DENGUE FEVER

Hilmi Asmungi

 10 Years old Malay Boy

No known medical illness / No known drugs allergy
1st Hospitalization
C/O : Fever for 3 days
-no documented temp at home
-persistent fever
-associated with chills and rigors
-had arthralgia and myalgia with headache and retro orbital
pain
Vomiting for 3 days
-started together with the onset of fever
-3-4 times per day
-contain food particles and fluids
Abdominal pain for 2 days
-started at day 2 of illness
-pain over the epigastric region

Otherwise
No bleeding tendency
No diarrhea
No UTI symptoms
Reduced oral intake, but still able to tolerate fluids
Social History
-Lives in Bandar Saujana Putra (Dengue prone area)
-No history of recent travelling / jungle trekking / water
activities
-Other family members healthy
Birth history
-Full term baby delivered via SVD
-Uneventful
Development
-Standard 4
-Education wise, bright student in the class according to
mother

In Emergency Department
BP 110/66
HR 110
T 38.5 degree
spo2 100%
FBC stat: WBC 5.1 Plt 130 HCT 42 HB 13
LFT : ALP 197 / AST 54 / ALT 45 / ALB 41
RP : U 2.5 / Na 135 / K 3.7 / Cr 61
NS1 +ve
IMP: dengue fever in day 3 of illness, in febrile phase with
warning sign (increase bleeding tendencies)
Started on IVD 3cc/kg/hr
Case was referred to peads MO - admit ward

In ward:
Anthropometry
Weight : 53.1kg
Height : 1.55m
BMI : 22.1
Alert, conscious
Warm peripheries
Good pulse volume
CRT <2 seconds
Hydration fair - Mucosa membrane moist
Not tachypnic/ tachycardiac
No rashes seen
Vitals
BP 118/64
PR 82
RR 20
T 37C Paracetamol given in ED at 2130H, 01/01/2016
SPO2 : 98% under RA

Lungs : clear, equal air entry

Cvs : s1s2, no murmur
P/A : soft, tender over the epigastric region, no
hepatospenomegally
Impression :
Dengue fever day 3 of illness in Febrile Phase with warning
sign of persistent vomiting and abdominal pain
Differential Diagnosis:
Leptospirosis
Malaria

During In patient
Day 1 of admission
Patient was tolerating fluids well
vomited x 2
Still having fever , abdominal pain
warm peripheries, good pulse volume, CRT <2secs
BP 108/64
PR 97
T 39.2
SPO2 99% under RA
Lung : clear
CVS : s1s2 no murmur
PA : soft, mild tender over the epigastric region
uo = 3.5cc/hour
oral intake = 1275mL
Dengue fever Day 4 of illness, in febrile phase with warning sign
abdominal pain and resolved persistent vomiting,
Since admission to ward, patient was on IVD 3cc/kg/hr and IVD was off in
ward
Encouraged orally

Day 2
tolerate orally , no vomiting
still having fever, flushed over the face, abdominal pain
alert ,warm periphery ,good pulse volume,CRT<2Secs,
BP 115/67
PR 105
T 39.5
SPO2 99% under RA
Lung : clear, no crepts
CVS : s1s2 no murmur
PA : soft, mild tender over the epigastric region
io: +ve balance (amount not documented)
ou: 3.9cc/kg/hr
Dengue fever Day 5 of illness, in febrile phase with warning
sign abdominal pain and resolved persistent vomiting
No IVD
Encouraged orally

Day 3
-still having fever, flushed over the face , abdominal pain
-alert ,lethargic, warm periphery ,good pulse volume, CRT<2Secs,
BP 102/76
PR 92
T 38.5
SPO2 99% under RA
Lung : clear, no crepts
CVS : s1s2 no murmur
PA : soft, mild tender over the epigastric region
I/O : 3635/2200 = + 1435
U/O : 1.7cc/kg/hr
Dengue fever Day 6 of illness, in febrile phase with warning sign abdominal
pain and resolved persistent vomiting
CRP taken: 11.9
T.PCM given as per mother request / temp >38
Started on IVD 2cc/kg/hr in view of increasing HCT and patient looks
lethargic

Day 4
-Patient tolerating orally , no vomiting
-still having abdominal pain
-alert ,warm periphery ,good pulse volume,CRT<2Secs,
-Noted petechial like rash over the both arms
BP 110/67
PR 92
T 37
SPO2 99% under RA
Lung : clear, no crepts
CVS : s1s2 no murmur
PA : soft, mild tender over the epigastric region
I/O 3790/900 = + 2890
U/O : 1.5cc/kg/hr
Dengue fever day 7 of illness, in defervescence phase with warning
sign abdominal pain and resolved persistent vomiting
Encouraged orally
IVD was reduced to 1cc/kg/hr
FBC 4 hourly

Day 5
-Patient tolerating orally well, no vomiting,
-no abdominal pain , afebrile
-warm peripheries, good pulse volume , CRT<2Secs
BP 117/69
PR 91
T 36.7
SPO2 99% under RA
Lung : clear, no crepts
CVS : s1s2 no murmur
PA : soft, non tender
i/o not documented
u/o 0.9cc/kg/hr
Dengue fever day 8 of illness, in recovery phase with resolved
warning sign of abdominal pain and persistent vomiting
Patient was allowed home
To repeat FBC in Klinik Kesihatan

D3 of illness

D4

D5

Hb

0330 1200 1800 0000 0600 1200 1800 0000 0600

H
H
H
H
H
H
H
H
H
12.5 10.8 12.7 12.6 12.3 13.1 13.3 13.4 12.3

Hct

38.3

33.9

39.4

38.7

38.1

40.2

40.4

41.5

38.2

Plt

160

94

140

98

82

53

57

45

24

Wbc

5.6

3.6

4.4

4.8

4.3

6.0

5.4

8.2

7.3

D5

D6

D7

Hb

1200
H
14.6

1800 0000
H
H
12.8 12.5

0600 1200
H
H
13.0 12.0

1800 0000 0600

H
H
H
11.8 11.4 12.0

Hct

45.6

39.4

38.6

40

37.2

36.3

35.5

37.5

Plt

25

63

24

35

36

51

56

73

Wbc

8.5

6.8

8.1

9.7

9.0

11.9

8.6

7.9

LFT:
AST 54 > 54
ALT 45 > 58
ALP 197 > 147
ALB 41 > 33

Epidermiology
An Emerging disease
DHF present in the WHO regions of the Americas, South-East
Asia, Eastern Mediterranean and Western Pacific; Africa reports
DEN but only sporadic DHF

Transmission

Dengue is passed from human-to-human by the bite of female

mosquitoes: Aedes aegypti is most common
Ae. aegypti is very efficient vector: Anthropophilic (prefers to feed
on humans)
Single-stranded RNA virus
Member of Flavivirus family
Four serotypes DENV-1, -2, -3, -4
All cause full spectrum of disease

Breeding areas

Ae aegypti immature stages are typically found in water-filled

habitats associated with human habitation;
Lays eggs in artificial, water-holding containers, and occasionally
tree holes
Primarily feeds from dawn to dusk, rests in dark areas and bites
indoors
Most female Ae. aegypti mosquitoes spend their lifetime in or
around the houses where they emerge as adults, meaning people
rather than mosquitoes rapidly move the virus within and
between communities

Vertical Transmission
DENV can be transmitted from the mother to the fetus in
utero or to the neonate at parturition (vertical
transmission)
Rates of vertical transmission vary and may depend on
severity of maternal infection and timing of infection
Reported cases were symptomatic and had a symptomatic
mother with infection late in pregnancy or at delivery
Most congenital cases described had fever plus
thrombocytopenia and hepatomegaly.
Half had hemorrhagic manifestation
One quarter had pleural effusion and/or rash
Clinical presentation not associated with maternal immune
status or mode of delivery

Clinical Course of Dengue

Clinical Warning Signs

1.Severe abdominal pain
2.Persistent vomiting
3.Mucosal bleed
4.Lethargy; restlessness
5.Liver enlargement >2cm
6.Clinical fluid accumulation

Development of warning signs:

Identify dengue patients already in shock or at
risk of developing shock

Laboratory
1.Leukopenia
2.Rapid decrease platelet count
3.Rising haematocrit

Pearls in clinical examination of dengue patients

The 5-in-1 maneuver CCTV-R
Hold the patients hand to evaluate peripheral perfusion.
1.
Colour

2.
Capillary
refill

3.

Temperature

4.
Pulse

Volume

5.
Pulse Rate

Investigations

Complete blood count (CBC) with haematocrit (HCT) are usually

all that are necessary for monitoring
Of special importance are:
HCT
white blood cell count (WBC)
platelet count

For confirmation, e.g. NS1/IgM rapid tests or RNA detection

(depending on resources of health facility)*
Blood chemistry tests (liver function, glucose, serum electrolytes,
urea, creatinine

*False positive dengue serology

Serological tests for dengue have been shown to cross-react with:

other flavivirus Japanese Encephalitis

non-flavivirus malaria, leptospirosis, toxoplasmosis, syphilis

connective tissue diseases rheumatoid arthritis

Management decision

Group A

Send home

Management

Group B

Refer for inhospital

management

Group C

Require
emergency
treatment
and urgent
referral

Outpatient management: Group A

Group A Send home if
patient meets all of the
following
Intake: Getting adequate
volume of oral fluids
Output: Passing urine at least
once every 4 to 6 hours
Does not have any warning
signs
Has stable haematocrit and
hemodynamic status
Does not have co-existing
conditions

Patients who are able to drink enough to

pee enough
1. Give anticipatory guidance
before sending home
1. Follow up daily
2. Do serial CBCs
3. Identify warning signs early

Inpatient Management: Group B

Group B (any of following)
Presence of warning signs.
Infants.
Children with co-morbid
factors (diabetes, renal
failure, immune compromised
state, hemoglobinopathies
and obesity).
Social factors - living far from
health facilities, transport
issues.

1. Admit for inpatient care

2. Monitor hemodynamic status
frequently
3. Use HCT to guide
interventions
4. Use isotonic IV fluids
judiciously
5. Correct metabolic acidosis,
electrolytes as needed

Emergency management: Group C

Group C
(any of following)
Severe plasma leakage with shock
and/or fluid accumulation with
respiratory distress
Severe bleeding
Severe organ impairment:
AST or ALT 1000
and/or impaired consciousness

Requires emergency
treatment and urgent
referral

When to start and stop intravenous fluid therapy

Febrile phase
Limit IV fluids
Early IV therapy may lead to fluid overload especially with non-isotonic
IV fluid
Critical phase
IV fluids are usually required for 2448 hours
NOTE: For patients who present with shock, IV therapy should be <48
hours
Recovery phase
IV fluids should be stopped so that extravasated fluids can be
reabsorbed
Minimum required to maintain good perfusion and urine output of 0.5ml/kg/hr
Reduce IV infusion rate in step-wise manner whenever:
Haemodynamic state is stable
Rate of plasma leakage decreases towards end of critical phase indicated by:
Improving haemodynamic signs
Increasing urine output Adequate oral fluid intake
Haematocrit decreases below baseline value in a stable patient

Four phases of intravenous fluid therapy: a

conceptual model E.A. Hoste, BJA 2014

How to calculate ideal

weight for
overweight/obese children
There is no consensus on the best method for calculating IBW
for children.
If a child is overweight or obese (i.e. BMI-for-age 85% and 95%,
respectively) use US growth charts
Calculate IBW using Body Mass Index Method:
[BMI at the 50th percentile for that child's age height in meters)2]

Example:
4 years old and 105 cm tall? (BMI at 50th percentile for
age/sex is 15.3)
IBW = 15.3 1.05 1.05 = 16.9 kg.

Group C: Emergency treatment

Compensated shock (systolic pressure maintained + reduced perfusion)

Conduct CBC, HCT, GXM and other

blood investigations before fluid
resuscitation

Obtain reference blood readings for all shock

patients before fluid therapy.
Start IV fluid resuscitation

Start IV fluid therapy with

isotonic crystalloids: 510
ml/kg/hr (adult) or
1020 ml/kg/hr (child) for 1 hour

*REASSESS

Then reassess haemodynamic response:

Vital signs
Peripheral perfusion: 5-in-1 magic touch, CCTV-R
Urine output
Decide if improved or not improved

Group C: Emergency treatment

Compensated shock (systolic pressure maintained + reduced perfusion)
Start isotonic crystalloid therapy 510 ml/kg/hr (adult) or
1020 ml/kg/hr (child) for 1 hour

Step-wise
reduction of
isotonic crystalloid
therapy: 57
ml/kg/hr for 12
hours
35 ml/kg/hr for 2
4 hours
23 ml/kg/hr for 2
4 hours

If patients condition improves after first bolus,

reduce IV fluids gradually in step-wise manner.
Reassess and repeat HCT after 36 hours
If improved, decrease IV fluid volume and rate
Reassess and repeat HCT
If plasma leakage is still ongoing, further boluses
may be required
If oral intake and urine output improve, reduce IV
fluid volume and rate further

Further boluses may be

required

Clinical improvement or improved

oral intake: reduce fluids step-wise

Stop IV fluids at 2448 hours

Stop IV fluid therapy at 2448 hours

Group C: Emergency treatment

Compensated shock (systolic pressure maintained + reduced perfusion)
After first bolus, if patient has not
improved, check HCT.

Start isotonic crystalloid therapy 510

ml/kg/hr (adult) or
1020 ml/kg/hr (child) for 1 hour

*REASSESS
Increasing or
high HCT

Not improved

Check haematocrit

Crystalloid (2nd bolus) or colloid** 1020

ml/kg/hr for 1 hour

*REASSESS
If improved
Reduce IV
crystalloids to 710
ml/kg/hr
for 12 hours
Continue
step-wise reduction
of IVF

If not improved,
recheck haematocrit

If HCT increases or is still high, give

second bolus of crystalloid at
1020 ml/kg/hr for 1 hour. Use colloid**
if patient has already received several
boluses of crystalloid.
*REASSESS
If patient improves, reduce IVF rate to 7
10 ml/kg/hr for 12 hours, and continue
step-wise reduction of IVF.
If plasma leakage continues, further
boluses may be required in the next 2448
hours.
If not improved, recheck haematocrit

Group C: Emergency treatment bleeding?

Start isotonic crystalloid therapy 510
ml/kg/hr (adult) or
1020 ml/kg/hr (child) for 1 hour

Not improved

*REASSESS

Check haematocrit

Decreasing HCT
Urgent blood
transfusion

YES

Continue step-wise
reduction of IVF

Severe overt bleed

After first bolus, if patient has not

improved, check HCT.
If HCT decreases or is lower than baseline,
look for severe bleeding (gastrointestinal
haemorrhage, haematoma)
If severe bleeding is present, transfuse
blood urgently, using
510 ml/kg packed red cells or 1020
ml/kg fresh whole blood. Give colloid until
blood becomes available.
If patient improves after blood transfusion,
continue step-wise
reduction of IVF.

Compensated shock (systolic

pressure maintained + reduced
perfusion)

Group C: Emergency treatment bleeding? (cont.)

Compensated shock (systolic pressure maintained + reduced perfusion)
Start isotonic crystalloid therapy 510
ml/kg/hr (adult) or
1020 ml/kg/hr (child) for1 hour

After first bolus, if patient has not

improved, check HCT.

Not improved

*REASSESS

If HCT decreases or is lower than

baseline, look for severe bleeding
(gastrointestinal haemorrhage,
haematoma)

Check haematocrit
Decreasing HCT
Urgent blood
transfusion

YES

Severe overt bleed

No

Continue step-wise
reduction in IVF

Colloid 1020 ml/kg/hr

Improved

Reduce IV colloids
710 ml/kg/hr for 12 hours
Continue step-wise reduction in IVF

*REASSESS

If NO bleeding is seen, give colloid 10 20 ml/kg

over 1 hour
*REASSESS
If patient improves after colloids, continue stepwise reduction of IVF

Not improved
Urgent blood transfusion

If patient has not improved, HCT would have

decreased. Transfuse blood urgently (same
volume as previous slide)

DISCHARGE CRITERIA
No fever for 24 48 hours
Improvement in clinical status
General well-being, good appetite, stable haemodynamic status,
adequate urine output, no respiratory distress and no organ
dysfunction

Increasing trend of platelet count (usually preceded by rising

WBC)
Stable haematocrit with oral intake and off IV fluids

Rash characteristic of
dengue

Who needs to be followed up?

Follow up patients with organ
impairment

REFERENCES
1.Dengue update 2015
2.Management of Dengue in Children CPG
3.CDC