DENGUE HEMORRHAGIC FEVER

PROF S SHIVAKUMAR’S UNIT

D RAVI SHANKAR MD PG

Komala 20yrs/ female Admitted on 11/ 04/ 06 C/o

Fever with rigor - 3 days Running nose Dry cough - 3 days Severe headache Body ache - 3 days Redness of eyes Maculopapular rash- 1 day

No H/o Dysuria Jaundice Vomiting Diarrhea Bleeding symptoms Abdominal pain Vaginal discharge

Past / Personal/ Family/ Drug H/o Nothing relevant

GENERAL EXAMINATION Conscious Oriented Febrile No pallor/ icterus/ cyanosis/

clubbing/ Lt posterior cervical LN + Maculo papular rash over the face

and neck + Conjuntival suffusion + + PR – 110/ mt, BP 110/ 70mmHg Temp- 102 F, RR – 18/ mt

CVS RS NAD ABD CNS

VIRAL EXANTHEMATOUS FEVER

DIAGNOSIS

ON 12/ 04/ 06 Morning

Conscious Highly febrile Rash spread all over the body Conjunctival suffusion

increased Little breathless PR – 100/mt , BP – 100/ 70 ECG & CXR – normal Treated with IV fluids and

antibiotics

ON 12/ 04/ 06

Evening Conscious, Disoriented Febrile with severe rigors Restless Excessive sweating Breathless C/o

Black vomitus Vaginal bleeding Epistaxis Sub conjunctival heamorrhage

Contd…… Suddenly patient

Unconscious Peripheries became cold Sweating++ Urinary and fecal incontinence Pulse – feeble 130/ mt BP - 50/ ? Hemogram done in the morning

was normal

Contd…… Patient was treated with

3- 4 liters of Normal saline Fresh blood Platlet transfusion Dopamine infusion BP picked up and patient became

conscious Patient shifted to IMCW PLATLET count done outside at

11pm 68,000/ cu mm

VIRAL HEMORRHAGIC FEVER

? DENGUE SHOCK SYNDROME

DIAGNOSIS

ON 13/ 04/ 06 in IMCW

Conscious, oriented Afebrile No rash Severe conjunctival hage Loose stools Vaginal bleeding + Blood stained vomiting BP stable Treated with IV fluids, platlets(12 units),

blood transfusion ( 2 units ), antibiotics.

INVESTIGATIONS

HEMOGRAM

12/04 17/0420/04 Hb 10.2 9.8 8.1 TLC 54OO 4000 3600 DLC P58 L42 P65L35 P63 L37 ESR 12/ 20 8/ 20 10/ 22 RBC 3.6 million 3.12 2.9 PCV 3O% 30% 29% PLATLET 68,000 50,000 1.45Lac

12/ 04 / 06 - 68,000

18/ 04 / 06 - 50,000

21/ 04 / 06 - 1.45 Lacs

20/ 04 / 06 - 1.84 Lacs

24/ 04 / 06 - 2.1 Lacs

SERIAL PLATLET COUNT

OTHER INVESTIGATIONS RFT

UREA - 38 mg/ dl Creatinine- 1.0 mg/ dl

Blood sugar - 138mg /dl LFT

TB - 1.0 mg/ dl SGOT - 126 IU/ L SGPT- 83 IU / L SAP - 63 IU / L T. protein- 7.8 g/ dl Sr. Alb - 3.8 g/ dl

QBC MP - -VE

MSAT - -VE

WIDAL - -VE

DENDUE Ig M - +VE

Ig G - +VE PS STUDY - Microcytic

Hypochromic anemia and thrombocytopenia.

USG ABD - N study

DIAGNOSISDENGUE HEMORRHAGIC FEVER

WITH

DENGUE SHOCK SYNDROME

VIRAL HEMORRHAGIC FEVER DENGUE YELLOW FEVER EBOLA LASSA HANTA MARBURG RIFT VALLEY FEVER CRIMEAN CONGO

SIMILARITIES IN VHF All are membrane bound viruses All are RNA viruses Most have Zoonotic life cycles except

DENGUE Acute fever and myalgia Capillary leak syndrome Host immune response decides

severity of disease All infections are immunosuppressive All are mosquito or tick born

COMMON PATHOGENESIS Affinity to capillary endothelium Immune complex mediated endothelial

injury Complement mediated increased capillary

permeability

Increased capillary permeabilityCapillary Leak – ascites, pl effusion, edemaHypovolemia, hypotension, shock, Hypoxia , Acidosis and HyperkalemiaDIC

DENGUE RNA virus, Flavi viridae Four serotypes ( 1 – 4 ) Transmitted by Aeidis aegypti and

albopictus Artificial containers Day biter Mosquitoes infective life long Trans ovarian transmission

Preferentially in urban areas Common in children and is mild than

in adults

DENGUE - EPIDEMIOLOGY

All continents are endemic except Europe 50- 100 million cases 5 lac DHF All 4 types reported in INDIA(1&2

common) Epidemics in INDIA

1970 – DEN 3 1996 - DEN 2 ( Delhi )

2003 status 12,750 cases 217 deaths 1600 cases and 8 deaths in TN

DENGUE INFECTIONASYMPTOMATIC

SYMPTOMATIC

DENGUE FEVER DENGUE HEMORRHAGICFEVER

WITHOUT SHOCK

WITH SHOCK ( DSS )

VIRAL SYNDROME

BREAK BONE FEVER

WITH OR WITHOUTHEMORRHAGE

CLINICAL FEATURES Undifferentiated fever with myalgia Typical dengue fever

Older children and adults Biphasic fever ( 5 – 7 days ) Head ache, Myalgia, arthralgia Upper Resp. symptoms Flushed face, retro orbital pain, photophobia RASH

• Diffuse flushing or fleeting pin point eruptions fece, neck & chest during 1-3 days of fever

• Maculopapular or scarlantiform – 4th day• After defevescence – petichiae and +ve

Tourniquet test Epistaxis, gum bleeding and GI bleeding may

occur Lecopenia with left shift

DHF AND DSS High fever Hemorrhagic phenomena

Peticheal rash Epistaxis GI bleed Vaginal bleeding Bleeding at IV cannula sites +ve tourniquet test

Thrombocytopenia Hemoconcentration Circulatory failure( Febrile to afebrile)

Narrow pulse pressure Hypotension Cold clammy skin Cyanosis Profound shock

ICH, convulsions and encephalopathy

DHF - GRADES Grade I - Fever

Non sp symptomsTorniquet test +ve

Grade II - Spontaneous bleedingwith above symptoms

Grade III - Rapid, weak pulseNarrow pulse pressureHypotension

Grade IV - Profound Shock

Platelet < 1 lac, PCV > 20 % in all grades

IMMUNOLOGYDENGUE INFECTION

HOMOLOGOUS ANTIBODIESCMI

LIFE LONG PROTECTIONAGAINST SAME SEROTYPE

HETEROLOGOUSANTIBODIES to other3 serotypes

NEUTRALISINGLEVEL 2-12 MONTHS(partial protection )

REDUCED TO NONNEUTRALISING LEVELAFTER 12 MONTHS

IMMUNE ENHANCEMENT

PRIMARY DENGUEINFECTION

NON NEUTRALISINGLEVEL- HeterotypicAntibodies ( 1 – 5 yrs)

Secondary DengueInfection – diff serotype

VIRUSMACROPHAGE

Highly infectedMacrophage

DSS - PATHOGENESISUncontrolled multiplicationOf virus in Macrophage

Macrophageactivation

Excessive releaseOf cytokines (TNF & IL)

VASODILATATIONINCREASED PEMEABILITY

CAPILLARY LEAK

HEMATOCRIT

HYPOTENSION

SHOCK( INTERNAL HEMORRHAGE)

DSS - PATHOGENESIS

CD 8 mediated destruction of infected Macrophage

Release of proteolyticEnzymes

Complementactivation

C 3a C 5aanphylotoxins

Coagulation activation

DIC( rare)

Immunecomplex

Thrombocytopenia

Viral endothelialdamage

Potent vasodilatation/ Leak

DSS – PRE REQUISITE

Primary dengue infection

Secondary & sequential infection with other serotypes with in 1-5 yrs of primary infection

DSS can occur in primary infection in infants who has maternal antibodies in non neutralizing level

LAB PROFILE Hemogram

Leucopenia with relative Lymphocytosis

Thrombocytopenia < 1 lac PCV increased > 20 % Prolonged PT & aPTT Reduced complement levels

Hypoproteinemia , mild SGOT & SGPT elevations

Virus isolation < 5 days Serology - Ig M & Ig G ELISA

Treatment of DF/ DHF Febrile phase

Bed rest Paracetamol – 4times/day Avoid Aspirin & Brufen Avoid antibiotics Oral Rehydration therapy –

fluid loss due to vomiting / high temp. (2.5-4 litres /day)

Afebrile phase - observe

CRYSTALLOIDS(RL/DNS) 6ml/kg/hr

Improvement3ml/kg/hr

Discontinue after6-12 hrs

CRYSTALLOIDS 6ml/kg/hr No Improvement10ml/kg/hr

HctHct

improvement

No improvement

Colloidsdiscontinue

DHF

10-6-3ml Crystalloids

Blood transfusion

improvement

CRYSTALLOIDS(10-20 ml/kg/hr)

No Improvement

Hct Hct

Discontinue

10-6-3ml

DSS

Improvement Reduce10-6-3ml/kg/hr

CRYSTALLOIDS(10-20 ml/kg/hr)

COLLOID

Blood transfusion( 10ml/ kg/ hr )

ImprovementCrystalloids

10-6-3ml

Points to be remembered

Hct - IV Crystalloids or colloids (Dextran 40) or plasma (10 ml/kg/hr)

Hct - Blood Transfusion (10ml/kg/hr)

Platelets < 5000cu.mm - platelet

transfusion