A.M is a 30/F who came at the OPD with a chief complaint of on and off fever, for five days accompanied by body malaise and chills.

Review of systems:No vomiting, no abdominal pain, no rashes, no

hematemesis, no melena, no cough, no colds, no change in the color of the urine.

Past Medical History: unremarkablePersonal/Social: Patient is a smoker consumimg 1-2

sticks per day and an occasional alcoholic beverage drinker.

Physical Examination: VS BP:100/70, CR:78, RR:22, T:38 C

General Survey: Patient is conscious, coherent not in cardiorespiratory distress.

HEENT: pink palpebral conjunctivae, anicteric sclerae, (+) subconjunctival suffusion, no tonsillopharyngeal congestion, no cervical lymphadenopathies.

Chest/Lungs:Symmetrical chest expansion, (-) retractions, clear breath sounds.

Heart: Adynamic precordium, normal rate regular rhythm, (-) murmur.

Abdomen: Flabby, normoactive bowel sounds, soft, non tender

Extremities: Grossly normal, no rashes, no edema

Pertinent 1.A.M 30 y/o, female2.Fever (37.9) on and off3.Body malaise4.Chills

Impression: To consider Dengue Fever Syndrome without Warning signs

New Case Classification and Levels of Severity

Case Definition for Dengue without Warning Signs

Probable dengueLives in or travels to dengue-endemic area, with

fever, plus any two of the ff:- Headache- Body malaise- Myalgia- Arthralgia- Retro-orbital pain- Anorexia

NauseaVomitingDiarrheaFlushed skinRash (petechial, Hermann’s rash) AndLaboratory test, at least CBC (leukopenia with or

without thrombocytopenia) and/or dengue NSI antigen or dengue IgM

antibody test (optional)Confirmed dengue:Viral culture isolationPCR

Case definition for Dengue with warning signs:Lives in or travels to dengue-endemic area, with fever lasting for 2-7 days, plus any one of the

ff:- Abdominal pain or tenderness- Persistent vomiting- Clinical signs of fluid accumulation- Mucosal bleeding- Lethargy, restlessness- Liver enlargement- Laboratory: increase in Hct and/or decreasing

platelet countConfirmed dengue:-Viral culture isolation-PCR

Case Definition for Severe DengueLives in or travels to a dengue-endemic area with

fever of 2-7 days, and any of the above clinical manifestations for dengue with or without warning signs, plus any of the ff:

Severe plasma leakage leading to:ShockFluid accumulation with respiratory distressSevere bleedingSevere organ impairmentLiver: AST or ALT >/= 1000CNS: e.g., myocarditisKidneys e.g., renal failure

General guidelines

Dengue infection is a systemic and dynamic disease. It has a wide clinical spectrum that includes severe and non-severe forms of clinical manifestations. After the incubation period, the illness begins abruptly and be followed by 3 phases: febrile, critical and recovery phase.

COURSE OF DENGUE ILLNESSFEBRILE PHASE1.The acute febrile phase usually lats 2-7 days.

Monitoring for warning signs is crucial to recognize its progression to the phase.

2.Clinical Signs/Symptoms- fever

- Headcahe- Body malaise- Myalgia- Arthralgia- Retro-orbital pain- Anorexia- Nausea- Vomiting- Diarrhea- Flushed skin- Rash3.Laboratory test, at least CBC (leukopenia with or

without thrombocytopenia) and /or dengue NS1 antigen test or dengue IgM test (optional)

Critical Phase1.Defervescence occurs on day 3-7 of illness, when the

temperature drops to 37.5- 38 C or less and remain below this level. Around the time of defervescence, patients can either improve or deteriorate. Those who improve after defervescence have DENGUE WITHOUT WARNING SIGNS. Those who deteriorate will manifest warning signs have DENGUE WITH WARNING SIGNS.

2.Warning Signs- Abdominal pain or tenderness- Persistent vomiting- Clinical signs of fluid accumulation- Mucosal bleeding- Lethargy, restlessness- Liver enlargement

3.Laboratory: inc. in hematocrit and/or decreasing platelet count some may deteriorate—SEVERE DENGUE defined by one or more of the following:

a. Plasma leakage that may lead to shock (dengue shock) and/or fluid accumulation with or without respiratory distress, and/or

b. Severe bleeding, and/orc. Severe organ impairment

Recovery Phase1.takes place in the next 48-72 hours2.well being improves3.hemodynamic status stabilizes4.Diuresis ensues5.Hermann’s rash (“isles of white in the sea of

red”)6.Normalizaton of the platelet count is typically

later than that of the WBC count.

Clinical Problems encountered during the different phases of dengue are:

Febrile Phase- dehydration; high fever may cause febrile seizure in young children; neurological disturbances

Critical phase- shock from plasma leakage; severe hemorrhage; organ impairment

Recovery phase- hypervolemia (only if intravenous fluid therapy has been excessive and/or extended into this period).

Treatment Guidelines: A Stepwise Approach To Management Of Dengue

AssessmentStep 1– Overall Assessment

1.1 History1.2 Physical Examination1.3 Investigaton

Step 2– Diagnosis, Assessment of Disease Phase and Severity

Step 3– Management

Treatment (by type of patient)I Group A- patients who may be sent homeAction Plan: Oral rehydration solution

Calculation of oral Rehydration fluid Using weight

(Ludan Method)Body weight (kg) ORS to be Given> 3-10 100ml/kg/day>10-20 75ml/kg/day>20-30 50-60/kg/day>30-60 40-50ml/kg/

day

II Group B- Patients who should be referred for in-hospital management.

Action Plan:Dengue without warning signs1.Encourage oral fluids.2.If not tolerated, start the patient with

intravenous fluid using isotonic solution(D5LRS, D5NSS,D5 0.9 NACL)

Calculation of maintenance IVF Body Weight Total Fluid Requirement (ml/day)

0-10 100ml/kg >10-20 1000ml + 50ml/kg for each kg >10kg >20 1500ml + 20 ml/kg for each kg > 20kg

TFR = Maintenance IVF + Fluids as for Mild Dehydration

Where the volume of fluids for mild dehydration is computed as follows:

infants 50ml/kgOlder child or adult 30ml/kg

One–half of the computed TFR is given in 8 hours and the remaining one-half is given in the next 16 hours

The IVF rate may be decreased anytime as necessary based on clinical assessment

Dengue With Warning Signs1.Obtain a reference hematocrit before fluid

therapy2.Give only isotonic solutions such as 0.9% NaCl,

Ringer’s lactate, Hartmann’s solution.Start with 5-7 ml/kg/hr for 1-2hours then, reduce to 3-5ml/kg/hr for 2-4 hours,then reduce to 2-3 ml/kg/hr or less according to clinical response

3.Reassess the clinical status and repeat the hematocrit

4.If the hematocrit remains the same or rises only minimally, continue with the same rate (2-3 ml/kg/hr) for another 2-4 hrs.

5. If there are worsening of vital signs and rapidly rising hematocrit, increase the rate to 5-10ml/kg/hr for 1-2 hours.

6. Reassess the clinical status, repeat hematocrit and review fluid infusion rates accordingly.

7. Give the minimum intravenous fluid volume required to maintain good perfusion and urine output of about 0.5ml/kg/hr. Intravenous fluid are usually neede only 24 to 48 hours.

III Group C- Patients with Severe Dengue requiring emergency Treatment and Urgent Referral

COMPENSATED SHOCK1.Start IVF resuscitation with isotonic crystalloid at

5-10 ml/kg/hr over 1 hour, then reassess the patient’s condition

2.If the patient’s condition improves, IVF should be gradually reduced to:5-7ml/kg/hr for 1-2 hrs,then3-5ml/kg/hr for 2-4 hours, then2-3ml/kg/hr and thento reduce further depending on hemodynamic status, which can be maintained for up to 24 to 48 hours.

3.If vital signs are still unstable (shock persists), check the hematocrit after the first bolus:*If hematocrit increases or still high (>50%), repeat a second bolus of crystalloid solution at 10-20ml/kg/hr for 1 hour. After this second bolus, if there is improvement, then reduce the rate to 7-10 ml/kg/hr for 1-2 hrs, and then continue to reduce as above* If hematocrit decreases compared to the initial reference hematocrit (<40% in children and adult females, <45% in adult males) this indicates bleeding and the need to crossmatch and transfuse blood as soon as possible. reduce to 3-5ml/kg/hr

HYPOTENSIVE SHOCK1.Initiate intravenous fluid resuscitation with

crystalloid or colloid solution (if available) at 20 ml/kg as bolus given over 15min to bring the patient out of shock as quickly as possible

2.If the patient’s condition improves, give a crystalloid/colloid infusion of 10ml/kg/hr for 1 hour, then continue with cryatalloid infusion and gradually reduce

to 5-7ml/kg/hr for 1-2hours,then to 3-5 ml/kg/hr for 2-4 hours and then to 2-3 ml/kg/hr or less, which can be maintained

for up to 24-48 hours

3. If vital signs are still unstable, check hematocrit after the first bolus:

*If hematocrit increases compared to the previous value or remaining very high (>50%) change IVF to colloid solutions at 10-20 ml/kg as a second bolus over ½ hours, then change back to crysalloid solution and reduce rate of infusion as mentioned above when the patient’s condition improves

*If hematocrit decreases compared to the previous value (40% in children and adult females, <45% in adult males), this indicates bleeding and the need to cross-match and transfuse blood as soon as possible

4. Further boluses of fluids may need to be given during the next 24hrs. The rate and volume of each bolus infusion should be titrated to the clinical response. Patients with dengue should be admitted to the high dependency or intensive areas.

Hemorrhagic Complications1.Strict bed rest and strict protecton from trauma2. Do not give intramuscular injections to avoid

trauma

Discharge criteria:All of the following must be present1.No fever for more than 48 hours2.Improvement in clinical status3.Increasing trend of platelet count4.Stable hematocrit without IVF