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Author: Daniel D Price, MD, Director of Ultrasound Fellowship, Department of Emergency Medicine, Highland General Hospital, Alameda County Medical Center

Daniel D Price is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Coauthor(s): Sharon R Wilson, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center

Editors: William K Chiang, MD, Associate Professor, Department of Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine; Consulting Staff, Bellevue Hospital Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Barry E Brenner, MD, PhD, FACEP, Program Director, Department of Emergency Medicine, University Hospitals, Case Medical Center

Author and Editor Disclosure

Synonyms and related keywords: breakbone fever, ki denga pepo, mosquito-transmitted viral disease, febrile syndrome, bleeding diathesis, disseminated intravascular coagulation, DIC, dengue hemorrhagic fever, DHF, dengue shock syndrome, DSS, dengue viral infections, dengue fever

Background

Dengue has been called the most important mosquito-transmitted viral disease in terms of morbidity and mortality. Dengue fever is a benign acute febrile syndrome occurring in tropical regions. In a small proportion of cases, the virus causes increased vascular permeability that leads to a bleeding diathesis or disseminated intravascular coagulation (DIC) known as dengue hemorrhagic fever (DHF). Secondary infection by a different dengue virus serotype has been confirmed as an important risk factor for the development of DHF. In 20-30% of DHF cases, the patient develops shock, known as the dengue shock syndrome (DSS). Worldwide, children younger than 15 years comprise 90% of DHF subjects; however, in the Americas, DHF occurs in both adults and children.

Dengue is a homonym for the African ki denga pepo, which appeared in English literature during an 1827-28 Caribbean outbreak. The first definite clinical report of dengue is attributed to Benjamin Rush in 1789, but the viral etiology and its mode of transmission via mosquitos were not established until the early 20th century.

Pathophysiology

Dengue viral infections frequently are not apparent. Classic dengue primarily occurs in nonimmune, nonindigenous adults and children. Symptoms begin after a 5- to 10-day incubation period. DHF/DSS usually occurs during a second dengue infection in persons with preexisting actively or passively (maternally) acquired immunity to a heterologous dengue virus serotype. Illness begins abruptly with a minor stage of 2-4 days' duration followed by rapid deterioration. Increased vascular permeability, bleeding, and possible DIC may be mediated by circulating dengue antigen-antibody complexes, activation of complement, and release of vasoactive amines. In the process of immune elimination of infected cells, proteases and lymphokines may be released and activate complement coagulation cascades and vascular permeability factors.

Frequency

United States

Between 1990 and 1992, reports of 10 imported cases of dengue fever were published. While still rare, this is a dramatic increase from 1 case reported during the period from 1987 to 1989; this probably results from increases in air travel and an exotic vector that has adapted to cold climates. Cases along the Texas-Mexico border have been cited recently.

International

Dengue virus causes about 100 million cases of acute febrile disease annually, including more than 500,000 reported cases of DHF/DSS. Currently, dengue is endemic in 112 countries. The world's largest known epidemic of DHF/DSS occurred in Cuba in 1981, with more than 116,000 persons hospitalized and as many as 11,000 cases reported in a single day. Current outbreaks can be monitored via the ProMed listserve by contacting owner-promed@promedmail.org.

Mortality/Morbidity

 

  • Treated DHF/DSS is associated with a 3% mortality rate.
  • Untreated DHF/DSS is associated with a 50% mortality rate.

 

Race

Ethnicity is nonspecific, but the disease's distribution is geographically determined. Fewer cases have been reported in the black population than in other races.

Sex

No predilection is known; however, fewer cases of DHF/DSS have been reported in men than in women.

Age

All ages are susceptible. In endemic areas, a high prevalence of immunity in adults may limit outbreaks to children.



History

 

  • Fever
    • Abrupt onset, rising to 39.5-41.4°C
    • Accompanied by frontal or retro-orbital headache
    • Lasts 1-7 days, then defervesces for 1-2 days
    • Biphasic, recurring with second rash but not as high
  • Rash
    • Initial rash transient, generalized, macular, and blanching; occurs in first 1-2 days of fever
    • Second rash occurring within 1-2 days of defervescence, lasting 1-5 days
    • Second rash morbilliform, maculopapular, sparing palms and soles
    • Occasionally desquamates
  • Bone pain
    • Absent in dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS)
    • After onset of fever
    • Increases in severity
    • Not associated with fractures
    • May last several weeks
    • Most common in legs, joints, and lumbar spine
  • Miscellaneous symptoms
    • Nausea and vomiting
    • Cutaneous hyperesthesia
    • Taste aberrations
    • Anorexia
    • Abdominal pain (severe in DHF/DSS)

 

Physical

 

  • Fever
  • Signs of intravascular volume depletion
  • Hemorrhagic manifestations
    • Positive tourniquet test
    • Petechiae, purpura, epistaxis, gum bleeding, GI bleeding, menorrhagia
  • Rash
  • Hepatomegaly (inconsistent)
  • Generalized lymphadenopathy

 

Causes

 

  • Dengue virus types 1-4
    • Aedes aegypti mosquito vector
    • Human-mosquito-human cycle
    • Found in tropical regions, especially Southeast Asia

 



Hepatitis
Malaria
Meningitis
Pediatrics, Bacteremia and Sepsis
Pediatrics, Meningitis and Encephalitis
Tick-Borne Diseases, Rocky Mountain Spotted Fever
Yellow Fever

Other Problems to be Considered

Leptospirosis
Rickettsioses
River viruses
Scrub typhus
Typhoid
Viral infections (eg, influenza, chikungunya, Mayaro fever, Rift Valley fever, West Nile, Sindbis, and Ross River)



Lab Studies

 

  • Isolation of virus in serum and detection of immunoglobulins (IgM and IgG) by enzyme-linked immunosorbent assay (ELISA) antibody capture, monoclonal antibody, or hemagglutination
  • Complete blood count
    • Hemoconcentration (hematocrit increased 20%)
    • Thrombocytopenia (platelet count <100 x 109/L)
    • Leukopenia
  • Chemistry panel
    • Electrolyte imbalances
    • Acidemia
    • Elevated BUN
  • Liver function tests
    • Elevated transaminases
    • Hypoproteinemia
  • Guaiac test for occult blood in stool (see Media file 3)
  • DIC panel, as indicated

 

Imaging Studies

 

  • Chest radiography
    • Bronchopneumonia
    • Pleural effusion
  • Head CT scan without contrast
    • For altered level of consciousness
    • Intracranial bleeding
    • Cerebral edema

 

Other Tests

 

  • Electrocardiography
    • Nonspecific changes may be effects of fever, electrolyte disturbances, tachycardia, or medications.
    • Usefulness of these changes as a marker of cardiac involvement is unclear.

 



Prehospital Care

 

  • Initiate supportive therapy
    • Intravenous (IV) crystalloids, as needed to keep systolic blood pressure above 90 mm Hg
    • O2, empirically

 

Emergency Department Care

 

  • Supportive therapy
    • IV access, O2, and monitoring are helpful.
    • IV crystalloids may be necessary for hypotension; central line may be needed.
    • Correct electrolyte abnormalities and acidemia.
  • Implement therapy for DIC if indicated.
  • Corticosteroids are not helpful.
  • No antiviral therapy is available.

 

Consultations

 

  • Infectious disease
  • Travel clinic, if available

 



No specific medications are indicated for direct treatment of the dengue virus infection.



Further Inpatient Care

 

  • Admit to ICU if hypotensive or in DIC, otherwise admit to medicine ward.
    • Patient may require a central line.
    • Patient may require an arterial line.
    • Patient may require blood components.

 

Deterrence/Prevention

 

  • Reduce A aegypti vector populations.
  • Reduce exposure to A aegypti.
    • Use insect repellent.
    • Sleep under a mosquito net in affected areas.
    • Wear protective clothing.
  • Vaccines against all 4 serotypes are currently under development. While this is challenging due to the complex immune response, vaccines may ultimately be the most effective control strategy, since vector control programs have been largely unsuccessful and of only short-term local benefit.

 

Complications

 

  • Complications are rare but may include the following:
    • Brain damage from prolonged shock or intracranial hemorrhage
    • Myocarditis
    • Encephalopathy
    • Liver failure

 

Prognosis

 

  • Morens states that the rapid clinical response to aggressive fluids and electrolytes in even moribund children with DHF/DSS "is among the most dramatic events in clinical medicine." Treated promptly, children in shock and coma can wake up and return to near normalcy within hours.
  • Convalescence may be prolonged, with weakness and mental depression.
  • Continued bone pain, bradycardia, and premature ventricular contractions (PVCs) are common.
  • Survival is related directly to early hospitalization and aggressive supportive care.
  • Dengue fever is not contagious through person-to-person contact.

 

Patient Education

 

 



Medical/Legal Pitfalls

 

  • Failure to admit patients for aggressive supportive therapy
  • Failure to rule out other possible illnesses and specific therapies

 

Special Concerns

 

  • Pediatric deaths associated with dengue viral infection most commonly occur in infants younger than 1 year.

 



Media file 1:  A child with dengue hemorrhagic fever or dengue shock syndrome may present severely hypotensive with disseminated intravascular coagulation (DIC), as this severely ill PICU patient did. Crystalloid fluid resuscitation and standard DIC treatment are critical to the child's survival.
Click to see larger picture Click to see detailView Full Size Image
 
Media type:  Photo
Media file 2:  Delayed capillary refill may be the first sign of intravascular volume depletion. Hypotension usually is a late sign in children. This child's capillary refill at 6 seconds was delayed well beyond a normal duration of 2 seconds.
Click to see larger picture Click to see detailView Full Size Image
 
Media type:  Photo
Media file 3:  Signs of early coagulopathy may be as subtle as a guaiac test positive for occult blood in the stool. This test should be performed on all patients in whom dengue virus infection is suspected.
Click to see larger picture Click to see detailView Full Size Image
 
Media type:  Photo


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Article Last Updated: Jan 31, 2008

   

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