Dengue Fever/Dengue Fever SyndromeIs a tropical disease caused by different strains of dengue virus which are transmitted by Aedes

Aegypti mosquitos. It is an acute infectious disease characterized by severe pain behind the eye and the joints and bones and accompanied by rash. No bleeding occurs. Dengue Shock SyndromeMedical emergency due to loss of plasma and requires immediate administration of IVF to expand plasma volume. Dengue Hemorrhagic FeverThose cases with gross hemorrhages. A severe illness characterized by abnormal vascular permeability, hypovolemia and abnormal blood clotting mechanism Causative Agent 4 5 serotype of the dengue virus (1,2,3 and 4 Group B Arbovirus) the 4 viruses are antigenically close to each other however, they only give partial cross protection after being infected by any of them

Aedes Aegypti Bite of the Female Aedes Aegypti (day biting, low flying, breeds in stagnant water, in urban areas). Why female? It is because that they use the blood obtained for laying of eggs. It is the primary vector for the transmission of dengue.

Sources:

1.

Infected Persons virus is present in the blood of patients during the acute phase of the disease and will become a reservoir of the virus

2.

Standing water will serve as a breeding place for the mosquitoes

Mode of transmissionBy the bit of an infective Aedes Aegypti mosquito

Incubation Period4-6 days (minimum: 3 days; maximum: 10days) Pathophysiology

    
1.

Each of the 4 types of Dengue virus can cause either classical or dengue hemorrhagic fever. Virus enters the blood stream Neutralizing antibodies are produced principally against the virus type Because of the production of antibodies, and the response of the immune system to the initial attack, constitutional signs and symptoms are manifested Because of the increasing antigen-antibody complex Increased capillary fragility brought about by a strong immune complex reaction the produce toxic substance like histamine, serotonin and bradykinin which damages the capillary wall in an attempt to repair lesions, clotting occurs DISSEMINATED INTRAVASCULAR COAGULATION

2. 3. 4.

Increased capillary permeability loss of plasma from intravascular space Thrombocytopenia acute excessive consumption of platelets due to generalized intravascular clotting Decreased blood coagulation factors initiated by lesions in the capillary wall

Diagnosis

1.

Clinical 1. 2. Fever acute in onset, high and continuous, lasting for 7-10 days Tourniquet test (Rumpel-Leede test)

test to determine capillary fragility

1. 1.

Presence of bleeding (petechiae, purpura, ecchymosis, epistaxis, gum bleeding, hematemesis, melena)

Laboratory 1. 2. thrombocytopenia 100,000/ mm3 or less Hemoconcentration

   
1. 1. 2. a increase of at least 20% in the hct steady rise in hematocrit

Confirmatory test Serologic test simplest and most rapid method of confirming clinical diagnosis of dengue infection Isolation of the virus most reliable although this is complicated and requires time.

For Dengue Fever Syndrome

a. Oral fluid and electrolyte replacement

- encouraged to prevent and correct dehydration which results from fever

b. For fever

antipyretics like Acetaminophen but not aspirin

c. Hematocrit Determination

 

useful guide in therapy as this reflects the degree of plasma leakage and the need for IV fluid test is recommended daily until the 3 until patient is afebrile for 1-2 days.
rd

d. Close surveillance continuous monitoring of BP/Hct/Platelet For Dengue Shock Syndrome

1. 2. 3.

IVF (5% Dextrose in 0.3 NaCl is initially given) Plasma volume expanders During fluid reabsorption phase (decreasing Hct) - slow down rate of administration of IVF - if fluid overload occurs, give Furosemide 1 mg/kg IV stat doses

 

MEDICAL & SURGICAL MANAGEMENT Dengue fever can be diagnosed by doing two blood tests, 2 to 3 weeks apart. The tests can show whether a sample of your blood contains antibodies to the virus. In epidemics, a health care provider often can diagnose dengue by typical signs and symptoms. There is no specific treatment for classic dengue fever, and like most people you will recover completely within 2 weeks. To help with recovery, health care experts recommend Getting plenty of bed rest Drinking lots of fluids Taking medicine to reduce fever

  

Often health care provider advises people with dengue fever not to take aspirin. Acetaminophen or other over-the-counter painreducing medicines are safe for most people. For severe dengue symptoms, including shock and coma, early and aggressive emergency treatment with fluid and electrolyte replacement can be lifesaving. The best way to prevent dengue fever is to take special precautions to avoid contact with mosquitoes. Several dengue vaccines are being developed, but none is likely to be licensed by the Food and Drug Administration in the next few years. When outdoors in an area where dengue fever has been found Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus Dress in protective clothing-long-sleeved shirts, long pants, socks, and shoes

 

Because Aedes mosquitoes usually bite during the day, be sure to use precautions especially during early morning hours before daybreak and in the late afternoon before dark. Other precautions include Keeping unscreened windows and doors closed Keeping window and door screens repaired Getting rid of areas where mosquitoes breed, such as standing water in flower pots, containers, birdbaths, discarded tires, etc.

  

Most people who develop dengue fever recover completely within 2 weeks. Some, however, may go through several weeks to months of feeling tired and/or depressed. Scientists supported by the National Institute of Allergy and Infectious Diseases (NIAID) are trying various approaches to develop vaccines against dengue. Researchers in NIAID laboratories in Bethesda, Maryland, are using weakened and harmless versions of dengue viruses as potential vaccine candidates against dengue and related viruses. Other NIAID-funded investigators are trying to develop dengue virus vaccines using recombinant proteins (with or without adjuvants), viral vectors, and DNA. Several projects are currently ongoing to identify the host and viral factors that determine the virulence and transmissibility of different dengue virus strains. Other researchers supported by NIAID are investigating ways to treat infected individuals and to prevent dengue viruses from reproducing inside mosquitoes. Although dengue virus has emerged as a growing global threat, scientists know little about how the virus infects cells and causes disease. New research is beginning to shed light on how the virus interacts with humans-how it damages cells and how the human immune system responds to dengue virus invasion.

Dengue fever (UK: / d

e /, US: /

/), also known as breakbone fever, is an infectious tropical disease caused by

the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles. In a small proportion of cases the disease develops into the life-threatening dengue hemorrhagic fever, resulting in bleeding, low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs. Dengue is transmitted by several species of mosquito within the genus Aedes, principally A. aegypti. The virus has four different types; infection with one type usually gives lifelong immunity to that type, but only short-term immunity to the others. Subsequent infection with a different type increases the risk of severe complications. As there is no vaccine, prevention is sought by reducing the habitat and the number of mosquitoes and limiting exposure to bites. Treatment of acute dengue is supportive, using either oral or intravenous rehydration for mild or moderate disease, and intravenous fluids andblood transfusion for more severe cases. The incidence of dengue fever has increased dramatically since the 1960s, with around 50100 million people infected yearly. Early descriptions of the condition date from 1779, and its viral cause and the transmission were elucidated in the early 20th century. Dengue has become a global problem since the Second World War and is endemic in more than 110 countries. Apart from eliminating the mosquitoes, work is ongoing on a vaccine, as well as medication targeted directly at the virus.

Signs and symptoms Typically, people infected with dengue virus are asymptomatic (80%) or only have mild symptoms such as an uncomplicated fever.[1][2][3] Others have more severe illness (5%), and in a small proportion it is life-threatening.[1][3] The incubation period (time between exposure and onset of symptoms) ranges from 314 days, but most often it is 47 days.[4] Therefore, travelers returning from endemic areas are unlikely to have dengue if fever or other symptoms start more than 14 days after arriving home.[5]Children often experience symptoms similar to those of the common cold and gastroenteritis (vomiting and diarrhea),[6] but are more susceptible to the severe complications.[5] [edit]Clinical course The characteristic symptoms of dengue are sudden-onset fever, headache (typically located behind the eyes), muscle and joint pains, and a rash. The alternative name for dengue, "break-bone fever", comes from the associated muscle and joint pains.[1][7]The course of infection is divided into three phases: febrile, critical, and recovery.[8] The febrile phase involves high fever, often over 40 C (104 F), and is associated with generalized pain and a headache; this usually lasts two to seven days.[7][8] At this stage, a rash occurs in approximately 5080% of those with symptoms.[7][9] It occurs in the first or second day of symptoms as flushed skin, or later in the course of illness (days 47), as a measles-likerash.[9][10] Some petechiae (small red spots that do not disappear when the skin is pressed, which are caused by brokencapillaries) can appear at this point,[8] as may some mild bleeding from the mucous membranes of the mouth and nose.[5][7] The fever itself is classically biphasic in nature, breaking and then returning for one or two days, although there is wide variation in how often this pattern actually happens.[10][11] In some people, the disease proceeds to a critical phase, which follows the resolution of the high fever and typically lasts one to two days.[8] During this phase there may be significant fluid accumulation in the chest and abdominal cavity due to increased capillary permeability and leakage. This leads to depletion of fluid from the circulation and decreased blood supply to vital organs.[8] During this phase, organ dysfunction and severe bleeding, typically from the gastrointestinal tract, may occur.[5][8] Shock (dengue shock syndrome) and hemorrhage (dengue hemorrhagic fever) occur in less than 5% of all cases of dengue,[5] however those who have previously been infected with other serotypes of dengue virus ("secondary infection") are at an increased risk.[5][12] The recovery phase occurs next, with resorption of the leaked fluid into the bloodstream.[8] This usually lasts two to three days.[5] The improvement is often striking, but there may be severe itching and a slow heart rate.[5][8] During this stage, a fluid overload state may occur; if it affects the brain, it may cause a reduced level of consciousness or seizures.[5] [edit]Associated problems Dengue can occasionally affect several other body systems,[8] either in isolation or along with the classic dengue symptoms.[6] A decreased level of consciousness occurs in 0.56% of severe cases, which is attributable either to infection of the brain by the virus or indirectly as a result of impairment of vital organs, for example, the liver.[6][11] Other neurological disorders have been reported in the context of dengue, such as transverse myelitis and Guillain-Barr syndrome.[6] Infection of the heart and acute liver failure are among the rarer complications.[5][8] [edit] Transmission

Dengue virus is primarily transmitted by Aedes mosquitoes, particularly A. aegypti. These mosquitoes usually live between the latitudes of 35 North and 35 South below an elevation of 1,000 metres (3,300 ft). They bite primarily during the day.
[14] [2] [2]

[2]

Other Aedes species that transmit the disease include A. albopictus, A. polynesiensis and A. scutellaris. Humans are the
[2][11]

primary host of the virus,

but it also circulates in nonhuman primates.

[15]

An infection can be acquired via a single bite.

[16]

female mosquito that takes a blood meal from a person infected with dengue fever becomes itself infected with the virus in the cells lining its gut. About 810 days later, the virus spreads to other tissues including the mosquito's salivary glands and is subsequently released into its saliva. The virus seems to have no detrimental effect on the mosquito, which remains infected for life. Aedes aegypti prefers to lay its eggs in artificial water containers, to live in close proximity to humans, and to feed off people rather than other vertebrates.
[17]

Dengue can also be transmitted via infected blood products and through organ donation.
[21]

[18][19]

In countries such as Singapore,

[20]

where dengue is endemic, the risk is estimated to be between 1.6 and 6 per 10,000 transfusions. mother to child) during pregnancy or at birth has been reported. reported, but are very unusual. Laboratory tests Dengue fever may be diagnosed by microbiological laboratory testing.
[23] [7]

Vertical transmission (from

Other person-to-person modes of transmission have also been

This can be done by virus isolation in cell cultures, nucleic

[13][25]

acid detection by PCR, viral antigen detection or specific antibodies (serology).

[5][13]

Virus isolation and nucleic acid detection are

[25]

more accurate than antigen detection, but these tests are not widely available due to their greater cost. in the early stages of the disease.

All tests may be negative

These laboratory tests are only of diagnostic value during the acute phase of the illness with the exception of serology. Tests for dengue virus-specific antibodies, types IgG and IgM, can be useful in confirming a diagnosis in the later stages of the infection. Both IgG and IgM are produced after 57 days. The highest levels (titres) of IgM are detected following a primary infection, but IgM is also produced in secondary and tertiary infections. The IgM becomes undetectable 3090 days after a primary infection, but earlier following re-infections. IgG, by contrast, remains detectable for over 60 years and, in the absence of symptoms, is a useful indicator of past infection. After a primary infection the IgG reaches peak levels in the blood after 1421 days. In subsequent re-infections, levels peak earlier and the titres are usually higher. Both IgG and IgM provide protective immunity to the infecting serotype of the virus. In the laboratory test the IgG and the IgM antibodies can cross-react with other flaviviruses, such as yellow fever virus, which can make the interpretation of the serology difficult.
[7][13][26]

The detection of IgG alone is not considered diagnostic unless blood

samples are collected 14 days apart and a greater than fourfold increase in levels of specific IgG is detected. In a person with symptoms, the detection of IgM is considered diagnostic. Management There are no specific treatments for dengue fever. Treatment depends on the symptoms, varying from oral rehydration therapy at home with close follow-up, to hospital admission with administration of intravenous fluids and/or blood transfusion.
[5] [28] [1] [26]

A decision for

hospital admission is typically based on the presence of the "warning signs" listed in the table above, especially in those with preexisting health conditions.

Intravenous hydration is usually only needed for one or two days.

[28] [5]

The rate of fluid administration is titrated to a urinary output of

[5]

0.51 mL/kg/hr, stable vital signs and normalization ofhematocrit. Invasive medical procedures such as nasogastric intubation, intramuscular injections and arterial punctures are avoided, in view of the bleeding risk. Paracetamol(acetaminophen) is used for fever and discomfort while NSAIDs such as ibuprofen and aspirin are avoided as they might aggravate the risk of bleeding.
[28]

Blood transfusion is initiated early in patients presenting with unstable vital signs in the face of a decreasing hematocrit,

rather than waiting for the hemoglobin concentration to decrease to some predetermined "transfusion trigger" level. blood cells or whole blood are recommended, while platelets and fresh frozen plasma are usually not.
[5] [29]

[29]

Packed red

During the recovery phase intravenous fluids are discontinued to prevent a state of fluid overload. If fluid overload occurs and vital signs are stable, stopping further fluid may be all that is needed.
[29]

If a person is outside of the critical phase, a loop diuretic such

[29]

as furosemide may be used to eliminate excess fluid from the circulation.