What`s New in DHF: Clinical aspect

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Whats New in DHFClinical aspect

• Professor Siripen Kalayanarooj,
• Director, WHO Collaborating Centre for
• Case Management of Dengue/DHF/DSS,
• Queen Sirikit National Institute of Child Health.

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1. Adults is more affected than Children
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2. Expanded Dengue Syndrome
or Unusual Manifestations of Dengue

• Infant lt 1 year old
• Commonly found in adults
• In newly outbreak countries
• In endemic countries where there are limited
  laboratory facilities

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Expanded Dengue Syndrome(EDS)

• Encephalopathy confusion, seizure, coma
• Liver failure
• Renal failure
• Cardiac involvement myocarditis
• Other organs involvement

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Causes of EDS

• Prolonged shock Liver, renal, respiratory and
  other organs (unrecognized at the very
  beginning)
• Dengue infections in patients with underlying
  diseases DM, HT, Heart diseases, Thalassemia,
  Liver and renal diseases, etc
• Co-infections with other microbial agents
• Dengue virus virulence encephalitis, liver
  failure

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Clinical manifestations of EDS

• Mostly manifestations of DHF
• Complications
• Underlying diseases
• Co-infections

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Clues to diagnose EDS

• Detection of plasma leakage (early when the
  patients present to the healthcare facilities)
• Rising Hct 20
• Pleural effusion clinical, CXR right lateral
  decubitus, ultrasound
• Ascites clinical, ultrasound
• Hypoalbuminemia serum albumin 3.5 gm in
  normal nutritional status
• Other evidence of DHF
• Thrombocytopenia especially when platelet count lt
  50,000 cells/cumm.
• Clinical bleeding

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CXR compare between 2 positions
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Early clinical diagnosis Management

• Suspected EDS in patients with thrombocytopenia
  (platelet count 100,000 cells/cumm.) or
  clinical bleeding or shock with high fever
  (probably with encephalopathy)
• Look for evidence of plasma leakage, if positive
  more likely to have DHF with complication
• DHF with superimposed bacterial infections
• DHF with liver injury hepatitis, liver
  dysfunction/ failure
• DHF with concealed internal bleeding (mostly GI
  bleed)

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3. Dengue Classifications
1975, 1986, 1997, 2011
2009
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Dengue Classification

• Original WHO

• Newly suggested

• WHO 1975, 1986,1997, 2011
• Undifferentiated febrile illness
• Dengue Fever (DF)
• Dengue hemorrhagic fever (DHF)
• Dengue Shock Syndrome (DSS)
• Expanded Dengue Syndrome (EDS)

• WHO TDR 2009
• Dengue (D)
• Dengue Warning signs (D WS)
• Severe Dengue (SD)

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Dengue virus infection
10,000
Asymptomatic
Symptomatic
Viral syndrome Dengue
fever DHF




1,000
9,000
100
400
500
Plasma leakage

• Expanded dengue syndrome
• Prolonged shock liver failure,
• renal failure,Encephalopathy
• Co-morbidities
• 3. Co-infections
• 4. True dengue infection - encephalitis

DHF DSS
1-2
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(No Transcript)
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Suspected dengue infectionsFever with any 2 of
the followingsin dengue endemic area
Original WHO
Suggested New

• Headache
• Retro-orbital pain
• Myalgia
• Arthralgia/ bone pain
• Rash
• Bleeding manifestations (Tourniquet positive)
• Leukopenia
• Rising Hct 10-15
• Platelet 150,000 cels/cumm

• Nausea/ vomiting
• Rash
• Aches and pain
• Tourniquet positive
• Leukopenia
• Any warning signs

Tourniquet positive Leukopenia
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AT QSNICH OPD Suspected dengue cases that need
close observation

• Original

• Newly suggested

• Tourniquet positive Leukopenia
• 1,500 cases

• Warning signs nausea/vomiting and abdominal pain
• 30,000 cases
• (20 times more workload)

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QSNICH IPD (June August 2009)
Confirmed dengue Confirmed dengue Confirmed dengue Confirmed dengue
DF DHF DSS Dengue D with WS SD
180 72 22 85 160 29
180 94 85 189
Non- Dengue Non- Dengue Non- Dengue Non- Dengue
DF DHF DSS Dengue D with WS SD
19 5 0 10 13 1
19 5 10 14

Total clinical suspected dengue cases Total clinical suspected dengue cases Total clinical suspected dengue cases Total clinical suspected dengue cases
DF DHF DSS Dengue D with WS SD
199 99 95 203

Confirmed 274/298 91.9
Kalayanarooj S. J Med Assoc Thai 2011 94(3)
s74-83.
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Different between the two classifications
Original WHO
Suggested New

• Emphasize on
• plasma leakage and abnormal hemostasis (platelet
  count 100,000 cells/cumm)
• Rising Hct 20
• Pleural effusion PE, CXR (right lateral
  decubitus, ultrasound)
• Ascites PE, ultrasound
• Hypoalbuminemia (Alb 3.5 gm)

• Emphasize on
• warning signs
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation
• Mucosal bleed
• Lethargy, restlessness
• Liver gt 2 cm
• Lab. increase in Hct concurrent with rapid
  decrease in Platelet count

Need close monitoring
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Natural course of DHF
Day 1 2 3
4 5 6
7 8
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Shock
Fever
Pleural effusion, Ascites
Hematocrit
Plasma leakage
Stop leakage
Reabsorption
Fluid overload
IV fluid NSS, DAR, DLR Colloid 10Dextran,
10Haes-steril M5 Deficit ( 4,600 ml in adult)
WBC
Tourniquet test
WBC 6,000-9,000
5,000 Platelet count 200,000
100,000
lt50,000 Hct 35
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45 (rising 20) Albumin

3.5 gm Cholesterol

100 mg
Professor Siripen Kalayanarooj
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Early diagnosis by CBCGuide for management
Date HCT WBC PLT
Day 2 41 6,500 160,000
Day 3 43 4,200 143,000
Day 4 47 2,300 90,000
Day 5 39 70,000
BP 90/70 mmHg, P 118/min
AST/ALT 62/59
A 20-year-old woman Good consciousness
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Compare between 2 classifications

• Plasma leakage

• Warning signs

• Follow up platelet and frequent Hct (at least q 6
  hours) at critical period
• Can prevent shock and severe cases with
  complications of organs failure

• Follow warning signs which are non-specific
• Shock cannot be prevented. Organs failure as a
  consequence of prolonged shock are detected late
  with overt manifestations and poor prognosis

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Lahore Experienced (Sep.-Nov. 11)

• Total suspected cases 600,000 cases
• Confirmed 20,000 cases (lt 4)
• At the peak 4,000-6,000 patients/day
• Admission 500-600 cases/day
• Death 10-15 cases per day

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Multi-country study 18 countriesValidation
study of the newly suggested classification
Revised not classified Dengue without Warning Signs Dengue With Warning Signs Severe dengue Total
Not classify 23 57 159 29 268
DF 7 551 684 75 1,317
DHF 2 8 240 39 289
DSS 0 0 12 76 88
Total 32 616 1,095 219 1,962
Barniol J et al BMC Infectious Disease 2011,11
106
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Original and Newly suggested WHO Classification
for Dengue Severity 2005-2010 (total 494
patients)
DHFDSS 152 patients DWSD 467 patients
Narvaez F et al PlosNTD 2011, 5 e1397.
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Advantages

• Original WHO

• Suggested new

• Proven in reducing CFR
• Can prevent shock so less severe cases and less
  complications
• No need for confirmed dengue laboratories (PCR,
  NS1Ag, IgM/IgG tests) diagnosis DHF/DSS by
  clinical criteria correct gt 90

• Easy and friendly use
• Use only clinical especially warning signs.
• No need for any laboratory tests to follow up
  CBC
• Increase number of cases report so may be more
  effective control?

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Disadvantages

• Original WHO

• Suggested new

• Need follow up of laboratory test especially CBC
  and frequent Hct monitoring
• Need close monitoring especially during 24-48
  hours of critical period of plasma leakage

• More workload to healthcare personnel, at least
  20 times at OPD and 2 times for IPD
• More complication of fluid overload (admit and
  observe early with IV fluid infusion)
• More severe cases with EDS
• Need dengue confirm labs. except those with
  shock, with complication of fluid overload
• Increase in CFR

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4. IV fluid management in shock cases

• Original WHO

• Newly suggested

• 10 ml/kg/hr in children or 300-500 ml/hr in adult

• 20 ml/kg in 20 mins. and can repeat another 2
  times

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4. IV fluid management in non-shock
(compensated shock) cases

• Original WHO

• Newly suggested

• 1.5 ml/kg/hr in children or M/2 in early and
  adjust rate accordingly to clinical, vital signs,
  Hct and urine output

• 5-7 ml/kg/hr

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4. Others management

• Original WHO

• Newly suggested

• Colloidal solution only plasma expander
  (hyper-oncotic) - 10 Dextran-40 in NSS
• No platelet prophylaxis except in adults with
  underlying HT and Plt lt 10,000 cells/cumm.

• Any colloidal solution including FFP
• Platelet prophylaxis

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Hotline DHF089-2045522 M.D.089-2042255
GN.siripenk_at_gmail.com
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Thank you !!!