Transcript Dengue Shock Syndrome

Dengue
Divya Bappanad
Karapitya Hospital
Galle, Sri Lanka
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.
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
Studies
• WBC 5.2 86% N, 12% L and 1.2% M, Hgb 14 and
Platelets 16,000
• Dengue IgM + and IgG +
• CXR: clear
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
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
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
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
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
Clinical Progression
• Recovery phase
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2-3 days
Reabsorption of extravascular fluid
Bradycardia and ECG changes common
Hemodynamics stabilize, auto diuresis begins and
patient clinically improves
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.
Diagnosis
• Clinical diagnosis
▫ Live and travel in endemic area and fever + 2
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Anorexia and nausea
Rash
Myalgias/arthralgias
Leukopenia
Tourniquet test +
Signs of severe dengue
Serologic Diagnosis
• Decreasing wbc
▫ 1st serologic abnormality
• Dengue IgM and IgG
▫ tests viral specific antibodies
▫ 76% sensitive for primary infection and 88% for
secondary infection
▫ 88%-99% specificity
Treatment
• Supportive
• WHO management algorithm for fluid
resuscitation
• Transfusion
• Oxygen
• ICU monitering
Prognosis
• Dengue fever < 1% mortality
• Dengue hemorrhagic fever approx 2.5%
mortality
▫ Primarily children
• Dengue shock up to 47% mortality
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
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
• 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.