management and prevention of Dengue according to guideline , Basngladesh

dengue - symptom,management,prevention according to latest guideline , simplified

1. Dengue Burden In Bangladesh
2019

2. Dengue management
Dengue Management

3. Dr. Tanveer kamal Fahim
Phase B Resident , Pulmonology
NIDCH
Dengue Management

4. “Dengue is one disease entity
with different clinical
presentations and often with
unpredictable clinical evolution
and outcome”

5. History of Dengue
Benjamin Rush first confirmed the case in 1789 and termed
"breakbone fever" because of the symptoms of myalgia and
arthralgia
Slaves in the West Indies who had dengue said to have the
posture and gait of a dandy thus also known as "Dandy
Fever“
The first record of probable dengue fever is in a Chinese
encyclopedia from Jin Dynasty (265–420 AD) which referred to
a “water poison” associated with flying insects

6. Dengue Virus
Dengue is caused by Dengue virus (DENV), a mosquito-borne single
stranded RNA positive-strand flavi virus
There are four dengue virus serotypes : DENV-1, DENV-2, DENV-3, and
DENV-4
Infection with any of these serotypes produces lifelong immunity to that
serotype
Secondary infection with another serotype or multiple infection with
different serotypes enhance chances of occurring more severe disease

7. Vectors
Aedesaegyptiand Aedesalbopictus
Typically lay eggs in near standing water in containers like buckets, bowls,
animal dishes, flower pots ,vases tree holes, axils, bamboo stumps, coconut
shells etc
The eggs can remain in a viable dry condition for more than a year and
emerge within 24 hours once it comes in contact with water
The female Aedesmosquito usually becomes infected with the dengue
virus when it takes a blood meal from a person during the acute febrile
(viremia) phase
The virus is transmitted when the infected female mosquito bites and injects
its saliva into the wound of the person bitten

9. Recent Out break Observation
2018
Less rash
Fever persists longer
duration
More Leucopenia
High AST
Tourniquet test +veearly
Diarrhea
Pharyngeal congestion
Myocarditis
2019
Almost no rash ( 3 types )
Fever persists longer duration ( > 5
days)
More Leucopenia ( as low as 2130/mm3
High AST ( 3123 IU )
Tourniquet test +veearly ( even during
febrile period)
Diarrhea ( Very common )
Expanded Dengue with Organopathy
(Very frequent)
Myocarditis ( very often )

10. Pathophysiology of Dengue
Virus Infection

12. Tourniquet Test (TT)
Clinical test for detecting covert hemorrhage
Procedure :Inflate a blood pressure cuff in forearm to mid-way between
the systolic and diastolic pressures for five minutes
After deflating wait for return of normal skin hue and count the number of
petechie
Considered positive when 10 or more petechiae per 1 inch² seen
In DHF, Definite positive result is when there is ≥ 20 petechiae per 1
inch² with a sensitivity of more than 90%

13. Capillary Refill Time
Clinical examination for volume status of the body
Measured by pressing the nail of the thumb of left hand in right handed person or vice
versa till blanching then suddenly release the pressure
The time taken for flushing of nail If more than 3sec, gross hypovolemia present

14. Clinical Manifestation of
Dengue Infection

16. Characteristics of Fever
Sudden onset
Sharp rise
Chills may accompany
Temperature –usually 102°F to 104°F
Biphasic/ Saddleback
Lasting 2–7 days usually

17. Fever is frequently associated with
Flushed face
Headache
Retro-orbital pain or eye pressure
Photophobia
Backache
Pain in the muscles and joints/bones
Anorexia and altered taste sensation
Constipation
Colicky abdominal tenderness

18. Rash:
First 2 -3 days -Diffuse flushing or fleeting eruptions
may be seen on the face , neck and chest
3-4
th
day-maculopapular or rubelliform
Afebrile period or defervescence-Petechiaemay
appear over the dorsum of the feet, legs, and hands and
arms
Skin itchingmay be present

19. Hemorrhagic Manifestations:
In DF with unusual hemorrhage, Petechiaemay be
present
Other bleeding such as massive epistaxis,
menorrhagia andgastrointestinal bleeding rarely
occur
Tourniquetest will be positive

20. Clinical course of Dengue Fever

21. Critical phase
Usually developsafter 3 to 4 days of onset of fever
Plasma leakage and high haemoconcentrationoccur
Persists for 36-48 hrs
Leads to shock, bleeding, pleural effusion and
ascities
Best simple indicator is platelet < 100000/cu.mm

22. Convalescent phase
The extracellular fluid which was lost due to capillary leakage
returns to the circulatory system
signs and symptoms improve
Usually occur after 6-7 days of fever
Last for 2-3 days
May develop pulmonary oedema due to fluid overload

23. Dengue Hemorrhagic Fever
Critical phase with plasma leakage is the hallmark of DHF
Tendency to develop hypovolemic shock (dengue shock
syndrome)
usually lasts for 24-48 hours
Results in Increase in HcT

24. Evidence of Plasma leakage
Haematocrit(HcT) –
A 20% rise of HcTfrom the baseline is
indicative of significant plasma leakage
Ascites and pleural effusion may develop

25. Dengue Shock Syndrome
DHF plus signs of circulatory failure, manifested
by:
Rapid and weak pulse
Narrow pulse pressure (≤ to 20 mm Hg)
Hypotension
Undetectable pulse and blood pressure
Cold clammy skin
Restlessness

26. Expanded dengue syndrome/ Isolated
Organopathy(unusual
manifestations)
Usually rare
Management is symptomatic
May be associated with coinfections and comorbidities
Mostly as a result of prolonged shock leading to organ failure
May involve liver, kidneys, brain or heart with or without
evidence of fluid leakage

27. Lab Investigation for Dengue
Diagnosis and Management

28. DENGUE DIAGNOSTIC TEST
Detection of Antigen, NS1 antigen (non-
structural protein 1):
The ELISA NS1 antigen will be positive on first
day of illness
This test becomes negative from day 4-5 of
illness

29. DENGUE DIAGNOSTIC TEST
Dengue IgM /IgG test (MAC ELISA or Rapid ICT):
Anti-dengue IgM specific antibodies can be detected after 5 days of the
onset of fever and highest level achieved after 7 days
Can be detected in low level up to 1-3 months after fever
In primary dengue infection-IgM will be more than Ig G early period
and increased IgG at 9
th
or 10 thday of fever
Level of IgG may persist at low levels for decades, indicating past dengue
infection
In secondary dengue infection-higher elevation of anti-dengue
specific IgG antibodies and lower levels of IgM
The higher IgG levels remain for 30–40 days

30. Time and frequency of doing
investigation
Within 3 days -CBC, Haematocrit , NS1 antigen, SGOT,
SGPT
Follow up testing may be done on 1st afebrile day
Follow up testing should be done daily once DHF is
suspected
Once the platelet count begins to rise and reaches ≥
50,000/mm3, daily lab evaluations may be
discontinued

31. Complete Blood Count(CBC)
Haematocrit:
Slight increase may be due to high fever, anorexia and vomiting
Sudden rise may occur during or just after the drop in
platelet count
Haemoconcentration or rising haematocrit by 20% from the
baseline , e.g. from haematocrit of 35% to ≥42% is objective
evidence of leakage of plasma

32. White Blood Cells :
Leucopeniais common
White cell count ≤ 5000 cells/mm3and ratio of
neutrophils to lymphocyte(neutrophils
<lymphocytes) precedes thrombocytopenia or
rising haematocrit, useful in predicting the
critical period of plasma leakage

33. Platelets :
Mild Thrombocytopenia(100 000 to 150 000
cells/mm3) is common
Platelet count is correlated with severity of DHF
Severe thrombocytopenia (<100,000/mm3) usually
precedes / accompanies overt plasma leakage

34. 2. Biochemical Tests:
Serum AST(SGOT)and ALT (SGPT):
Levels are frequently elevated
Significantly higher (5 to 15 times than normal) in DHF
Commonly AST > ALT
In Special Cases:
hypoproteinemia/Hypoalbuminaemia (as a consequence of
plasma leakage)
Hyponatremiais frequently observed
Hypocalcemia(corrected for hypoalbuminemia)
Metabolic acidosis : frequently found in prolonged shock
Blood urea nitrogen : elevated in prolonged shock

35. 3. Coagulation Profile:
coagulation and fibrinolytic factors are reduced in
DSS
Partial thromboplastin time and prothrombin time :
prolonged in about 1/3
rd
DHF cases
Thrombin time is also prolonged in severe cases

36. 4. Other tests:
Urine R/M/E: Albuminuria
Stool test: Occult blood is often positive
Chest X-Ray or Ultrasonography: Detection of pleural
effusions or ascites
Other tests for exclusion: Malaria (MP/ICT), typhoid fever
(Blood culture) if needed
Other tests when clinically indicated (especially for
Dengue expanded syndrome): Serum Albumin, Liver
Function Tests, Renal Function test, Serum electrolytes,
imaging ,ECG, Echocardiography, CSF etc

37. Nucleic Acid Detection:
The reverse transcriptase ploymerase chain reaction
(RT-PCR)-confirms diagnosis (<5 days of illness)
Dengue Viral Isolation

38. Dengue Case Classification by
Severity

41. Patients Group A
Dengue patients without warning sign
Able to tolerate adequate volumes of oral fluids
Can pass urine at least once every six hours
May be sent home

42. Patients Group B
Patients with warning signs
Should be admitted for close observation as they
approach the critical phase
Rapid fluid replacement is the key to prevent
progression to the shock state

43. Warning Signs of Dengue
No clinical improvement or worsening of the situation
Lethargy and/or restlessness
Giddiness
Sudden behavioural changes
Persistent vomiting
Severe abdominal pain
Liver enlargement > 2cm

44. Bleeding: Epistaxis, black stool, haematemesis,
excessive menstrual bleeding, dark colored urine
(haemoglobinuria) or haematuria
Pale, cold and clammy hands and feet
Less/no urine output for 4 –6 hours
Hematocrit >20%

45. Following conditions may need careful monitoring
and hospitalization even without warning signs :
Pregnancy
Infancy
Old age
Obesity
Diabetes mellitus
Hypertension
Heart failure
Renal failure
Chronic hemolytic diseases
such as (autoimmune
diseases)
Certain social circumstances
such as living alone, or living
far from a health facility
without reliable means of
transport

46. Patients Group C
Severe dengue, require emergency treatment and
urgent referral
Patient is in the critical phase of the disease
Severe plasma leakage leading to dengue shock
and/or fluid accumulation with respiratory
distress

47. Patients Group C
Severe organ impairment (hepatic damage,
renal impairment)
Myocarditis, cardiomyopathy,
encephalopathy or encephalitis
Severe metabolic abnormalities (metabolic
acidosis, severe Hypocalcaemia etc)

50. These patients will be advised to
1.Adequate bed rest
2.Adequate fluid intake
> 6 glasses for an average-sized adult, or
accordingly in children-e.g. milk, fruit juice (caution
with diabetes patient), oral rehydration solution (ORS) or
barley/rice water/coconut water
Note: Plain water alone may cause electrolyte imbalance
3. Take paracetamol (not more than 3 grams per day for adults ; 10-
15
mg/kg/dose, not more than 3 to 4 times in 24 hours in children)
4. Tepid sponging
Category A Dengue Treatment

51. These patients will be advised to avoid
Acetylsalicylic acid (aspirin), mefenemicacid ,
ibuprofen or other NSAIDs
Steroids
Antibiotics
If any warning sign develops , the patient
should be immediately taken to the nearest
hospital

52. Management of Patients in Group B
Oral fluid intake should be encouraged
Obtain a reference haematocrit before intravenous
fluid therapy begins
Indications for IV fluid:
inadequate oral fluid intake
vomiting
HCT continues to rise 10%–20% despite oral rehydration
impending shock/shock

53. General principles of Fluid therapy
Crystalloids
0.9% Nacl(isotonic normal saline solution) (0.9%NS) (Preferable)
0.45% half strength normal saline solution (0.45%NS) (For children)
5% dextrose in lactated Ringer's solution (5%DRL)
5% dextrose in acetated Ringer's solution (5%DRA)
Hartman solution (Preferable)
Colloids
Dextran 40
Hemaceel
Plasma
Blood & Blood Components
Human Albumin

54. Fluid Requirement:
The fluid requirement, both oral and intravenous, in critical phase (48 hours) is calculated as
M+5% (maintenance + 5% deficit)
5% deficit is calculated as 50 ml/kg up to 50kg
Normal maintenance fluid per hour can be calculated on the basis of the following formula* (equivalent to
Holliday-Segar formula):
4 ml/kg/hr for first 10 kg body weight
+ 2 ml/kg/hr for next 10 kg body weight
+ 1 ml/kg/hr for subsequent kg body weight
Calculations for normal maintenance of intravenous fluid Infusion:
For example, in a child weighing 20 kg,
The deficit of 5% is 50 ml/kg x 20 = 1000 ml. The maintenance is 1440 ml for one day. Hence, the
total of M + 5% is 2440 ml . This volume is to be administered over 48 hours in non shock patients.

56. If vital signs is stable, then the escalation of fluid is not needed
and the same rate can be maintained for a period of 48 hours
I/V fluid should be started at a rate of 1.5ml/kg/hror 40ml/hr(12
d/min) for adults and should be given for 6 hours
Fluid allowance (oral + IV) to be administered over 48 hours in
non shock patients

57. This fluid can be escalated to 5ml/kg/hr(adult
120ml/hror 30d/min) and then upto7ml/kg/hr
adult (200ml/hror 50d/min) in every 6 hours
until stable vital sign or urine output
If patient doesn’t have stable vital signs and
adequate urine output, the fluid should be
escalated to 3ml/kg/hr (adult 80ml/hr or 20
drops/min) foranother 6 hours

58. Monitor every 2 hours with special attention to vital signs, urine
output, respiratory signs and haematocritetc
if patient become stable in 6 hours , the fluids can
be gradually decline from 7 to 5 to 3 to 1.5 (ml/kg
/hr) or from stages where he was stable
But the fluids should be maintained always for at least 48
hours

60. Dengue with co-existing conditions but
without warning signs
Encourage oral fluids
If not tolerated, start I/V fluid therapy
Infuse minimum volume required to maintain good perfusion and
urine output
I/V fluids are usually needed only for 24−48 hours
Monitor temperature , fluid intake , urine, warning signs,
haematocrit, WBC and platelets etc
Depending on availability , other tests such as liver and renal
functions tests can also be carried out.

61. Management of Patients in Group C
Treatment of shock :
Most cases of DSS will respond to 10 ml/kg in children or
300–500 ml in adults over one hour or by bolus
Continued for minimum 24 hours and discontinued by 36
to 48 hours

62. ABCS
ABREVIATION LABORATORY INVESTIGATIONS NOTES
A.Acidosis
Blood gas
(Capacity or venous)
Indicate prolonged shock. Organ
involvement should also look for; Liver
function and BUN., Creatinine.
B. Bleeding
Hematocrit If dropped compared to the previous
value or not rising, cross match for rapid
blood transfusion.
C.Calcium
Electrolyte, Ca++ Hypocalcemia is found in almost all
cases of DHF but asymptomatic. Ca
supplement in more severe/ complicated
cases is indicated. The dosage is 1 ml/kg
dilute to 2 times IV push slowly,
maximum dose 10 ml of Ca gluconate.
S-Blood sugar
Serum sugar (Dextrostix) Most severe DHF cases have poor
appetite together with vomiting. Those
with impaired liver function may have
hypoglycemia. Some cases may have
hyperglycemia.
National guideline for clinical management of Dengue syndrome-2018,DGHS,GOB

63. Duration of Intravenous Fluid
1. Who do not have shock : not more than 60 to 72
hours
2. Shock patients : 24 to 48 hours
As the shock patients have experienced a longer duration of
plasma leakage before intravenous therapy is begun

66. ICU is needed preferably

67. Discharge Criteria:
No fever for at least 24 hours without the usage of antipyretic
drugs
At least two days have lapsed after recovery from shock
Good general condition with improving appetite
Normal HcT at baseline value or around 38 -40 % when baseline
value is not known
No distress from pleural effusions
No ascites
Platelet count has risen above 50,000 /mm3
No other complications

68. Management of
Fluid Overload

69. Indications for using Colloid [(10% Dextran-40
in NSS)/Plasmasol/Human albumin]
Signs of fluid overload
Dyspnea, tachypnea, puffy eyelids, tense/distended
abdomen
Positive lung signs: crepitation, rhonchi, wheezing
Persistent high Hct, 25 -30% hemoconcentration for >
4-8 hours

70. Furosemide should be administered during
dextran infusion
Furosemide depletes intravascular volume , not
ascites or pleural effusion
Colloid(Dextran/Plasmasol) holds intravascular
volume and draws back ascites and pleural
effusion

71. Situations
Some common situations are as follows:
Pregnancy and labor
Elderly patient
Infant patient
Mandatory Surgery
Chronic Liver Disease
Chronic Kidney Disease
Cardiac diseases: Heart Failure, Ischemic Heart Disease, HTN
Diabetes Mellitus
Patient on steroid therapy
Female patients on Menstrual period
Anti-coagulant therapy
Haemolytic diseases and haemoglobinopathies

72. In dengue shock syndrome have you
used corticosteroids before?
DHF pathogenesis is hypothesized to be immunologic that is
tempting for immunomodulatory drugs most common of which is
steroid
No significant effect on severe dengue manifestations (shock or
severe bleeding)
No significant effect on thrombocytopenia or bleeding
No significant effect on ICU or hospital admission
No significant effect on platelet count recovery
No significant effect on haematocrit change

73. Indication for platelet concentrate
Very limited role of platelet transfusion
Most of the situations, fresh whole blood transfusion is
sufficient
The indication of platelet concentrate as follows:
1. Very severe Thrombocytopaniawho need urgent surgery
2. Clinical judgement of the treating physcian
If platelet concentrate is not available fresh whole blood may
be transfused

75. PEARLs (Personal Experience &
Resource Listing)

76. Leucopenia indicates that within the next 24 there will be no
fever and pt will be entering the critical phase
Hemorrhage in febrile phase signifies DF with unusual
hemorrhage
Hemorrhage without fever should be assessed for DHF
Sudden deterioration of hemodynamic status or hypotension
or refractory to fluid therapy indicates the possibility of
concealed blood loss
Best simple indicator of critical phase is platelet
<100000/cu.mm

77. HcT measurement every hour is more important than platelet
count
No evidence supporting transfusing platelet concentrates
and/or fresh-frozen plasma for severe bleeding
Transfusions of platelet concentrates and fresh frozen
plasma do not sustain the platelet counts and coagulation
profile
Instead, they often exacerbate the fluid overload
If Hct level can not be done , apprx. HCT level = Hb*3

78. Take Home Message

80. •Dengue tetravalent vaccine (live, attenuated yellow virus)
•3 doses, 6 months apart
•79% fewer cases of dengue in children vaccinated compared with
placebo
•Risk of severe dengue in vaccinated people who did not have previous
dengue infection, if they later became infected with the virus
Only for use in people
from 9 to 45 years of
age who have been
infected with dengue
virus before and who
live in endemic areas
protects against
serotypes 1, 2, 3 and 4

81. Future Mosquito Prevention
Transgenic
symbiotic
bacteria
introduction

82. Acknowledgement
Professor Dr. Khairul Hassan Jessy
Asst. Prof. Dr Jalal Mohsin Ahmed
Dr Jewel Sarkar Rayhan
Dr Anonnya Rahman
Dr Naeem Hassan
Dr Leema Saha

83. Questions !!!!
Questions
!!!
NIDCH, Front of Ward 1-2

84. Thank You All

85. Thank You All
Prevention
is better
than
cure