This document discusses dengue management in the emergency department. It begins with an overview of how dengue patients may present to any zone of the ED. It then discusses challenges in dengue diagnosis including similarities to COVID-19. Key aspects of dengue diagnosis and management are outlined, including the use of point-of-care ultrasound to assess for plasma leakage. Outpatient dengue management is also briefly covered. The document concludes by presenting a case study of a patient initially diagnosed with dyspepsia who was later found to have dengue, highlighting some of the challenges in dengue diagnosis and management in the ED.

1. Dengue in Emergency
Department
Dr Dayang Rafidah binti Awang Habeni
Emergency Physician
Dengue Course 2022

5. Respi/Non respi
Respi/Non respi
Respi/Non respi
COVID tent
The dengue patient maybe ended up at ANY zones in
ED

6. Outline
• Dengue in Triage
• Dengue and COVID-19
• Diagnosis of Dengue
• Role of POCUS in ED
• Outpatient Management
• Challenges in managing Dengue in ED

7. Principle have changed!
Fever
Dengue!
Until proven
otherwise
No!!!
COVID-19!
Until proven
otherwise

8. Dengue and COVID-19
• COVID-19 and dengue infection are hard to distinguish because they
share similar clinical features
Coronavirus Disease of 2019: a Mimicker of Dengue Infection? Henrina J et al. SN Comprehensive Clinical Medicine (2020) 2:1109–1119

9. Fig. 1 SARS-CoV2 and DENV pathomechanisms of clinical manifestations. This flowchart diagram depicts similarities between COVID-19
and DENV clinical manifestations with their respective pathomechanisms

10. 6.3% - Dengue igG
positive
21.1%- Dengue igM
positive
Cross reaction and
false positive between
dengue and COVID-19
are observed!
Co-infection was also
found!
Assessment of dengue and COVID-19 antibody rapid diagnostic tests cross-reactivity in Indonesia Santoso et al. Virol J (2021)

11. Dengue in Triage
• Clinical features of dengue are non specific
• May mimic other diseases
• Patient presented at different phases of dengue infection
Dengue???
Fever
Vomiting
Diarrhea Abdominal pain
URTI symptoms
Myalgia/arthralgia

12. Evaluation at Triage
Aim of triage!
Send the RIGHT
patient to the RIGHT
zone so that
treatment can be
instituted at the
RIGHT time

13. Systematic Dengue Triage Assessment
•Ask, Look and Touch
•Shock Markers
•Previleged information

14. Ask
• Chief complaint
• Associated symptoms
• WARNING signs!!!!
Look
• Lethargy
• Altered mental state
• Rapid breathing
• Jaundice
• Skin colour – mottled, pale
Touch
Identification of SHOCK by
assessing the
“CCTVR”

15. CCTVR
• Colour
• CRT
• Temperature
• Volume
• Rate

16. Shock Markers
• Secondary Triage - interpretation of vital signs
• Shock markers:
•Heart rate
•Shock index
•Pulse pressure

17. Tachycardia
• First sign of shock
• Disproportionate tachycardia in relation to fever
Carl von Liebermeister (1833 – 1901) was a German
Physician.
Liebermeister rule:
relationship between pulse frequency and body temperature in fever. In fever,
when the body temperature increases by one degree centigrade, the pulse
frequency increases by eight beats per minute.
Temp: 38
Heart Rate : 130

18. Shock Index
• HR/SBP
• Shock Index > 1 or Heart rate > SBP  indicates SHOCK
BP: 120/80
PR: 130
SI : >1
Compensated Shock!!

19. Pulse Pressure
• SBP-DBP
• Normal 30-40
• Changes in monitoring
12:00pm
BP: 120/80
PR: 110
12:30pm
BP: 120/90
PR: 117
COMPENSATED SHOCK!!

20. Previleged Information
• Read the referral letter
• Blood parameter
• Reasessment
• Note the date and time of the
referral letter

21. Diagnosis of Dengue in ED

26. DIAGNOSIS

28. Full blood Count
White cell count and Platelet
• In the early febrile phase WCC and platelet count are usually normal but will decrease rapidly as the disease
• The decrease in WCC is accompanied by platelet reduction.
• Platelet count and severity - NO CORRELATION and NOT A PREDICTIVE OF BLEEDING
• In recovery phase, the WCC normalises followed by platelet.
Haematocrit (HCT)
• A rising HCT is a marker of plasma leakage in dengue infection. The median:
Male < 60 years – 46%
Male > 60 years – 42%
Female (all age groups) – 40%

29. Diagnostic Test
• POCT  dengue NS1 antigen test and rapid combo tests (NS1
antigen and dengue IgM/IgG antibodies)
• Laboratory test  NS1 antigen test, dengue antibody detection tests
including IgM and IgG ELISA, dengue genome detection assay (real
time RT-PCR) and dengue viral isolation assay.

30. Rapid Combo Test (RCT)
• Reading too late gives false results.

31. Non-Structural Protein-1 (NS1 Antigen)
• highly conserved glycoprotein that seems to be essential for virus viability
• Secretion of the NS1 protein is a hallmark of flavivirus
• False positive results have been reported in chronic diseases and haematological
malignancies
• primary infection (75%-97%) secondary infection (60%-70%)
• The sensitivity of NS1 antigen detection drops from day 4-5 of illness onwards
and usually becomes undetectable in the convalescence phase
• The presence of NS1 detection after day five may predict severe dengue

32. Dengue IgM test
• The IgM capture enzyme-linked immunosorbent assay (ELISA) is the
most widely used serological test
• antibody titre is significantly higher in primary infections compared
to secondary infections.
• In primary dengue infection, anti-dengue IgM can be detected after
five days of illness in approximately 80% of the cases.
• Almost 93%-99% of cases will have detectable IgM from day 6
through day 10.
• In the event of a negative IgM result, a repeat serum should be
collected after five days

33. Dengue IgG test
• primary and secondary dengue infection, dengue IgG was detected in
100% of patients after day seven of onset of fever.

34. Note: False positive dengue serology
Serological tests for dengue have been shown to cross-react with:
• other flavivirus – Japanese Encephalitis
• non-flavivirus – malaria, leptospirosis, toxoplasmosis, syphilis
• connective tissue diseases – rheumatoid arthritis
• COVID-19

35. Laboratory tests in the Emergency Department
In cases of suspected dengue infection :
• FBC and HCT
• Point of care testing e.g. Rapid combo test (RCT) or NS1 antigen
In suspected severe dengue
• Blood gases and serum lactate
• LFT/AST and RP
• Creatine kinase (CK) to detect myocarditis and rhabdomyolysis
• GXM

36. Chest x-ray
• If suspected to have vascular leakage
Ultrasonography
• Third space fluid loss such as the presence of pleural effusion, i.
pericardial effusion, gallbladder wall oedema and intraperitoneal fluid
collection.
• Collapsibility of the inferior vena cava (IVC) as an indirect indicator of
adequacy of the intravascular fluid compartment & response to
intravenous fluids.

37. Point of Care Ultrasound in Dengue
• Practice-changing technology for critically ill patient
• Real-time assessment
• Helps in narrowing the differential diagnosis
• Guide decision for further investigations
• Initiates proper treatment and timely resuscitation

38. Point of Care Ultrasound in Dengue
Role of ultrasound in Dengue – evaluate plasma leakage
Ultrasound done in hospitalized dengue patient
Most common findings in dengue:
Ascites ( 60%),
pleural effusion (58%),
gallbladder wall thickening (55%)
Ultrasound in Dengue: A Scoping Review, Dewan N et al, The American Journal of Tropical Medicine and Hygiene 2021

39. Plasma leakage
Fluid in the
Morrison’s pouch
Fluid in the
splenorenal space Pleural effusion

40. Parmar J et al. Patterns of Gall Bladder Ultrasound Int Open 2017; 3: E76–E81

41. Honeycombing pattern – most common pattern in severe dengue

42. Fluid status assessment and responsiveness
IVC size and collapsibility

44. Out patient management of
Dengue

47. Challenges in managing
Dengue

48. Case 1
Mr S, 41 Malay gentleman
No medical illness
1st visit to ED on 20/06/2020 @ 0442hrs
• Chief complaint: Headache x 1 day
• Took PCM at home
• Associated symptoms: giddiness, epigastric
pain, nausea, no vomiting
• Took spicy food last night 
• BP:112/73,PR: 87/min, RR: 20, Temp: 37.3,
pain score 4
• Rx : IM stemetil, IV tramadol, IV
maxolon,MMT, iv ranitidine
• Imp: Acute dyspepsia
• He was observed in Observation ward and
reassess after 1 hour
• Review at 7am: patient is well, ambulating, no
headache
• Reassessing cerebellar sign- negative
• Revised diagnosis:
• 1)Resolved headache secondary to peripheral
vertigo
• 2)Resolved acute dyspepsis
• Discharge with: PCM, Stemil, MMT

49. 23/06/2020 @ 1022hrs

51. FBC taken
• WBC: 43.6
• Hb: 18.4
• Hct: 52.2
• Plt: 9

52. Other interesting findings
Dengue combo test : NS1 : positive /
IgG/ IgM : negative
TP 63/ ALP 107/ ALT 552/ TB 14.3/
AST 640
CK 1086/ LDH 928

53. Challenges
1) Afebrile in Dengue
- Dengue diagnosis SHOULD NOT be dismissed in afebrile
- Establishing the history of fever
- Beware of subnormal temperature  SHOCK

55. 2) Abdominal pain
- Common
- Often neglected
- Presumed gastritis
- Pathophysiology in dengue??

56. 3) I forget to touch the patient
- Vitals are normal, I assume everything is okay
- CCTVR must be assess in ALL dengue patient
- allow us to detect subtle signs of compensated shock

57. 3) Underestimating lethargy
4) Non-specific presentation
- High index of suspicion
5) Isolated vital sign/FBC interpretation

58. References

59. The end…