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Severe Dengue Infection

  • Author: Daniel D Price, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Nov 10, 2015
 

Overview

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).[1, 2] Secondary infection by a different dengue virus serotype has been confirmed as an important risk factor for the development of DHF.[3, 4, 5]

In 20-30% of DHF cases, the patient develops shock, known as the dengue shock syndrome (DSS).

Worldwide, children younger than 15 years make up 90% of DHF cases.[6] In the Americas, however, DHF occurs in adults and children.

Dengue fever is not contagious through person-to-person contact.

Complications

Complications are rare but may include the following[7] :

  • Brain damage from prolonged shock or intracranial hemorrhage
  • Myocarditis
  • Encephalopathy
  • Liver failure

Go to Dengue Infection, Pediatric Dengue, and Dermatologic Manifestations of Dengue for complete information on these topics.

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Prehospital Care

Initiate supportive therapy as follows:

  • Intravenous (IV) crystalloids, as needed to keep systolic blood pressure above 90 mm Hg
  • Oxygen, empirically
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Emergency Department Care

Continue supportive care by administering isotonic NS solution intravenously to maintain adequate blood pressure and adequate urine output of 0.5-1 mL/kg/h.

A bolus of 10-20 mL/kg every 30 minutes may be required to maintain blood pressure. A Foley catheter is helpful in monitoring urine output. The plasma leakage period is short (24-48 h), and intravenous fluids may be reduced if the patient maintains adequate oral hydration.

When the plasma leakage phase starts to resolve, the hematocrit level begins to fall, making identification of significant occult hemorrhage difficult. Administer blood transfusion if significant hemorrhage ensues (GI bleeding may be profound). Administer fresh frozen plasma or platelets if DIC is extensive and the patient is hemodynamically unstable. Prophylactic platelet transfusions in a stable thrombocytopenic patient are not needed.

Administer acetaminophen for fever control (not salicylates or ibuprofen, which can further hinder platelet function and increase bleeding complications). Glucocorticoids are not indicated.

Avoid procedures and treatments that may precipitate further bleeding, such as nasogastric tube placement or arterial punctures.

Corticosteroids are not helpful.

No antiviral therapy is available.

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Inpatient Care

Admit the patient to the intensive care unit (ICU) if he or she is hypotensive or in DIC; otherwise, admit to medicine ward.[8, 9]

The patient may require a central line. An arterial line may be required. The patient may require blood components.

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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.[10]

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.

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

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Contributor Information and Disclosures
Author

Daniel D Price, MD Director of International Ultrasound, Department of Emergency Medicine, Alameda County Medical Center, Highland Hospital and Trauma Center

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

Disclosure: Nothing to disclose.

Coauthor(s)

Sharon R Wilson, MD Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center

Sharon R Wilson, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, American Association of University Women

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Pok KY, Squires RC, Tan LK, Takasaki T, Abubakar S, Hasebe F, et al. First round of external quality assessment of dengue diagnostics in the WHO Western Pacific Region, 2013. Western Pac Surveill Response J. 2015 Apr-Jun. 6 (2):73-81. [Medline].

  2. Khursheed M, Khan UR, Ejaz K, Fayyaz J, Qamar I, Razzak JA. A comparison of WHO guidelines issued in 1997 and 2009 for dengue fever - single centre experience. J Pak Med Assoc. 2013 Jun. 63 (6):670-4. [Medline].

  3. Teoh BT, Sam SS, Tan KK, Johari J, Shu MH, Danlami MB, et al. Dengue virus type 1 clade replacement in recurring homotypic outbreaks. BMC Evol Biol. 2013 Sep 28. 13(1):213. [Medline].

  4. Chiang CY, Pan CH, Hsieh CH, Tsai JP, Chen MY, Liu HH, et al. Lipidated Dengue-2 Envelope Protein Domain III Independently Stimulates Long-Lasting Neutralizing Antibodies and Reduces the Risk of Antibody-Dependent Enhancement. PLoS Negl Trop Dis. 2013 Sep 19. 7(9):e2432. [Medline]. [Full Text].

  5. Huy NT, Van Giang T, Thuy DH, Kikuchi M, Hien TT, Zamora J, et al. Factors associated with dengue shock syndrome: a systematic review and meta-analysis. PLoS Negl Trop Dis. 2013 Sep 26. 7(9):e2412. [Medline]. [Full Text].

  6. Malavige GN, Fernando S, Fernando DJ, Seneviratne SL. Dengue viral infections. Postgrad Med J. 2004 Oct. 80(948):588-601. [Medline]. [Full Text].

  7. Puccioni-Sohler M, Rosadas C, Cabral-Castro MJ. Neurological complications in dengue infection: a review for clinical practice. Arq Neuropsiquiatr. 2013 Sep. 71(9B):667-71. [Medline].

  8. Bunnag T, Kalayanarooj S. Dengue shock syndrome at the emergency room of Queen Sirikit National Institute of Child Health, Bangkok, Thailand. J Med Assoc Thai. 2011 Aug. 94 Suppl 3:S57-63. [Medline].

  9. Thomas L, Moravie V, Besnier F, Valentino R, Kaidomar S, Coquet LV, et al. Clinical presentation of dengue among patients admitted to the adult emergency department of a tertiary care hospital in Martinique: implications for triage, management, and reporting. Ann Emerg Med. 2012 Jan. 59 (1):42-50. [Medline].

  10. Morens DM. Antibody-dependent enhancement of infection and the pathogenesis of viral disease. Clin Infect Dis. 1994 Sep. 19(3):500-12. [Medline].

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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.
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.
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.
 
 
 
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