable BP. Leaking of plasma in serous cavities leads to
peritoneal, pleural and pericardial effusions and generalised oedema.
Congestive Phase- After 2-3 days leaks stop and extravasated fluid during leaky phase returns back
to circulation and may lead to signs of congestive heart failure during defervescence phase.
Convalescence- End of congestive phase heralds recovery.
Warning signs of DSS- Intense sustained abdominal pain, Persistent vomiting, Restlessness,
Lethargy, Sudden change from fever to hypothermia with sweating & prostration.
LAB FEATURES
• Increase in PCV.
• Thrombocytopenia(<1 lakh)
• Leucopenia with neutropenia and relative lymphocytosis
• SGOT may be raised
• Detection of Dengue virus by culture:
• Detection of Dengue RNA using specific Oligonucleotide primers, reverse transcriptase and –
polymerase chain reaction (PCR) amplification assay
• MAC Elisa - Dengue specific IgM & IgG antibodies raised after the 2 weeks of infections.
Haemagglutination - inhibition test – detection of H I antibodies, Complement fixation –
detection of complement fixing antibodies.
A TYPICAL PLAN FOR CLINICAL DIAGNOSIS:-
Fever and dengue facies (non catarrhal measly look) during post monsoon season should raise the
suspicion for Dengue fever. A positive tourniquet test indicating bleeding tendency, augments
possibility. Patient showing rise in PCV (haemoconcentration) and drop in platelets
(thrombocytopenia) should be categorized as DHF and should be kept under close observation &
monitoring for sign and symptoms of shock.
Management of Dengue Fever (DF)
Management of Dengue fever is symptomatic and supportive
i. Bed rest is advisable during the acute phase.
ii. Use cold sponging to keep temperature below 39 0C .

3. iii. Antipyretics may be used to lower the body temperature. Aspirin/NSAID like Ibuprofen etc
should be avoided since it may cause gastritis, vomiting, acidosis and platelet dysfunction.
Paracetamol is preferable.
iv. Oral fluid and electrolyte therapy are recommended for patients with excessive sweating or
vomiting.
v. Patients should be monitored in DHF endemic area until they become afebrile for one day
without the use of antipyretics and after platelet and haematocrit determinations are stable,
platelet count is >50,000/ cumm.
The management of DHF (febrile phase) is similar to that of DF. Paracetamol, Copious amount of oral
fluid. IV fluid may be administered if the patient is vomiting persistently or refusing to feed. Patients
should be closely monitored for the initial signs of shock. The critical period is during the transition
from the febrile to the afebrile stage and usually occurs after the third day of illness. Serial
haematocrit should be determined daily from the third day until the temperature has remained
normal for one or two days. Management of DHF & DSS involves intensive fluid therapy and proper
monitoring. Patient should preferably be managed in ICU setting.
Dr. Ravi Malik
Paediatrician
Malik Radix Hospital