Dengue Cu Resident 01 2010

Dengue and Dengue Hemorrhagic Fever in Adult:

• Epidemiology• Definition• Pitfalls in Management

Terapong Tantawichien,M.D.Division of Infectious DiseasesDepartment of MedicineChulalongkorn University

DEN 1DEN 2DEN 3DEN 4

Risk of infection > 2.5 billion people100 countries have endemic dengue transmission

60 countries have DHF reported cases

Expert consensus groups in Latin America (Havana, Cuba, 2007), South-East Asia(Kuala Lumpur, Malaysia, 2007), and at WHO headquarters in Geneva, Switzerland in 2008 agreed that:

“dengue is one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcome”;

Who Guideline 2009

DF and DHF in Thailand

Year Number of patients 0-4 years 5-9 years 10-14 years > 15 years Total

1998 19,837 48,171 36,427 25,519 (20%) 12,954

1999 4,101 8,163 6,747 5,814 (23%) 24,826

2000 2,758 6,181 5,260 4,418 (23%) 18,617

2001 16,952 43,813 40,213 38,337(27%) 139,355

2002 11,380 33,299 35,248 34,960(30%) 114,833

0

50

100

150

200

250

300

350

400

2003 2004 2005 2006 2007

0-4 5-9 10-14 15-24 25-34 35+

Rat

e per

100

,000

Pop.

Reported Cases of D.H.F,Total(26,27,66) per 100,000 Population, by Age-group, Thailand, 2003 - 2007 Fig 2

0%

20%

40%

60%

80%

100%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

DF DHF DSS

Per

cent

(%

)

P roportion (%) of Cases of Dengue haemorrhagic fever, Thailand, 1998 - 2007Fig 3

0

0.1

0.2

0.3

0.4

0.5

0-4 5-9 10-14 15-24 25-34 35-44 45-54 55-64 65+

Fig. 8 Reported Case Fatality Rate (%) of Dengue haemorrhagicfever by Age -Group, Thailand, 2005

Case F

ata

lity

Rate

(%

)

0.00

50.00

100.00

150.00

200.00

250.00

1998 1999 2000 2001 2002 2003 2004 2005 2006 20070.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

Cases-Rate CFR

Rate

per

100,0

00 P

op

.

Case F

ata

lity

Rate

(%

)

Reported Cases and Case fatality Rate of D.H.F,Total(26,27,66) per 100,000 Population, by Year, Thailand, 1998 - 2007Fig 1

Travel-Associated Dengue Infections- United States, 2001-2004

The median age of the 71 patients for whom age was reported was 38 years (range: 8 months--72 years).

The most commonly reported symptoms were fever (54 patients [96%]), headache (36 [64%]), myalgias (32 [57%]), chills (19 [34%]), and rash (20 [36%]).

Fourteen patients (25%) had at least one hemorrhagic symptom (e.g., petechiae, purpura, hemoptysis, hematemesis, hematuria, or epistaxis), and nine (16%) had elevated liver transaminases.

15 patients (27%) required hospitalization, including one who died.

Travel destinations were available for 66 patients (86%); 20 patients (30%) reported recent travel to a Caribbean island during the 2 weeks before illness onset, 14 (21%) to Pacific islands, 11 (17%) to Asia, 10 (15%) to Central America, 10 (15%) to South America, and one (2%) to Africa.

J Travel Med 2009

Eli Schwartz; EID 2008

Severe Dengue Virus Infection in Travelers: Risk Factors and Laboratory IndicatorsOle Wichmann,; Clin Infect Dis 2007

219 dengue virus infections imported from various regions of endemicity were reported.Serological analysis revealed a secondary immune response in 17%. Spontaneous bleeding was observed in 17(8%) patients and was associated with increased serum alanine and aspartate aminotransferase levels and lower median platelet counts.

23(11%) travelers had severe clinical manifestations (internal hemorrhage, plasma leakage, shock, or marked thrombocytopenia).

A secondary immune response was significantly associatedwith both spontaneous bleeding and other severe clinical manifestations.

Dengue virus infection

Asymptomatic Symptomatic

Undifferentiated fever Dengue fever Dengue hemorrhagic fever

Without Unusual No shock Dengue shock

hemorrhage hemorrhage syndrome(DSS)

DF DHF

Primary infectionSecondary infection ?

Dengue Fever

Fever, myalgia, headacheBreakbone feverRash : petechiaeTourniquet test-positiveLeukopenia( WBC < 5,000 /cumm ) , thrombocytopenia

Unusual hemorrhage

Criteria for diagnosis of DHF

Clinical : 1. Fever, acute onset, high continuous

for 2-7 days

2. Haemorrhagic manifestations including

a positive tourniquet test and any

of the following:

petechiae, purpural, echymosis

epistaxis, gum bleeding, hematemesis,

3. Enlargement of liver

4. Shock

Laboratory

1. Thrombocytopenia (< 100,000/mm3)

2. Hemoconcentration (>20% increase

in Hct level)

Leakage syndrome : High Hct, pleural effusion, ascitis, thickening gallbladder

A. T. A. Mairuhu ATA; Eur J Clin Microbiol Infect 2004Dengue: an arthropod-borne disease of global importance

Clinical manifestations of DF/DHF in adults(Tantawichien T)

DF/DHF DF DHF (n = 140) (n=89) (n=51)

Age :Mean+SD (years) : Range (years) : Median (years)

15-20 years (%)>20-30 years (%)>30 years (%)

Total duration of feverMean+SD (days)Range (days)Fever 5-7 days

26.915-67

24 41.431.427.2

5.22-8

75.7%

28.6+13.215-67

38.3

34.8

5.26+1.12-8

23.4+7.615-44

47

17.6

5.22+0.963-880.4

Dengue infection 14 yr boy

Dengue infection 14 yr boy

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Guideline for management of dengue fever/dengue hemorrhagic fever (DF/DHF) in Adults

Awareness of DF/DHF

- Fever < 10 days- Myalgia- Headache- Nausea/vomiting- No respiratory tract infection symptoms- No other organ-specific symptom/sign

Fever < 3 days 2 Fever > 4 to 10 days-CBC (blood smear)-optional-Tourniquet test (suggestive investigation)

Consider DF/DHF

1

DDxOther diseases

No

Consider DF/DHF

Check clinical syndrome of DHFFever, nausea/vomitingHemorrhageEnlarged liver+tendernessHypotension

OPD case( follow up q 1-2 days) until no fever > 2 days - Clinical signs/symptoms - Oral hydration - Avoid unnecessary drugs

Laboratory (every 1-3 days) - CBC ( blood smear ) - Tourniquet test ( not recommended if platelet

count < 80,000 mm3 or spontaneous petechiae ) - AST, ALT (if indicated)

Consider DF/DHF DDx Other diseasesNo Indications for hospitalization

Yes

3

3

4

Indication for hospitalization Yes Hospitalization4

No

3

Who Guideline 2009

Severe dengue should be considered if the patient is from an area of dengue risk presenting with fever of 2–7 days plus any of the followings

• There is evidence of plasma leakage, such as:– high or progressively rising haematocrit;– pleural effusions or ascites;– circulatory compromise or shock (tachycardia, cold and clammy

extremities, capillary refill time greater than three seconds, weak or undetectable pulse, narrow pulse pressure or, in late shock, unrecordable blood pressure).

• There is significant bleeding.• There is an altered level of consciousness (lethargy or restlessness, coma, convulsions).• There is severe gastrointestinal involvement (persistent vomiting, increasing or intense abdominal pain, jaundice).• There is severe organ impairment (acute liver failure, acute renal failure, encephalopathy or encephalitis, or other unusual manifestations, cardiomyopathy) or other unusual manifestations.

Who Guideline 2009

Pitfalls in Management of DF/DHF in Adults

Severe bleeding : severe thrombocytopenia, operation

Hemodynamic abnormalityDSS in adults Monitoring in DHF/DSS adult patientsRate and volume of IV replacement in DHF/DSS

Avoid inadequate volume / volume overload

Elevated liver enzyme :More unnecessary drugs ( toxicity, adverse reaction)

Unusual manifestations in a few cases:

Female, 21 yrs, worker, previously healthy

CC : Fever 6 days PTA

PI : 6 d PTA : She developed high grade fever, myalgia, anorexia, nausea/vomiting.

No other organ specific symptoms.

She took the analgesics from private clinic.

Physical examination at Bangpong hospital

BP 80/50 mmHg, PR 100/min, RR 28/min, BT 39˚ c

HEENT : pink conjunctiva, mild icteric sclera.

Abdomen : Liver 2 cm below Rt costal margin,

no splenomegaly

22/11/09 Lab

Hct 46.6 %

WBC 3,620

PMNs 70

Lymp 18

Plt 20,900

Dx Dengue shock syndrome

Date Time BP Fluid Rate(ml/h)

In-takE (ml)

Out-put(ml)

Med Lab

D 1 80/50 5%DNSSNSSDextran

500-1,000

1.5h 100/60 60

2.5h 110/80 FFP2uPRC2u5%DNSS

Hct4636%+

Vaginal bleed

3,125 1,155 Hct = 46%


In-takE (ml)

Out-put(ml)

Med Lab

D 2 110/60 5%DNSSDextranFFP2U

200 Hct46%Plt11,500WBC 5,380 (N65%,L20%)AST/ALT994/411TB/DB 1.89/1.05PT20.3,PTT64INR 1.8

16 h 4,000 2,455


In-take (ml)

Out-put(ml)

Med Lab

D2 18 h 70/50 PltdextranFFP 1 uNSSIv load

•ETT•Dexamet

hasone 5 mg

Hct 45%NG lavage: Coffee ground

20 h DopamineLevophed0.13mcg/kg/min

Resuscitate 6 h , IVF 3,500ml BP 90/50 refer KCMH

KCMH D1Fever D7

KCMHD2Fever D8

KCMHD3Fever D9

KCMHD4

KCMHD5

KCMHD6Follow to command

BP 90/50 Hct 49.4 , Plt 9,000, WBC 14,600(N 81%,L5%)

AST/ALT 3,567/996,ALP 110TB/DB 3.32/2.07

PT 22, PTT 75, INR 2BUN/Cr 24/2.41

NG content: fresh blood, hematochesiaFU Hct 493320

MN : FFP(6u),LPRC(7U),PltCVVHIV PPI

Ceftriaxone 2 g iv







If major bleeding occurs it is usually from the gastrointestinal tract, and/or vagina in adult females. Internal bleeding may not become apparent for many hours until the first black stool is passed.

Patients at risk of major bleeding are those who:– have prolonged/refractory shock;– have hypotensive shock and renal or liver failure and/or severe and persistent metabolic acidosis;– are given non-steroidal anti-inflammatory agents;– have pre-existing peptic ulcer disease;– are on anticoagulant therapy;– have any form of trauma, including intramuscular injection.

Patients with haemolytic conditions are at risk of acute haemolysis with haemoglobinuria and will require blood transfusion.

Predictors of spontaneous bleeding in Dengue.Shivbalan S,et al; Indian J Pedtric 2004

60 children (most DHF) compared control ( mucosa,skin bleeding )

The combination of biphasic pattern of fever with hemoconcentration, platelet count less than 50,000 and elevated ALT

Other studies :-PT and PTT were found to predict bleeding - Patients with platelet counts < 50,000/mm3 have been reported to have

a six-fold increase in mortalilty- Risk of spontaneous bleed has been associated with platelet <20,000- No significant difference in bleeding manifestations among

thrombocytopenic and non-thrombocytopenic patients in Dengue-Increased levels of AST, ALT, G-GT have been observed in patients with episodes of bleeding

Platelet counts (x103/mm3)

Day -2 : mean + SD

Day 0 : mean + SD

< 20,000/mm3 on day 0

Tantawichien T.

Laboratory findings of DF/DHF in adults

DF/DHF DF DHF(n=140) (n=89) (n=51)

94.6 + 39.4

38.0 + 34.6

91.2 + 39.5

47.2 + 34.6

25.3%

102.2+42.8

22.8+17.8*

56.9%

DIFFERENCES IN DENGUE SEVERITY IN INFANTS, CHILDREN, AND ADULTS INA 3-YEAR HOSPITAL-BASED STUDY IN NICARAGUASAMANTHA NADIA HAMMOND: Am J Trop Med Hyg 2005

Jacqueline Deen, Lucy Lum, Eric Martinez, Lian Huat Tan.Dengue: guidelines for diagnosis, treatment, prevention and control -- New edition. WHO 2009

Severe bleeding can be recognized by:– persistent and/or severe overt bleeding in the presence of unstable haemodynamic status,

regardless of the haematocrit level;– a decrease in haematocrit after fluid resuscitation together with unstable haemodynamic status;– refractory shock that fails to respond to consecutive fluid resuscitation of 40-60 ml/kg;– hypotensive shock with low/normal haematocrit

before fluid resuscitation;– persistent or worsening metabolic acidosis + a well-

maintained systolic blood pressure, especially in those with severe abdominal tenderness and distension.

Clinical manifestations of DF/DHF in adults(Tantawichien T)

DF/DHF DF DHF (n = 140) (n=89) (n=51)

Bleeding manifestations

Petechiae

Epistaxis

Gum bleeding

Hematemesis

Vaginal bleeding

Bleeding > 2 sites

35.7%

22.1%

7.8%

7.1%

2.1%

24.6%

27%

24.7%

14.6%

4.4%

5.5%

0%

21%

6.7%

54.9%

35.2%

14.3%’

10.2%

5.9%

31.6%

19.6%

Gastroduodenoscopic findings in 26 Dengue patients

Findings No. of cases %

DU 11 42.3

GU + superficial gastritis 3 11.5

DU + superficial gastritis 3 11.5

GU + DU + superficial 3 11.5

gastritis

GU or DU or hemorrhagic 6 23

gastritis or erosion

Tsai CJ; Am J Gastroenterology 1991

Chiu YC, Am J Trop Med 2005

Patients having PU with recent hemorrhage require more transfusions with PRBCs and FFP for management of UGI bleeding than do those without recent hemorrhage.

PU with recent hemorrhage is encountered during an endoscopic procedure, endoscopic injection therapy is not an effective adjuvant treatment of hemostasis in dengue patients with UGI bleeding.

A FATAL CASE OF SPONTANEOUS RUPTURE OF THE SPLEEN DUE TO DENGUE VIRUS INFECTION: CASE REPORT AND REVIEW. Southeast Asian J Trop Med Hyg 2008 Apatcha Pungjitprapai, Terapong Tantawichien.

Hospitalized patient who* was considered DF/DHF

Bleeding5 (excluded petechiae)

-Avoid unnecessary drugs( eg. NSAIDs,……) -Supportive care, oral or intravenous hydration-Lab CBC every 1-3 days AST, ALT (every 1-3 days) when indicated PT/PTT if bleeding Serologic test for acute dengue infection if

confirmation is needed2

Bleeding 5 No bleeding

Major bleeding( vital organs, CNS,GI )

Consider :Blood transfusionPlatelet transfusionFresh frozen plasmaCorrect cause of bleeding

Minor bleeding( nose, gum, vagina )

Correct causeof bleeding

High Hct (>50%) orLeakage syndrome (eg. increased Hct > 20%, pleural effusion, clinical ascites) or hypotension

No Yes

Possible-DHF stage II

No fever (discharge if no bleeding, platelet count > 20,000 /mm3)– Lab before discharge (option) - CBC - Serologic test for acute dengue infection ( IgM, IgG, HI ) if confirmation is needed2

- ALT, AST ( if indicated )

YesSupportive treatment

Fever

No

Lack of efficacy of prophylactic platelet transfusion for severe thrombocytopenia in adults with acute uncomplicated dengue infection. Lyn DC; Clin Infect Dis 2009

Thrombocytopenia in dengue infection raises concerns about bleeding risk. Of 256 patients with dengue infection who developed thrombocytopenia (platelet count, < 20 x 103 platelets/microL) without prior bleeding, 188 were given platelet transfusion. Subsequent bleeding, platelet increment, and platelet recovery were similar between patients given transfusion and patients not given transfusion. Prophylactic platelet transfusion was ineffective in preventing bleeding in adult patients with dengue infection.







Natural History of DHF ; 3 stages

Acute febrile stage Fever 2-7 days, nausea

/vomiting, myalgia, flushed face, rash

Critical stage Plasma leakage - hypotension ,

abdominal pain, liver tenderness, abnormal

bleeding

Convalescent stage Increased appetite, rash ,

normotention, bradycardia and decreased Hct

Hospitalized patient who* was considered DF/DHF

Bleeding5 (excluded petechiae)

-Avoid unnecessary drugs( eg. NSAIDs,……) -Supportive care, oral or intravenous hydration-Lab CBC every 1-3 days AST, ALT (every 1-3 days) when indicated PT/PTT if bleeding Serologic test for acute dengue infection if

confirmation is needed2

Bleeding 5 No bleeding

Major bleeding( vital organs, CNS,GI )

Consider :Blood transfusionPlatelet transfusionFresh frozen plasmaCorrect cause of bleeding

Minor bleeding( nose, gum, vagina )

Correct causeof bleeding

High Hct (>50%) orLeakage syndrome (eg. increased Hct > 20%, pleural effusion, clinical ascites) or hypotension

No Yes


No fever (discharge if no bleeding, platelet count > 20,000 /mm3)– Lab before discharge (option) - CBC - Serologic test for acute dengue infection ( IgM, IgG, HI ) if confirmation is needed2

- ALT, AST ( if indicated )

YesSupportive treatment

Fever

No

Anon Srikiatkhachorn,Pediat Infect Dis J 2007

Physical findings of DF/DHF in adults(Tantawichien T)

DF/DHF DF DHF (n = 140) (n=89) (n=51)

Hypotension/a pulse

pressure < 20 mmHg

Pleural effusion

(by CXR)

Epigastrium/RUQ

tenderness

Hepatomegly (+by U/S)

Splenomegaly (by U/S only)

Ascites (by U/S only)

2.1%

18.6%

21.4%

2.1%

3.6%

0%

0%

10.1%

11.2%

0%

0%

5.8%

29.4%

29.4%

39.2%

5.9%

9.8%


Wichmann O: Tropical Med Int Health 2004


DIFFERENCES IN DENGUE SEVERITY IN INFANTS, CHILDREN, AND ADULTS IN A 3-YEAR HOSPITAL-BASED STUDY IN NICARAGUASAMANTHA NADIA HAMMOND: Am J Trop Med Hyg 2005

0 6 12 18 24 Hour after Shock

10

8

6

4

2

IV fluid mL/kg/hr Rate of IV Fluid for DHF ( Shock )

Crystalloid: 5% D/NSS NSS, 5% D/RA 5%D/RLColloid : FFP, Dextran

10-5

5

3

3-1Hct q 4 hr,record I/O

Criteria : leakage, increased Hct > 20 % narrow pulse pressure

Causes of fluid overload are:– excessive and/or too rapid intravenous fluids;– incorrect use of hypotonic rather than isotonic

crystalloid solutions;– inappropriate use of large volumes of intravenous

fluids in patients with unrecognized severe bleeding;

– inappropriate transfusion of fresh-frozen plasma, platelet concentrates and cryoprecipitates;

– continuation of intravenous fluids after plasma leakage has resolved (24–48 hours from defervescence);

– co-morbid conditions such as congenital or ischaemic heart disease, chronic lung and renal diseases.

WHO Guideline 2009

Yes


High Hct (>50%) orLeakage syndrome :ed Hct > 20%, pleural effusion, ascites orHypotension

Hypotension, pulse pressure < 20 mmHg, poor tissue perfusion

Consider vasopressor/Invasive monitoring

Check volume loss eg. GI bleedingClose monitoring facility

Monitoring Vital sign every 1-4 hrs Clinical sign/symptom Serial Hct (1-4 times/day), platelet count ( option )- Intake/output (u/o 0.5-1

ml/kg/hr ) Keep urine sp. gr. 1010-1020

v/s Oral/iv fluid+

monitor

Resuscitation: supportive care, IV NSS,(loading 500-1000 ml/hr)

1-2 hr after resuscitation

2 hrs after resuscitation

Hypotension -Change IV fluid to: Plasma expanders, NSS + albumin

-Cardiovascular - Shock

Plasma leakage in DHF/DSS

- Cardiac arrhythmia

sinus bradycardia( CI-subnormal )

sinus arrhythmia

APC, PVC

1st degree AV block,

2nd degree AV block Mobitz type 1

- EF , end diastolic volume

- Generalized low voltage/ ST-T change

Apichai K; Intensive Care Med 2003

Natural History of DHF ; 3 stages

Acute febrile stage Fever 2-7 days, nausea

/vomiting, myalgia, flushed face, rash

Critical stage Plasma leakage - hypotension ,

abdominal pain, liver tenderness, abnormal

bleeding

Convalescent stage Increased appetite, rash ,

normotention, bradycardia and decreased Hct







Day of fever 4 5 6 7 8 9 10 11

39

BT 38

37

BP stable Bradycardia

Fever no diarrhea

N/V N/V N/V

Hct 42 44

WBC/mm 4200 2,200

N/L (%) 65 /25 100 / 70

Platelet/mm3 80.000 47,000

SGOT/SGPT 5650/2690 849/862(TB/DB 4.5/3.5) 324/287( TB 2)

AP 152 Albumin 3.5

Hemoculture neg no pleural effusion

24 year - old patient (male)

80/

FeverHepatitisThrombocytopenia

Investigation ?

Liver function test in DF/DHF patients

Kuo CH* Kalaganaroaj S** Tantawichien T.

DF DF DHF DF DHF

n=230 n=20 n=21 n=38 n=30

Age:Mean+SD

SGOT : Mean+SD

Range

SGPT: Mean+SD

Range

Bilirubin

Abnormal/range

Akaline phasphatase

Abnormal/range

41+12

220+341

17-3210

146+178

8-1177

7.2%0.2-35

16%320-536

3.7+1

64+46

35+18

4.3+1.2

124+166

51+59

28.6+13.2

258+436

17-2128

184+255

19-1171

0%

all<1.5

23.4+7.6

399+554

15-2580

261+321

3-1382

1 case (5)

all<1.5

*Kuo CH; Am J Trop Med Hyg 1992**Kalayanarooj S; JID 1997

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

AST

ALT

Mean transaminase levels ( U/I ) in relation to days after symptom onset in 270 patients.

Days after onset of symptom

Kuo CH; Am J Trop Med Hyg 1992

- Gastrointestinal - Nausea/vomiting, diarrhea

- GI bleeding

- Liver involvement

- Hepatitis/fulminant liver failure

1) Viral factor

2) Prolonged shock

3) Reye’s syndrome

4) Drug intoxication

5) Pre-existing liver diseases

- Ascites

- Appendicitis

- Splenomegaly

Manifestations in dengue virus infection

Transactions of the Royal Society of Tropical Medicine and Hygiene 2007

The mean time from onset of fever to abdominal pain was 2.2 days ( SD 0.9).Leucocytopenia and thrombocytopenia occurred by the third or fourth day of illness in all patients.







Viral Etiology of Encephalitisin

Thailand

Japanese encephalitis virus

Dengue virus

Herpes simplex

Enteroviruses

Rabies

Others: mumps virus, HIV, HHV-6...

Details of the co-infections in the 14 dengue patientsSex Age Coinfections Distinctive Clinical Clues

(yr) Organism Diagnosis

F

M

FMF

F

FFFM

M

MM

F

9/12

4

714

3/12

1

69

1112

1

3/126

6/12

Burkholderia pseudomalleiBurkholderia pseudomalleiVaricella zosterSalmonellaShigella

SalmonellaEscherichia coliSalmonellaHerpes simplexEscherichia coliMycobacterium tuberculosisStreptococcus pneumoniaeShigellaMycoplasma pneumoniaeEscherichia coli

Melioidosis

Melioidosis, disseminatedChickenpoxSalmonellosisShigellosis

DiarrheaVaginitisSalmonellosisHerpes labialisUTITuberculosis, pulmonaryPneumococcal bacteremiaShigellosisMycoplasma pneumoniaUTI

Persistence of fever and dyspneaPersistence of fever, ARDS

VesiclesProlonged fever, diarrheaDrowsiness, convulsionDiarrhea, leukocytosis

Diarrhea, convulsionLeukocytosisVesicles

Prolonged fever and cough Persistence of fever, leukocytosisDiarrheaProlonged fever and cough

CLINICAL CHARACTERISTICS AND RISK FACTORS FOR CONCURRENT BACTEREMIA IN ADULTS WITH DENGUE HEMORRHAGIC FEVER LEE IK; J Trop Med Hyg 2004

Concurrent bacteremia (dual infection=5.5%) in patients DHF/DSS

100patients with DHF/DSS (7 with a dual infection and 93with DHF/DSS alone [controls])

Patients with a dual infection were older, and tended to have prolonged fever, higher frequencies of acute renal failure, GI bleeding, altered consciousness, unusual dengue manifestations, and DSS.

Acute renal failure (odds ratio [OR] 51.45,P=0.002,and prolonged fever (> 5 days) (OR 26.07,p=0.017 were independent risk factors for dual infection.Bacteremia : Klebsiella pneumoniae, enterococci, Moraxella, Rosemonas

Concurrent Chikungunya and Dengue Virus Infections during Simultaneous Outbreaks, Gabon, 2007

Eric M. Leroy : Emerg Infect Dis 2009

An outbreak of febrile illness occurred in Gabon in 2007,with 20,000 suspected cases. Chikungunya or dengue-2 virusinfections were identifi ed in 321 patients; 8 patients haddocumented co-infections. Aedes albopictus was identifi edas the principal vector for the transmission of both viruses.

• Dengue Infection Complicated by Severe Hemorrhage and Vertical Transsmission in a Parturient Woman

Pimolratn Thaithumyanon, Usa ThisyakornJitladda Deerojnawong, Bruce L. Innis

Clinical Infect Dis 1994;18:248-9.• Dengue hemorrhagic fever during Pregnancy

Suvit Bungavejchevin, Somchai TanawattanacharoenNimit Taechakraichana, Usa Thisyakorn,Yuen Tanniroundorn, Kobohitt Limpaphayom

J Obstet Gynaecol Res 1997;23:445-8.• Effect of Dengue Fever during Pregnancy in French Guiana

C. Carles, II. Peiffer, J. Lelarge, A. talarmin Abst 4th International Symphosium on Dengue Fever,

Tahiti, April 1997.• Vertical Transmission of Dengue

Joon K Chqe, Chin T Lim, Kwee B. Ng, et al. Clinical Infect Dis 1997; 25: 1374-7

Wagner D, Emerg Infect Dis 2004

Tamblay PA; N Engl J Med 2008

Twelve (0.07%) of 16,521 blood donations tested were TMA-positive (transcription-mediated amplification).

Four were positive by RT-PCR (DENV serotypes 2 and 3). Virus was cultured from 3 of 4 RT-PCR–positive donations. One of the 12 TMA-positive donations was IgM-positive.

Transfusion 2008

Treatment

Supportive treatment, hydration

Drugs : Acetaminophen,Anti-gastritis ; H2 blocker,NSAIDs

Unnecessary drugs; muscle relaxant……

Antibiotic treatment ( 20-30 % case )

Transfusion : Platelet transfusion, PRC, FFP

Procedure : catheter, NG tube, endoscopy, operation

Adjunctive therapy : Steroid, IVIG

Carbazochrom sodium sulfonate (AC-17),

Recombinant activated factor VII,

Desmopressin

Rajapakse S : Trans Royal Society Trop Med Hyg 2009 103, 122—126

Efficacy of low dose dexamethasone in severe thrombocytopenia caused by dengue fever: a placebo controlled study

S A M Kularatne, Postgrad Med 2009







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Dengue Cu Resident 01 2010