Dengue fever

FACT:MOSQUITOES HAVE KILLED MORE HUMANS THAN ALL THE WAR IN HISTORY…!.

Dr. Roni Dudhwala (M.D.)

Dr. Roni Dudhwala (M.D. hom) 3

Alternative Names

Onyong- Nyang Fever West Nile Fever Break Bone Fever Dengue like Disease


Interplay of Three factors

HUMAN

MOSQUITO

VIRUS


Etiological agent• Dengue viruses - flaviviruses• DEN-1

• DEN-2

• DEN-3

• DEN-4


Principal vector• Aedes albopictus• Aedes aegypti


Aedes aegypti-(Infected Female Mosquito)

• Day biting – normally catches us unaware• Loves / lives in fresh water in homes• Usually breed in stagnant water• Lays eggs preferentially in jars, discarded containers, coconut shells, old tires etc.• Year round breeding • Tropical regions like India are its favorite zones. • Usually active in dark or shaded places outdoors, but indoor activity is also

possible• Distance of flight： less than 100 meter• Most active: 2 hours before sunset (5-6pm) and morning (8-9am)


Mode of transmission

Infected mosquito

Healthy person Infected personIncubation Period: 3 to 14 daysMost commonly 4 to 7 days


Dengue feverNo

symptoms With symptoms

No different from other

feverDengue Fever Syndrome

Without haemorrhage

With unusual symptoms

High fever, severe headache, pain behind the eyes, muscle, bone

and joint pains, nausea, vomiting, rash,

petecheae

Dengue Haemorrhagic fever

Sudden rise in temperature, flush, sore throat, bleeding gums, elevation in

blood haematocrit level, breathlessness

No shock Dengue shock Syndrome

Skin cold and blotchy, pulse rapid and weak, lethargy, restlessness, acute abdominal pain


Clinical Phase

•Mainly 3 phases are seen:1. Febrile2. Critical3. Recovery


1. Febrile Phase

• Common viral symptoms:• High grade fever usually lasts for 2-7 days.• Facial flushing, skin erythema, generalized body ache, myalgia,

arthralgia and headache.• Some patients have sore throat and conjunctival injection.• Anorexia, nausea and vomiting are common.• A positive TORNIQUET test in this phase increases the probability

of dengue.


Warning Signs:

Clinical

• Abdominal pain or tenderness• Persistent Vomiting• Clinical Fluid accumulation• Mucosal Bleed• Lethargy, restlessness• Liver enlargement >2cm

Laboratory • Increase HCT concurrent with rapid decrease in Platelet count


• Some specific Symptoms:•Mild haemorrhagic symptoms like petechiae and mucosal

membrane bleeding e.g. nose and gums may be seen•Massive vaginal bleeding in women of child bearing age

and gastrointestinal bleeding may occur.• The liver is often enlarged and tender after a few days of

fever.• The earliest abnormality in the full blood count is a

progressive decrease in platelet count and white cell count, which should alert the physician to a high probability of dengue.


2. Critical phase

• On 3rd-7th day of illness the temperature drops down, an increase in capillary permeability in parallel with increasing in haematocrit levels may occur.• The period of clinically significant plasma leakage usually lasts 24-48

hours.• Progressive leukopenia followed by rapid decrease in platelet counts

usually precedes plasma leakage.• Pleural effusion and ascites may be clinically detectable depending on

the degree of plasma leakage and the volume of fluid therapy.• Shock occurs when a critical volume of plasma is lost through leakage.


• Plasma is lost through leakage which is preceded by warning signs.• The body temperature may be subnormal.• With prolonged shock, the consequent organ hyperperfusion results in

progressive organ impairment, metabolic acidosis and disseminated intravascular coagulation.• this in turn leads to severe haemorrhage causing the hematocrit to

decrease in severe shock.• Instead of the leukopenia usually seen during this phase, the total

WBC count may increase in patients with severe bleeding.• In addition, severe organ impairment such as severe hepatitis,

encephalitis or myocarditis and/or severe bleeding may also develop without obvious plasma leakage or shock.


• Those who improve after defervescence are said to have non-severe dengue.• Some patients progress to the critical phase of plasma

leakage without defervescence and, in these patients, changes in the full blood count should be used to guide the onset of the critical phase and plasma leakage.• These patients who manifests warning signs will probably

recover with early intravenous rehydration.• Some patients may deteriorate to severe dengue.


3. Recovery Phase

• After survival of 24-48 hours of critical phase, a gradual reabsorption of extravascular compartment fluid takes place in the following 48-72 hours.• General well being improves, appetite returns, GI symptoms abate,

haemodynamic status stabilizes and diuresis ensues.• Some patients may have a rash of “Isles of white in the sea of red” and

some may experience generalized pruritus.• Bradycardia and ECG changes are common during this phase.


Isles of white in the sea of red


• The hematocrit stabilizes or may be lower due to the dilutional effect of reabsorbed fluid.• 1st rise in WBC count than platelet count.• Respiratory distress from massive pleural effusion and ascites will

occur at any time if excessive IV fluid have been administered.• During the critical and/or recovery phase, excessive fluid therapy is

associated with pulmonary edema or congestive cardiac failure


1 Febrile Phase Dehydration; high fever may cause neurological disturbances and febrile seizures in young children.

2 Critical Phase Shock from plasma leakage; severe haemorrhage; organ impairment

3 Recovery Phase Hypervolemia( only if IV fluids has been excessive)


4. Severe Dengue

• It usually takes place around defervescence, usually day 3-7 of illness, preceded by warning signs.• It is defined by one or more of the following:

1. Plasma leakage that may lead to shock and/or fluid accumulation, with or without respiratory distress.

2. Severe bleeding.3. Severe organ impairment.

• As dengue vascular permeability progresses, hypovolemia worsens and results in shock.


• During initial stage of shock, the compensatory mechanism which maintains a normal systolic blood pressure also produces tachycardia and peripheral vasoconstriction with reduced skin perfusion, resulting in cold extremities and delayed capillary refill time.• Uniquely, the diastolic pressure rises towards the systolic pressure and

the pulse pressure narrows as the peripheral vascular resistance increases.• Patients in dengue shock often remain conscious and lucid.• Finally, there is decompensation and both pressures disappear

abruptly.• Prolonged hypotensive shock and hypoxia may lead to multi-organ

failure and extremely difficult clinical course.


Hemodynamic changesParameters Stable circulation Compensated circulation Hypotensive Shock

Shock Clear and lucidClear and lucid(shock can be missed if you donot touch the patient)

Changes in mental state(restless, combative)

Capillary refill time Brisk(<2sec) Prolonged(<2 sec) Very prolonged, mottled skin

Extremities Warm and pink Cool peripheries Cold, clammyPeripheral pulse volume Good Weak and thread Feeble or even absent

Heart rate Normal for age Tachycardia Severe tachycardia with bradycardia in late shock

Blood pressureNormal for ageNormal pulse pressure for age

Normal systolic pressure but rising diastolic pressureNarrowing Pulse pressurePostural hypotension

Narrowed pulse pressure(<20 mmHg)HypotensionUnrecordable blood pressure

Respiratory rate Normal for age TachypnoeaMetabolic acidosisHyperpnoea/Kussmaul’s breathing


Laboratory Investigations

• Full blood count• Viral isolation and serotype identification• Nucleic acid detection• Antigen detection• IgM ELISA / IgM rapid• IgG (paired sera) by ELISA, HI or neutralization test


A stepwise approach to the management:

Step 1 overall assessment1. History, including information on symptoms, past medical and

family history2. Physical examination including full physical and mental assessment3. Investigation including routine laboratory and dengue specific

laboratoryStep 2 Diagnosis, assessment of disease phase and severityStep 3 management


A. Step 1 over all assessment1. History:• Date of onset of fever/illness• Quantity of oral intake• Assessment for warning signs• Diarrhoea• Change in mental state/seizure/dizziness• Urine output(frequency, volume ad time of last voiding)• Other important relevant histories, such as family or

neighbourhood dengue• Travel to dengue endemic areas, co existing conditions (e.g.

infancy, pregnancy, obesity, DM, Hypertension), jungle trekking and swimming in waterfall.


2. Physical examination:• Assessment of mental state• Assessment of hydration state• Assessment of haemodynamic status• Checking for tachypnea/acidotic breathing/pleural effusion• Checking for abdominal tenderness/hepatomegaly/ascites• Examination for rash and bleeding manifestation• Torniquet test


3. Investigations:• As mention above CBC, hematocrit value and other routine tests

are required to conform diagnosis.• Dengue test is diagnostic but not always positive.• In this case, the presenting complains are to be taken in

consideration.

B. Step 2 Diagnosis, assessment of disease phase and severity• From above mention points, the diagnosis of disease is conformed.• After diagnosis, we should look for the warning signs, hydration

and haemodynamic status of the patient, and whether patient requires admission.


C. Management:• At present, no specific drug that can treat dengue fever effectively.• Patient should be isolated in a mosquito-free environment to prevent the

spread of disease.• Patients infected with classical dengue should have more rest, drink plenty

of water and take medication according to doctor’s instructions.• They usually recover in 1 to 2 weeks.• For serious cases, supportive treatments are provided by hospitals.• For high fever, wipe the body with warm water and proper use of anti-fever drugs can

relieve the fever• Don’t take aspirin-containing drugs because they worsen the haemorrhage.


ROLE OF HOMOEOPATHY:


Aconite• skin dry and hot; face red, or pale and red alternately; burning thirst for large

quantities of cold water; intense nervous restlessness, tossing about in agony; becomes intolerable towards evening and on going to sleep.• - Convulsions : of teething children; heat, jerks and twitches of single muscles;

child gnaws its fist, frets and screams; skin hot and dry; high fever.• Aconite should never be given simply to control the fever, never alternated with

other drugs for that purpose. If it be a case requiring Aconite no other drug is needed; Aconite will cure the case.• Aggravation. Evening and night, pains are insupportable; in a warm room; when

rising from bed; lying on affected side (Hep., Nux. m.).• Amelioration. In the open air (Alum., Mag. c., Puls., Sab.).• Rarely indicated in fevers which bring out eruptions.


Arsenicum Album• High temperature. • Periodicity marked with adynamia.• Cold sweats. • Complete exhaustion. • Delirium; worse after midnight. • Great restlessness. • Great heat about 3 a.m. • Sordes.• Great prostration, with rapid sinking of

the vital forces; fainting.• Reduces the refractive index of blood

serum (also China and Ferr. phos.).• Liver and spleen enlarged and painful. • Ascites and anasarca. • Abdomen swollen and painful. • Scanty, burning, involuntary urine. • Palpitation• Worse, wet weather, after midnight;

from cold, cold drinks, or food, Seashore. Right side. • Better from heat; from head elevated;

warm drinks.


Belladona

• A high feverish state with comparative absence of toxaemia. • Burning, pungent, steaming, heat. • Feet icy cold. • Superficial blood-vessels, distended. • Perspiration dry only on head. • No thirst with fever.• Fundus congested. • Bleeding of nose, with red face. • Haematuria where no pathological condition can be found.


Bryonia• Pulse full, hard, tense, and quick. • Chill with external coldness, dry cough, stitches. • Internal heat. • Sour sweat after slight exertion. • Easy, profuse perspiration. • Rheumatic and typhoid marked by gastro-hepatic complications. • Knees stiff and painful. • Joints red, swollen, hot, with stitches and tearing; worse on least movement. • Painful stiffness in nape of neck. • Stitches and stiffness in small of back.


China officinalis

• Pains in limbs and joints, as if sprained; worse, slight touch; hard pressure relieves. • Sensation as of a string around limb. • Joints swollen; very sensitive, with dread or open air. • Great debility, trembling, with numb sensation.


Colocynth

• Agonizing cutting pain in abdomen causing patient to bend over double, and pressing on the abdomen. • Sensation as if stones were being ground together in the abdomen, and

would burst. • Intestines feel as if bruised. • Colic with cramps in calves. • Contraction of muscles. • All the limbs are drawn together.


Eupatorium Perforatum• Known as "Bone-set", from the prompt

manner in which it relieves pain in limbs and muscles that accompanies some forms of febrile disease, like malaria and influenza.

• It is a boon in miasmatic districts, along rivers, marshes, etc., and in all conditions where there is a great deal of bone-pain.

• Marked periodicity• Throbbing pain in head• Top and back of head with pain and

soreness of eyeballs. • Occipital pain after lying down, with sense

of weight. • Perspiration relieves all symptoms except

headache. • - Chill between 7 and 9 a.m. , preceded by

thirst with great soreness and aching of bones.

• - Nausea, vomiting of bile at close of chill or hot stage; throbbing headache.

• - Knows chill is coming on because he cannot drink enough.

• Aching pain in back. Aching in bones of extremities with soreness of flesh. Aching in arms and wrists.


Ferrum Metalicum

• General coldness of extremities; head and face hot. • - Chill at 4 a.m. • - Heat in palms and soles. • - Profuse, debilitating sweat.


Hamamelis• Passive venous haemorrhages from

any part. • Painful weakness; sore pain in eyes;

bloodshot appearance; inflamed vessels greatly injected. • Bleeding from nose profuse; flow

passive, non-coagulable, with tightness in bridge of nose. • Haematemesis of black blood. • Throbbing and pain in stomach.

• Haematuria, with increased desire. • Haemoptysis; tickling cough. • Chest feels sore and constricted. • Sore pain down cervical vertebrae. • Severe pain in lumbar and

hypogastric region, extending down legs. • Tired feeling in arms and legs. • Very sore muscles and joints. • Purpura


Ipecac

• Haemorrhages bright-red and profuse. • Bones of skull feel crushed or bruised. • Bleeding from lungs, with nausea; feeling of constriction; rattling

cough. • Body stretched stiff, followed by spasmodic jerking of arms towards

each other.


Rhus Tox

• Eye painful on turning it or pressing, can hardly move it• Colic, compelling to walk bent. • Pains tearing in tendons, ligaments, and fasciae. • Soreness of condyles of bones. • Adynamic; restless, trembling. • During heat, urticaria.


• first stage: Acon. and Bry., with Ipec. for the vomiting,• Ars. for diarrhoea• when eruption is out on the skin: Bry. or Rhus.• Gastric symptoms: Coloc., Nux v.• jaundice, Chin., Eup. perf., Merc., Nux v., Pod.• Haemorrhagic conditions: Ars., Chin., Fer., Ham.. Sec., Sulph. ac.; • renal haemorrhage: Ars., Bell., Canth., etc. Warm drinks are better

relished than cold ones.


• CURES - SYMPTOMATIC 1 . Aconite-30 in alternation with Ipecac-30 in dengue fever with vomiting, nausea, anxiety. 2. Arsenicum-30. Dengue fever with diarrhoea and thirst. 3. belladonna-30. High fever, red hot face, red eyes, hot head and cold extremities, puffy eyes, no thirst, sore throat and red rash-over skin. 4. Bryonia-30. Dengue fever with frontal headache, pain in joints and muscles, constipation, great thirst for large quantity of water, and skin rash. 5. Gelsemium-30. Dengue with pains all over the body no thirst, headache frontal and occipital with great debility, backache, lachrymation. 6. Bapt, China, Colocynth, Eup-perf, Ipecac, Nux. v, Podophy, Rhus. t or Sulphure-30 also deserve your attention.


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Dengue fever

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