DENGUE HEMORRHAGIC FEVER

1
DENGUE HEMORRHAGIC FEVER

• PROF S SHIVAKUMARS UNIT
• D RAVI SHANKAR MD PG

2

• Komala
• 20yrs/ female
• Admitted on 11/ 04/ 06
• C/o
• Fever with rigor - 3 days
• Running nose
• Dry cough - 3 days
• Severe headache
• Body ache - 3 days
• Redness of eyes
• Maculopapular rash- 1 day

3

• No H/o
• Dysuria
• Jaundice
• Vomiting
• Diarrhea
• Bleeding symptoms
• Abdominal pain
• Vaginal discharge
• Past / Personal/ Family/ Drug H/o
• Nothing relevant

4
GENERAL EXAMINATION

• Conscious
• Oriented
• Febrile
• No pallor/ icterus/ cyanosis/ clubbing/
• Lt posterior cervical LN
• Maculo papular rash over the face and neck
• Conjuntival suffusion
• PR 110/ mt, BP 110/ 70mmHg
• Temp- 102 F, RR 18/ mt

5

• CVS
• RS NAD
• ABD
• CNS

DIAGNOSIS
VIRAL EXANTHEMATOUS FEVER
6
ON 12/ 04/ 06

• Morning
• Conscious
• Highly febrile
• Rash spread all over the body
• Conjunctival suffusion increased
• Little breathless
• PR 100/mt , BP 100/ 70
• ECG CXR normal
• Treated with IV fluids and antibiotics

7
ON 12/ 04/ 06

• Evening
• Conscious, Disoriented
• Febrile with severe rigors
• Restless
• Excessive sweating
• Breathless
• C/o
• Black vomitus
• Vaginal bleeding
• Epistaxis
• Sub conjunctival heamorrhage

8
Contd

• Suddenly patient
• Unconscious
• Peripheries became cold
• Sweating
• Urinary and fecal incontinence
• Pulse feeble 130/ mt
• BP - 50/ ?
• Hemogram done in the morning was normal

9
Contd

• Patient was treated with
• 3- 4 liters of Normal saline
• Fresh blood
• Platlet transfusion
• Dopamine infusion
• BP picked up and patient became conscious
• Patient shifted to IMCW
• PLATLET count done outside at 11pm
• 68,000/ cu mm

10
DIAGNOSIS
VIRAL HEMORRHAGIC FEVER ? DENGUE SHOCK SYNDROME
11
ON 13/ 04/ 06 in IMCW

• Conscious, oriented
• Afebrile
• No rash
• Severe conjunctival hage
• Loose stools
• Vaginal bleeding
• Blood stained vomiting
• BP stable
• Treated with IV fluids, platlets(12 units), blood
  transfusion ( 2 units ), antibiotics.

12
INVESTIGATIONS

• HEMOGRAM
• 12/04 17/04 20/04
• Hb 10.2 9.8 8.1
• TLC 54OO 4000 3600
• DLC P58 L42 P65L35 P63 L37
• ESR 12/ 20 8/ 20 10/ 22
• RBC 3.6 million 3.12 2.9
• PCV 3O 30 29
• PLATLET 68,000 50,000 1.45Lac

13
SERIAL PLATLET COUNT

• 12/ 04 / 06 - 68,000
• 18/ 04 / 06 - 50,000
• 21/ 04 / 06 - 1.45 Lacs
• 20/ 04 / 06 - 1.84 Lacs
• 24/ 04 / 06 - 2.1 Lacs

14
OTHER INVESTIGATIONS

• RFT
• UREA - 38 mg/ dl
• Creatinine- 1.0 mg/ dl
• Blood sugar - 138mg /dl
• LFT
• TB - 1.0 mg/ dl
• SGOT - 126 IU/ L
• SGPT - 83 IU / L
• SAP - 63 IU / L
• T. protein- 7.8 g/ dl
• Sr. Alb - 3.8 g/ dl

15

• QBC MP - -VE
• MSAT - -VE
• WIDAL - -VE
• DENDUE Ig M - VE
• Ig G - VE
• PS STUDY - Microcytic Hypochromic anemia and
  thrombocytopenia.
• USG ABD - N study

16
DIAGNOSIS

• DENGUE HEMORRHAGIC FEVER
• WITH
• DENGUE SHOCK SYNDROME

17
(No Transcript)
18
VIRAL HEMORRHAGIC FEVER

• DENGUE
• YELLOW FEVER
• EBOLA
• LASSA
• HANTA
• MARBURG
• RIFT VALLEY FEVER
• CRIMEAN CONGO

19
SIMILARITIES IN VHF

• All are membrane bound viruses
• All are RNA viruses
• Most have Zoonotic life cycles except DENGUE
• Acute fever and myalgia
• Capillary leak syndrome
• Host immune response decides severity of disease
• All infections are immunosuppressive
• All are mosquito or tick born

20
COMMON PATHOGENESIS

• Affinity to capillary endothelium
• Immune complex mediated endothelial injury
• Complement mediated increased capillary
  permeability

Increased capillary permeability Capillary Leak
ascites, pl effusion, edema Hypovolemia,
hypotension, shock, Hypoxia , Acidosis and
Hyperkalemia DIC
21
DENGUE

• RNA virus, Flavi viridae
• Four serotypes ( 1 4 )
• Transmitted by Aeidis aegypti and albopictus
• Artificial containers
• Day biter
• Mosquitoes infective life long
• Trans ovarian transmission
• Preferentially in urban areas
• Common in children and is mild than in adults

22
DENGUE - EPIDEMIOLOGY

• All continents are endemic except Europe
• 50- 100 million cases
• 5 lac DHF
• All 4 types reported in INDIA(12 common)
• Epidemics in INDIA
• 1970 DEN 3
• 1996 - DEN 2 ( Delhi )
• 2003 status
• 12,750 cases
• 217 deaths
• 1600 cases and 8 deaths in TN

23
DENGUE INFECTION
ASYMPTOMATIC
SYMPTOMATIC
DENGUE FEVER
DENGUE HEMORRHAGIC FEVER
BREAK BONE FEVER
WITHOUT SHOCK
VIRAL SYNDROME
WITH OR WITHOUT HEMORRHAGE
WITH SHOCK ( DSS )
24
CLINICAL FEATURES

• Undifferentiated fever with myalgia
• Typical dengue fever
• Older children and adults
• Biphasic fever ( 5 7 days )
• Head ache, Myalgia, arthralgia
• Upper Resp. symptoms
• Flushed face, retro orbital pain, photophobia
• RASH
• Diffuse flushing or fleeting pin point eruptions
  fece, neck chest during 1-3 days of fever
• Maculopapular or scarlantiform 4th day
• After defevescence petichiae and ve Tourniquet
  test
• Epistaxis, gum bleeding and GI bleeding may occur
• Lecopenia with left shift

25
DHF AND DSS

• High fever
• Hemorrhagic phenomena
• Peticheal rash
• Epistaxis
• GI bleed
• Vaginal bleeding
• Bleeding at IV cannula sites
• ve tourniquet test
• Thrombocytopenia
• Hemoconcentration
• Circulatory failure( Febrile to afebrile)
• Narrow pulse pressure
• Hypotension
• Cold clammy skin
• Cyanosis
• Profound shock
• ICH, convulsions and encephalopathy

26
DHF - GRADES

• Grade I - Fever
• Non sp symptoms
• Torniquet test ve
• Grade II - Spontaneous bleeding
• with above symptoms
• Grade III - Rapid, weak pulse
• Narrow pulse pressure
• Hypotension
• Grade IV - Profound Shock

Platelet lt 1 lac, PCV gt 20 in all grades
27
IMMUNOLOGY
DENGUE INFECTION
HETEROLOGOUS ANTIBODIES to other 3 serotypes
HOMOLOGOUS ANTIBODIES CMI
NEUTRALISING LEVEL 2-12 MONTHS (partial
protection )
LIFE LONG PROTECTION AGAINST SAME SEROTYPE
REDUCED TO NON NEUTRALISING LEVEL AFTER 12 MONTHS
28
IMMUNE ENHANCEMENT
PRIMARY DENGUE INFECTION
Secondary Dengue Infection diff serotype
NON NEUTRALISING LEVEL- Heterotypic Antibodies (
1 5 yrs)
MACROPHAGE
VIRUS
Highly infected Macrophage
29
DSS - PATHOGENESIS
Uncontrolled multiplication Of virus in Macrophage
Macrophage activation
Excessive release Of cytokines (TNF IL)
VASODILATATION INCREASED PEMEABILITY
HYPOTENSION
CAPILLARY LEAK
SHOCK
HEMATOCRIT
( INTERNAL HEMORRHAGE)
30
DSS - PATHOGENESIS
CD 8 mediated destruction of infected Macrophage
Release of proteolytic Enzymes
Immune complex
Viral endothelial damage
Complement activation
Coagulation activation
Thrombocytopenia
C 3a C 5a anphylotoxins
DIC( rare)
Potent vasodilatation/ Leak
31
DSS PRE REQUISITE

• Primary dengue infection
• Secondary sequential infection with other
  serotypes with in 1-5 yrs of primary infection
• DSS can occur in primary infection in infants who
  has maternal antibodies in non neutralizing level

32
LAB PROFILE

• Hemogram
• Leucopenia with relative Lymphocytosis
• Thrombocytopenia lt 1 lac
• PCV increased gt 20
• Prolonged PT aPTT
• Reduced complement levels
• Hypoproteinemia , mild SGOT SGPT elevations
• Virus isolation lt 5 days
• Serology - Ig M Ig G ELISA

33
Treatment of DF/ DHF

• Febrile phase
• Bed rest
• Paracetamol 4times/day
• Avoid Aspirin Brufen
• Avoid antibiotics
• Oral Rehydration therapy fluid loss due to
  vomiting / high temp. (2.5-4 litres /day)
• Afebrile phase - observe

34
DHF
CRYSTALLOIDS (RL/DNS)
Improvement
6ml/kg/hr
3ml/kg/hr
Discontinue after 6-12 hrs
No Improvement
CRYSTALLOIDS
6ml/kg/hr
10ml/kg/hr
No improvement
Hct?
Hct?
Blood transfusion
Colloids
discontinue
Crystalloids
10-6-3ml
improvement
improvement
35
DSS
Improvement
CRYSTALLOIDS (10-20 ml/kg/hr)
Reduce 10-6-3ml/kg/hr
No Improvement
CRYSTALLOIDS (10-20 ml/kg/hr)
Hct ?
Hct ?
Blood transfusion ( 10ml/ kg/ hr )
COLLOID
10-6-3ml
Discontinue
Crystalloids
Improvement
10-6-3ml
36
Points to be remembered

• Hct ? - IV Crystalloids or colloids (Dextran 40)
  or plasma (10 ml/kg/hr)
• Hct ? - Blood Transfusion (10ml/kg/hr)
• Platelets lt 5000cu.mm - platelet transfusion

37
thank u