Pathophysiology of Dengue Hemorrhagic

Fever
By Jessica Pestka, eHow Contributor
updated: May 25, 2010

Signs of dengue fever

Dengue fever, a contagious disease transmitted by the Aedes aegypti mosquito, infects between
50 million and 100 million people worldwide each year. Also known as breakbone or dandy
fever, dengue fever is found in the tropical and subtropical regions of the world. Exposure to the
flavivirus that causes dengue fever results in one of three pathophysiologies: dengue fever, the
more severe dengue hemorrhagic fever (DHF) or dengue shock syndrome.

Transmission of Dengue Fever

1. Dengue fever is transmitted only through an infected mosquito or by contact with the
blood of someone who is actively infected with one of the four viruses responsible for the
fever. Infection with one of these viruses generally provides immunity from dengue fever
for as much as a year after the illness. A small minority of cases of dengue fever develop
into severe forms of the fever, DHF or dengue shock syndrome, which require
hospitalization.

Symptoms of Dengue Fever

2. Early symptoms of dengue fever include headache, chills, backache, fever, nausea and
joint pain. The initial fever may be as high as 104 degrees Fahrenheit at the onset of the
illness and individuals may develop severe pain in the legs and behind the eyes. A rash
consisting of patchy bright red spots may develop over the body after the first few days of
illness.

Time Frame:Dengue Infection

 3. After five to eight days of incubation, individuals infected with dengue fever develop
symptoms abruptly. The initial symptoms of dengue fever last about six to seven days.
The fever climbs rapidly in the first 48 to 96 hours of the illness and then may break for a
day before elevating rapidly again. This second phase of the fever is often when a rash
may appear on the limbs or chest.

Diagnosis of Dengue Fever

4. A diagnosis of dengue fever is typically not considered unless the individual has been in
a tropical location where the virus is present such as Central America, South America,
Africa or Asia. Clinically, individuals with dengue fever may develop a low white blood
cell count by the second day of illness. This low white blood cell count, coupled with the
"dengue triad" of fever, rash and headache, represent the most common diagnostic
criteria for dengue fever.

Prevention of Dengue Fever

5. Dengue fever can only be prevented by avoiding travel to those tropical locations where
the illness is present. If travel to tropical regions cannot be avoided, travelers should use
barrier and chemical methods to prevent mosquito bites. Once contracted, treatment of
dengue fever generally includes rest and fever/pain management. Total recovery from
dengue fever may take several weeks.

Dengue Fever: Tropical and Subtropical Climates

6. Dengue fever is not present in the United States, although the Centers for Disease Control
reports that 100 to 200 cases of dengue fever are brought into the United States each year.
Dengue fever is considered endemic in tropical and subtropical areas and outbreaks have
occurred in the Virgin Islands, the Caribbean and Puerto Rico.

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Dengue(Breakbone Fever; Dandy Fever)

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Dengue is a mosquito-borne disease caused by a flavivirus. Dengue fever usually

results in abrupt onset of high fever, headache, myalgias, arthralgias, and
lymphadenopathy, followed by a rash that appears with a 2nd temperature rise
after an afebrile period. Respiratory symptoms, such as cough, sore throat, and
rhinorrhea, can occur. Dengue can also cause potentially fatal hemorrhagic fever
with bleeding tendency and shock. Diagnosis involves serologic testing and
PCR. Treatment is symptomatic and, for dengue hemorrhagic fever, includes
meticulously adjusted intravascular volume replacement.

Dengue is endemic to the tropical regions of the world in latitudes from about
35° north to 35° south. Outbreaks are most prevalent in Southeast Asia but also
occur in the Caribbean, including Puerto Rico and the US Virgin Islands,
Oceania, and the Indian subcontinent; more recently, dengue incidence has
increased in Central and South America. Each year, only about 100 to 200 cases
are imported to the US by returning tourists, but an estimated 50 to 100 million
cases occur worldwide, with about 20,000 deaths.

The causative agent, a flavivirus with 4 serogroups, is transmitted by the bite of

Aedes mosquitoes. The virus circulates in the blood of infected humans for 2 to 7
days; Aedes mosquitoes may acquire the virus when they feed on humans during
this period.

Symptoms and Signs

After an incubation period of 3 to 15 days, fever, chills, headache, retro-orbital

pain with eye movement, lumbar backache, and severe prostration begin
abruptly. Extreme aching in the legs and joints occurs during the first hours,
accounting for the traditional name of breakbone fever. The temperature rises
rapidly to up to 40° C, with relative bradycardia. Bulbar and palpebral
conjunctival injection and a transient flushing or pale pink macular rash
(particularly of the face) may occur. Cervical, epitrochlear, and inguinal lymph
nodes are often enlarged.

Fever and other symptoms persist 48 to 96 h, followed by rapid defervescence

with profuse sweating. Patients then feel well for about 24 h, after which fever
may occur again (saddleback pattern), typically with a lower peak temperature
than the first. Simultaneously, a blanching maculopapular rash spreads from the
trunk to the extremities and face.

Mild cases of dengue, usually lacking lymphadenopathy, remit in < 72 h. In more

severe disease, asthenia may last several weeks. Death is rare. Immunity to the
infecting strain is long-lasting, whereas broader immunity to other strains lasts
only 2 to 12 mo.

Diagnosis

• Acute and convalescent serologic testing

Dengue fever is suspected in patients in endemic areas if they develop sudden

fever, headache, myalgias, and adenopathy, particularly with the characteristic
rash or recurrent fever. Evaluation should rule out alternative diagnoses,
especially malaria and leptospirosis. Diagnostic studies include serologic testing,
antigen detection, and PCR of blood. Serologic testing involves
hemagglutination inhibiting or complement fixation tests using paired sera, but
cross-reactions with other flavivirus antibodies are possible. Antigen detection is
available in some parts of the world (not in the US), and PCR is usually done
only in laboratories with special expertise. Although rarely done and difficult,
cultures can be done using mosquitoes or specialized cell lines in specialized
laboratories.

CBC may show leukopenia by the 2nd day of fever; by the 4th or 5th day, the
WBC count may be 2000 to 4000/μL with only 20 to 40% granulocytes.
Urinalysis may show moderate albuminuria and a few casts.

Treatment

• Supportive care

Treatment is symptomatic. Acetaminophen Some Trade Names

GENAPAP
TYLENOL
VALORIN
Click for Drug Monograph
can be used, but NSAIDs, including aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
, should be avoided because bleeding is a risk. Aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
increases the risk of Reye's syndrome in children and should also be avoided for
that reason.

Prevention

People in endemic areas should try to prevent mosquito bites. To prevent further
transmission by mosquitoes, patients with dengue should be kept under mosquito
netting until the 2nd bout of fever has resolved. Vaccines are being evaluated.

Dengue Hemorrhagic Fever

(Philippine, Thai, or Southeast Asian Hemorrhagic Fever; Dengue Shock

Syndrome)

Dengue hemorrhagic fever (DHF) is a variant presentation that occurs primarily

in children < 10 yr living in areas where dengue is endemic. DHF requires prior
infection with the dengue virus. It is an immunopathologic disease; dengue
virus–antibody immune complexes trigger release of vasoactive mediators by
macrophages. The mediators increase vascular permeability, causing vascular
leakage, hemorrhagic manifestations, hemoconcentration, and serous effusions,
which lead to circulatory collapse (ie, dengue shock syndrome).

Symptoms and Signs

In adults, DHF begins with abrupt fever and headache and is initially
indistinguishable from classic dengue. Shock and increasing illness may develop
rapidly 2 to 6 days after onset. Bleeding tendencies occur, usually as purpura,
petechiae, or ecchymoses at injection sites; sometimes as hematemesis, melena,
or epistaxis; and occasionally as subarachnoid hemorrhage. Hepatomegaly is
common, as is bronchopneumonia with or without bilateral pleural effusions.
Myocarditis can occur. Mortality is usually < 1% in experienced centers but
otherwise can range to 30%.
 Diagnosis

• Clinical and laboratory criteria

DHF is suspected in children with World Health Organization (WHO)–defined

clinical criteria for the diagnosis: sudden fever that stays high for 2 to 7 days,
hemorrhagic manifestations, and hepatomegaly. Hemorrhagic manifestations
include at least a positive tourniquet test and petechiae, purpura, ecchymoses,
bleeding gums, hematemesis, or melena. The tourniquet test is done by inflating
a BP cuff to midway between the systolic and diastolic BP for 15 min. The
number of petechiae that form within a 2.5-cm diameter circle are counted; > 20
petechiae suggests capillary fragility.

CBC, coagulation tests, urinalysis, liver function tests, and dengue serologic tests
should be done. Thrombocytopenia (≤ l00,000 platelets/μL) and a prolonged PT
characterize the coagulation abnormalities. There may be mild proteinuria and
increases in AST levels. Complement fixation antibody titers against flaviviruses
are usually high.

Patients with WHO-defined clinical criteria plus thrombocytopenia (≤

100,000/μL) or hemoconcentration (Hct increased by ≥ 20%) are presumed to
have the disease.

Treatment

• Supportive care

Patients require intensive treatment to maintain euvolemia. Both hypovolemia

(which can cause shock) and overhydration (which can cause acute respiratory
distress syndrome) should be avoided. Urine output and the degree of
hemoconcentration can be used to monitor intravascular volume.

No antivirals have been shown to improve outcome.

http://www.merck.com/mmpe/sec14/ch191/ch191b.html
Alternative Names
-Hemorrhagic dengue; Dengue shock syndrome; Philippine hemorrhagic fever; Thai
hemorrhagic fever; Singapore hemorrhagic fever

Definition
-Dengue hemorrhagic fever is a severe, potentially deadly infection spread by
certain mosquitoes (Aedes aegypti ).

Causes
-Four different dengue viruses have been shown to cause dengue hemorrhagic
fever. This condition occurs when a person catches a different dengue virus after
being infected by another type sometime before. Prior immunity to a different
dengue virus type plays an important role in this severe disease.

Worldwide, more than 100 million cases of dengue fever occur every year. A small
number of these develop into dengue hemorrhagic fever. Most infections in the
United States are brought in from other countries. It is possible for a traveler who
has returned to the United States to pass the infection to someone who has not
traveled.

Risk factors for dengue hemorrhagic fever include having antibodies to dengue
virus from prior infection and being younger than 12, female, or Caucasian.

Symptoms
-Early symptoms of dengue hemorrhagic fever are similar to those of dengue fever,
but after several days the patient becomes irritable, restless, and sweaty. These
symptoms are followed by a shock-like state.

Bleeding may appear as pinpoint spots of blood on the skin (petechiae) and larger
patches of blood under the skin (ecchymoses). Bleeding may occur from minor
injuries.

Shock may cause death. If the patient survives, recovery begins after a one-day
crisis period.

Early symptoms include the following:

Fever
Headache
Muscle aches
Joint aches
Malaise
Decreased appetite
Vomiting

Acute phase symptoms include the following:

Shock-like state
-Sweaty (diaphoretic)
-Cold, clammy extremities
Restlessness followed by:
-Worsening of earlier symptoms
-Petechiae
-Ecchymosis
-Generalized rash

Exams and Tests

Physical examination may reveal the following:

-Low blood pressure

-A weak, rapid pulse
-Rash
-Red eyes
-Red throat
-Swollen glands
-Enlarged liver (hepatomegaly)

Tests may include the following:

-Hematocrit
-Platelet count
-Electrolytes
-Coagulation studies
-Liver enzymes
-Blood gases
-Tourniquet test (causes petechiae below the tourniquet)
-X-ray of the chest (may demonstrate pleural effusion)
-Serologic studies (demonstrate antibodies to Dengue viruses)
-Serum studies from samples taken during acute illness and convalescence
(increase in titer to Dengue antigen)

Treatment

Because Dengue hemorrhagic fever is caused by a virus for which there is no known
cure or vaccine, the only treatment is to treat the symptoms.

-Rehydration with intravenous (IV) fluids is often necessary to treat dehydration.

-IV fluids and electrolytes are also used to correct electrolyte imbalances.
-A transfusion of fresh blood or platelets can correct bleeding problems.
-Oxygen therapy may be needed to treat abnormally low blood oxygen.

Outlook (Prognosis)
-With early and aggressive care, most patients recover from dengue hemorrhagic
fever. However, half of untreated patients who go into shock do not survive

Possible Complications

-Shock
-Encephalopathy
-Residual brain damage
-Seizures
-Liver damage

When to Contact a Medical Professional

-Call your health care provider if you have symptoms of dengue fever and have
been in an area where dengue fever is known to occur.

Prevention
-There is no vaccine available to prevent dengue fever. Use personal protection
such as full-coverage clothing, netting, mosquito repellent containing DEET, and if
possible, travel during periods of minimal mosquito activity. Mosquito abatement
programs can also reduce the risk of infection.

http://answers.yahoo.com/question/index?qid=20071119040532AA480vc
OBJECTIVES

General

This case presentation aims to

identify and determine the general
heath problems and needs of the
patient with an admitting diagnosis of
Dengue Hemorrhagic Fever, Type 1.
This presentation also intends to help
patient promote health and medical
understanding of such condition
through the application of the nursing
skills.

Specific

• To raise the level of

awareness of patient on
health problems that she may encounter.
• To facilitate patient in taking necessary actions to solve and prevent the identified problems on
her own.
• To help patient in motivating her to continue the health care provided by the health workers.
• To render nursing care and information to patient through the application of the nursing skills.

Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related dengue
viruses. This disease used to be called “break-bone” fever because it sometimes causes severe joint and
muscle pain that feels like bones are breaking, hence the name. Health experts have known about dengue
fever for more than 200 years.

INTRODUCTION

Dengue fever is found mostly during and shortly after the rainy season in tropical and subtropical areas of

• Africa
• Southeast Asia and China
• India
• Middle East
• Caribbean and Central and South America
• Australia and the South and Central Pacific

An epidemic in Hawaii in 2001 is a reminder that many states in the United States are susceptible to
dengue epidemics because they harbor the particular types of mosquitoes that transmit it. Worldwide,
more than 100 million cases of dengue infection occur each year. This includes 100 to 200 cases reported
annually to the Centers for Disease Control and Prevention (CDC), mostly in people who have recently
traveled abroad. Many more cases likely go unreported because some health care providers do not
recognize the disease. During the last part of the 20th century, many tropical regions of the world saw an
increase in dengue cases. Epidemics also occurred more frequently and with more severity. In addition to
typical dengue, dengue hemorrhagic fever and dengue shock syndrome also have increased in many parts
of the world.
Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-
4. You can be infected by at least two, if not all four types at different times during your lifetime, but only
once by the same type.

You can get dengue virus infections from the bite of an infected Aedes mosquito. Mosquitoes become
infected when they bite infected humans, and later transmit infection to other people they bite. Two main
species ofmosquito , Aedes aegypti and Aedes albopictus, have been responsible for all cases of dengue
transmitted in this country. Dengue is not contagious from person to person.

Symptoms of typical uncomplicated (classic) dengue usually start with fever within 5 to 6 days after you
have been bitten by an infected mosquito and include

• High fever, up to 105 degrees Fahrenheit

• Severe headache
• Retro-orbital (behind the eye) pain
• Severe joint and muscle pain
• Nausea and vomiting
• Rash

The rash may appear over most of your body 3 to 4 days after the fever begins. You may get a second
rash later in the disease. Symptoms of dengue hemorrhagic fever include all of the symptoms of classic
dengue plus

• Marked damage to blood and lymph vessels

• Bleeding from the nose, gums, or under the skin, causing purplish bruises

This form of dengue disease can cause death.

Symptoms of dengue shock syndrome-the most severe form of dengue disease-include all of the
symptoms of classic dengue and dengue hemorrhagic fever, plus

• Fluids leaking outside of blood vessels

• Massive bleeding
• Shock (very low blood pressure)

This form of the disease usually occurs in children (sometimes adults) experiencing their second dengue
infection. It is sometimes fatal, especially in children and young adults.

http://nursingcrib.com/case-study/dengue-fever-case-study/