Iii clinical manifestations of dengue and dengue hemorrhagic fever
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CENTERS FOR DISEASE CONTROL AND PREVENTION. III. Clinical Manifestations of Dengue and Dengue Hemorrhagic Fever. Dengue Clinical Syndromes. Undifferentiated fever Classic dengue fever Dengue hemorrhagic fever Dengue shock syndrome. Undifferentiated Fever.

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III. Clinical Manifestations of Dengue and Dengue Hemorrhagic Fever

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Iii clinical manifestations of dengue and dengue hemorrhagic fever

CENTERS FOR DISEASE CONTROL

AND PREVENTION

III. Clinical Manifestations of Dengue and Dengue Hemorrhagic Fever


Dengue clinical syndromes

Dengue Clinical Syndromes

  • Undifferentiated fever

  • Classic dengue fever

  • Dengue hemorrhagic fever

  • Dengue shock syndrome


Undifferentiated fever

Undifferentiated Fever

  • May be the most common manifestation of dengue

  • Prospective study found that 87% of students infected were either asymptomatic or only mildly symptomatic

  • Other prospective studies including all age- groups also demonstrate silent transmission

DS Burke, et al. A prospective study of dengue infections

in Bangkok. Am J Trop Med Hyg 1988; 38:172-80.


Clinical characteristics of dengue fever

Clinical Characteristicsof Dengue Fever

  • Fever

  • Headache

  • Muscle and joint pain

  • Nausea/vomiting

  • Rash

  • Hemorrhagic manifestations


Signs and symptoms of encephalitis encephalopathy associated with acute dengue infection

Signs and Symptoms ofEncephalitis/EncephalopathyAssociated with Acute Dengue Infection

  • Decreased level of consciousness: lethargy, confusion, coma

  • Seizures

  • Nuchal rigidity

  • Paresis


Hemorrhagic manifestations of dengue

Hemorrhagic Manifestationsof Dengue

  • Skin hemorrhages: petechiae, purpura, ecchymoses

  • Gingival bleeding

  • Nasal bleeding

  • Gastro-intestinal bleeding: hematemesis, melena, hematochezia

  • Hematuria

  • Increased menstrual flow


Clinical case definition for dengue hemorrhagic fever

Clinical Case Definition forDengue Hemorrhagic Fever

4 Necessary Criteria:

  • Fever, or recent history of acute fever

  • Hemorrhagic manifestations

  • Low platelet count (100,000/mm3 or less)

  • Objective evidence of “leaky capillaries:”

    • elevated hematocrit (20% or more over baseline)

    • low albumin

    • pleural or other effusions


Clinical case definition for dengue shock syndrome

Clinical Case Definition for Dengue Shock Syndrome

  • 4 criteria for DHF

  • Evidence of circulatory failure manifested indirectly by all of the following:

    • Rapid and weak pulse

    • Narrow pulse pressure ( 20 mm Hg) OR hypotension for age

    • Cold, clammy skin and altered mental status

  • Frank shock is direct evidence of circulatory failure


Four grades of dhf

Four Grades of DHF

  • Grade 1

    • Fever and nonspecific constitutional symptoms

    • Positive tourniquet test is only hemorrhagic manifestation

  • Grade 2

    • Grade 1 manifestations + spontaneous bleeding

  • Grade 3

    • Signs of circulatory failure (rapid/weak pulse, narrow pulse pressure, hypotension, cold/clammy skin)

  • Grade 4

    • Profound shock (undetectable pulse and BP)


Danger signs in dengue hemorrhagic fever

Danger Signs inDengue Hemorrhagic Fever

  • Abdominal pain - intense and sustained

  • Persistent vomiting

  • Abrupt change from fever to hypothermia, with sweating and prostration

  • Restlessness or somnolence

Martínez Torres E. Salud Pública Mex 37 (supl):29-44, 1995.


Iii clinical manifestations of dengue and dengue hemorrhagic fever

Warning Signs for Dengue Shock

  • Alarm Signals:

  • Severe abdominal pain

  • Prolonged vomiting

  • Abrupt change from fever to hypothermia

  • Change in level of

  • consciousness (irritability or somnolence)

  • Four Criteria for DHF:

  • Fever

  • Hemorrhagic manifestations

  • Excessive capillary permeability

  •  100,000/mm3 platelets

  • Initial Warning Signals:

  • Disappearance of fever

  • Drop in platelets

  • Increase in hematocrit

  • When Patients Develop DSS:

  • 3 to 6 days after onset of symptoms


Signs and symptoms in 57 hospitalized cases of dhf puerto rico 1990 1991

Signs and Symptoms in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

SIGNS AND SYMPTOMS FREQUENCY* PERCENT

Fever57100 %

Rash27 47.4%

Hepatomegaly 6 10.5%

Effusions 3 5.3%

Frank shock 3 5.3%

Coma 2 3.5%

Any hemorrhage**57100 %

* Minimum estimate, search was not uniform for all patients

** Only 2 (3.5%) cases had severe hemorrhagic manifestations


Hemorrhagic signs and symptoms in 57 hospitalized cases of dhf puerto rico 1990 1991

SIGNS & SYMPTOMS FREQUENCY*PERCENT**

Microscopic hematuria28 51.9%

Petechiae26 45.6%

Epistaxis13 22.8%

Gingival hemorrhage 8 14.0%

Blood in stools 8 14.0%

Positive tourniquet test 5 31.3%

Hemorrhagic Signs and Symptoms in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

* Minimum estimate; the search was not uniform for all patients

** Percents were calculated using the number of patients among

whom each symptom was sought as the denominator


Hemorrhagic signs and symptoms in 57 hospitalized cases of dhf puerto rico 1990 19911

SIGNS & SYMPTOMS FREQUENCY* PERCENT

Blood in vomitus 4 7.0%

Bleeding at venipuncture 4 7.0%

Hemoptysis 3 5.3%

Vaginal hemorrhage 2 3.5%

Gross hematuria 2 3.5%

Other hemorrhage** 2 3.5%

Hemorrhagic Signs and Symptoms in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

* Minimum estimate; the search was not uniform for all patients

** Only 2 (3.5%) cases had severe hemorrhagic manifestations


Clinical laboratory analyses in 57 hospitalized cases of dhf puerto rico 1990 1991

Test with Abnormal Result Frequency* Mean Result (Range)

Thrombocytopenia

Platelet count 57/57 (100%) 45,980 (9 - 99,000)

Increased Capillary Permeability

Hemoconcentration  0.20 34/57 (59.6%) 0.26 (0 - 1.0)

Low serum protein 18/51 (35.3%) 6.3 (3.8 - 8.3)

Low serum albumin 35/52 (67.3%) 3.5 (2.3 - 4.9)

Clinical Laboratory Analyses in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

* Average result in the tested cases


Profile of the progression of illness

Profile of the Progression of Illness

Mean Days from Onset of Symptoms, and

Mean Value (± 2 SD) of Selected Clinical Tests

57

Maximum

Hematocrit (%)

44

45.2

Minimum

Hematocrit (%)

36.3

34

88

Lowest Diastolic

(mm Hg)

23

99,000

65.6

Platelets

per mm3

45,980

42

9,000

5 6 7 8

DAYS AFTER ONSET

Average admission - day 4.5

Average discharge - day 11

Puerto Rico, 1990-1991 (N=57 patients)


Unusual presentations of severe dengue fever

Unusual Presentationsof Severe Dengue Fever

  • Encephalopathy

  • Hepatic damage

  • Cardiomyopathy

  • Severe gastrointestinal hemorrhage


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