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Management of Dengue Fever . Dr David Tran 16/09/09. Classic clinical dengue fever. Incubation period 3 to 14 days (usually 4 to 7 days) Sudden onset of fever with severe headache Retro-orbital pain, fatigue Often associated with myalgia and arthralgia

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Management of Dengue Fever

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Management of Dengue Fever

Dr David Tran

16/09/09


Classic clinical dengue fever

  • Incubation period 3 to 14 days (usually 4 to 7 days)

  • Sudden onset of fever with severe headache

  • Retro-orbital pain, fatigue

  • Often associated with myalgia and arthralgia

  • Duration of fever usually 5 to 7 days

  • Sometime maculopapular rash(50% to 66% of cases)

  • Other non specific signs as inflamed pharynx, gastro-intestinal symptoms


Classic definition of dengue fever(WHO 1997)


Hemorrhagic manifestations / biologic abnormalities

  • Petechiae, purpura

  • Gum bleeding, epistaxis, menorrhagia, gastro-intestinal bleedings (rare)

  • Thrombocytopenia, leukopenia with lymphopenia

  • Mild elevation of hepatic transaminases & LDH


Definition of dengue hemorrhagic fever (WHO 1997)


Dengue hemorrhagic fever & Dengue shock syndrome

  • Physiopathology: capillary leakage & hemorrhagic manifestations.

  • 4 to 7 days after the onset (at approximately the date of defervescence)

  • Abdominal pain, vomiting, consciousness troubles, hypothermia

  • Marked decrease in platelet count.

  • Mortality: up to 10 or 20%


Definition of dengue shock syndrome (WHO 1997)


Diagnosis of dengue hemorrhagic fever (triad of symptoms)

  • Hemorrhagic manifestations

  • Platelet count < 100.000 (often >3rd day of illness)

  • Evidence of plasma leakage (Hematocrite  pleural effusion, ascites, hypoproteinemia)


Lowest platelet count by day of illness in adult dengue hemorrhagic patients


Dengue shock syndrome

  • Rapid weak pulse & low blood pressure (BP < 90mmHg)

  • The duration of this shock is short after appropriate volume replacement therapy (Colloid or Cristalloid infusions)

  • Mortality rate is up to 40%


Different clinical presentation of dengue fever


Serodiagnosis of dengue fever

  • Serology (IgM capture ELISA)

  • Problem: negativity of the test early in the course of the disease > should be performed only 4 to 5 days after the onset of fever.

  • IgM: remain positive for 3 to 6 month

  • IgG: remain positive for life


Dengue NS1 antigen testing

  • Early detection of Ag NS1 in blood sample of infected patients > confirm early acute infection

  • Detection of all 4 types of dengue serotypes

  • Result available in 15 min. (BioRad® chromatographic strip test)

  • High specificity (100%) and positive predictive value


Although in some reports, the same efficiency of detection for virus of the 4 serotypes has been described for the Dengue Early ELISA and Strip tests (Dussart et al., 2008), A recent analysis of the performance of these tests in Vietnam suggests a lower sensitivity for DENV-2 compared with DENV-1 and DENV-3.


Problem of sensibility of NS1 detection tests(Ramirez, diagnostic microbiology & infectious disease, Sept 2009)

These tests in Vietnam suggests a lower sensitivity for DENV-2 compared with DENV-1 and DENV-3. Also, a decreased sensitivity for DENV-4 with the Dengue Early ELISA has been reported in studies from South America (Bessoff et al., 2008; Dussart et al., 2008).

A lower sensitivity for DENV-2 has been described in samples from Vietnam (Hang et al., 2009) tested by the PLATELIA™systems (ELISA and Strip) and belonging to the Asian genotype 1 (according to the classification of Twiddy et al., 2002).


Sensitivity of NS1 Ag detection tests according to the day of illness(Mc Bride, Diagnostic Microbiology & Infectious Diseases, 64 – 2009 – 31,36)


Management of dengue virus infected patient

  • Most of cases can be managed on an outpatient basis (antipyretic like paracetamol, bed rest, oral hydratation)

  • Platelet counts and hematocrite determination should be repeated at least every 24 hours

  • Patient with platelet count < 100.000 should be hospitalized (high risk for dengue hemorrhagic & dengue shock syndrome)


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