dengue hemorrhage fever 2
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DENGUE HEMORRHAGIC FEVER
Dr. CHOEUNG Chea
MD, MMed (Paediatrics)
Diseases in Childhood
Updated : April 2008
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TRANSMISSION OF DENGUE VIRUS• Dengue virus cMlgeTAmnusStamryHkarxaMebs;
infected Aedes aegypti. • Virus
eFVIdMeNIrkñúgcrnþQaménmnusSEdlva)anxaM eFVIeLIgkñúgkMLúgeBl EdlGñkCMgWmanRKunekþA.
• Uninfected mosquitoes Gacqøg virus
RbsinebIva)anxaMmnusSEdlkMBugenAkñúgtMNak;kal viremic
• Virus
bnÞab;mkk¾eFVIkarvivtþenAkñúgxøÜnrbs;musxøakñúgryHeBl 8-10éf¶ munnwgvaGaccMlgeTAmnusSepSgeTót kñúgkMLúgeBlbWtQam rweBlsuwcMNIGahar.
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THE VIRUS• Dengue virus sßitenAkñúg family Flaviridae.
• Dengue virus man 4 serotypes (DEN-1, DEN-2, DEN-3, DEN-4)
EdleKGacEbgEckva)anedaysar serological methods.
• .kalNamnusSqøgvIrusén serotype NamYy vanwgbegáIteGayman immunity
mYyCIvitRbqaMgnwg reinfection
edaysarvirusén serotype RbePTenaH b:uEnþvabegáIteGayman immunity temporary and
partial RbqaMgeTAnwgvIrusén serotypes
RbePTepSg²eTót .
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THE HOST
• .kñúgcMeNam serotypes TaMg4 énvIrusénCMgWRKunQam vIrusén serotypes NamYyk¾edayGacbgáeGayman DF and DHF )anEdr .
• Dengue shock syndrome (DSS) ekIteLIgenAelI– .buKþlEdlFøab;qøgCMgWRKunQamBImunmk (Previous dengue infection)
– .enAelITarkenAeBlEdlRbBn½ækarBarCMgWRKunQamrbs;mþay enAelITarkmankarfycuH (Infants with waning levels of maternal dengue antibody)
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THE HOST
• Incubation manryHeBl 3-14 éf¶• Acute phase of infection: 5-7 éf¶• Followed by an immune respond
• Infection elIkTImYybegáIteGayman immunity
mYyCIvitRbqaMgnwg reinfection
edaysarvirusén serotype RbePTenaH b:uEnþvabegáIteGayman immunity temporary and
partial RbqaMgeTAnwgvIrusén serotypes 3
RbePTepSgeTót . • Infections elIkTI2 rW bnÞab;mkeTót
GacekItmanenAmYyryHeBl xøIeRkaymk .
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-Fever
-Flushed face
-Headache
-Retro-orbital pain
-Myalgia
-Arthralgia
-Rash
-Haemorrhagic
manifestation
-Leucopenia
Thrombocytopenia*
Hepatomegaly
capillary
permeability
Serous
effusion
(pleural, ascite)
Hypoprotidemia
Hypovolemia
(haemoconcentration)Shock
DIC
Intestinal
haemorrhage
Acidosis
Anoxia
Dead
DFDHF
DSS
*Trombocytopenia is not constant in DF
DENGUE PATHOGENESIS
Ag-Ab-complement complex
Primary Dengue infection
Secondary dengue infection
Neutralizing Ab for the same serotype dengue virus
Non-neutralizing Abs → need to enhancing Ab for new infected dengue serotype
Ag – Ab complex
Chemical substances released: C3a, C5a, IL-1, IL-6, TNF-α,
Histamine Increased vascular permeability
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Central Peripheric
Bone marrow suppression
Utilization-Excessive used for platelet aggravation-Consumptive coagulopathy
Platelet destruction
MECANISM OF THROMBOCYTOPENIA
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Proposed Hypothesis of Liver Damage
• Dysregulation of host immune response against virus
• Direct viral effect
Manifestation of dengue virus infection
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Asymptomatic
Symptomatic
Undifferentiate fever
Dengue fever (DF)
Dengue haemorrhagic
fever (DHF)
Classical DF
DF with unusual haemorrhage
No shock (DHF grade I and II)
With shock (DHF grade III and IV)
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DIAGNOSIS OF THE DENGUE INFECTION
Febrile phase Afebrile phase
DF
Acute and very high fever + 2 or more of following signs: Flushed face and/or conjunctival injection Headache Retro-orbital pain Cutaneous rash Haemorrhagic manifestation (petechiae, Tourniquet test+) Lab: Leucopenia Ht: normal
minman aggravation énCMgWeT (xusBI DHF), fÞúyeTAvij sPaBrbs;GñkCMgW mankarRbesIreLIg Lab: Ht: always normal Platelet: normal or
Symptoms and Laboratory
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DIAGNOSIS OF THE DENGUE INFECTION
Febrile phase Afebrile phase
DHF
Above DF signs + always very sensitive hepatomegaly (abdominal pain) Lab: Ht: still normal Platelets: still normal
The child status deteriorates: somnolence important asthenia abdominal pain
hemodynamic status ± compensated No signs of shock Lab: Ht: 20% of normal value Platelets: 100.000/mm3
Symptoms and Laboratory
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DIAGNOSIS OF THE DENGUE INFECTION
Febrile phase Afebrile phase
DSS
Same symptoms as DF/DHF Lab: Ht: still normal Platelets: still normal
Same symptoms as DHF + signs of circulatory failure with shock Lab: Ht: 20% of normal value (except digestive haemorrhage) Platelets: 100.000/mm3
Symptoms and Laboratory
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Grading the severity of dengue infectionType Grade Symptoms Laboratory
DF DHF
I
II
Fever with 2 or more of the following signs: flushed face, headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic signs Above signs plus: positive tourniquet test and/or bruising (ecchymosis) Above signs plus spontaneous bleeding or haemorrhage
-Leucopenia - +/- Thrombocytopenia -Normal Ht -Thrombocytopenia 100.000/mm3 - Ht 20% of normal value -Thrombocytopenia 100.000/mm3 - Ht 20% of normal value
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Grading the severity of dengue infection
Type Grade Symptoms Laboratory
DSS
III
IV
Above signs plus circulatory failure (weak and rapid pulse, narrow BP, hypotension, cold and clammy skin, restlessness Pronfound shock with undertectable pulse and/or BP
-Thrombocytopenia 100.000/mm3 - Ht 20% of normal value (except digestive haemorrhage) -Thrombocytopenia 100.000/mm3 - Ht 20% of normal value (except digestive haemorrhage)
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Tourniquet Test• Raise the blood pressure to mid
way between systolic and diastolic pressure for 5 minutes.
• Release the pressure and wait for 1 minute before reading the result.
• Positive test is considered when there is 10 petechia per square inches or 2.5 cm square cm
2.5 cm
2.5 cm
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Baseline Value for Ht
• Age 2 years = 30-35%
• Age > 2-10 years = 35-40%
• Age > 10 years = 40-45%
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Laboratory Tests for Dengue Infection
• Uncomplicated DHF case: Ht & Platelet count
• Complicated DHF case:– Blood grouping– Blood sugar– Blood electrolyte– Liver function test– Renal function test – Blood gas– Coagulogram (PTT, PT, TT)
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Confirmed Laboratory Test for Dengue Infection
• Early test:– 1. Viral isolation– 2. Polymerase Chain Reaction (PCR)– 3. Antigen detection infixed tissues
• Late test:– Serology test- Antibody detection: detectable
around or after the time of defervescence (usually day 5-7 of illness)
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Differential Diagnosis• .kRBa©il: RKunekþAxøaMg 39-
40oC with oculo-nasal and bronchitic catarrh. Rash, specific to the disease on the 4th-5th day and persistent fever during the rash.
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Differential Diagnosis• Rubella (German measles):
RKunekþAmFümkñúgkMLúgeBl 3-4 éf¶ rYcbnþeday rash, which characterized the disease. Retro-cervical and occipital lymphadenopahties are common.
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Differential Diagnosis• Typhoid fever: fever progressively increasing up
to 39-40oC and persistent after the 7th day, saburral tongue and rumbling of the right iliac fossa.
• Malaria: fever with thrombocytopenia often associated. History of travel or live in a malaria endemic zone. The fever persists over 7 days.
• Meningococcal meningitis: the shock with thrombocytopenia, caused by the meningococcemia before the appearance of a necrotic purpura, can simulate DSS.
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MENAGEMENT OF DF
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MENAGEMENT OF DF• Febrile phase (2-7 days):
– .eGayGñkCMgWsMrakeGay)aneRcIn ,Oral rehydration
– . RbsinebIkMedA >38oC RtUveGay Paracetamol
10mg/kg/dose, kMueGayelIsBI 4dgkñúgmYyéf¶
– .minRtUveGay ASPIRIN eT– .RtYtBinitü pla/Ht erógral;éf¶;cab;éf¶TI 3 eTA
• Afebrile phase (2-3 days):
– . eGayGñkCMgWsMrakeGay)aneRcIn– . RtYtBinitü Pla/Ht 2 dgkñúg1éf¶kñúgryHeBl
24-48h– Oral fluid therapy
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MENAGEMENT OF DF
• Convalescence phase (7-10 days):
– .KµandMbUnµanGVIBiesseT (No special advice)
– .kumarGacjaMcMNIGaharFmµta (Normal diet without any restriction)
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MENAGEMENT OF DHF
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MANAGEMENT OF DHF
• The manifestations and management of DHF during the febrile phase are the same as DF.
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MENAGEMENT OF DHFGRADE I & II
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Type of IV fluids• Crystalloid solutions
- 5%D/NSS- 5%D/N/2* (only for < 1 year of age)- 5%DLR- 5%DAR
• Colloid solutions - 10% Dextran 40- 10% Haes-Sterile
D= Dextrose, NSS= Normal Saline Solution, AR= Acetate Ringer, LR= Lactate Ringer
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Start IV fluid 3ml/kg/h crystalloid solutions over 1 – 3h
No improvement, stationary (2)
Continue with the same IV Continue with the same IV fluid for another 1 – 3hfluid for another 1 – 3h
Reevaluation VS hourly
Improvement (1)
IV fluid 3 ml/kg/h another 3h
Further Improvement
IV fluid therapy for DHF grade I & II
Improvement aggravation (3)
Reevaluation Ht, VS hourly
↓IV fluid to 1.5 ml/kg/h over 3h
Still improvement
IV fluid 1.5 ml/kg/h over 24 – 48h and stop
IV fluid to 6 ml/kg/h 1 – 3h
More aggravation (4)
See DHF grade III or IV
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1. Improvement:↓ Ht, stable pulse & Blood Pressure, ↑ urine diuresis
2. No improvement, stationary:Pulse and BP not changed and still having oliguria
3. Aggravation: pulse faster and oliguria
4. More aggravation: weak and rapid pulse or not detectable, narrow pulse pressure, hypotension or not measurable blood pressure
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MENAGEMENT OF DHF Grade I and II
• Convalescent phase:
– .jaMcMNIGaharFmµta– .mintMrUveGayeRbIfñaMeLIy
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MANAGEMENT OF DHF GRADE III
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• Crystalloid solutions:- 5%D/NSS- 5%DLR*- 5%D/AR
• Colloid solution: - Dextran 40- Fresh whole blood (FWB)
Type of solutions
* * Lactate Ringer solutions are contra-indicated Lactate Ringer solutions are contra-indicated in case of acidosis.in case of acidosis. NSS or Acetate Ringer should be used instead of LR NSS or Acetate Ringer should be used instead of LR in case of shockin case of shock
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Ht immediately, IV fluid 10ml/kg/h crystalloid solutions over 1 – 2h + oxygen
No improvementImprovement
↓ IV to 6 ml/kg/h over 3h
Further Improvement
IV fluid therapy for DHF grade III
Ht
↓IV to 3 ml/kg/h over 6h
Always improvement
↓IV to 1.5 ml/kg/h over 24 –
48h and stop
Control Ht
Ht
Dextran 40 10ml/kg/h and repeated if
necessary (not exceed 30ml/kg/day)
FWB 10ml/kg/h
Improvement
↓ IV fluid of crystalloid from 10 → 6 → 3 → 1.5 ml/kg/h
No improvement
ASCB* see complications
guideline
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• A – Acidosis (Bicarbonate Na 8.4%
1ml/kg/dose)
• S – Blood sugar (<60mg%) →
D10% 5ml/kg/dose.
• C – Calcemia ( Ca gluconate 10%
1ml/kg/dose Max: 1 ampoule
• B - Bleeding → Blood Transfusion, Platelet Transfusion
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• If shock: oxygen (nasal prongs)
- Infant < 1 year = 1L/min
- Children > 1 year = 2L/min
OXYGEN USED IN SHOCK CASES
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MANAGEMENT OF DHF GRADE IV
(PROFOUND SHOCK)
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• Crystalloid solutions:
- NSS
- AR
• Colloid solution: - Dextran 40
- Fresh Whole Blood
Type of solutions
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IV fluid therapy for DHF grade IV
NSS or AR 10ml/kg bolus
Improvement No improvement
NSS/AR 10ml/kg bolus5%NSS/DAR 10ml/kg 1 – 2h
Improvement No improvementNo improvementImprovement
Lab: Hct, blood gas, ionogram, Ca, LFT, BUN, creatinin, glucose
Hct ↑ Hct ↓
FWB 10ml/kg/hDextran 40 10ml/kg/h and repeated if necessary
Improvement
↓ IV 10 → 6 → 3 → 1.5 ml/kg/h discontinue IV after 24 – 48h
No improvementImprovement
ASCB and see complications guideline
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Follow up
• .tamdan: Vital sign (CIBcr- sMBaFQam- cgVak;degðIm- kMedA), capillary refill time nig SpO2
erógral; 15-30 min.
• Urine hourly
• Consciousness hourly
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Fluid Overload• The common causes:
– Early IV fluid therapy in the early febrile phase– Use of hypotonic solution– Do not reduce the rate of IV fluid and do not
discontinue IV fluid when entering convalescence period
– Do not use colloidal solution when indicates– Do not give blood transfusion when there is
concealed bleeding and continue giving crystaloid and colloidal solutions
– Do not calculate the amount of IV fluid according to ideal body weight in obese/overweight patients
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Note for Overweight Patients
• Use ideal body weight (weight for age) to calculate the IV fluid in overweight/obese patients
• Maximum weight for IV calculation is 50 kg (for adult and overweight patients)
Weight (kg) = 2 (Age + 4)
(Child aged between 1-10 years)
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Signs of Fluid overload • .ehImRtbkEPñk• .CIBcrvayxøaMg• Dyspnea (cgVak;degðImjab;)
• Crepitation enAelIsYtTaMgsgxag• .TMhMeføImeLIgFM
(Hepatomegaly)• Turgescence of jugular veins• CXR follow the heart size: increase the heart size
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Management of Patient with Fluid Overload
• Change IV fluid to Dextran 40
• Insert urinary catheter with special precaution
• Furosemide 1mg/kg/dose IV. Vital signs should be monitored every 15 min for at least 1 hour after furosemide and observe clinical signs of shock
• Shock: Colloidal solution: Dextran 40 10ml/kg/h IV over 10-15 minutes or until the patient has stable vital signs, usually not more than 30 min and then switch to crystalloid solution.
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kMrwtFmµtaén cgVak;degðIm nig
cgVak;ebHdUg eTAtamGayu
• .Gayu cgVak;degðIm
cgVak;ebHdUg • (qñaM ) (kñúg 1 naTI)
(kñúg 1 naTI)• < 1 30-40 110-160• 2 – 5 20-30 95-140• 5 – 12 15-20 80-120• > 12 12-15 60-100
Minimum BP = 70 + (Age in year x 2)
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Criteria sMrab;eGayGñkCMgW
ecjeTApÞH• .KµanRKunekþAy:agtic 24
em:agedayKµankareRbIfñaMbBa©úHkMedAeT .
• .GñkCMgWcab;epþImXøanGahareLIgvij• Visible clinical improvement
• .GñkCMgWmanenameRcIn• Stable haematocrit
• .qøgputy:agtic 2 éf¶eRkayBI recovery from shock
• .Kµan respiratory distress EdlbNþalmkBI pleural effusion or ascites
• Platelet count elIsBI 50.000/mm3
• No other complications
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THANK YOU
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