1. DENGUE HEMORRHAGIC FEVER
PROF S SHIVAKUMAR’S UNIT
D RAVI SHANKAR MD PG

2. Komala 20yrs/ female Admitted on 11/ 04/ 06 C/o
Fever with rigor - 3 days
Running nose
Dry cough - 3 days
Severe headache
Body ache - 3 days
Redness of eyes
Maculopapular rash- 1 day

3. Past / Personal/ Family/ Drug H/o
No H/o
Dysuria
Jaundice
Vomiting
Diarrhea
Bleeding symptoms
Abdominal pain
Vaginal discharge
Past / Personal/ Family/ Drug H/o
Nothing relevant

4. GENERAL EXAMINATION Conscious Oriented Febrile
No pallor/ icterus/ cyanosis/ clubbing/
Lt posterior cervical LN +
Maculo papular rash over the face and neck +
Conjuntival suffusion + +
PR – 110/ mt, BP 110/ 70mmHg
Temp- 102 F, RR – 18/ mt

5. CVS
RS NAD
ABD
CNS
DIAGNOSIS
VIRAL EXANTHEMATOUS FEVER

6. ON 12/ 04/ 06 Morning Conscious Highly febrile
Rash spread all over the body
Conjunctival suffusion increased
Little breathless
PR – 100/mt , BP – 100/ 70
ECG & CXR – normal
Treated with IV fluids and antibiotics

7. ON 12/ 04/ 06 Evening Conscious, Disoriented
Febrile with severe rigors
Restless
Excessive sweating
Breathless
C/o
Black vomitus
Vaginal bleeding
Epistaxis
Sub conjunctival heamorrhage

8. Contd…… Suddenly patient Unconscious Peripheries became cold
Sweating++
Urinary and fecal incontinence
Pulse – feeble 130/ mt
BP - 50/ ?
Hemogram done in the morning was normal

9. Contd…… Patient was treated with 3- 4 liters of Normal saline
Fresh blood
Platlet transfusion
Dopamine infusion
BP picked up and patient became conscious
Patient shifted to IMCW
PLATLET count done outside at 11pm
68,000/ cu mm

10. VIRAL HEMORRHAGIC FEVER
DIAGNOSIS
VIRAL HEMORRHAGIC FEVER
? DENGUE SHOCK SYNDROME

11. ON 13/ 04/ 06 in IMCW Conscious, oriented Afebrile No rash
Severe conjunctival hage
Loose stools
Vaginal bleeding +
Blood stained vomiting
BP stable
Treated with IV fluids, platlets(12 units), blood transfusion ( 2 units ), antibiotics.

12. INVESTIGATIONS HEMOGRAM 12/04 17/04 20/04 Hb 10.2 9.8 8.1
12/04 17/04 20/04 Hb
TLC 54OO
DLC P58 L42 P65L35 P63 L37
ESR 12/ 20 8/ / 22
RBC 3.6 million
PCV 3O% 30% 29%
PLATLET 68,000 50, Lac

13. SERIAL PLATLET COUNT 12/ 04 / 06 - 68,000 18/ 04 / 06 - 50,000
12/ 04 / ,000
18/ 04 / ,000
21/ 04 / Lacs
20/ 04 / Lacs
24/ 04 / Lacs

14. OTHER INVESTIGATIONS RFT Blood sugar - 138mg /dl LFT UREA - 38 mg/ dl
Creatinine- 1.0 mg/ dl
Blood sugar - 138mg /dl
LFT
TB mg/ dl
SGOT IU/ L
SGPT - 83 IU / L
SAP - 63 IU / L
T. protein- 7.8 g/ dl
Sr. Alb g/ dl

15. DENDUE Ig M - +VE Ig G - +VE QBC MP - -VE MSAT - -VE WIDAL - -VE
PS STUDY - Microcytic Hypochromic anemia and thrombocytopenia.
USG ABD - N study

16. DIAGNOSIS
DENGUE HEMORRHAGIC FEVER
WITH
DENGUE SHOCK SYNDROME

18. VIRAL HEMORRHAGIC FEVER
DENGUE
YELLOW FEVER
EBOLA
LASSA
HANTA
MARBURG
RIFT VALLEY FEVER
CRIMEAN CONGO

19. SIMILARITIES IN VHF All are membrane bound viruses All are RNA viruses
Most have Zoonotic life cycles except DENGUE
Acute fever and myalgia
Capillary leak syndrome
Host immune response decides severity of disease
All infections are immunosuppressive
All are mosquito or tick born

20. COMMON PATHOGENESIS Affinity to capillary endothelium
Immune complex mediated endothelial injury
Complement mediated increased capillary permeability
Increased capillary permeability
Capillary Leak – ascites, pl effusion, edema
Hypovolemia, hypotension, shock,
Hypoxia , Acidosis and Hyperkalemia
DIC

21. DENGUE RNA virus, Flavi viridae Four serotypes ( 1 – 4 )
Transmitted by Aeidis aegypti and albopictus
Artificial containers
Day biter
Mosquitoes infective life long
Trans ovarian transmission
Preferentially in urban areas
Common in children and is mild than in adults

22. DENGUE - EPIDEMIOLOGY All continents are endemic except Europe
million cases
5 lac DHF
All 4 types reported in INDIA(1&2 common)
Epidemics in INDIA
1970 – DEN 3
DEN 2 ( Delhi )
2003 status
12,750 cases
217 deaths
1600 cases and 8 deaths in TN

23. DENGUE INFECTION ASYMPTOMATIC SYMPTOMATIC DENGUE FEVER
DENGUE HEMORRHAGIC
FEVER
BREAK BONE
FEVER
VIRAL
SYNDROME
WITHOUT SHOCK
WITH OR WITHOUT
HEMORRHAGE
WITH SHOCK ( DSS )

24. CLINICAL FEATURES Undifferentiated fever with myalgia
Typical dengue fever
Older children and adults
Biphasic fever ( 5 – 7 days )
Head ache, Myalgia, arthralgia
Upper Resp. symptoms
Flushed face, retro orbital pain, photophobia
RASH
Diffuse flushing or fleeting pin point eruptions fece, neck & chest during 1-3 days of fever
Maculopapular or scarlantiform – 4th day
After defevescence – petichiae and +ve Tourniquet test
Epistaxis, gum bleeding and GI bleeding may occur
Lecopenia with left shift

25. DHF AND DSS High fever Hemorrhagic phenomena Thrombocytopenia
Peticheal rash
Epistaxis
GI bleed
Vaginal bleeding
Bleeding at IV cannula sites
+ve tourniquet test
Thrombocytopenia
Hemoconcentration
Circulatory failure( Febrile to afebrile)
Narrow pulse pressure
Hypotension
Cold clammy skin
Cyanosis
Profound shock
ICH, convulsions and encephalopathy

26. DHF - GRADES Grade I - Fever Non sp symptoms Torniquet test +ve
Grade II - Spontaneous bleeding
with above symptoms
Grade III - Rapid, weak pulse
Narrow pulse pressure
Hypotension
Grade IV - Profound Shock
Platelet < 1 lac, PCV > 20 % in all grades

27. IMMUNOLOGY DENGUE INFECTION HETEROLOGOUS ANTIBODIES to other
3 serotypes
HOMOLOGOUS
ANTIBODIES
CMI
NEUTRALISING
LEVEL 2-12 MONTHS
(partial protection )
LIFE LONG
PROTECTION
AGAINST SAME
SEROTYPE
REDUCED TO NON
NEUTRALISING LEVEL
AFTER 12 MONTHS

28. IMMUNE ENHANCEMENT PRIMARY DENGUE INFECTION Secondary Dengue
Infection – diff serotype
NON NEUTRALISING
LEVEL- Heterotypic
Antibodies ( 1 – 5 yrs)
MACROPHAGE
VIRUS
Highly infected
Macrophage

29. DSS - PATHOGENESIS SHOCK Uncontrolled multiplication
Of virus in Macrophage
Macrophage
activation
Excessive release
Of cytokines
(TNF & IL)
VASODILATATION
INCREASED PEMEABILITY
CAPILLARY LEAK
HYPOTENSION
SHOCK
HEMATOCRIT
( INTERNAL HEMORRHAGE)

30. DSS - PATHOGENESIS DIC( rare) CD 8 mediated destruction
of infected Macrophage
Release of proteolytic
Enzymes
Immune
complex
Viral endothelial
damage
Complement
activation
Coagulation
activation
Thrombocytopenia
C 3a C 5a
anphylotoxins
DIC( rare)
Potent vasodilatation/ Leak

31. DSS – PRE REQUISITE Primary dengue infection
Secondary & sequential infection with other serotypes with in 1-5 yrs of primary infection
DSS can occur in primary infection in infants who has maternal antibodies in non neutralizing level

32. LAB PROFILE Hemogram Virus isolation < 5 days
Leucopenia with relative Lymphocytosis
Thrombocytopenia < 1 lac
PCV increased > 20 %
Prolonged PT & aPTT
Reduced complement levels
Hypoproteinemia , mild SGOT & SGPT elevations
Virus isolation < 5 days
Serology - Ig M & Ig G ELISA

33. Treatment of DF/ DHF Febrile phase Afebrile phase - observe Bed rest
Paracetamol – 4times/day
Avoid Aspirin & Brufen
Avoid antibiotics
Oral Rehydration therapy – fluid loss due to vomiting / high temp. (2.5-4 litres /day)
Afebrile phase - observe

34. DHF CRYSTALLOIDS (RL/DNS) Improvement 6ml/kg/hr 3ml/kg/hr
Discontinue after
6-12 hrs
No Improvement
CRYSTALLOIDS
6ml/kg/hr
10ml/kg/hr No
improvement
Hct
Hct
Blood transfusion
Colloids
discontinue
Crystalloids
10-6-3ml
improvement
improvement

35. DSS Hct  Hct  Blood transfusion ( 10ml/ kg/ hr ) CRYSTALLOIDS
Improvement
Reduce
10-6-3ml/kg/hr
No Improvement
CRYSTALLOIDS
(10-20 ml/kg/hr)
Hct 
Hct 
Blood transfusion
( 10ml/ kg/ hr )
COLLOID
10-6-3ml
Discontinue
Crystalloids
10-6-3ml
Improvement

36. Points to be remembered
Hct  - IV Crystalloids or colloids (Dextran 40) or plasma (10 ml/kg/hr)
Hct  - Blood Transfusion (10ml/kg/hr)
Platelets < 5000cu.mm - platelet transfusion

37. thank u