DENGUE IN CHILDREN_NEW.pptx.............

dengue

1. DENGUE IN CHILDREN PRESENTER: SHAKIRA SUPERVISOR MO: DR. MICHELLE SPECIALIST IN CHARGE: DR. MUSHAMMA

2. CONTENTS INTRODUCTION CLINICAL MANIFESTATION AND PATHOPHYSIOLOGY DIAGNOSIS RISK FACTORS FOR SEVERE DENGUE TREATMENT DISCHARGE CRITERIA

3. INTRODUCTION Dengue fever (DF) is a common and serious mosquito-borne viral disease. Caused by dengue virus (DENV) which has 4 serotypes (DEN 1, DEN 2, DEN 3, DEN 4) All serotypes found in Malaysia and the predominant serotype changes from year to year

4. CLINICAL MANIFESTATION AND PATHOPHYSIOLOGY

5. Incubation: 4-7 days; Febrile phase: 2-7 days (5), Critical phase: Day 3- Day 8 of illness

6. FEBRILE PHASE Usually lasts 2-7 days. Common features Abrupt high grade fever Facial flushing, skin erythema, generalised body ache, myalgia, arthralgia, retro-orbital pain, photophobia, rubelliform exanthema and headache Anorexia, nausea and vomiting Earliest abnormality in FBC is a gradual drop in WCC Haematological manifestation are mild e.g. petechiae, mucosal membrane bleeding (nose, gum), easy bruising or bleeding at venepuncture site

7. CRITICAL PHASE Usually begin after 3 rd (or earlier) of illness but can be as late as day 8 of illness. Typically occurs around the time of defervescence Plasma leakage may occur as a result of increased capillary permeability and is manifested by warning sign

8. FOOTNOTE

9. HAEMODYNAMIC ASSESSMENT: CONTINUUM OF HAEMODYNAMMIC CHANGES

10. RECOVERY PHASE Most cases of severe dengue will enter convalescent phase 24-48H hours after the onset of plasma leakage. Followed by gradual reabsorption of extravascular compartment in the next 48-72H Improvement of general condition Gradual return of appetite Disappearance of GI symptoms Stabilisation of haemodynamic status and commencement of diuresis Some may develop confluent erythematous or petechial rash with small areas of normal skin over extremities described as ISLES OF WHITE IN THE SEA OF RED

11. ISLES OF WHITE IN THE SEA OF RED

12. DIAGNOSIS

13. LABORATORY DIAGNOSIS RAPID TEST NS 1 Ag Sensitivity 67-71% Specificity 86-99% NS1 Ag + IgM Sensitivity 89% NS1 Ag+ IgM/IgG Sensitivity 93%

14. RISK FACTOR FOR SEVERE DENGUE Demographic: female sex, age > 5 y.o , obesity Epidemiology: secondary infection , infection by DENV-2 Clinical signs: PP <20, SBP <90mmHg Lab: TWC 5000/ uL , Hb < 9 g/dL, prolonged PT/ APTT, low fibrinogen Imaging: gallbladder wall thickness >5mm or pleural effusion + ascites +/- gallbladder wall thickening

15. Other signs: Lethargy abdominal pain Bleeding tendency Hepatomegaly HCT > 22% of baseline Plt < 100,000/µL

16. TREATMENT Febrile phase - May be admitted or as outpatient

17. ADMISSION CRITERIA for children with dengue Age < 12 months Presence of warning signs Features of severe Dengue Presence of co- morbids Social factors e.g. difficulty of outpatient monitoring

18. CRITICAL PHASE three main priorities of managing hospitalised patients with dengue in critical phase are: - replacement of plasma losses - early recognition and treatment of haemorrhage - prevention of fluid overload

19. IV FLUID THERAPY To maintain effective circulation for 24-48H during critical phase Fluid resuscitation must be clearly separated from fluid maintenance Fluid resus of 10-20ml/kg fluid boluses are administered for a limited period of time under close supervision

20. GOALS

21. Hematocrit Monitoring And Dengue Hypovolaemia Compensated shock Improved circulation and tissue perfusion Capillary refill <2 seconds Normal heart rate Normal blood pressure Normal pulse pressure Urine 0.5ml/kg/ hr  HCT to normal Improving acid-base Bleeding DIC Multi-organ failure Hypotensive shock Fluid overload: Pulmonary oedema Respiratory distress Worsening pleural effusion and ascites Clinical deterioration

22. CHOICE OF RESUS FLUID Most children with dengue in shock respond well with isotonic crystalloid solution – should not contain glucose Early intervention with colloidal solution is not indicated In case of persistent shock despite resus with crystalloid solution, colloid solutions can be considered

23. RECOVERY PHASE Venofix / branula should be removed when there is no indication for further IV therapy

24. 01 02 03 04 No fever for 24 -48 hours Improvement in clinical status (general well-being, appetite, haemodynamics , urine output) Absence of respiratory distress Recovery of organ dysfunction Discharge of Children with Dengue Source: CPG Management of Dengue in Children (Second Edition), 2020 05 06 Increasing trend of platelet count Stable HCT without IV fluids

25. CASE 1 PM, 10Y8M HOPI: Fever 5/7 Headache 5/7 Myalgia 5/7 Vomiting 2/7 Diarrhea 1/7 Abdominal pain 1/7 Cough 2/7 Went to KK, took FBC – low platelet and WCC Dengue combo test – negative

26. On admission, FBC: WCC 2.4/Hb 13.2/ Plt 153/HCT 38, Dengue serology pending So what is your diagnosis with differential diagnosis and how to manage the patient?

27. CASE 2 AI, 5Y4M HOPI: Fever 5/7 Rashes 4/7 Vomitting 1/7 Reduced oral intake Dengue combo stat NS1 and IgG positive, IgM negative O/E: lips dry, good PV, warm peripheries, CRT 2sec, lethargic looking BP 85/69, HR 124, RR 31, T 37 Lungs clear, CVS DRNM, P/A soft non tender

28. What is your diagnosis for this patient and how to manage?

29. REFERENCE CPG Management of Dengue in Children (Second Edition) Managing Paediatrics Dengue, Dr. Ngian Geok Hoon , HPSF, Muar

30. THANK YOU