eMedicine Specialties > Infectious Diseases > Viral Infections

Dengue Fever: Differential Diagnoses & Workup

Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Coauthor(s): Patrick B Hinfey, MD, Associate Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center; William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Contributor Information and Disclosures

Updated: Oct 23, 2009

Differential Diagnoses

Arenaviruses
Meningococcal Infections
Ebola Virus
Meningococcemia
Hepatitis, Viral
Orbivirus
Influenza
Rocky Mountain Spotted Fever
Leptospirosis
Sepsis, Bacterial
Lymphocytic Choriomeningitis
Septic Shock
Malaria
Typhus
Meningitis
Yellow Fever

Other Problems to Be Considered

Chikungunya virus
Mayaro fever
Ross River fever
Sindbis virus
Hemorrhagic fever viruses
Early severe acute respiratory syndrome (SARS)

Workup

Laboratory Studies

  • Complete blood cell count findings include the following:
    • Leukopenia, often with lymphopenia, is observed near the end of the febrile phase of illness. Lymphocytosis, with atypical lymphocytes, commonly develops before defervescence or shock. A recent systematic review found that patients with dengue had significantly lower total WBC, neutrophil, and platelet counts than patients with other febrile illnesses in dengue-endemic populations.27
    • A hematocrit level rise of greater than 20% is a sign of hemoconcentration and precedes shock. The hematocrit level should be monitored at least every 24 hours to facilitate early recognition of dengue hemorrhagic fever and every 3-4 hours in severe cases of dengue hemorrhagic fever or dengue shock syndrome.
    • Thrombocytopenia has been demonstrated in up to 50% of dengue fever cases. Platelet counts of less than 100,000 cells/μL are seen in dengue hemorrhagic fever or dengue shock syndrome and occur before defervescence and the onset of shock. The platelet count should be monitored at least every 24 hours to facilitate early recognition of dengue hemorrhagic fever.
  • Basic metabolic panel findings include the following:
    • Hyponatremia is the most common electrolyte abnormality in patients with dengue hemorrhagic fever or dengue shock syndrome.
    • Metabolic acidosis is observed in those with shock and must be corrected rapidly.
    • Elevated BUN levels are observed in those with shock. Acute kidney injury is uncommon.28,29
  • Liver injury panel findings include the following:
    • Transaminase levels may be mildly elevated into the several thousands in patients with dengue hemorrhagic fever who have acute hepatitis.
    • Low albumin levels are a sign of hemoconcentration.
  • Coagulation studies may help to guide therapy in patients with severe hemorrhagic manifestations. Findings are as follows:
    • Prothrombin time is prolonged.
    • Activated partial thromboplastin time is prolonged.
    • Low fibrinogen and elevated fibrin degradation product levels are signs of disseminated intravascular coagulation.
  • Typing and crossmatching of blood should be performed in cases of severe dengue hemorrhagic fever or dengue shock syndrome because blood products may be required.
  • Serum specimens should be sent to the laboratory for serodiagnosis, PCR, and viral isolation. Because the signs and symptoms of dengue fever are nonspecific, attempting laboratory confirmation of dengue infection is important.
    • Serodiagnosis is made based on a rise in antibody titer in paired IgG or IgM specimens. Results vary depending on whether the infection is primary or secondary.
    • The IgM capture enzyme-linked immunosorbent assay (MAC-ELISA) has become the most widely used assay, although other tests, including complement fixation (CF), neutralization test (NT), hemagglutination inhibition (HI), and IgG ELISA are also used.
    • A recent European study found that, if only a single serum sample is available, a single positive result on ELISA (PanBio IgM or IgG) was found to have a high rate of false positivity and should be confirmed using a second more specific diagnostic technique.30,31
    • In order to provide a more rapid reliable diagnosis, clinically available PCR studies are being developed.32,33
  • Cultures of blood, urine, CSF, and other body fluids should be performed as necessary to exclude or confirm other potential causes of the patient's condition.

Imaging Studies

  • Chest radiography: Right-sided pleural effusion is typical. Bilateral pleural effusions are common in patients with dengue shock syndrome.
  • Serial ultrasonography
    • Ultrasonography is a potentially timely, cost-effective, and easily used modality in the evaluation of potential dengue hemorrhagic fever. Positive and reliable ultrasonographic findings include fluid in the chest and abdominal cavities, pericardial effusion, and a thickened gallbladder wall. Thickening of the gallbladder wall may presage clinically significant vascular permeability.34,2
    • The utility of previous studies was limited because of the use of single studies for evaluation. However, a recent study involving 158 patients examined the role of daily serial ultrasonographic examinations of the thorax and abdomen in the evaluation of patients with suspected dengue hemorrhagic fever.34 Plasma leakage was detected in some patients within 3 days of fever onset. Pleural effusion was the most common sign. Based on ultrasonographic findings, dengue hemorrhagic fever was predicted in 12 patients before hemoconcentration criteria had been met.

Other Tests

  • Arterial blood gas should be assessed in patients with severe cases to assess pH, oxygenation, and ventilation.

Procedures

  • Large-bore intravenous catheter - For fluid administration
  • Central venous catheter
    • For fluid administration
    • For central venous pressure measurement
  • Arterial catheter
    • For continuous blood pressure measurement
    • For serial arterial blood gas measurement
  • Urethral catheterization - May be useful to strictly monitor urine output

More on Dengue Fever

Overview: Dengue Fever
Differential Diagnoses & Workup: Dengue Fever
Treatment & Medication: Dengue Fever
Follow-up: Dengue Fever
References
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Further Reading

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Keywords

dengue, dengue fever, breakbone fever, DF, dengue virus, dengue infection, dengue hemorrhagic fever, DHF, dengue shock syndrome, DSS, dengue virus 1, DENV-1, dengue virus 2, DENV-2, dengue virus 3, DENV-3, dengue virus 4, DENV-4, Flaviviridae, Flavivirus, Aedes aegypti, A aegypti, Aedes albopictus, A albopictus, mosquitoes, viral epidemic, epidemic, saddleback fever, epidemic dengue, hyperendemic dengue, breakbone fever, dengue hepatitis

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Contributor Information and Disclosures

Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Patrick B Hinfey, MD, Associate Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center
Patrick B Hinfey, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Glaxo Smith Kline Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Medical Editor

Martin J Wood, MD †, Former Consulting Staff, Department of Infection and Tropical Medicine, Birmingham Heartlands Hospital, UK
Martin J Wood, MD † is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, American Society for Microbiology, Infectious Diseases Society of America, International Society for Infectious Diseases, and Royal College of Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M Kerkering, MD, Chief of Infectious Diseases, Virginia Tech, Carilion School of Medicine, Roanoke, Virginia
Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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