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DENGUE HEMORRHAGIC FEVER
PROF S SHIVAKUMAR’S UNIT
D RAVI SHANKAR MD PG
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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
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No H/o Dysuria Jaundice Vomiting Diarrhea Bleeding symptoms Abdominal pain Vaginal discharge
Past / Personal/ Family/ Drug H/o Nothing relevant
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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
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CVS RS NAD ABD CNS
VIRAL EXANTHEMATOUS FEVER
DIAGNOSIS
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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
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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
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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
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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
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VIRAL HEMORRHAGIC FEVER
? DENGUE SHOCK SYNDROME
DIAGNOSIS
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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.
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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
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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
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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
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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
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DIAGNOSISDENGUE HEMORRHAGIC FEVER
WITH
DENGUE SHOCK SYNDROME
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VIRAL HEMORRHAGIC FEVER DENGUE YELLOW FEVER EBOLA LASSA HANTA MARBURG RIFT VALLEY FEVER CRIMEAN CONGO
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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
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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
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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
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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
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DENGUE INFECTIONASYMPTOMATIC
SYMPTOMATIC
DENGUE FEVER DENGUE HEMORRHAGICFEVER
WITHOUT SHOCK
WITH SHOCK ( DSS )
VIRAL SYNDROME
BREAK BONE FEVER
WITH OR WITHOUTHEMORRHAGE
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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
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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
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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
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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
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IMMUNE ENHANCEMENT
PRIMARY DENGUEINFECTION
NON NEUTRALISINGLEVEL- HeterotypicAntibodies ( 1 – 5 yrs)
Secondary DengueInfection – diff serotype
VIRUSMACROPHAGE
Highly infectedMacrophage
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DSS - PATHOGENESISUncontrolled multiplicationOf virus in Macrophage
Macrophageactivation
Excessive releaseOf cytokines (TNF & IL)
VASODILATATIONINCREASED PEMEABILITY
CAPILLARY LEAK
HEMATOCRIT
HYPOTENSION
SHOCK( INTERNAL HEMORRHAGE)
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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
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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
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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
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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
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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
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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
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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
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