What`s New in DHF: Clinical aspect
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WHAT`S NEW IN DHF: CLINICAL ASPECT Professor Siripen Kalayanarooj, Director, WHO Collaborating Centre for Case Management of Dengue/DHF/DSS, Queen Sirikit National Institute of Child Health.
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What`s New in DHF: Clinical aspect. Professor Siripen Kalayanarooj, Director, WHO Collaborating Centre for Case Management of Dengue/DHF/DSS, Queen Sirikit National Institute of Child Health. 1. Adults is more affected than Children. 2. Expanded Dengue Syndrome or - PowerPoint PPT Presentation
Transcript of What`s New in DHF: Clinical aspect
WHAT`S NEW IN DHF:CLINICAL ASPECTProfessor Siripen Kalayanarooj,
Director, WHO Collaborating Centre for
Case Management of Dengue/DHF/DSS,Queen Sirikit National Institute of Child Health.
1. ADULTS IS MORE AFFECTED THAN CHILDREN
2. Expanded Dengue Syndrome orUnusual Manifestations of DengueInfant < 1 year oldCommonly found in adultsIn newly outbreak countriesIn endemic countries where there
are limited laboratory facilities
EXPANDED DENGUE SYNDROME(EDS)
Encephalopathy: confusion, seizure, coma
Liver failure Renal failure Cardiac involvement: myocarditis Other organs involvement
CAUSES OF EDS
Prolonged shock: Liver, renal, respiratory and other organs (unrecognized at the very beginning)
Dengue infections in patients with underlying diseases: DM, HT, Heart diseases, Thalassemia, Liver and renal diseases, etc…
Co-infections with other microbial agents:
Dengue virus virulence: encephalitis, liver failure
CLINICAL MANIFESTATIONS OF EDS
Mostly manifestations of DHF + Complications Underlying diseases Co-infections
CLUES TO DIAGNOSE EDSDetection of plasma leakage (early when the
patients present to the healthcare facilities): Rising Hct ≥ 20% Pleural effusion: clinical, CXR – right lateral
decubitus, ultrasound Ascites: clinical, ultrasound Hypoalbuminemia: serum albumin ≤ 3.5 gm%
in normal nutritional statusOther evidence of DHF: Thrombocytopenia especially when
platelet count < 50,000 cells/cumm. Clinical bleeding
CXR – COMPARE BETWEEN 2 POSITIONS
EARLY CLINICAL DIAGNOSIS &MANAGEMENT
Suspected EDS in patients with thrombocytopenia (platelet count ≤ 100,000 cells/cumm.) or clinical bleeding or shock with high fever (probably with encephalopathy)
Look for evidence of plasma leakage, if positive more likely to have DHF with complication:
1. DHF with superimposed bacterial infections2. DHF with liver injury: hepatitis, liver
dysfunction/ failure3. DHF with concealed internal bleeding (mostly
GI bleed)
3. DENGUE CLASSIFICATIONS
1975, 1986, 1997, 2011 2009
DENGUE CLASSIFICATION
WHO 1975, 1986,1997, 2011
Undifferentiated febrile illness
Dengue Fever (DF) Dengue hemorrhagic fever
(DHF) Dengue Shock Syndrome
(DSS) Expanded Dengue
Syndrome (EDS)
WHO TDR 2009 Dengue (D) Dengue ± Warning
signs (D ± WS) Severe Dengue (SD)
Original WHO Newly suggested
Asymptomatic Symptomatic
Viral syndrome Dengue fever DHF
Dengue virus infection
Plasma leakage
100400500
1,0009,000
1-2
10,000
Expanded dengue syndrome1.Prolonged shock: liver failure, renal failure,…Encephalopathy…
2. Co-morbidities3. Co-infections4. True dengue infection -
encephalitis
DHF DSS
SUSPECTED DENGUE INFECTIONS:FEVER WITH ANY 2 OF THE FOLLOWINGSIN DENGUE ENDEMIC AREA
Headache Retro-orbital pain Myalgia Arthralgia/ bone pain Rash Bleeding manifestations
(Tourniquet positive) Leukopenia Rising Hct 10-15% Platelet ≤ 150,000
cels/cumm
Nausea/ vomiting Rash Aches and pain Tourniquet positive Leukopenia Any warning signs
Original WHO Suggested New
Tourniquet positive + Leukopenia
AT QSNICH OPD: SUSPECTED DENGUE CASES THAT NEED CLOSE OBSERVATION
Tourniquet positive + Leukopenia
1,500 cases
Warning signs: nausea/vomiting and abdominal pain
30,000+ cases (20 times more
workload)
Original Newly suggested
QSNICH: IPD (JUNE – AUGUST 2009)
Confirmed dengue
DF DHF + DSS Dengue D with WS + SD
180 72 + 22 85 160 + 29
180 94 85 189
Non- Dengue
DF DHF + DSS Dengue D with WS + SD
19 5 + 0 10 13 + 1
19 5 10 14
Total clinical suspected dengue cases
DF DHF + DSS Dengue D with WS + SD
199 99 95 203
Confirmed = 274/298 = 91.9% Kalayanarooj S. J Med Assoc Thai 2011; 94(3); s74-83.
DIFFERENT BETWEEN THE TWO CLASSIFICATIONS
Emphasize on
plasma leakage* and abnormal hemostasis (platelet count ≤ 100,000 cells/cumm):
Rising Hct ≥ 20% Pleural effusion: PE, CXR
(right lateral decubitus, ultrasound)
Ascites: PE, ultrasound Hypoalbuminemia (Alb ≤
3.5 gm%)
Emphasize on
warning signs*: Abdominal pain or
tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy, restlessness Liver > 2 cm Lab.: increase in Hct
concurrent with rapid decrease in Platelet count
Original WHO Suggested New
*Need close monitoring
Day 1 2 3 4 5 6 7 8 9
Fever
WBC
WBC 6,000-9,000 ≤5,000
Platelet count 200,000 ≤100,000 <50,000
Hct 35 38 45 (rising 20% )
Albumin ≤3.5 gm%
Cholesterol ≤100 mg%
Hematocrit
Plasma leakage Stop leakage
Pleural effusion,Ascites
Reabsorption
Shock
IV fluid: NSS, DAR, DLRColloid: 10%Dextran, 10%Haes-sterilM+5% Deficit (= 4,600 ml in adult)
Natural course of DHF
Professor Siripen Kalayanarooj
EARLY DIAGNOSIS BY CBC:GUIDE FOR MANAGEMENT
Date HCT WBC PLT
Day 2 41 6,500 160,000
Day 3 43 4,200 143,000
Day 4 47 2,300 90,000
Day 5 39 70,000
A 20-year-old womanGood consciousness
AST/AL:T = 62/59
BP = 90/70 mmHg, P 118/min
COMPARE BETWEEN 2 CLASSIFICATIONS
Follow up platelet and frequent Hct (at
least q 6 hours) at critical period
Can prevent shock and severe cases with complications of organs failure
Follow warning signs which are non-specific
Shock cannot be prevented. Organs failure as a consequence of prolonged shock are detected late with overt manifestations and poor prognosis
Plasma leakage Warning signs
LAHORE EXPERIENCED (SEP.-NOV. 11)
Total suspected cases : 600,000+ cases
Confirmed 20,000 cases (< 4%)At the peak: 4,000-6,000 patients/dayAdmission 500-600 cases/dayDeath 10-15 cases per day
MULTI-COUNTRY STUDY: 18 COUNTRIESVALIDATION STUDY OF THE NEWLY SUGGESTED CLASSIFICATION
Revised not
classified
Dengue without Warning
Signs
Dengue With
Warning Signs
Severe dengue
Total
Not classify
23 57 159 29 268
DF 7 551 684 75 1,317
DHF 2 8 240 39 289
DSS 0 0 12 76 88
Total 32 616 1,095 219 1,962
Barniol J et al: BMC Infectious Disease 2011,11: 106
ORIGINAL AND NEWLY SUGGESTED WHO CLASSIFICATION FOR DENGUE SEVERITY: 2005-2010 (TOTAL 494 PATIENTS)
Narvaez F et al: PlosNTD 2011, 5: e1397. DHF+DSS = 152 patientsDW+SD = 467 patients
ADVANTAGES
Proven in reducing CFR
Can prevent shock so less severe cases and less complications
No need for confirmed dengue laboratories (PCR, NS1Ag, IgM/IgG tests): diagnosis DHF/DSS by clinical criteria correct > 90%
Easy and friendly use Use only clinical
especially warning signs.
No need for any laboratory tests to follow up: CBC
Increase number of cases report so may be more effective control?
Original WHO Suggested new
DISADVANTAGES
Need follow up of laboratory test especially CBC and frequent Hct monitoring
Need close monitoring especially during 24-48 hours of critical period of plasma leakage
More workload to healthcare personnel, at least 20 times at OPD and 2 times for IPD
More complication of fluid overload (admit and observe early with IV fluid infusion)
More severe cases with EDS Need dengue confirm labs.
except those with shock, with complication of fluid overload
Increase in CFR
Original WHO Suggested new
4. IV FLUID MANAGEMENT IN SHOCK CASES
10 ml/kg/hr in children or 300-500 ml/hr in adult
20 ml/kg in 20 mins. and can repeat another 2 times
Original WHO Newly suggested
4. IV FLUID MANAGEMENT IN NON-SHOCK (COMPENSATED SHOCK) CASES
1.5 ml/kg/hr in children or M/2 in early and adjust rate accordingly to clinical, vital signs, Hct and urine output
5-7 ml/kg/hr
Original WHO Newly suggested
4. OTHERS MANAGEMENT
Colloidal solution: only plasma expander (hyper-oncotic) - 10% Dextran-40 in NSS
No platelet prophylaxis except in adults with underlying HT and Plt < 10,000 cells/cumm.
Any colloidal solution including FFP
Platelet prophylaxis
Original WHO Newly suggested
Thank you !!!
