Today’s Morning Report is presented by Dr. Kendall!
THE DENGUE
Swahili: Ka dinga pepo → Caribbean, 1800s → West Indian
Spanish: dengue
Background
-Flavivirus transmitted by genus Aedes mosquito
-50 to 390 million annual infections, 25,000 deaths
-Primarily in the tropics, associated with urbanization
-1st infection – often asymptomatic, esp in children in endemic countries
-Non-immune adults – far more likely to develop classic symptoms of dengue
Pathophysiology
Infection → Viral replication (hepatocytes, endothelial cells, dendritic cells)
Inflammatory cytokines → fever, other non-specific symptoms
Bone marrow precursor destruction:
→ leukopenia
→ thrombocytopenia (petechiae, gingival bleeding)
→ “break bone pain”
Endothelial cell damage → capillary leakage → fluid extravasation → shock
Liver → elevated AST/ALT, hypoalbuminemia, coagulopathy (more bleeding)
Immunological Mystery
Four serologically similar but antigenically different viruses; DENV 1-4
Secondary infection (with different serotype) → non-neutralizing antibodies
→ unchecked viral replication
→ T cell involvement? Increased cytokines? (still unclear)
→ WORSE DISEASE PROGRESSION
Nomenclature
OLD: Dengue Fever – Dengue Hemorrhagic Fever (Grades 1-4)
NEW: Dengue (+/- warning signs) – Severe Dengue
DENGUE +/- WARNING SIGNS SEVERE DENGUE
| Probable DengueLive/travel endemic area
Fever + 2 of following: -nausea, vomiting -rash -myalgia -tourniquet test + -leukopenia -any warning sign
|
Warning signs-abdominal pain/tenderness
-persistent vomiting -clinical fluid accumulation -mucosal bleed -lethargy, restlessness -liver enlargement > 2cm – ↑Hct, ↓platelets
|
Severe plasma leakage-shock (DSS)
-fluid accumulation + respiratory distress Severe bleeding -as evaluated by clinician Severe organ involvement -liver: AST/ALT > 1000 -CNS: altered mental status -Heart, other organs |
Work-up
CBC, CMP, coags, fibrinogen
IgM, IgG for DENV 1-4
Treatment
Tylenol → avoid NSAIDs, aspirin (can worsen bleeding)
IV fluids – NS or LR
Shock (↑Hct) → crystalloids
Shock (↓Hct) → crystalloids + PRBCs
PRBC for hemorrhagic complications
Platelets and/or FFP for coagulopathy
Probable Dengue → needs prompt f/u
Dengue (with warning signs) → Admit
Severe Dengue → Admit
Jay Khadpe MD
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