Dengue Virus Medical Presentation

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Published on : Jul 27, 2019 | Views : 3025 | Downloads : 2

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DENGUE
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Introduction: Dengue is a febrile illness caused by a flavivirus transmitted by mosquitoes. It is the most rapidly spreading mosquito-borne viral illness. Approximately 400 million infections and 100 million clinically apparent infections occur annually.
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Vector: The principal vector is the mosquito Aedes aegypti. It breeds in standing water; collections of water in containers, water-based air coolers and tyre dumps are a good environment for the vector in large cities
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Clinical presentations: Many patients infected with dengue virus remain aymptomatic.Others, after an incubation period of 4-7 days, develop a febrile illness. The manifestations of which are similar & overlapping in nature & are grouped into ‘Dengue Syndrome’. Which encompasses the following: Undifferertiated fever DF DHF Expanded dengue syndrome
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Asymptomatic infection: Majority of dengue virus infection are asymptomatic. Age appears to influence the prevalence of symptomatic disease. The majority of infection in children under age 15 years are asymptomatic or minimally symptomatic.
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Symptomatic infection Undifferentiated fever: Those who have been infected with dengue virus, specially for 1st time may develop a simple fever indistinguishable from other viral infections. Maculopapular rash, upper respiratory tract symptoms & gastrointestinal symptoms are common.
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Dengue fever The onset of DF is sudden with a sharp rise in temperature which may associate with chills, flushed face & headache. The following features are usually observed: Retro-orbital pain Photophobia Backache Other common symptoms: anorexia, altered taste sensation, constipation, colicky pain & abdominal tenderness.
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Fever: The body temperature is usually between 102°F to 104°F. The fever may be biphasic. In the majority of cases lasts for 2-7 days.
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Rash: First 2-3 days – Diffuse flushing or fleeting eruptions may be seen on the face, neck & chest. 3rd & 4th day- a conspicuous rash that may be maculopapular or rubelliform. Afebrile period or defervescence- Petechiae may appear over the dorsum of the feet, on the legs, on the hands & arms. Skin itching may be observed.
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DF with unusual haemorrhage: In DF with unusual haemorrhage, petechiae may be present. Other bleeding such as massive epistaxis, hypermenorrhea & gastrointestinal bleeding rarely occur in DF. The cut-off point between DF & DHF is the evidence of plasma leakage which will be present in DHF but not in DF.
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Dengue Haemorrhagic fever DHF is characterized by the acute onset of high fever & is associated with signs & symptoms similar to DF in the early febrile phase. It is devided into 3 phases: Febrile phase Critical phase (leakage phase) Convalescent phase
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Febrile phase: Febrile phase is characterized by continuing high fever lasting for 2-7 days with signs & symptoms similar to DF. Mild haemorrhagic manifeatation can occur.
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Haemorrhagic manifestations: Easy bruising & bleeding. Fine petechiae scattered on the extremities, axillae, face & soft palate. Maculopapular or rubelliform rash may be observed. Epistaxis & gum bleeding are less common. Mild GIT haemorrhage is occasionally observed.
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Clinical features of dengue fever Incubation period:2–7 day Prodrome: 2 days of malaise and headache Acute onset Fever Backache Arthralgias Headache Generalised pains (‘break-bone fever’) Pain on eye movement
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Clinical features of dengue fever Lacrimation Scleral injection Anorexia Nausea Vomiting Pharyngitis upper respiratory tract symptoms relative bradycardia
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Clinical features of dengue fever Prostration Depression Hyperaesthesia Dysgeusia Lymphadenopathy
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Clinical features of dengue fever Fever: Continuous or ‘saddle-back’ Usually breaks on 4th or 5th day and then recrudescence Usually lasts 7–8 days
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Clinical features of dengue fever Rash: Initial flushing faint macular rash in 1–2 days. Maculopapular, scarlet morbilliform blanching rash from days 3–5 on trunk spreading centrifugally and sparing palms and soles Onset often with fever defervescence May desquamate on resolution or give rise to petechiae on extensor surfaces
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Investigations: CBC: Including Total Leucocyte Count, Total Platelet Count & HCT. Leucopenia (WBC <5,000/mmᶟ) & thrombocytopenia (<150,000/mmᶟ) are common in late febrile phase in DHF.
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Dengue Diagnostic Test: Detection of Antigen: NS1 antigen: It is positive on the first day of illness Becomes negative from day 4-5 of illness
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Investigations: Detection of Antibody: Dengue IgM/IgG test: Anti Dengue IgM specific antibodies can be detected 3-6 days after the onset of fever & is increased to 95-98% by day 6-10. In primary dengue infection IgM will be more than IgG in early period. IgG is increased at 9th or 10th day of fever. Level of IgG may persist at low levels for decades, indicating past dengue infection.
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Investigations: Recommendations: Serum AST (SGOT) & ALP (SGPT): Ast & ALT levels are frequently elevated in both DF & DHF. Levels are significantly higher (5-15 times the upper limit of normal) in patients with DHF. Other findings are hypoproteinemia, hyponatremia, albuminuria. Occult blood is often found in the stool.
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High risk patients: Infants & elderly Obesity Pregnant women Peptic ulcer disease Women who have menstruation or abnormal vaginal bleeding Haemolytic diseases such as G-6PD deficiency, thalassemia & other haemoglobinopathies. Congenital heart disease.
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High risk patients: Chronic diseases such as DM, HTN, asthma, IHD, CKD, liver cirrhosis. Patients on steroid or NSAID treatment.
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Warning signs: The following clinical observation needs hospitalization for close monitoring. No clinical improvement or worsening of the situation just before or during the transition to afebrile phase or as the disease process. Persisting vomiting. Severe abdominal pain. Lethargy &/or restlessness, sudden behavioural changes.
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Warning signs: Bleeding: Epistaxis, Black stool, haematemesis, excessive menstrual bleeding, dark coloured urine (Haemoglobinuria) or haematuria. Giddiness. Pale, cold & clammy hands & feet. Less/no urine output for 4-6 hours Liver enlargement > 2 cm Haematocrit > 20%
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When to stop I/V fluid therapy: Recognizing when to decrease or stop I/V fluids as part of the treatment of severe dengue is crucial to prevent fluid overload. When any of the following signs are present, I/V fluid should be reduced or discontinued. Signs of cessation of plasma leakage Stable BP, pulse & peripheral perfusion HCT decreases in the presence of a good pulse volume
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When to stop I/V fluid therapy: Apyrexia (without the use of antipyretics) for more then 24-48 hours. Resolving bowel/abdominal symptoms Improving urine output Continuing I/V fluid therapy beyond the 48 hours of the critical phase will put the patient at risk of pulmonary oedema.
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Some Important Instructions Check list Cases of DHF should be observed every hour. Serial platelet and hematocrit determinations for drop in platelets and rise in hematocrit are essential for early diagnosis of DHF. Timely intravenous therapy - isotonic crystalloid solution - can prevent shock and or lessen the severity.