1. Dengue Divya Bappanad Karapitya Hospital Galle, Sri Lanka

2. Initial Presentation HPI: 18 yo Sri Lankan male in USOH until developed fever, myalgias and vomiting x 3 days. On basketball team and day prior to fever participated in game with no complaints. PMH: none Medications: none Immunizations: up to date SH: student, lives with mother in nearby community outside Galle, + electricity and running water, no siblings, no recent travel.

3. Physical Exam Vitals: T 40C BP 110/80 supine 90/70 standing HR 96 RR 16 SpO2 not available Gen: Alert, Ill appearing HEENT: PERRLA, EOMI, + conjunctival injection, OP clear, MM dry Neck: No LAD CV: RRR, no m/g/r Lungs: CTAB, no w/r/r Ab: +BS, soft, NT, ND, no HSM Ext: No edema Skin: No petechia

4. Studies WBC 5.2 86% N, 12% L and 1.2% M, Hgb 14 and Platelets 16,000 Dengue IgM + and IgG + CXR: clear

5. Continued Clinical Course Day 2 Coffee ground emesis ▫Transfused FFP, plts and has transfusion rx Day 3 Increased work of breathing ▫Transferred to ICU and intubated ▫Abx, plts and steroids Day 4 Hypotension, decreased urine output with worsening hypoxia ▫Started on pressors

6. Progressive Deterioration Day 6 Abdominal compartment syndrome ▫Paracentesis with 1.5 L removed Day 7 Worsening hypotension, decreased urine output and difficulty ventilating Day 10 ▫Withdrawal of ventilatory support

7. Dengue Epidemiology Incidence ▫2.5 billion people in over 100 endemic countries ▫50 million people infected annually with 500,000 cases of DHF and approx 20,000 deaths ▫Wide spectrum of illness although most subclinical or asymptomatic Dengue virus ▫Flavivirus: Single Stranded RNA virus ▫Serotypes: DEN-1 to DEN-4 ▫DEN-2 and DEN-3 severe disease with secondary dengue infections

8. Epidemiology Vector ▫Mosquito ▫Primarily Aedes Aegypti  Aedes albopictus, Aedes polynesiensis and other Aedes species also ▫Most female Ae. aegypti appear to spend lifetime in or around the houses where they emerge as adults. ▫Suggest people rather than mosquitoes, rapidly move the virus within and between communities

9. Clinical Progression Critical phase ▫3-7 days ▫Temperature defervescence with possible increased capillary permeability and increasing hematocrit ▫If no change in capillary permeability will improve and “non-severe dengue” ▫If fail to defervesce and develop leakage concerning for development shock

10. Clinical Progression Recovery phase ▫2-3 days ▫Reabsorption of extravascular fluid ▫Bradycardia and ECG changes common ▫Hemodynamics stabilize, auto diuresis begins and patient clinically improves

11. Severe Dengue( Dengue Hemorrhagic Fever or Dengue Shock Syndrome) Fever of 2–7 days plus : ▫Evidence of plasma leakage, such as:  high or rising hematocrit; pleural effusions or ascites; circulatory compromise or shock ▫Significant bleeding. ▫Altered level of consciousness (lethargy or restlessness, coma, convulsions). ▫Severe gastrointestinal involvement (persistent vomiting, increasing or intense abdominal pain, jaundice). ▫Severe organ impairment (acute liver failure, acute renal failure, encephalopathy or encephalitis, or other unusual manifestations, cardiomyopathy) or other unusual manifestations.

12. Diagnosis Clinical diagnosis ▫Live and travel in endemic area and fever + 2  Anorexia and nausea  Rash  Myalgias/arthralgias  Leukopenia  Tourniquet test +  Signs of severe dengue

13. Serologic Diagnosis Decreasing wbc ▫1 st serologic abnormality Dengue IgM and IgG ▫tests viral specific antibodies ▫76% sensitive for primary infection and 88% for secondary infection ▫88%-99% specificity

14. Treatment Supportive WHO management algorithm for fluid resuscitation Transfusion Oxygen ICU monitering

15. Prognosis Dengue fever < 1% mortality Dengue hemorrhagic fever approx 2.5% mortality ▫Primarily children Dengue shock up to 47% mortality

16. Recurrent infection Active infection protected from illness from different serotype for 2-3 months, but not long term Infection by one serotype confirms lifelong immunity to that serotype No immunization currently available

17. Bibliography Dengue: guidelines for diagnosis, treatment, prevention and control. Second edition. Geneva: World Health Organization. 2009. Accessed at http://whqlibdoc.who.int/publications/2009/9789241547871_eng. pdf http://whqlibdoc.who.int/publications/2009/9789241547871_eng. pdf Singhi S, Kissoon N, Bansal A. Dengue and dengue hemorrhagic fever: management issues in an intensive care unit. J Pediatr (Rio J). 2007; 83(2 Suppl):S22-35.