(Flavivirus)50nm, RNA,11000 base pairs C-protein,M-protein, E-protein. DEN-1,DEN-2,DEN-3,DEN-4

1234

3~8 (: 14)

1 ~ 5

3

Aedes aegypti : Nervous feeder : bite > 1 host to complete one blood meal Need more than 1 feed to complete the gonotropic cycle multiple casesAedes albopictus :

4

5

6

WHO: comprehensive guidelines for prevention & control of dengue & DHF, 2011DHF DF + bleeding 7

50-90% (DHF) (DSS)

8

9WHO classification & grading

WHO: comprehensive guidelines for prevention & control of dengue & DHF, 201110WHODHF/DSSDHF: 11*

*

Suggested dengue case classification and levels of severity

12Unusual or atypical manifestations of dengue

WHO: comprehensive guidelines for prevention & control of dengue & DHF, 201113Unusual or atypical manifestations of dengue

WHO: comprehensive guidelines for prevention & control of dengue & DHF, 2011143812 39403615(1)38(2)12(3)39403631223(4)24(breakbone fever)3 ~6

16

47

White island in Red sea

-

: :

(): : 20% (): 20%3gm/dl

18 (tourniquet test): (2.5) petechiae : (2.5x2.5=6.25)20 petechiae

19

20

Hct: 39, PLT 22K, WBC 6400/uL, GOT 329, GPT 256Hct: 35.5, PLT 35K, WBC 4600/uL, plasma reabsorptionDay 6 Day 921 - : DSS

20 mmHg)

12 22DSS12

DIC

shock Shock: D5 or D6: fluid reabsorptionfluid overload23: (PMN) CBC

24 1020%18 42%45%50%

25 - WBC3 5 RBCPLTGPTA/G10Hct PLT 10*DHF*: DHFDHF39

Chief Complaintfever and general malaise for 4 daysThis 15-year-old girl has no significant past medical history. She went to Cambodia on 8/10~8/17 with her church group for a mission trip. After coming back, she started to have mild fever with temperature of 37.5~38.0. The fever was accompanied by rhinorrhea and a mild cough with sputum.

Present Illness41ER Initial Evaluation 8/21Influenza rapid test: negative

Hb: 13.1 g/dL Ht: 38.8%WBC: 1300 /mL ANC: 728 /mL DC: (0-56-0-0-16-28)PLT: 43103/mLCRP: 0.57 mg/dL

428/23 CBC, WBC/DC, ChemistriesHb: 14.7 g/dL Hct: 43.3% (11%)Reticulocyte: 1/1000 RBCsWBC: 1300 mL DC: (2-37-0-0-11-47-Atypical-Lym: 3)PLT:19103/mLANC: 507ASL(GOT):200 U/LALT(GPT):59 U/L LDH: 501 IU/L 438/25

448/27

45Description of demographics and clinical manifestations of fatal patients 10 fatality (8 M and 2 F; median age, 63.5 years) with DHF (7 grade II DHF and 3 DSS) a dengue-related mortality rate of 1.3%. Of these 10 fatal patients, the time lapses between onset and hospital presentation ranged from 1 to 6 days (median, 2 days) hospital presentation to fatality 2 to 18 days (median, 4.5 days)onset to fatality 4 to 21 days (median, 7.5 days) 9 was sampled for dengue diagnosis within 24 h after admission median from dengue onset to the definitive diagnosis was 5 days (range, 411 days) 46Causes of fatalitiesIntractable GI bleeding with hypovolemic shock: 4 DSS alone : 2 DSS with SAH K. P bacteremia and meningitis with septic shock sepsis due to VAP concurrent E. faecalis bacteremia +massive GI bleeding

47DHFCaseAgeOnsetReport as DHF ExpireUnderlying diseaseDHF symptom1608/278/318/31DMHTNLGI bleeding26610/2410/2410/24DMHTNUGI & LGI bleedingshock36911/311/811/7DMHTN cirrhosisUGI & LGI bleedingshock46410/1610/2410/23HTN ESRDgoutUGI & LGI bleedingshock54812/612/1712/17DMHTN ESRD hyperlipidemia CADUGI & LGI bleedingshock AMI 4GI bleeding 3shock, 1OHCA , DHF48Case 1 64 y/o M went to ER at 4AM, 2011/10/16 because of fever / bone pain since yesterday Lived in xx Chronic Kidney Disease, gout Hx At ER T/P/R=38/83/19, BP=138/86 mmHg lab: Hb=9.7gm/dl, PLT=121K, WBC: WNL, Seg=78%, Cr=7.3 Keto 1amp, N/S 250ml MBD (11AM): URI/pharyngitis: panadol, keflex, peace x 3 days

49Revisit ER on 10/19 7AM (D5)DOE and chest discomfort for 2 days T/P/R=37.4/103/24, BP=116/94 Muscle soreness(+), deny URI symptoms or skin rash , low grade fever (+), abdominal pain (+) Lab : WBC=7.5K, Hb=15gm/dl, PLT=37K, GPT=73,BUN/Cr=121/10, ABG=7.322/22/63/11.3, INR=1.15, aPTT=39.4 sAdmission at 11AM, BW=78Kg , IBW=60 Dengue: only NS1(+) Abd echo: ascites (+), CXR: bil lower lung infiltrate (+), cardiomegaly(+) Tentative diagnosis : dengue fever+ thrombocytopenia, acute onset of CKD 50Few bloody stool noted at 3PM, 10/20 Increase IVF =1000ml/day, and suspect DHF Worsening dyspnea on 4 : 30PM , plan to transfer to ICU Transfer to KMUH T/P/R=36/64/22, BP=91/42

51Case 2 60 y/o male, visit ER by 119 at 8:30 AM, 2011/8/31 because of SOB, nasal and anal bleeding this morning Lived in xx, wife and daughter had dengue Had fever for 4 days s/p LMD tx DM, HCVD Hx At ER T/P/R=37.8/138/30, BP=116/76mmHg, E4V5M6 08:35 profuse bleeding in mouth 08:47 CPR Lab : WBC=9.2K, N/L=77/19, Hb=17.8, Hct=51.5%, PLT=20K Cr=1.6,AST/ALT=176/73, sugar=330, HbA1c=10.3, Transfer to ICU, repeated CPR, AAD at 11:50AM

52Case 370 y/o male, visit ER at 7PM, 2011/11/5 because of fever x 3 days, anorexia, tarry stool Lived in xxHTN, DM (+) At ER (D3) T/P/R, 36.9 /103/20, BP=161/103 mmHg, Lab : WBC =5.61K, Hb=16.6 gm/dl, Hct=49.4%, PLT=44K,BUN/Cre=25/1.1, ALT=115 MBD at 11PM, Dx : fever, cause? r/o UGIB , thrombocytopenia

53Revisit ERRevisit ER at 7PM the next day (D4) because of general weakness, At ER (11/6) T/P/R=36.8 /137/20, BP=92/65mmHg, consciousness clear Lab : WBC=6.14K, Hb=14.4 gm/dl, Hct=43.4%, PLT=16K, ALT/AST=242/353, Bun/Cre=36/1.3, Glu=418, CRP=1.7, s/p PLT B/T, arrange PES

54At ER (11/7) 5AM: BT=38 , tarry stool, BP=93/63mmHg, 6AM: WBC=7.67K, Hb=10.7, Hct=32.2, PLT=17K, s/p PRBC, PLT, FFP B/T 12 AM: SBP=40, s/p endo intubation ,r/o UGIB related 4 PM: skin rash seen, notify dengue 9 PM: AAD55Case 4 48 y/o female, went to ER by 119 at 7PM, 2011/12/08 because of general malaise, fever for 2 days Lived in xx DM, HTN, CAD (+) ESRD under H/D At ER T/P/R=37.8/88/16, BP=166/89, Lab : WBC=4.9K, Hct=34.7%, PLT=97K, AST/ALT=454/256 Notify dengue on 12/11, and stayed at ER till 12/13

56At ward 12/15 : T/P/R=37.1/80/20, BP=80/55mmHg, At night tarry stool (+), consciousness disturbed Lab: WBC=11.3K, Hct=31.3%, PLT=158K, AST/ALT=51/42 12/16: WBC=22.1K, Hct=40.5%, PLT=256K, sudden collapse s/p CPR, At ICU added tazocin, profound shock (+) died on 12/17

57Lesson learned Reducing dengue mortality requires an organized process that guarantees early recognition of the disease, and its management and referral when necessaryWhen major bleeding does occur, it is always associated with Profound shock ThrombocytopeniaHypoxia and acidosisMultiple organ failure Disseminated intravascular coagulation58: infants and the elderlyobesitypregnant womenpeptic ulcer diseasewomen who have menstruation or abnormal vaginal bleedinghemolytic diseases, e.g. G-6PD deficiencythalassemia and other hemoglobinopathiescongenital heart diseasechronic diseases such as DM, HTN, asthma, ischemic heart dzchronic renal failure, liver cirrhosispatients on steroid or NSAID treatment

WHO: comprehensive guidelines for prevention & control of dengue & DHF, 201159Severe dengue should be consideredPatient from an area of dengue risk with fever of 27 days plus any of the following features:Evidence of plasma leakage, such as:high or progressively rising hematocrit;pleural effusions or ascites;circulatory compromise or shockSignificant bleedingAltered level of consciousnessSevere gastrointestinal involvementSevere organ impairment60Criteria for transfer Early presentation with shock (on days 2 or 3 of illness);Severe plasma leakage and/or shock;Undetectable pulse and blood pressure;Severe bleeding;Fluid overload;Organ impairment (such as hepatic damage, cardiomyopathy, encephalopathy, encephalitis and other unusual complications).6162Day 1 2 3 4 5 6 7 8 9