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Dengue Hemorrhagic Fever and DSS
1. Dr Soumar Dutta
Consultant & Coordinator– Emergency Medicine
Narayana Superspeciality Hospital, Guwahati
DENGUE HEMORRHAGIC
FEVER AND DSS
2.
3. What causes Dengue
Dengue is the most rapidly spreading mosquito-borne viral disease
of mankind, with a 30-fold increase in global incidence over the last
five decades.
Flavivirus
DEN-1
DEN-2
DEN-3
DEN-4
Dengue
7. Probable DF
2 or more
1. Headache
2. Retro-orbital Pain
3. Myalgia
4. Arthralgia
5. Rash
6. Hemorrhagic
Manifestations
ELISA based NS1 antigen/ IgM positive.Or
An acute febrile illness of 2-7 days duration during an outbreak
8. Confirmed DF
• Isolation of the dengue virus (Virus culture +VE) from serum, plasma, leucocytes.
• Demonstration of IgM antibody titre by ELISA positive in single serum sample.
• Demonstration of dengue virus antigen in serum sample by NS1-ELISA.
• IgG seroconversion in paired sera after 2 weeks with four fold increase of IgG titre
• Detection of viral nucleic acid by PCR.
9. DHF
Confirmed
DF
Thrombocytopenia
(<100 000 cells per cumm)
Haemorrhagic tendencies evidenced by one or more:
1. Positive tourniquet test
2. Petechiae, ecchymoses or purpura
3. Bleeding from mucosa, GIT, injection sites or other sites
Evidence of plasma leakage:
• A rise in haematocrit for age and sex > 20%
• A more than 20% drop in haematocrit
following volume replacement treatment.
• Signs of plasma leakage (pleural effusion,
ascites, hypoproteinemia)
11. DHF I: Fever of 2-7 days with two or more of following- Headache,
Retro orbital pain, Myalgia, Arthralgia with or without leukopenia,
thrombocytopenia and no evidence of plasma leakage
DHFII: Above plus some evidence of spontaneous bleeding in skin
or other organs (Malena, epistaxis, gum bleeds) and abdominal
pain. Thrombocytopenia with platelet count less than 100000/
cu.mm and Hct rise more than 20% over baseline.
DHFIII (DSS): Above plus circulatory failure (weak rapid pulse,
narrow pulse pressure < 20 mm Hg, Hypotension, cold clammy skin,
restlessness). Thrombocytopenia with platelet count less than
100000/ cu.mm and Hct rise more than 20% over baseline.
DHF IV (DSS): Profound shock with undetectable blood pressure
or pulse. Thrombocytopenia with platelet count less than 100000/
cu.mm and Hct rise more than 20% over baseline.
G
R
A
D
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12. 4-10
Days
Natural Course of the dengue infection
2-7 days 3-4 days after fever onset 6-7 days after fever,2-3 days
Febrile Critical Convalescent
Extrinsic
Incubation
period
13. Natural Course of the dengue infection
2-7
Days
Febrile Phase
Sudden Onset
High Grade Fever
Lasts 2-7 Days
Facial Flushing
Skin Erythema
Gen Body ache
Myalgia
Arthalgia
Headache
Retro Orbital Pain
14. Natural Course of the dengue infection
Critical Phase onset from around day 3–6 of illness, lasting for 48–72 hours
Unexplained “vasculopathy” : Capillary Leakage Syndrome
Hemorrhagic manifestations and hematological abnormalities - thrombocytopenia,
leukopenia and deranged hemostasis.
15. Natural Course of the dengue infection
Recovery Phase onset from around day 6-8 days of illness
Spontaneous reabsorption of fluids begins
Dysfunction of specific organs (hepatic failure or myocarditis) may persist for
several weeks after resolution of the vasculopathy
16. Pathogenesis of DHF & DSS
Exact pathogenesis is still unclear.
Immunopathologic response - Host immune responses play an important role in the
pathogenesis of DF.
• Complex immune mechanism.
• T-cell mediated antibodies cross reactivity with vascular endothelium.
• Enhancing antibodies.
• Complement and its products.
• Various soluble mediators including cytokines and chemokines.
17. Pathogenesis of DHF & DSS
“Cytokine Tsunami”.
Target
• Vascular endothelium
• Platelets
• Various organs leading to
vasculopathy and
coagulopathy
• Responsible for the
development of
haemorrhage and shock.
18. Pathogenesis of DHF & DSS
Capillary leakage and shock: mild/transient/profound.
Capillary Permeability
Pleural effusion
Ascites
Haemoconcentration
3-7
Days
• Loss of functionality of endothelial glycocalyx layer.
• Autoantibodies: Anti NS1 Ab against platelets & Endothelial Cell.
19. Pathogenesis of DHF & DSS
Coagulopathy in dengue
Unclear Mechanism
↓ Fibrinogen Level
Heparin Sulphate
Chondrotin Sulphate
↑ aPTT
20. Pathogenesis of DHF & DSS
Thrombocytopenia
Destruction of platelet (antiplatelet antibodies)
DIC
Bone marrow suppression in early stage
Peripheral sequestration of platelets
23. Clinical Manifestation of DHF/DSS
The clinical presentations depend on various factors such as age, immune status of
the host, the virus strain and primary or secondary infection.
Infection with one dengue serotype gives lifelong immunity to that particular
serotype.
25. Mild DF Severe DFModerate DF
A. Undifferentiated DF
B. Fever without
complications-
bleeding,hypotension
and organ
involvement.
C. Without evidence of
capillary leakage
DF with high risk and
Comorbid conditions
• Extreme of Age
• HTN/DM
• Pregnancy
• CAD
• Hemoglobinopathies
• Immunocompromised
• On Steroids, anti-coagulants
or immunosuppressants
DF with warning S&S
A. DF with warning S&S:
• Rec vomiting
• Abdominal pain/tenderness
• Gen weakness/Alt Mentation
• Pl effusion/ascites
• Hepatomegaly
• Increased Hct >20%
B. DHF I & II with minor bleeds
26. Severe DF
A. DF/DHF with significant hemorrhage
B. DHF with shock
C. Severe organ involvement
D. Severe metabolic disorder
27. Laboratory Diagnosis
ELISA based NS1 antigen test: acute infection, Early detection, Highly sensitive and specific.
IgM ELISA ~ 5 days. Disappears by 60 days.
Isolation of DEV (sample- 5 days)
IgG ELISA – differentiates Primary or Secondary DF
28. Management
• Treatment modality vary depending on severity of illness.
Confirmed DF
Bed rest during acute phase
Cold/tepid sponging to keep temperature < 38.5 C.
Antipyretics may be used to lower the body temperature. Paracetamol is DOC.
Aspirin/NSAIDS should be avoided.
Fluid and Electrolytes Correction
Intense monitoring
