Case Discussion On Dengue Fever Dengue Virus

CASE DISCUSSION ON DENGUE FEVER
DENGUE VIRUS
- Causes dengue and dengue hemorrhagic fever
- It is an arbovirus, and within this group it is a flavivirus, in the same family as the viruses that
cause yellow fever, St. Louis encephalitis, West West Nile fever and Japanese encephalitis Nile
fever, and Japanese encephalitis
- Transmitted by mosquitoes
- Composed of single of single-stranded stranded RNA
- Has 4 serotypes (DEN-1, 2, 3, 4)
- Each serotype provides specific lifetime immunity, and short-term cross-immunity
- All serotypes can cause severe and fatal disease
- Genetic variation within serotypes
- Some genetic variants within each serotype appear to be more virulent or have greater epidemic
potential
Transmission of Dengue Virus by Aedes
The The transmission cycle of dengue virus by the transmission cycle of dengue virus by the
mosquito Aedes aegypti begins with a dengue infected person. This person will have virus circulating
in the blood—a viremia that that lasts for about 5 days.
During the viremic period, an uninfected female Aedes aegypti mosquito bites the person and ingests
blood that contains dengue virus. Although there is some evidence of transovarial transmission of dengue
virus in Aedes aegypti, usually mosquitoes are only infected by biting a viremic person
Then, within the mosquito, the virus replicates during an extrinsic incubation period of eight to twelve
days. The mosquito then bites a susceptible person and transmits the virus to him or her, as well as to
every other susceptible person the mosquito bites for the rest of its lifetime
The virus then replicates in the second person and produces symptoms. The symptoms begin to appear
an average of four to seven days after the mosquito bite—this is the intrinsic incubation period, within
humans. While the intrinsic incubation period averages from four to seven days, it can range from three to
14 days The viremia begins slightly before the onset of symptoms.
The viremia begins slightly before the onset of symptoms.

Symptoms caused by dengue infection may last 3 to 10days, with an average of five days, after the onset
of symptoms—so the illness persists several days after the viremia has ended
Replication and Transmission of Dengue Virus
1. The virus is inoculated into humans with the mosquito saliva
2. The virus localizes and replicates in various target organs for example local lymph nodes and the liver
, for example, local lymph nodes and the liver
3. The virus is then released from these tissues and spreads through the blood to infect white blood cells
and other lymphatic tissues
4. The virus is then released from these tissues and circulates in the blood.
5. The mosquito ingests blood containing the virus
6. The virus replicates in the mosquito midgut, the ovaries, nerve tissue and fat body. It then escapes into
the body cavity, and later infects the salivary glands
7. The virus replicates in the salivary glands and when the mosquito bites another human, the cycle
continues.
Aedes aegypti Mosquito

- The most common epidemic vector of dengue in the world is the Aedes aegypti mosquito.
- It can be identified by the white bands or scale patterns on its legs and thorax.
- Dengue transmitted by infected female mosquito
- Primarily a daytime feeder
- Lives around human habitation
- Lays eggs and produces larvae preferentially in artificial containers
Risk Factors Reported for DHF:

a) Virus strain: DHF can occur in primary infection with certain genetic strains of virus
b) Pre-existing anti-dengue antibody, either caused by previous infection or to maternal antibodies
previous infection or to maternal antibodies passed to infants
c) Host genetics—for example, race seems to be a factor: data from Cuba suggest that whites may
data from Cuba suggest that whites may be at greater risk, and blacks at lower risk.
d) Age—in Southeast Asia, children are most affected, though in the Americas, all age- groups
are affected Higher risk in secondary infections
e) Higher risk in locations with two or more serotypes circulating simultaneously at high levels
(hyperendemic transmission)
Clinical Manifestations of Dengue and Dengue Hemorrhagic Fever
four dengue clinical syndromes:

1. Undifferentiated fever
2. Classic dengue fever
3. Dengue hemorrhagic fever, or DHF
4. Dengue shock syndrome, or DSS.
Undifferentiated Fever
- May be the most common manifestation of dengue
- Prospective study found that 87% of students infected were either asymptomatic or only mildly
symptomatic
- Other prospective studies including all age-groups also
demonstrate silent transmission
Clinical Characteristics of Dengue Fever
Dengue fever is an acute viral illness characterized by:
a) fever, often with sudden onset;
b) Severe headache, often described as retro-ocular;
c) Myalgias and arthralgias that can be very severe;
d) Nausea and vomiting;
e) A rash that may present at different stages of the illness, and whose appearance can be variable
—it may be maculopapular, petechial, or erythematous.
f) And Hemorrhagic manifestations
Signs and Symptoms of Encephalitis/Encephalopathy Associated with Acute Dengue Infection

Some cases may present with or develop encephalitic
or encephalopathic signs and symptoms, such as:
- Decreased level of consciousness—including lethargy, confusion, and coma
- Seizures;
- Nuchal rigidity; and Paresis.
- Some of these cases may subsequently develop typical dengue hemorrhagic fever.
Hemorrhagic Manifestations of Dengue
- Skin hemorrhages:
o petechiae, purpura, ecchymoses
- Gingival bleeding
- Nasal bleeding
- Gastrointestinal bleeding:
o hematemesis, melena, hematochezia hematochezia
- Hematuria
- Increased Increased menstrual flow menstrual flow
Clinical Case Definition for Dengue Hemorrhagic Fever

- Fever, or recent history of acute fever
- Hemorrhagic manifestations
- Low platelet count (100,000/mm3 or less)
- Objective evidence of “leaky capillaries:”
 Elevated hematocrit (20% or more over baseline)
 low albumin
 Pleural Pleural or other effusions or other effusionsClinical Case Definition for
Dengue Shock Syndrome
The four criteria for DHF
Evidence of circulatory failure manifested indirectly by all of the following:
- Rapid and weak pulse
- Narrow pulse pressure (< 20 mm Hg) OR hypotension for age
- Cold, clammy skin and altered mental status
- Frank shock is direct evidence of circulatory failure
There are four grades of DHF, For all grades the four criteria for DHF must be met:
- Grade 1
o Fever and nonspecific constitutional symptoms
o Positive tourniquet test is only hemorrhagic manifestation
- Grade 2
o Grade 1 manifestations + spontaneous bleeding
- Grade 3
o Signs of circulatory failure (rapid/weak pulse, narrow pulse pressure, hypotension,
cold/clammy skin)
- Grade 4
o Profound shock (undetectable pulse and BP)
Danger Signs in Dengue Hemorrhagic Fever

o Abdominal pain - intense and sustained
o Persistent vomiting
o Abrupt change from fever to hypothermia, with sweating and prostration
o Change in the mental status of the patient, going to be restlessness or somnolence.
o All of these are signs of impending shock and should alert clinicians that the patient
needs close observation and fluids.
Warning Signs for Dengue Shock

This thermometer illustrates the developments in the illness that are progressive warning signs that DSS
may occur :
Laboratory Tests in Dengue Fever

Clinical laboratory tests
o CBC—WBC, platelets, hematocrit
o Albumin
o Liver function tests
o Urine—check for microscopic hematuria
Dengue-specific tests
o Virus isolation
o Serology
Laboratory Methods for Dengue
- two most important types of analysis are
- virus isolation(serotyping) and immunoglobulin M enzyme and immunoglobulin M enzyme
linked immunoassay, or IgM ELISA.(basic test for serologic diagnosis)

Treatment
- If the patient has no hemorrhagic manifiestations and is well-hydrated, he or she can be sent
home with instructions for "followup."
- If there are hemorrhagic manifestations or hydration status is borderline, the patient should be
observed, either in an outpatient observation center or in the hospital
- If warning signs are present even without warning signs are present even without evidence of
shock, or if DSS is present, the patient should be hospitalized
Treatment of Dengue Fever

- Fluids.
- Rest
- Antipyretics—aspirin and nonsteroidal antiinflammatory inflammatory drugs such as ibuprofen
should be drugs such as ibuprofen should be avoided so that platelet function will not be
impaired.
- Monitoring of blood pressure urine output hematocrit, platelet count, and level of consciousness
- Mosquito Barriers
Treatment of Dengue hemorrhagic fever:

- Close monitoring
- oxygen
- Rapid intravenous replacement of fluids and electrolytes
- plasma or colloid preparations
- Transfusions of fresh blood or platelets suspended in plasma
- Paraldehyde or chloral hydrate may be required for children who are markedly agitated
- Salicylates are contraindicated
Vector Control Methods:
1. Chemical Control
- Larvicides may be used to kill immature aquatic stages
- Ultra-low volume fumigation ineffective against adult mosquitoes
- Mosquitoes may have resistance to commercial aerosol sprays
2. Environmental Control
a) Biological control
- Largely experimental
Option: place fish in containers to eat larvae
b) Elimination of larval habitats
- Most likely method to be effective in the long term likely method to be effective in the long term

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CASE DISCUSSION ON DENGUE FEVER

The viremia begins slightly before the onset of symptoms.

Aedes aegypti Mosquito

Risk Factors Reported for DHF:

Clinical Manifestations of Dengue and Dengue Hemorrhagic Fever

four dengue clinical syndromes:

Signs and Symptoms of Encephalitis/Encephalopathy Associated with Acute Dengue Infection

Clinical Case Definition for Dengue Hemorrhagic Fever

Danger Signs in Dengue Hemorrhagic Fever

Warning Signs for Dengue Shock

Laboratory Tests in Dengue Fever

Treatment of Dengue Fever

Treatment of Dengue hemorrhagic fever:

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