The document provides a comprehensive clinical update on dengue, detailing its epidemiology, symptoms, management strategies, and complications associated with co-infections, particularly with COVID-19. It highlights the critical phases of the disease, diagnostic approaches, treatment protocols, and considerations for patients with pre-existing conditions such as hypertension and diabetes. The update also discusses recent vaccine developments and recommendations for monitoring and managing dengue effectively.

1. CLINICAL UPDATE
AND
MANAGEMENT OF
DENGUE 2021
Dr. Balaganesh
2nd Year Post graduate in M.D. Gen Medicine
GMKMCH Salem
20-10-2021

2. INTRODUCTION
 Dengue is the world’s most common
arboviral infection-
a leading cause of morbidity
throughout the tropics and subtropics.
 CYCLICAL EPIDEMIC in india

3. EPIDEMIOLOGY
AGENT
• Dengue Virus
serotypes of the dengue virus:
• DENV-1, DENV-2, DENV 3, and DENV-4.
HOST
People of all ages and both genders are at risk of being infected.
VECTOR
• AEDES AEGYPTI
• AEDES ALBOPICTUS

4. WHATS NEW ..
Dengue's D2 strain –DENV2
• it was one of the reasons behind the mysterious
fever which had hit the western UP districts
• DENV 2 or the strain D2 is considered to be the most
severe and can even lead to fatal internal bleeding
and shocK
IT IS HIGHLY TRANSMISSIBLE AND SPREADS FASTER
AND MORE VIRULENT

5. SPECTRUM OF DENGUE INFECTION
► The incubation period for dengue infection is 4-7 days (range
3-14).
► Symptomatic dengue infection is a systemic and dynamic
disease with clinical, haematological and serological profiles
changing from day to day.
► These changes accelerate within hour or even minutes during
the critical phase, particularly in those with plasma leakage

6. Febrile phase
High-grade fever(biphasic) sudden onset-usually lasts
2-7 days
Facial flushing,
 Skin erythema,
 generalized body ache, myalgia, arthralgia,.
retro-orbital eye pain, photophobia.
 Rubelliform exanthematous rashes and headache .
Anorexia, nausea and vomiting are common

7. Confluenterythematosusrash
withislandofskinsparing
Rashindenguefever
isamaculopapularormacular
confluentrashovertheface,
thorax,andflexorsurfaces.
ISLANDSOFSKINSPARINGIN
SEAOFRED
HERMAN RASH

8. Critical phase
• The warning signs mark the beginning of the critical phase.
patients become worse around the time of defervescence,
when the temperature drops to 37.5-38°C or less and remains
below this level, usually on days 3–8 of illness.
• Progressive leukopenia followed by a rapid decrease in platelet
count usually precedes plasma leakage.
• An increasing haematocrit above the baseline may be one of
the earliest additional sign. The period of clinically significant
plasma leakage usually lasts 24-48 hours.
• A rising haematocrit precedes changes in blood pressure (BP)
and pulse volume

9. Recovery Phase
• Plasma leakage stops followed by reabsorption of
extravascular fluid
• General well being improves
• appetite returns, gastrointestinal symptoms
improve, haemodynamic status stabilises and
diuresis ensues
• The recovery of platelet count is typically preceded
by recovery of white cell count.

13. History
• Date of onset of fever/illness;
• Quantity of oral fluid intake;
• diarrhoea
• urine output (frequency, volume and time of last voiding);
• assessment of warning signs
• change in mental state/seizure/dizziness
• other important relevant history, such as family or neighbourhood dengue
• travel to dengue-endemic areas
• co-existing conditions (e.g. infancy, pregnancy, obesity, diabetes mellitus,
hypertension), jungle trekking and swimming
• in waterfalls (consider leptospirosis, typhus, malaria), recent unprotected sex
or drug abuse (consider acute HIV-seroconversion illness).

14. Physical examination
• Assessment of mental state
• Assessment of hydration status
• Assessment of hemodynamic status
• Checking for quiet tachypnea/acidotic breathing/pleural effusion
• Checking for abdominal tenderness/hepatomegaly/ascites;
• Examination for rash and bleeding manifestations;
• Tourniquet test (repeat if previously negative or if there is no
bleeding manifestation).

15. INVESTIGATIONS
• COMPLETE BLOOD COUNT
• RENAL FUNCTION TEST
• LIVER FUNCTION TEST
• URINE ROUTINE
• RANDOM BLOOD SUGAR
• ECG
• CHEST XRAY PA VIEW
• USG ABDOMEN AND PELVIS
• SEROLOGY

16. WHATS NEW
PLATELET INDICES-NORMAL VALUES
• MPV (fL) -8.6-15.5
• PDW (fL) -8.3-25
• PDW (%) -8.3-56
• PCT (%) -0.22-0.24
• IPF (%) -1.1-6.1
• P-LCR (%) -15-35
• An increased P-LCR is seen in destructive
thrombocytopenia (more likely in dengue)

17. USG ABDOMEN AND PELVIS
• GB WALL EDEMA
• ASCITES
• PLEURAL EFFUSION
• ORGANOMEGALY
• IVC DIAMETER-
NORMAL-1.5-2.5 CM
(3CM FROM RIGHT ATRIUM)
• IVC COLLAPSIBILITY

18. DENGUE SEROLOGY
• NS1 ANTIGEN
• IGM
• IGG

19. DIFFERENTIAL DIAGNOSIS

20. Parameters Stable circulation Compensated shock Hypotensive shock
Conscious level Clear and lucid Clear and lucid (shock can bemissed if
you do not touch the patient)
Change of mental state(restless,
combative)
Capillary refill time Brisk (< 2 sec) Prolonged (> 2 sec) Very prolonged, mottled skin
Extremities Warm and pink
extremities
Cool peripheries Cold, clammy extremities
Peripheral pulsevolume Good volume Weak and thready Feeble or absent
Heart rate Normal for age Tachycardia Severe tachycardia with bradycardia
in late shock
BP Normal for age
Normal pulse pressurefor age
rising diastolic pressure
Narrowing pulse pressure(≤ 20
mmHg in children)
Postural hypotension
Hypotension (see definitionbelow)
Unrecordable BP
Respiratory rate(RR) Normal for age Quiet tachypnoea Metabolic acidosis/hyperpnoea/
Kussmaul’s breathing
Urine output Normal Reducing trend Oliguria/anuria

21. INTERPRETATIONOF HEMATOCRIT
• A rising or persistently high hematocrit together with unstable
vital signs (such as narrowed pulse pressure) indicates active
plasma leakage
• However, a rising or persistently high hematocrit together with
stable hemodynamic status and adequate urine output does not
require extra intravenous fluid
• A decrease in hematocrit (for example from 50% to 40% or below
the patient’s known baseline) together with unstable vital signs
may indicate major hemorrhage.
• If there is severe hemorrhage, urgent blood transfusion should
be given

22. Group B- Dengue with warning signs
• These are patients who should be admitted for in-
hospital management for close observation as they
approach the critical phase.
• These include patients with warning signs
• those with co-existing conditions that may make
dengue or its management more complicated those
with certain social circumstances PLUS WARNING
SIGNS OF DENGUE

23. TREATMENT
• Give isotonic solutions such as 0,9% saline, Ringer lactate,
• start with 5-7 ml/kg/hr for 1-2 hours,
then reduce to 3- 5 ml/kg/hr for 2-4 hr,
and then reduce to 2-3 ml/kg/hr or less according to clinical response
Reassess clinical status and repeat Hct
• if Hct remains the same or rises only minimally -> continue with 2-3 ml/kg/hr
for another 2-4 hours
• If worsening of vital signs and rapidly rising Hct -> increase rate to 5-10
ml/kg/hr for 1-2 hours
• Reassess clinical status, repeat Hct and review fluid infusion rates accordingly
• Reduce intravenous fluids gradually when the rate of plasma leakage decreases
towards the end of the critical phase.

24. MONITORING-GROUP B
• Temperature pattern
• Volume of fluid intake and losses
• Warning signs
• HCt, white blood cell and platelet counts

25. GROUP C
• Patients with any of the following
features.
• Severe plasma leakage with shock
and/or fluid accumulation with
respiratory distress
• Severe bleeding
• Severe organ impairment

31. INDICATIONS FOR BLOOD
TRANSFUSION
• LOSS OF BLOOD-OVERT GI
BLEED;MUCOSAL BLEED-MORE THAN 10%
• REFRACTORY SHOCK DESPITE ADEQUATE
FLUID THERAPY AND HEMATOCRIT
DECLINE

32. INDICATIONS FOR PLATELET
TRANSFUSION
• PLATELET TRANSFUSION NOT THE MAIN STAY OF
TREATMENT IN DENGUE
• IF PLT COUNT>10000 WITH NO BLEED-NO NEED
OF PROPHYLACTIC TRANSFUSION
• IF<10000-CAN BE GIVEN
• ABNORMAL COAGULATION PROFILEWITH
PROLONGED SHOCK

34. CNS manifestations
Intra-cerebral haemorrhage
 Encephalitis
Aseptic meningitis
ADEM
Cerebral infarct
Cortical venous thrombosis
 Myelitis
 Hypokalemic periodic paralysis
G.B. syndrome
 Opsoclonus myoclonus
Optic neuropathy
Myalgia cruris
Rhabdomyolysis
Dysarthria clumsy-hand
syndrome

35. Cardiovascular manifestations
• Asymptomatic myocarditis
• Symptomatic myocarditis
• Pericarditis
• Myocardial infarction
• S-A nodal block A-V nodal block
• Acute atrial fibrillation
• Cardiomyopathy

36. Gastrointestinal manifestations
• Hepatic dysfunction (without ALF)
• Acalculous cholecystitis
• Fulminant hepatic failure
• Acute pancreatitis
• Diffuse peritonitis
• Acute appendicitis
• Acute parotitis
• Spleen rupture

37. Renal manifestations
• Myoglobinuric acute renal failure
• Rhabdomyolysis
• AKI associated with DHF
• AKI with DSS/DHF
• IgA nephropathy
• Hemolytic-uremic syndrome

38. Challenges when managing dengue patients with pre-
existing hypertension
BradycardIa
Tachycardia:
End-organ damage
from chronic
hypertension:
ß-blockers, a common antihypertensive medication, cause
bradycardia and may block the tachycardic response in shock.
calcium channel blockers may cause tachycardia.Tachycardia in
these patients may not indicate hypovolemia.
Heart failure and renal failure are common complications of
chronic uncontrolled hypertension. Clinicians should be aware if
there is pre-existing or new onset of end-organ damage.
Interpretation of urine output as a marker of renal perfusion
has to
be revoked in these situations.

39. Hyperglycemia
Osmotic diuresis:
increased risk of
concomitant sepsis:
Diabetic ketoacidosis
and hyperosmolar
hyperglycaemia:
dengue can precipitate diabetic ketoacidosis or hyperosmolar
hyperglycemia.
Hyperglycemia results in osmotic diuresis and worsens intravascular
hypovolemia.
Patients at risk of bacterial infection.
Clinical manifestations of diabetic ketoacidosis and hyperosmolar
hyperglycaemia(nausea, vomiting and abdominal pain) are similar to the
warning signs of severe dengue.
Hypoglycaemia: Hypoglycaemia may occur in those patients taking oral hypoglycaemic
agents .
Hypoglycaemia could beaggravated by severe hepatitis from dengue.
Challenges when managing dengue patients with pre-existing
diabetes mellitus

40. CHRONIC KIDNEY DISEASE
• Dengue patients with chronic Kidney disease(CKD)
have a significantly higher risk of severe dengue
and mortality.
The warning signs of severe dengue are similar to
those of uremia in CRF.
Ascites and/or pleural effusion, and signs of
plasma leakage in dengue
Low baseline hematocrit and platelet count
• Patients with CRF have a low baseline hematocrit.

42. DENGUE VACCINES
• All vaccines aim at eliciting high level of neutralizing antibodies
• ▶ Vaccines needs to be tetravalent
• ▶ Dengue vaccines in development are of four types :
• ▶ Live a ttenua ted va ccines (LAV )
• ▶ C himeric live a ttenua ted va ccines
• ▶ Ina ctiva ted or subunit va ccines
• ▶ Nucleic acid based vaccines
• CYD-TDV OR DENGVAXIA
Live attenuated recombinant tetravalent vaccine
3 injections of 0.5ml administered 6 months interval
Freeze dried product
Reconstitution fluid is 0.9% saline for single dose preparation
0.45% saline for multidose preparations(5)
Dosage – 0.5ml subcutaneously . Contains no adjuvants or preservatives

43. CONTRAINDICATION
• SEVERE ALLERGY TO COMPONENT OF VACCINE
• PREGNANT AND BREAST FEEDING WOMEN
• IMMUNODEFICIENCY STATE
• SYMPTOMATIC HIV INFECTION

44. DOUBLE TROUBLE-COVID
AND DENGUE
• Case Classification of co-infection:
• 1. Asymptomatic Co-infection
• 2. Symptomatic co-infection
• a. Predominant Corona Viral Diseases (P-CVD)
• b. Predominant Dengue Viral Disease (P-DVD)
• c. Co-dominant co-infection (CDCI)

45. MANAGEMENT
• LMWH – LMWH is being used and has been included in the
guidelines for the management of moderate to severe COVID-19
cases as it is associated with increased thrombosis.
• LMWH is indicated in moderate to severe category; however, careful
monitoring is required by D-dimer estimation and when the platelet
count falls below 1,00,000/mm3 •
• Use of Corticosteroids –Dexamethasone has recently been shown to
be effective in severe COVID-19 and has been recommended for the
same.
• Usually the course of illness among co infected patients may not be
affected much, if Dexamethasone is given after dengue viremic stage
i.e.,5/6 days of dengue illness.

46. THANK YOU