Management of Dengue Fever

Dr David Tran 16/09/09

Classic clinical dengue fever

Incubation period 3 to 14 days Retro-orbital pain, fatigue

(usually 4 to 7 days)

Sudden onset of fever with severe headache

Often associated with myalgia and arthralgia

Duration of fever usually 5 to 7 days Sometime maculopapular rash
(50% to 66% of cases)

Other non specific signs as inflamed pharynx, gastro-intestinal symptoms

Classic definition of dengue fever

(WHO 1997)

Hemorrhagic manifestations / biologic abnormalities

Petechiae, purpura
Gum bleeding, epistaxis, menorrhagia, gastrointestinal bleedings (rare) Thrombocytopenia, leukopenia with lymphopenia Mild elevation of hepatic transaminases & LDH

Definition of dengue hemorrhagic fever (WHO 1997)

Dengue hemorrhagic fever & Dengue shock syndrome

Physiopathology: capillary leakage & hemorrhagic manifestations. 4 to 7 days after the onset (at approximately the
date of defervescence)

Abdominal pain, vomiting, consciousness troubles, hypothermia Marked decrease in platelet count. Mortality: up to 10 or 20%

Definition of dengue shock syndrome (WHO 1997)

Diagnosis of dengue hemorrhagic fever (triad of symptoms)

Hemorrhagic manifestations Platelet count < 100.000

(often >3rd day of illness)

Evidence of plasma leakage (Hematocrite

pleural effusion, ascites, hypoproteinemia)

Lowest platelet count by day of illness in adult dengue hemorrhagic patients

160 140 120 100 80 60 40 20 0
1st day 2nd day 3rd day 4th day 5th day 6th day 7th day 8th day

Dengue shock syndrome

Rapid weak pulse & low blood pressure (BP < 90mmHg)

The duration of this shock is short after

appropriate volume replacement therapy

(Colloid or Cristalloid infusions)

Mortality rate is up to 40%

Different clinical presentation of dengue fever

Serodiagnosis of dengue fever

Serology (IgM capture ELISA) Problem: negativity of the test early in the course of the disease > should be performed only 4 to 5 days after the onset of fever. IgM: remain positive for 3 to 6 month IgG: remain positive for life

Dengue NS1 antigen testing

Early detection of Ag NS1 in blood sample of

infected patients > confirm early acute infection

Detection of all 4 types of dengue serotypes Result available in 15 min. (BioRad chromatographic
strip test)

High specificity (100%) and positive predictive value

Although in some reports, the same efficiency of detection for virus of the 4 serotypes has been described for the Dengue Early ELISA and Strip tests (Dussart et al., 2008), A recent analysis of the performance of these tests in Vietnam suggests a lower sensitivity for DENV-2 compared with DENV-1 and DENV-3.

Problem of sensibility of NS1 detection tests

(Ramirez, diagnostic microbiology & infectious disease, Sept 2009)

These tests in Vietnam suggests a lower sensitivity for DENV-2 compared with DENV-1 and DENV-3. Also, a decreased sensitivity for DENV-4 with the Dengue Early ELISA has been reported in studies from South America (Bessoff et al., 2008; Dussart et al., 2008). A lower sensitivity for DENV-2 has been described in samples from Vietnam (Hang et al., 2009) tested by the PLATELIA systems (ELISA and Strip) and belonging to the Asian genotype 1 (according to the classification of Twiddy et al., 2002).

Sensitivity of NS1 Ag detection tests according to the day of illness

(Mc Bride, Diagnostic Microbiology & Infectious Diseases, 64 2009 31,36)

Management of dengue virus infected patient

Most of cases can be managed on an outpatient basis

(antipyretic like paracetamol, bed rest, oral hydratation)

Platelet counts and hematocrite determination should

be repeated at least every 24 hours

Patient with platelet count < 100.000 should be hospitalized

syndrome) (high risk for dengue hemorrhagic & dengue shock