DHF

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DHF

• (Dengue hemorrhagic fever)

2
DHF

• Dengue virus
• Vector and transmitter
• Epidemiological
• Definition , Classification , Severity
• Diagnosis
• Manadement , Treatment
• ??? Refer

3
Dengue Virus

• Causes dengue and dengue hemorrhagic fever
• Is an arbovirus
• Transmitted by mosquitoes
• Composed of single-stranded RNA
• Has 4 serotypes (DEN-1, 2, 3, 4)

4
Dengue virus

• Each serotype provides specific lifetime
  immunity, and short-term cross-immunity
• All serotypes can cause severe and fatal disease
• Genetic variation within serotypes
• Some genetic variants within each serotype appear
  to be more virulent or have greater epidemic
  potential

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Epidemiological
6
????????????????????
7
Vector and Transmission

• Dengue Fever is an illness caused by infection
  with a virus transmitted by the
• Aedes mosquito.

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Aedes aegypti

• Dengue transmitted by infected female mosquito
• Primarily a daytime feeder
• Lives around human habitation
• Lays eggs and produces larvae preferentially in
  artificial containers

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Aedes aegypti Mosquito
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Aedes aegypti Mosquito
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Replication and Transmissionof Dengue Virus

• 1. Virus transmitted to
  human in mosquito
• saliva

2. Virus replicates in target organs 3. Virus
infects white blood cells and lymphatic
tissues
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Replication and Transmissionof Dengue Virus

• 4. Second mosquito
• ingests virus with blood
• 5. Virus replicates
• in mosquito midgut
• and other organs,
• infects salivary
• glands
• 6. Virus replicates
  in salivary glands

13
Life cycle of the Aedes Mosquito
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Dengue Clinical Syndromes

• Undifferentiated fever
• Classic dengue fever
• Dengue hemorrhagic fever
• Dengue shock syndrome

15
??????????
???????
Undifferentiated febrile illness
DF
DHF
no plasma leakage
plasma leakage
no bleeding
bleeding
Shock DSS
no shock
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Definition
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Undifferentiated Fever

• May be the most common manifestation of dengue
• ??????????? ???? ????????
• 87 of students infected a symptomatic or only
  mildly symptomatic
• ????? 2-3 ??? , ???????????????? (maculopapular
  rash)

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Dengue fever

• Classical DF break bone fever, rash ,
  hemorrhagic manifestation
• Tourniquet test Positive
• Leucopenia WBC lt 5000/mm3
• Thrombocytopenia plt lt 100,000/mm3
• Hct stable , ??? shock
• (??? shock ?????????????????)

19
Dengue Hemorrhagic Fever

• ??? 2-7 ???
• ???????? / Tourniquet test ve
• Platelet count lt 100,000 /cu.mm.
• Hct ? 20( plasma leakage )
• ??? Shock??? ( Grade III, IV )
• ?? evidence of plasma leakage

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Dengue shock syndrome

• ??????????? ??? ????????????? ???? ?????????
• ??????? ???? / ????
• ???????????????????? /Epigastium
• Capillary refill gt 2 sec
• BP - Pulse pressure ??? ( 20 )
• Hypotension / ?????????
• Pulse - ??? / ???? (???)

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Hemorrhagic Manifestations

• Skin hemorrhages petechia, purpura, echymoses
• Gingival bleeding
• Nasal bleeding
• GI bleeding hematemesis, melena, hematochezia
• Hematuria
• Increased menstrual flow

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Diagnosis
23
????????????? DF.

• Probable case ??????????????????? 2 symptom
• - ???????? -
  ?????? / ?????????
• - ??????????? - ????
• - ??????????????????? -
  ?????????????
• - CBC ?????????????????
• HI antibody gt 1280 , positive IgM/IgG ELISA
  test

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????????????? DF.

• Confirm case
• ????????????????? virus ???/????
  ????????? antibody ?????????????????

25
????????????? DHF.

• ????????????????????????????? 2-7 ???
• ????????????? (????????? Tourniquet test ve)
• Plt. Count lt 100,000/cu.mm
• Hct ? 20 ???? ?? sign of plasma leakage
• ( pleural effusion , ascites ,
  hypoalbuminemia )

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????????????? DSS

• 4 criteria ??? DHF
• Evidence of circulatory failure
• - 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

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Clinical manifestations

• 3 Stages
• 1. Febrile stage. ( ??????? )
• 2. Toxic stage. ( ????????? ---????????? )
• 3. Convalescence stage. ( ??????????? )

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Febrile stage

• ?????????2-7??? , biphasic (?????????)
• ???????(Flushed face) , Infected pharynx
• GI symptom ??????? , ?????????? , ???????
• ???????? , ??????????????

38.5 - 41 c
38.5 - 41 c
??????7
37.5 c
37.5 c
??????10
29
Febrile stage

• PE tender at RUQ , Hepatomegaly
• (?????????????????? 3-4??????)
• Hemorrhagic manifestation
• Tourniquet test positive
• (?????????????????? 2-3?????? )

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Tourniquet test

• ???????? 1 ve 50
• ???????? 2 ve 80
• ???????? 3 ve 90
• Tourniquet test ??????? Capillary
  fragility
• ?????? Vascular permeability

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Tourniquet Test

• Inflate blood pressure cuff to a point midway
  between systolic and diastolic pressure for 5
  minutes
• Positive test 20 or more petechia per 1 inch2
  (6.25 cm2)

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Petechiae
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Tourniquet test

• ???????? false negative ??
• 1. ????shock
• 2. ???????????
• 3. ??????????
• 4. ?????????

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Toxic stage

• ???????????????????
• ?? Plasma leakage
• ?? DF. ????????????????????? V/S ???? , Hct
  stable
• 1 ?? 3 ?????????? DHF Hypovolumic shock
• ???? shock ?????????????????????????????????????

35
Toxic stage

• Circulatory failure manifestation
• - pulse ???/????
• - Narrow pulse pressure ( 20 mm Hg) OR
  hypotension for age
• - Cold, clammy skin and altered mental status

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Toxic stage

• ????????????? Shock
• 1. Plasma leakage
• ????????????????????????
  ????????????????? ??????? 24 - 48 ??.
  ???????????????? leakage ??????
• Plasma loss blood loss
• Acute loss 20 - 25
  Shock

Hypovolumic shock
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Toxic stage

• Sign of plasma leakage
• - ????? Hct ??????????????
  Hct ????? gt20
• - ?????????????????????????
• - serum protein ,albumin
  ??????????????
• - central venous pressure ???

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Toxic stage

• Peripheral resistance ?????????
• - pulse pressure ??? (lt20mmHg)
• - Diastolic pressure ???????

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Severity

• Four Grades of DHF
• Grade I
• ?????????????? ????? positive tourniquet
  test ???/ ????
• easy bruising
• Grade 2
• Grade I Hemorrhagic manifestation

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Severity

• Grade 3
• Signs of circulatory failure (??????? ,
  ?????????????pulse ???/???? , pulse pressure ???
  , hypotension)
• Grade 4
• Profound shock (??????????????? ???/????
  ?????????????? )

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Severity

• 
  DHF gr 1,2
  ?????????? DF ?????? ??plasma leakage ???
  ???????????????

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Convalescence stage

• Apitizer
• Bradycardia
• Convalescent rash
• Diuresis
• Vital sign stable , Hct ????
• ????????? Pulmonary edema , Heart failure

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Laboratory finding

• leucopenia (lt 5,000cu/mm3)
• Thrombocytopenia (lt 100,000cu/mm3)
• Hemoconcentration (Hct gt 20)
• Abnormal coagulogram(???????? shock ????????????
  Disseminated Intravascular Clot DIC)
• CXR Pleural effusion
• Abnormal liver function test

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Laboratory finding

• ESR
• UA urine spec. , RBC ve (80)
• ketone ve (38)
• Electrolyte imbalance

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Right pleural effusion
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Laboratory

• MAC-ELISA
• Rapid ELISA test
• Haemagglutination-inhibition test
• Neutralization test
• Dot-Blot immunoassay
• Complement fixation test

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Treatment
48
Febrile Stage

• Antipyretics
• avoid aspirin and non-steroidal anti-inflammatory
  drugs
• Paracetamol 10 mg/kg/dose if Tgt39 ?c
• Tepid sponge

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Febrile Stage

• Diet
• soft diet
• milk, fruit juice, ORS if anorexia
• avoid red ,brown or black color diet
• if no sign of dehydration, IV fluid is not
  necessary

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Febrile Stage

• Drugs
• avoid unnecessary drugs
• if severe vomiting, consider domperidone 1
  mg/kg/day devided to tid.
• Anticonvulsants can be continued
• no antibiotics
• H2blocker is controversy

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Febrile Stage

• IV fluid
• sign of dehydration and vomiting
• 5D/N/2 ????????
• 5D/N/3 ??????lt1??
• rate MT/2 ???????????????????????????????????????
  ???

52
Febrile Stage

• Patient education for alarming symptoms
• ????????????????????
• ???????????????
• ??????????/??????????
• ?????????????????
• ??? ??????????
• ???? ??? ???????????, ?????????????
  ????????????????????, ??????? ???????? ??????,
  ????????????? ?????????? 4-6 ??.
• ??????????????????? ??????????????? ????
  ???????????

53
Febrile Stage

• Follow up
• ??????????????????? 3 ?????? ??????????? 24
  ??.????????????????
• History ??????????? ??? ??????? ???????? ????????
  ???????????? ????????????? ?????????/???????
• PE V/S , liver size , TT
• CBC WBC lt 5,000 ??????????????? 24 ??.????????
  ??? Pltlt100,000 ??????????? toxic stage
  ??? Hct ????????? 10-20 ???????????? toxic
  stage
• ????????????????? ?????????????????????????
  ???????? LFT

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Indication for admission

• Alarming symptoms
• Plt lt 100,000 or Hct ????????? 10-20
• ????????????????????????????
• capillary refill gt 2 sec
• Pulse Pressure lt 20 mmHg
• Hypotension
• ?????????????????????????????

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????????? Hct ???????

• ???? lt 1 ?? 30-35
• ???? gt1-10 ?? 35-40
• ???? gt 10 ?? 40-45

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High risk patient

• ???? lt 1 ??
• DHF grade IV
• Obesity
• Massive bleeding
• CNS involvement, Hepatic failure, Renal failure
• Underlying disease eg G-6-PD deficiency,
  Thalassemia ,Heart disease, Renal disease , DM
• ?????????

57
OPD
?????? / ??????? ????? ??????????? ?????????????
Tourniquet test
ve
-ve

• Bleeding ?
• PE. V/S. liver
• CBC. ( ????????????? 3 )
• WBC. 5,000
• atyp. L close observation
• Plt. 100,000
• Hct. ? Admit
• ?????????????????????.?????
• ????? gt?????
• ???????????????
• ??????????
• ??????????
• ??? ??????????
• ????
• ?????????????

• ??????????????
• CBC, UA
• Repeat tourniquet test
• F/U.

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Toxic stage

• V/S q 1-2 hr , ??? shock ?????????????? ???? q
  5-15 min until stable
• Hct q 4-6 hr ??? shock, unstable V/S, massive
  bleeding, ????? internal bleeding ??????? q 1-2
  hr
• Dengue chart V/S, Hct, I/O
• O2 ???????????????? ??? ??????????????
• ????????????????????? ???? ant nasal packing ??
  epistaxis

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Toxic stage

• ???????????????????????????????????? ???? NG
  tube, gastric lavage
• IV fluid ????????????????????????????????????(Plt
  lt 100,000 ??? Hct ????? 10-20 ) ?????
  ???????????????????????/???? ??????? complication
  ???? ??????????????? , ???????????
• acidosis ????????? internal bleeding
  ???????????????????????????????????? IV
  resuscitate ??? Hct ????

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Lab in high risk patient

• Blood grouping/ matching
• Blood sugar
• Electrolyte, Ca
• Blood gas
• Coagulogram PT, PTT, TT
• Liver function test
• BUN , Cr , Uric acid

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Toxic stage

• ??????? IV fluid
• ?????? ??? ??????? ??? isotonic solution ????
  5D/NSS ??? profound/prolonged shock ???
  non-dextrose solution (??? rate lt 10 ml/kg/hr ???
  5 dextrose???)
• ???? lt 1 ?? ??? 5D/N/2 (??? shock
  ???????????????)
• colloidal solution plasma expander ????
  Dextran-40

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Dextran-40

• 10Dextran-40 in NSS rate 10 ml/kg/hr ???????? 1
  hr ???? Hct ????? 10 ?????????????? IV ????
  crystalloid ????? rate ???? 5,3,1 ml/kg/hr or KVO
  ????.?????????
• ??? Hct ??????????????? ????????? Dextran-40
  ????????? ?? rate 10 ml/kg/hr ??? 2 ?????
• max 30 ml/kg/day ??????? ??????? BUN, Cr ???????
  , Coagulopathy

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????? IV fluid

• ??? ideal body weight ( age x 2 ) 8 kg
• age gt 15 ??? 50 kg
• Shock
• grade III ??? 5D/NSS 10 ml/kg/hr ?? V/S ????????
  1/2-1 ??. ????????? rate
• grade IV ??? NSS 10 ml/kg IV bolus or free flow
  5-10 min ????? BP ??????? pulse ??? ?????????????
  rate

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????? IV fluid

• Grade I II ??????????? MT/2
• BW lt 15 kg rate 2 ml/kg/hr
• BW 15-40 kg rate 1.5 ml/kg/hr
• BW gt 40 kg rate 1 ml/kg/hr
• ??? Hct ?????? ???????? MT ???? MT5Def 3-5
  ml/kg/hr
• ???? rate IV ???
• clinical sign appetite , capillary refill
• V/S BP , HR , T , RR
• Hct
• Urine output

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Evaluate Shock

• ?????? 15-30 ???? ?????? stable V/S ???????? 2-6
  ??.???? shock ??????????????????????????
  ?????????????? 1-2 ??. ?? rate lt 10 ml/kg/hr
• ?????????????? rate lt 10 ml/kg/hr ?? 2
  ??.???????? ???? lt 5 ml/kg/hr ?? 6 ??.????????
  ?????????????????????? ??? Hct ????????? ???
  Dextran-40 ?????? Hct ????????????????? ??????
  internal bleeding ?????????????????????

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Initial management in High risk

• ??????? DHF Grade IV, ??? refer, ?????????????
• ??????? Hct ???????????????????? IV fluid ??????
  ????????????????????????
• ???? blood sugar ??????????????
• Vit K1 IV push ???? F/U INR ??? gt 1.3 ??? Vit K1
  x 3 ???
• ?????????? ??? NaHCO3 1 ml/kg/dose ???? F/U blood
  gas
• ??? Ca gluconate 1 ml/kg/dose (max 10 ml) ????
  F/U Ca ???????????? Ca IV push ?????????? 6
  ??.

70
Indication of Blood Transfusion

• ???????? gt 10 total blood volume (TBV 60-80
  ml/kg) ?????? ?????????????????
• Thalassemia, G-6-PD deficiency ?????? ??????
  hemolysis
• unstable V/S ??? Hct ???? ??????????????
  ?????????? IV fluid ????????? ?????? FWB 10
  ml/kg/dose ???? PRC 5 ml/kg/dose
• ????????????? HR gt 130/min ????????, gt 140/min
  ?????????? ?????? metabolic acidosis
  ???????????????????????

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Platelet transfusion

• ???????????????
• ????????????????????????????? ??? ?? Plt ???????
  ???? ?? prolonged coagulogram ?????????????? DIC
• ???????? Plt concentrate ?????????????????????????
  ????????????????????

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Convalescence stage

• 24-48??. ???????? ???????? complication
• ????????????????? ???????????????????????
• V/S stable, PP ?????, Pusle ?????????
• Hct ?????????? ???????????????? ????????????????
  38-40
• ?????????????
• confluent petechial rash

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Convalescence stage

• off IV fluid
• rest , bleeding precaution
• ????????????????????? ??? bowel ileus ???
  hypokalemia ?????????? diuresis ?????????????
  ???????????? ?????? KCl solution ??????,
  hyporeflexia

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Indications for Hospital Discharge

• Absence of fever for 24 hours (without
  antipyretic drug)
• return of appetite
• Visible improvement in clinical picture
• Diuresis gt 1-2 ml/kg/hr
• Stable hematocrit
• 2 days after recovery from shock
• No respiratory distress from pleural
  effusions/ascites
• Platelets gt 50,000/mm3

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complication

• Hyponatremia
• ?????????? hypotonic solution
• ???????????? NSS , DLR , DAR
• ?????? ?????? ??? 3 NaCl

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complication

• Hypocalcemia
• DHF grade IV , ???? lt 1 ?? , ??????????? ,
  ???????????? , ??????
• ??? calcium gluconate 1 ml/kg/dose(max 10
  ml/dose) dilute and IV push ???? , ??? HR ??????

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complication

• ???????????
• toxic or convalescent stage
• ??????
• ??? IV fluid ?????????????????
• ??? hypotonic solution
• ??? IV fluid ?????????????????????
• ????????????? internal bleeding ??????
  crystalloid/colloid
• ?????? colloid ????????????????
• ????????????????? ideal body weight

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complication

• ???????????
• ?????
• dyspnea tachypnea,
• abdominal discomfort/distension
• pulse ???? ???
• lung crepitation , rhonchi , wheezing
• poor tissue perfusion

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complication

• ???????????
• IV KVO ???? Dextran-40
• Foleys catheter
• furosemide 1 mg/kg/dose IV
• ??? convalescent stage ????????? ?????????????
• ??? toxic stage ???? monitor V/S q 15 min
  ????????? 1 ??.
• ?????????????? furosemide ??? Dextran-40 ?????
  5-10 ???? ?????? rate ????????????????
  ???????????????????????

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complication

• ???????????
• ??????? CVP ???? ??????????????? ??? unstable V/S
• ????????? ???? respiratory distress , pulmonary
  edema
• inotropic drug ???? ???????????????????? ???? CVP
  ???
• ???? pulmonary edema, ascites ??? ???????
  furosemide ?????? positive pressure ventilation
  ?????????? ????? inadeqate ventilation
  ???????????/???????? ??????????????

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Unusual manifestion

• Encephalopathy/encephalitis
• Hepatic failure
• Renal failure
• Dual infection
• Underlying condition e.g. G-6-PD deficiency ,
  Thalassemia

82
?????????????? DHF
1. ?????????? / ???????????????????????????????
DHF grade IV ???? DHF grade III
?????????????? 6 ??????? 2. ??????????? (gt 50
???????????????) 3. ??????????? 4. Unusual
manifestations eg. Encephalopathy, hepatic
failure, renal failure
83
???????????

• ??????????????????????????????? Dengue virus
• ??????????????????????? (???? 2 ??????)
• ????????????????
• ??????????????? DHF ?????????? shock ???
• ??? IV fluid ?????????shock??? ??????????

84
??????????????

• ?????? 2-7 ??? ,??????????, ???????
  ,????????????????????
• Tourniquet test - positive
• ??????????????? ???? petechaie , melena
• Hct ??????????????? ???? ??????? 42
• ??????? shock - ??????? ???????????
  ????????????? ?????????? ?????????????
  ?????????????? 4-6 ???????
• - pulse ???? , Pulse pressure ??? ,
  Hypotension

85
?????????????????

• ???????
• ?????????? paracetamol ??????????????? 39 c
• ?????????????????? ???? ???????? ???????????
  ??????? ??? ??????
• ???????????????????????????????????????????
• ?????????? ?????????? ?????? ???????????
  ?????????? ?????????? ????????????????????

86
?????????????????

• ????????? shock ??? IV fluid 5 D/NSS
• ???? lt 5 ?? rate 60 cc/hr
• ???? gt 5 ?? rate 120 cc/hr
• ??????????????????????????????
• Profound Shock ??? IV fluid 0.9 NSS iv drip
  free flow 10-15 min ????? BP , PR ???
• - ??????? Hct ???????????? IV fluid
  (????????)

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????????????????

• ??????????????????? 1 ??
• ????????? Underlying disease ???? G-6-PD
  Deficiency , Thalassemia , Heart disease
• DHF gr 4 ????????? shock ??????
• ??????????????????
• Unusual manifestations

90
????????????????

• ??????? shock gr 3 ???
• - ????????? 5 NSS 10-20 cc/hr 1-2hr
  ?????????? ??? ?? rate ??????
• - ????????? 5 NSS 10-20 cc/hr 1-2hr
  ????????????? ????Hct ?????????? ????
  ???colloid????????????? , ??Shock ???
• - ??????? shock??? ,??rate IV??????,??????????
  ???????????? , ????? volume overload

91
????????????????

• ???????????????????? ???????? ?????????? (??
  massive ascites , pleural effusion)
• ??????????????????????????? ,?????????????????,???
  ??????????????????

92
??? Refer

• ??? Refer ????????????????????????????????????
  ????????????????????????????????????/??????
• ??????? refer ??????????.
• ??????? refer ???????????? stable vital signs
• Rate ??? IV fluid ??????? refer lt 10
  cc/kg/hr
• ????????????????????? 1 hr lt 5 cc/kg/hr

93
?? Refer

• ???????????????????????? ????????????? ,
  ??????????? , ??????? admit
• ??????? shock
• ?????????? vital signs , serial Hct ,
  intake/output ??????????
• ???????????????????????????? admit , ??????? IV
  fluid ?????? ??? ????????????

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THE END