Dengue Fever

Dengue

Dengue infection is a systemic and dynamic disease. It has a wide clinical spectrum that includes
both severe and non-severe clinical manifestations. After the incubation period, the illness
begins abruptly and is followed by the three phases; 1. Febrile 2. Critical and 3. Recovery.

For a disease that is complex in its manifestations, management is relatively simple, inexpensive and
very effective in saving lives so long as correct and timely interventions are instituted. The key is
early recognition and understanding of the clinical problems during the different phases of the disease,
leading to a rational approach to case management and a good clinical outcome.

Activities (triage and management decisions) at the primary and secondary care levels (where patients
are first seen and evaluated) are critical in determining the clinical outcome of dengue. A well-managed
front-line response not only reduces the number of unnecessary hospital admissions but also saves the
lives of dengue patients. The Early notification of dengue cases seen in primary and secondary care is
crucial for identifying outbreaks and initiating an early response

Febrile phase

Patients typically develop high-grade fever suddenly. This acute febrile phase usually lasts 2-7 days and is
often accompanied by facial flushing, skin erythema, generalized body ache, myalgia, arthralgia, and headache.
Some patients may have a sore throat, injected pharynx, and conjunctival injection. Anorexia, nausea, and
vomiting are common. It can be difficult to distinguish dengue clinically from non-dengue febrile diseases
in the early febrile phase. A positive tourniquet test in this phase increases the probability of dengue.
In addition, these clinical features are indistinguishable between severe and non-severe dengue cases.
Therefore, monitoring for warning signs and other clinical parameters is crucial to recognizing progression
to the critical phase.

Mild hemorrhagic manifestations like petechiae and mucosal membrane bleeding (e.g. nose and gums) may be seen.
Massive vaginal bleeding (in women of childbearing age) and gastrointestinal bleeding may occur during this
phase but is not common. The liver is often enlarged and tender after a few days of fever. The earliest
abnormality in the full blood count is a progressive decrease in total white cell count, which should
alert the physician to a high probability of dengue.

Critical phase

Around the time of defervescence, when the temperature drops to 37.5-38 C or less and remains below this level,
usually on days 3-7 of illness, an increase in capillary permeability in parallel with increasing
hematocrit levels may occur. This marks the beginning of the critical phase. The period of clinically
significant plasma leakage usually, lasts 24-48 hours.

Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage. At this
point patients without an increase in capillary permeability will improve, while those with increased
capillary permeability may become worse because of lost plasma volume. The degree of plasma leakage varies.
Pleural effusion and ascites may be clinically detectable depending on the degree of plasma leakage and the
volume of fluid therapy. Hence chest x-ray and abdominal ultrasound can be useful tools for diagnosis.
The degree of increase in the baseline hematocrit often reflects the severity of plasma leakage.

Shock occurs when a critical volume of plasma is lost through leakage. It is often preceded by warning signs.
The body temperature may be subnormal when the shock occurs. With prolonged shock, the consequent organ
hypoperfusion results in progressive organ impairment, metabolic acidosis and disseminated intravascular
coagulation. This, in turn, leads to severe hemorrhage causing the hematocrit to decrease in severe shock.
Instead of the leukopenia usually seen during this phase of dengue, the total white cell count may increase
in patients with severe bleeding. In addition, severe organ impairment such as severe hepatitis, encephalitis
or myocarditis and/or severe bleeding may also develop without obvious plasma leakage or shock. Those who
improve after defervescence are said to have non-severe dengue. Some patients progress to the critical phase
of plasma leakage without defervescence and, in these patients, changes in the full blood count should be
used to guide the onset of the critical phase and plasma leakage.

Those who deteriorate will manifest with warning signs. This is called dengue with warning signs (Text. Cases of
dengue with warning signs will probably recover with early intravenous rehydration. Some cases will deteriorate
to severe dengue.

Recovery phase

If the patient survives the 24-48-hour critical phase, a gradual reabsorption of extravascular compartment fluid
takes place in the following 48-72 hours. General well-being improves, appetite returns, gastrointestinal
symptoms abate, hemodynamic status stabilizes and diuresis ensues. Some patients may have a rash of "isles
of white in the sea of red". Some may experience generalized pruritus. Bradycardia and electrocardiographic
changes are common during this stage.

The hematocrit stabilizes or may be lower due to the dilutional effect of reabsorbed fluid. White blood cell
count usually starts to rise soon after defervescence but the recovery of platelet count is typically later
than that of white blood cell count.

Respiratory distress from massive pleural effusion and ascites will occur at any time if excessive intravenous
fluids have been administered. During the critical and/or recovery phases, excessive fluid therapy is
associated with pulmonary edema or congestive heart failure.

The various clinical problems during the different phases of dengue can be summarized as in Table below.

Febrile phase Dehydration; high fever may cause neurological disturbances and febrile seizures
in young children

Recovery phase Hypervolemia (only if intravenous fluid therapy has been excessive and/or has extended into
this period)

Severe dengue

Severe dengue is defined by one or more of the following: (i) plasma leakage that may lead to shock (dengue shock)
and/or fluid accumulation, with or without respiratory distress, and/or (ii) severe bleeding, and/or (iii)
severe organ impairment.

As dengue vascular permeability progresses, hypovolemia worsens and results in shock. It usually takes place
around defervescence, usually on day 4 or 5 (range days 3-7) of illness, preceded by the warning signs. During
the initial stage of shock, the compensatory mechanism which maintains a normal systolic blood pressure also
produces tachycardia and peripheral vasoconstriction with reduced skin perfusion, resulting in cold extremities
and delayed capillary refill time. Uniquely, the diastolic pressure rises towards the systolic pressure and the
pulse pressure narrows as the peripheral vascular resistance increases. Patients in dengue shock often
remain conscious and lucid. The inexperienced physician may measure a normal systolic pressure and misjudge
the critical state of the patient. Finally, there is decompensation and both pressures disappear abruptly.
Prolonged hypotensive shock and hypoxia may lead to multi-organ failure and an extremely difficult clinical course.

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