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Dengue

Background

Overview

Definition
Dengue fever is an acute arthropod-borne viral illness caused by an RNA virus of the Flaviviridae family.
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Pathophysiology
Dengue fever is caused by the dengue virus of the family Flaviviridae that includes four different serotypes (DEN-1, DEN-2, DEN-3, and DEN-4) and is transmitted through Aedes aegypti mosquito.
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Epidemiology
The average incidence of dengue in the Americas is 58.02 per 100,000 person-years.
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Disease course
The host-viral interaction, viral replication, and/or direct skin infection by the virus trigger humoral, cellular, and innate host immune response that leads to alterations in endothelial microvascular permeability and thromboregulatory mechanisms causing increased plasma and protein loss resulting in thrombocytopenia associated with platelet dysfunction, damage, or depletion causing significant hemorrhages, breakbone fever, multiorgan damage, and DIC.
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Prognosis and risk of recurrence
The mortality associated with a lack of early appropriate intervention is around 10-20%. The recurrence rate associated with shock is approximately 30%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of dengue are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2023), the Pan American Health Organization (PAHO/WHO 2022), the Center for Disease Control (CDC 2021), the European Academy of Neurology (EAN 2017), the Philippine Pediatric Society (PPS/PIDSP 2017), and the Association of British Neurologists ...
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Screening and diagnosis

Differential diagnosis, arbovirus infections: as per PAHO/WHO 2022 guidelines, recognize clinical manifestations of different arbovirus infections to help differentiate them:
Situation
Guidance
Dengue
Findings that help in differentiation - thrombocytopenia, progressive increase in hematocrit, leukopenia
Findings that probably help in differentiation - anorexia or hyporexia, vomiting, abdominal pain, chills, hemorrhages, including bleeding on the skin, mucous membranes, or both
Findings that may help in differentiation - retro-ocular pain, hepatomegaly, headache, diarrhea, dysgeusia, cough, elevated transaminases, positive tourniquet test
B
Chikungunya
Findings that help in differentiation - arthralgias
Findings that probably help in differentiation - eruption, conjunctivitis, arthritis, myalgias, bone pain
Findings that may help in differentiation - hemorrhages, including bleeding on the skin, mucous membranes, or both
B
Zika
Findings that help in differentiation - pruritus
Findings that probably help in differentiation - eruption, conjunctivitis
Findings that may help in differentiation - lymphadenopathies, pharyngitis, odynophagia
B
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Classification and risk stratification

Severity assessment: as per PAHO/WHO 2022 guidelines, consider assessing for the following warning signs to identify patients with an increased risk of progression to severe disease:
Situation
Guidance
Abdominal pain
Progressive until it is continuous or sustained and intense, and at the end of the febrile stage
Sensory disorder
Irritability, drowsiness, and lethargy
Mucosal bleeding
Gingivorrhagia, epistaxis, vaginal bleeding not associated with menstruation or more menstrual bleeding than usual, and hematuria
Fluid accumulation
Clinical, on imaging, or both, at the end of the febrile stage
Hepatomegaly
> 2 cm below the costal margin and abrupt onset
Vomiting
Persistent (≥ 3 episodes in 1 hour or 4 episodes in 6 hours)
Progressive increase in hematocrit
On at least 2 consecutive measurements during patient monitoring
C

Diagnostic investigations

Evaluation for encephalitis, flavivirus
As per ABN/BIA 2012 guidelines:
Obtain acute and convalescent blood samples in patients with suspected arbovirus encephalitis.
B
Test CSF for IgM antibodies in patients with suspected flavivirus encephalitis.
B

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  • Evaluation for encephalitis (tick-borne encephalitis virus)

Medical management

Setting of care: as per PAHO/WHO 2022 guidelines, consider using the following criteria for the hospitalization of patients with dengue:
presence of warning signs (abdominal pain, sensory disorder, mucosal bleeding, fluid accumulation, hepatomegaly, persistent vomiting, progressive increase in hematocrit)
meeting criteria for severe disease, according to the WHO 2009 definition
oral intolerance
difficulty breathing
narrowing pulse pressure
arterial hypotension
acute renal failure
prolonged capillary refill time
pregnancy
coagulopathy.
C

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  • Fluid resuscitation

  • Antipyretics

  • Corticosteroids

  • IVIG

Therapeutic procedures

Blood transfusion: as per PAHO/WHO 2022 guidelines, do not administer blood components (platelet concentrate, FFP) in patients with thrombocytopenia, regardless of platelet count. Consider administering blood component transfusion in patients with bleeding or additional conditions predisposing to bleeding (such as pregnancy).
D

Specific circumstances

Pediatric patients, indications for hospital admission: as per PIDSP/PPS 2017 guidelines, admit patients with a confirmed or presumptive diagnosis of dengue in an outpatient setting to a healthcare facility for closer monitoring and observation in the presence of the following signs and symptoms:
shortness of breath
irritability or drowsiness
pleural effusion
abdominal pain
melena
elevated hematocrit
decreased or decreasing platelet count.
B
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  • Pediatric patients (risk of bleeding)

  • Pediatric patients (risk of mortality)

  • Pediatric patients (fluid resuscitation)

  • Pediatric patients (blood transfusion)

  • Pediatric patients (mosquito repellents)

Preventative measures

Vaccination: as per CDC 2021 guidelines, offer vaccination against dengue (3-dose vaccination series, administered 6 months apart at 0, 6, and 12 months) in 9-16 years old pediatric patients with evidence of previous dengue infection (such as confirmation with previous laboratory-confirmed infection or a highly specific serodiagnostic test) and living in dengue-endemic areas.
E