Dr. jose n.

Rodriguez memorial hospital and sanitarium

Department of pediatrics

“dengue”
GROUP 5
AMER, ANGELES, BAGSARSA, MARCABAN
 DEFINITION OF TERMS
➢ Dengue fever is a benign syndrome caused by
several arthropod-borne viruses

➢ Dengue hemorrhagic fever is a severe, often

fatal, febrile disease caused by one of four
dengue viruses
➢ Dengue Shock Syndrome is a protein-losing shock
syndrome, which is thought to have an immunopathologic
basis

➢ Severe Dengue - cases accompanied by fluid loss

leading to shock, fluid loss with respiratory
distress, liver damage evidenced by elevations of ALT
or AST to > 1000 U/L, severe bleeding, and altered
consciousness or significant heart abnormalities
 ETIOLOGY
➢ Four distinct antigenic types of dengue virus (dengue 1,
2, 3, and 4), members of the family Flaviviridae
EPIDEMIOLOGY
Dengue viruses are transmitted by mosquitoes of the
Stegomyia family. Aedes aegypti, a daytime biting mosquito,
is the principal vector
EPIDEMIOLOGY
Transmission occurs from viremic humans by bite of the
vector mosquito where virus multiplies during an extrinsic
incubation period

And then by bite, is passed on to a susceptible human in

what is called the urban transmission cycle.
EPIDEMIOLOGY
EPIDEMIOLOGY
● Dengue outbreaks in urban areas infested with A. aegypti
may be explosive;
● Virgin soil epidemics, up to 70–80% of the population
● Most overt disease occurs in older children and adults.
● Viremic human beings and follows the main lines of
transportation.
EPIDEMIOLOGY
EPIDEMIOLOGY
Dengue hemorrhagic fever occurs where multiple types
of dengue virus are simultaneously or sequentially
transmitted.
A first infection, referred to as a primary
infection, may be followed by infection with a
different dengue virus, referred to as a secondary
infection.
In areas of high endemicity, secondary infections are
frequent.
EPIDEMIOLOGY
● Secondary dengue infections are relatively mild in the
majority of instances
● Ranging from an inapparent infection through an
undifferentiated upper respiratory tract or dengue-like
disease
● May also progress to dengue hemorrhagic fever.
EPIDEMIOLOGY
● Dengue hemorrhagic fever can occur during primary dengue
infections, most frequently in infants whose mothers are
immune to dengue.
● Dengue hemorrhagic fever or severe dengue occurs rarely
in individuals of African ancestry because of an as yet
incompletely described resistance gene.
PATHOGENESIS
● associated with second heterotypic infections with dengue types
1-4

● or in infants born to mothers who have had two or more lifetime

dengue infections

● the circulation of infection-enhancing antibodies at the time

of infection is the strongest risk factor for development of
severe disease.

● the absence of cross-reactive neutralizing antibodies and

presence of enhancing antibodies from passive transfer or
active production are the best correlates of risk for dengue
hemorrhagic fever
PATHOGENESIS
● viremia levels directly predicted disease severity
● dengue virus immune complexes attach to
monocyte/macrophage Fc receptors → suppresses innate
immunity → enhanced viral production
● rapid activation of the complement system → blood levels
of soluble tumor necrosis factor receptor, interferon-γ,
and interleukin-2 are elevated
PATHOGENESIS
Circulating viral nonstructural protein 1 (NS1)

● is a viral toxin that activates myeloid cells to release

cytokines by attaching to toll receptor 4.

● contributes to increased vascular permeability

○ by activating complement

○ interacting with and damaging endothelial cells

○ and interacting with blood clotting factors and platelets

PATHOGENESIS
● Capillary damage allows fluid, electrolytes, small
proteins, and, in some instances, red blood cells to leak
into extravascular spaces.

● This internal redistribution of fluid, together with

deficits caused by fasting, thirsting, and vomiting,
results in hemoconcentration, hypovolemia, increased
cardiac work, tissue hypoxia, metabolic acidosis, and
hyponatremia.
PATHOGENESIS
● death may be a result of gastrointestinal or intracranial
hemorrhages.

● dengue virus is frequently absent in tissues at the time

of death; viral antigens or RNA have been localized to
hepatocytes and macrophages in the liver, spleen, lung,
and lymphatic tissues.
CLINICAL MANIFESTATIONS (DENGUE FEVER)
● incubation period is 1-7 days.
● influenced by the age of the patient.
● fever for 1-5 days, pharyngeal inflammation, rhinitis, and
mild cough.
● sudden onset of fever, with temperature rapidly increasing
to 39.4-41.1°C (103-106°F).
● frontal or retroorbital pain
● severe back pain
● Macular, generalized rash that blanches
● Myalgia and arthralgia - Increase in severity over time.
● nausea and vomiting
● generalized lymphadenopathy, cutaneous hyperesthesia or
hyperalgesia, taste aberrations, and pronounced anorexia
● edema of the palms and soles
Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition. Philadelphia. Elsevier. 2020.
CLINICAL MANIFESTATIONS
(DENGUE HEMORRHAGIC FEVER & DENGUE HEMORRHAGIC SHOCK)
First phase:
abrupt onset of fever, malaise, vomiting, headache,
anorexia, and cough may be followed after 2-5 days by rapid
clinical deterioration and collapse.

Second phase:
cold, clammy extremities, a warm trunk, flushed face,
diaphoresis, restlessness, irritability, midepigastric pain,
and decreased urinary output. Petechiae on the forehead and
extremities; spontaneous ecchymoses, easy bruising and
bleeding. Maculopapular rash, circumoral and peripheral
cyanosis.
Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition. Philadelphia. Elsevier. 2020.
CLINICAL MANIFESTATIONS
(DENGUE HEMORRHAGIC FEVER & DENGUE HEMORRHAGIC SHOCK)
Respirations are rapid and often labored. The pulse is weak,
rapid, thready, and the heart sounds are faint.
The liver enlarge to 4-6 cm below the costal margin
Complicated by shock (dengue
shock syndrome).

Dengue shock can be subtle, arising in patients who are

fully alert, accompanied by increased peripheral vascular
resistance and raised diastolic blood pressure.

Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition. Philadelphia. Elsevier. 2020.
CLINICAL MANIFESTATIONS
(DENGUE HEMORRHAGIC FEVER & DENGUE HEMORRHAGIC SHOCK)
Shock is from venous pooling.
Diastolic pressure rises toward the systolic level and the
pulse pressure narrows.
Gross ecchymosis or gastrointestinal bleeding
Bradycardia and ventricular extrasystoles are common during
convalescence.

Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition. Philadelphia. Elsevier. 2020.
CLINICAL MANIFESTATIONS
(DENGUE WITH WARNING SIGNS AND DENGUE SEVERE)
dominant life-threatening event
When the four dengue viruses spread to
the American hemisphere and to South Asia, there were millions
of primary and secondary dengue infections, many of them adults
of all ages.
Dengue disease in these areas presented a wider clinical
spectrum resulting in a new diagnostic algorithm and case
definitions

Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition. Philadelphia. Elsevier. 2020.
CLINICAL MANIFESTATION (WHO criteria)

Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition. Philadelphia. Elsevier. 2020.
diagnosis
Dengue hemorrhagic fever
Fever (2-7 days in duration or biphasic), minor or major hemorrhagic
manifestations - positive tourniquet test, thrombocytopenia
(≤100,000/μL), (hematocrit increased by ≥ 20%), pleural effusion or
ascites (by chest radiography or ultrasonography), or
hypoalbuminemia.
Dengue shock syndrome - criteria include those for dengue
hemorrhagic fever as well as hypotension, tachycardia, narrow pulse
pressure (≤20 mm Hg), and signs of poor perfusion (cold
extremities).
Severe dengue - a mixture of syndromes associated with dengue
infection, including classical DHF/DSS, also has rare instances of
encephalitis or encephalopathy, liver damage, or myocardial damage.
Also includes respiratory distress, caused by overhydration, leading
to pulmonary edema.
 DIAGNOSTICS
● Hematology: CBC, platelet count, PT, PTT, INR, CT, BT
● Immunology & Serology: Dengue NS1, Dengue IgM and IgG
● Clinical Chemistry: SGPT, SGOT, Serum electrolytes, BUN,
Albumin
● Clinical Microscopy: Urinalysis
● Imaging studies: Chest xray, Ultrasonography
● Other ancillary: ECG

Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition. Philadelphia. Elsevier. 2020.
Bishop, M.L. et al. Clinical Chemistry: Techniques, Principles, Correlations. 6th edition. Philadelphia. Lippincott Williams and Wilkins. 2010.
Hoffman, et al. Hematology: Basic Principles and Practice. 5th edition. Churchill-Livingstone. 2009.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of dengue fever includes dengue-like diseases:
● Viral respiratory influenza-like diseases
● the early stages of malaria
● mild yellow fever
● scrub typhus
● viral hepatitis
● Leptospirosis
● chikungunya
Four arboviral diseases have dengue-like courses but without rash:
● Colorado
● tick fever
● sandfly fever
● Rift Valley fever,
● Ross River fever
Disease that produce a clinical picture
similar to dengue hemorrhagic fever:
● Meningococcemia
● Yellow fever
● Viral hemorrhagic fevers
● Many rickettsial diseases,
● Other severe illnesses caused by a variety of agents
LABORATORY FINDINGS in Dengue
● Pancytopenia ● The tourniquet test result may be
● Neutropenia positive
● Leukocytopenia ● Mild acidosis,
● Normal prothrombin ● Hemoconcentration,
● Platelet counts rarely fall below ● Increased transaminase values,
100,000/μL ● Hypoproteinemia
● Venous clotting ● Electrocardiogram may show sinus
● Bleeding Bradycardia,
● Prothrombin times, and plasma ● Ectopic ventricular foci, flattened T
fibrinogen values are within normal waves, and prolongation of the P-R
ranges interval.
Laboratory findings in dengue hemorrhagic fever
● Hemoconcentration With An Increase Of > 20% In The Hematocrit,
● Thrombocytopenia,
● A Prolonged Bleeding Time, And A Moderately Decreased Prothrombin Level That Is Seldom < 40% Of Control.
● Fibrinogen Levels May Be Subnormal
● Fibrin Split-product Values Are Elevated.
● Moderate Elevations Of Serum Transaminase Levels,
● Consumption Of Complement
● Mild Metabolic Acidosis With Hyponatremia,
● Occasionally Hypochloremia,
● Slight Elevation Of Serum Urea Nitrogen,
● Hypoalbuminemia.
● X Ray Of The Chest Reveal Pleural Effusions (right > left) in nearly all patients with dengue shock syndrome
TREATMENT
GROUP A - outpatient
● Control the fever

▶ Give acetaminophen every 6 hours (maximum 4 doses per day).

▶ Sponge patient’s skin with tepid water when temperature is high.

● Prevent dehydration

▶ Give plenty of fluids (not only water) and watch for signs of dehydration.

Prevent spread of dengue within your house

Group b - inpatient for dengue patients with warning signs
 Group c - Patients with Severe Dengue Requiring Emergency Treatment
Recommended Fluid Therapy for Compensated Shock

Pediatric Infectious Disease Society of the Philippines. Clinical Practice Guidelines on Dengue in children. 2017.
 Recommended Fluid Therapy for Hypotensive Shock

Pediatric Infectious Disease Society of the Philippines. Clinical Practice Guidelines on Dengue in children. 2017.
Pediatric Infectious Disease Society of the Philippines. Clinical Practice Guidelines on Dengue in children. 2017.
TREATMENT OF HEMORRHAGIC COMPLICATIONS

Give 5-10 mL/kg of fresh packed red blood cells or 10- 20 mL/kg of fresh whole
blood at an appropriate rate
Complications,
prognosis,
prevention
COMPLICATIONS
● HYPOVOLEMIA
● FLUID AND ELECTROLYTE LOSSES, HYPERPYREXIA AND FEBRILE
CONVULSIONS
● EPISTAXIS, PETECHIAE, PURPURIC LESIONS => SIGNIFICANT
BLEEDING
● CONVULSIONS => PROLONGED ASTHENIA, MENTAL DEPRESSION,
BRADYCARDIA, VENTRICULAR EXTRASYSTOLES
PROGNOSIS
DENGUE FEVER
● GOOD PROGNOSIS

DENGUE HEMORRHAGIC FEVER

● DEATH IN 40-50% WITH SHOCK
● <1% WITH ADEQUATE INTENSIVE CARE
● RESIDUAL BRAIN DAMAGE OR INTRACRANIAL HEMORRHAGE WITH
PROLONGED SHOCK
● FATALITIES WITH OVERHYDRATION
PREVENTION
● DENGUE VACCINE - DENGVAXIA
● USE OF INSECTICIDES,
● REPELLANTS,
● BODY COVERING WITH CLOTHING
● SCREENING OF HOUSES
● DESTRUCTION OF MOSQUITO BREEDING SITES
REFERENCE:
● Pediatric Infectious Disease Society of the Philippines. Clinical Practice
Guidelines on Dengue in children. 2017.
http://www.pidsphil.org/home/wpcontent/uploads/2017/06/2017_Dengue_CP
G_Final.pdf
● Dengue case Management.
https://www.cdc.gov/dengue/resources/dengue-clinician-guide_508.pdf
● Kliegman, R.M. et al. Nelson Textbook of Pediatrics. 21st edition.
Philadelphia. Elsevier. 2020.
● Bishop, M.L. et al. Clinical Chemistry: Techniques, Principles,
Correlations. 6th edition. Philadelphia. Lippincott Williams and Wilkins. 2010.
● Hoffman, et al. Hematology: Basic Principles and Practice. 5th edition.
Churchill-Livingstone. 2009.