Evaluation & Management of

Dengue
Case Study

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A 5 year-old female has high fever for 2 days
vomiting 4x, diarrhoea 4x for the past 2 days.

A diagnosis of acute gastroenteritis was made

Which two of the following features if present, would make you

suspect the diagnosis of dengue:

A. Headache / muscle pain

B. Sore throat
C. Bleeding
D. Abdominal pain
E. Rash

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A 5 year-old female has fever and
vomiting 4x, diarrhoea 4x for the past 2 days.

Which one question would you ask the mother to help you in the
clinical evaluation of this patient with suspected dengue?

A. Any Headache
B. Any Muscle pain
C. Any sore throat
D. Any Bleeding
E. Amount of oral intake

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A 5 year-old female has fever and
vomiting 4x, diarrhoea 4x for the past 2 days.
Physical examination: • Which 2 physical signs /symptoms
would you elicit to help in clinical
• Alert, temperature 39oC, evaluation?
• Heart rate 120/min,
• RR 20/min, A. Spleen enlargement
• BP 96/60 mmHg, B. Rash
• Throat was injected. C. Peripheral perfusion
• No cervical lymphadenopathy. D. Urine output
• Oral mucosa moist, tongue
slightly dry
• Lungs clear, Heart sounds normal
• Liver 1 cm, soft.

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A 5 year-old female has fever and
vomiting 4x, diarrhoea 4x for the past 2 days.
FBC:
• Hb 12 gm/L
• WBC: 7.8
• HCT: 40.1
• Platelet: 183

Based on the above results, what would be your decision?

A. The patient is unlikely to have dengue because the FBC is normal

B. The patient most likely has acute gastroenteritis
C. Dengue cannot not be excluded

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A 5 year-old female has fever and
vomiting 4x, diarrhoea 4x for the past 2 days.

Which diagnostic test would be best if you suspect dengue?

A. Dengue IgM
B. Dengue IgG
C. Dengue NS1Ag
D. Dengue PCR

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A 5 year-old female has fever and
vomiting 4x, diarrhoea 4x for the past 2 days.
She was discharged from ED Green zone, with paracetamol and
antibiotics and advised to return to the hospital if her fever
persisted.

• Would you agree to this plan of management?

• What management and advice would you give to this patient?

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 DOI 4 – 9 am in the ED
• On the 4th day of illness, patient experienced, in addition to
vomiting and diarrhoea, severe abdominal pain.

• 12 hours prior to her second presentation she experienced

shortness of breath, at about 10 pm

Which 3 questions would you ask to help you in clinical evaluation?

A. Any bleeding?
B. Any muscle ache
C. Any rash
D. Oral intake during illness
E. Urine output – quantity
F. Was she able to go to playschool last few days?

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 u1
• Oral intake has been poor – mainly fluids
• Reduced urine output – small amount of
concentrated urine every 4-5 hrs since the day
before admission
• There was no bleeding tendency or altered
behaviour
• Has not attended play-school since start of
illness.

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Slide 9

u1 Severe dehydration and starvation - inadequate oral intake

Two of the Three golden questions

ummc, 6/20/2016
ED (Yellow zone) DOI 4, 10.30am – Physical exam

• GCS was full (15/15),

• Cool peripheries, capillary refill time <2 sec,
• HR: 142/min, temp: 38.1 oC,
• Respiratory rate: 40/min, SpO2 :100% in room air,
• BP 132/88 mmHg,
• Glucometer: 10.4 mmol/L
• Hydration: dry coated tongue
• Normal heart sounds
• Lungs clear, adequate breath sounds
• Abdomen – soft but tender epigastrium and right hypochondrial
region

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 Clinical evaluation – heart rate and breathing rate
Cool peripheries, capillary refill time <2 sec,
HR: 142/min, temp: 38.1 oC,
respiratory rate: 40/min, SpO2 :100% in room air,
Lungs – Clear, adequate breath sounds

A. Her heart rate is appropriate for her temperature of 38.1oC

B. Her heart rate is disproportionately high for her temperature of 38.1oC
C. Her heart rate is due to pain
D. Her heart rate is due to shock

A. Her breathing rate is appropriate for temperature of 38.1oC

B. Her breathing rate is disproportionately high for 38.1oC

C. Her breathing rate is due to severe pain

D. Her breathing rate is due to chest infection
E. Her breathing rate is due to the severe metabolic acidosis

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For 14 year old, baseline heart rate ~ 90/min, hence the estimated heart rate for
temperature of 39oC should be about 110/min. However, this patient’s heart rate was
142/min which could not be explained by fever alone.

History of shortness of breath, rapid respiration (40/min) with clear breath sounds
point to metabolic acidosis (Kussmaul breathing) rather than a lung pathology, in the
context of poor fluid intake and diarrhoea, should suspect patient in hypovolemic
shock.

Also suspect prolonged shock from history. Shortness of breath since 10 pm the
night before
Thus, this case has prolonged shock, in the context of dengue, bleeding likely to have
occurred.

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 Clinical evaluation – Blood pressure and blood glucose
BP 132/88 mmHg,
Glucometer: 10.4 mmol/L

A. Her blood pressure is elevated, so she could have hypertension

B. Her blood pressure is elevated, so she is not likely to be in shock
C. She has compensated shock

A. High Blood glucose could be due to diabetes mellitus

B. High blood glucose could be due to anxiety
C. High blood glucose could be due to shock

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For 14 year old, baseline heart rate ~ 90/min, hence the estimated heart rate for
temperature of 39oC should be about 110/min. However, this patient’s heart rate was
142/min which could not be explained by fever alone.

History of shortness of breath, rapid respiration (40/min) with clear breath sounds
point to metabolic acidosis (Kussmaul breathing) rather than a lung pathology, in the
context of poor fluid intake and diarrhoea, should suspect patient in hypovolemic
shock.

Also suspect prolonged shock from history. Shortness of breath since 10 pm the
night before
Thus, this case has prolonged shock, in the context of dengue, bleeding likely to have
occurred.

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 Clinical evaluation –
Tender epigastrium and right hypochondria pain

Most likely cause of abdominal pain is:

A. Acute pancreatitis
B. Acute gastritis
C. Acute hepatitis
D. Pneumonia of lower lobes
E. Ischaemic pain due to regional autorregulation
F. Pain due to Mallory Weiss tear

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For 14 year old, baseline heart rate ~ 90/min, hence the estimated heart rate for
temperature of 39oC should be about 110/min. However, this patient’s heart rate was
142/min which could not be explained by fever alone.

History of shortness of breath, rapid respiration (40/min) with clear breath sounds
point to metabolic acidosis (Kussmaul breathing) rather than a lung pathology, in the
context of poor fluid intake and diarrhoea, should suspect patient in hypovolemic
shock.

Also suspect prolonged shock from history. Shortness of breath since 10 pm the
night before
Thus, this case has prolonged shock, in the context of dengue, bleeding likely to have
occurred.

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 Initial Investigation results
u2
FBC BUSE LFT
HB 17.4 Na 125 T.bilirubin 35
HCT 50.4 K 5.2 ALP 197

TWC 12.9 Urea 13.2 AST 3347

Cl 90 ALT 369
Neut 75%
Creatinine 125 Alb 35
PLT 14
CK 129

VBG
COAG Combo test for Negative
pH 7.27
PT 26.3 Dengue (NS1Ag,
pCO2 25 mmHg IgM, IgG)
PTT 56.3
HCO3 14 mmol/L
INR 1.7
BE -14 mmol/L
Lac 10.4 mmol/L
14

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Slide 14

u2 Refer to underlined parameters:

Severe thrombocytopenia would suggest diagnosis of dengue or severe sepsis.

Baseline HCT was 40% on day 2 of illness, now 49%, 22% increase above the baseline; This would
suggest presence of plasma leakage. However a 22% increase above baseline HCT is not enough to
explain the severity of acidosis and organ impairment
In this situation, should suspect occult bleeding and group and match for blood urgently.

Furthermore, the TWC is high, instead of being low, another reason to suspect severe bleeding
ummc, 6/20/2016
 Interpretation of blood investigations - FBC

A. Severe thrombocytopenia would suggest a diagnosis FBC

of bacterial sepsis.
HB 17.4
B. Severe thrombocytopenia would suggest a diagnosis
of dengue HCT 50.4
TWC 12.9
A. Her HCT is increased by 25% due to severe Neut 75%
dehydration
PLT 14
B. Her HCT is increased by 25% due to plasma leakage

A. High TWC is due to bacterial sepsis

B. His TWC is not leucopenia, thus dengue is less likely
C. High TWC is most likely due to severe bleeding in
dengue

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Severe thrombocytopenia would suggest a diagnosis of dengue or severe bacterial

sepsis.

Baseline HCT was 40% on day 2 of illness; a HCT of 49% is equivalent to 22% increase
above the baseline. This would suggest presence of plasma leakage.

However a 22% increase above baseline HCT is not enough to explain the severity of
acidosis and organ impairment
In this situation, one should suspect occult bleeding and group and match for blood
urgently.

Furthermore, the TWC is high, instead of being low, another reason to suspect severe
bleeding or severe sepsis.

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 Interpretation of Electrolytes & venous blood gas
pH 7.27 Na / K 125 / 5.2
pCO2 / HCO3 25 mmHg / 14 mmol/L Urea / Creatinine 13.2 / 125
BE / Lactate -14 mmol/L / 10.4 mmol/L Cl 90

A. The low PCO2 could be explained by rapid respiration due to anxiety

B. The low PCO2 could be explained by rapid respiration due to metabolic
acidosis

A. Hyponatremia – due to vomiting and diarrhoea

B. Hyperkalemia is the result of vomiting and diarrhoea
C. Hyperkalemia in this patient is most likely related to metabolic acidosis.
D. Elevated urea and creatinine – due to severe fluid loss in vomiting and
diarrhoea
E. Impending acute kidney injury

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Severe metabolic acidosis (the low PCO2 could be explained by rapid respiration)
Hyponatremia – due to vomiting and diarrhoea
Vomiting and diarrhoeal losses would result in hypokalemia rather than
hyperkalemia. Hyperkalemia in this patient is most likely associated with metabolic
acidosis.
Elevated urea and creatinine – corroborate with history of severe fluid loss and
impending acute kidney injury

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 Interpretation – Liver profile and coagulation
T.bilirubin 35
PT 26.3 Combo test for Negative ALP 197
PTT 56.3 Dengue (NS1Ag, AST 3347
IgM, IgG)
INR 1.7 ALT 369
Alb 35
CK 129

A. Liver enzymes are elevated, AST more than ALT, in keeping with severe
dengue
B. Deranged coagulation due to severe liver impairment
C. Deranged coagulation due to disseminated intravascular consumption

A. NS1 Ag, IgM and IgG were all negative; thus dengue is excluded as
diagnosis
B. NS1 Ag, IgM and IgG were all negative; but dengue should not be excluded
as diagnosis
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Liver enzymes are elevated, AST more than ALT, in keeping with severe dengue
Aspartate aminotransferase, or AST, is found in the liver, but also the brain, pancreas, heart,
skeletal muscle, kidneys and lungs. Alanine aminotransferase, or ALT, is primarily found in
the liver.

Deranged coagulation

NS1 Ag, IgM and IgG were all negative; does not exclude dengue;
At Day 4 of illness, the chances of NS1 Ag being positive is getting lower by the day of
illness while levels of IgM and IgG should be becoming higher with days of illness.

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 Timelines of Dengue Diagnostic Testing

Primary Dengue Virus Secondary Dengue Virus

Infection Infection

DENV DENV IgG

IgG
IgM
NS1 NS1
antigen antigen IgM may not be
detectable in ~20% of 2°
IgM cases (Innis,1997)
Critical
Phase

Febrile Convalescence

0 5 6 90 0 56 90
Days Post-Onset of Symptoms Days Post-Onset of Symptoms

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 • It is NOT adequate to write JUST the diagnosis;
• A thorough clinical evaluation is necessary to identify problems that
need to be resolved.
• Clinical evaluation: (Select no more than two responses)

A. Severe Acute Gastroenteritis with Severe hyponatremic Dehydration

and hypovolemic shock

B. Severe Dengue with Hyponatremic Dehydration

C. Severe dengue with Severe dehydration

D. Severe dengue with prolonged shock (from history) and severe

dehydration and plasma leakage and suspect severe bleeding

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HCT is not high enough to explain the shock entirely due to plasma leakage ALONE.

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 Management (select no more than 2)

A. Start with crystalloid, 0.9% saline, 10 ml/kg over 1 hour

B. Start with COLLOID, 10 ml/kg over 1 hour

C. Start with crystalloid, Dextrose 5% 0.9% saline, 10 ml/kg over 1

hour, because he has not eaten for 4 days

D. Cross-match and start transfusion of platelets and DIVC regime

E. Group and cross-match for fresh whole blood

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• Initial IVD: 0.9% saline at 5 ml/kg over one hour.
• After reviewing blood Ix results, diagnosis was changed to severe u3
dengue, IVD was upgraded into 10 ml/kg/hr
• Patient was upgraded to Red zone and referred to Medical MO at
11.30 am

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Slide 21

u3 Clinical evaluation:

Severe dengue with prolonged shock (from history)

Severe plasma leakage and suspect severe bleeding; HCT is not high enough to explain the shock
entirely due to plama leakage ALONE.

Should start with COLLOIDs if available, 10 ml/kg over 1 hour

ummc, 6/20/2016
ED Red zone : 11.30am, Paeds MO review, after 10 ml/kg
0.9% saline over 1 hour

• Patient was in compensated shock as evidenced by poor pulse

volume, CRT 3s, and tachycardia (HR 140 bpm)
• BP 126/88 (50th centile BP for age is 101/59)
• temp 38oC, RR 36
• Lungs – reduced breath sounds right lower zone, dull percussion
note
• Abdomen - tenderness over the right hypochondriac region
• Patient was alert and orientated, GCS 15/15.
• CVS: DRNM, no bleeding tendency/rash

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• Diagnosis :
– Severe dengue, day 4 of illness, in critical phase, in
compensated shock, complicated with severe hepatitis and
u4
pleural effusion
• Plan :
– change IV drip to a NS bolus 10 ml/kg over 1 hr
– start on NPO2 1L/min
u5
– To rpt FBC/VBG after completion of bolus

A. What do you think of the assessment?

B. Comment on the management.

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Slide 23

u4 Pleural effusion and severe hepatitis should not be considered as complications:

These are part and parcel of severe dengue. - Severe plasma leakage and severe organ impairment
ummc, 6/20/2016

u5 The second bolus should have been colloids.

ummc, 6/20/2016
ED Red zone : 12.30pm, Specialist review, 15 ml/kg saline

• Reassessed with specialist after completion of bolus NS

• Alert, conscious, appears lethargic
• Good pulse volume, CRT <2s
• HR 166, BP 138/88, temp 37oCelsius, Respiratory rate 30/min
(given neb Salbutamol at 12:30 pm for hyperkalaemia, )
• CXR – blunting of right costo-phrenic angle, CTR:0.43

A. What would be your clinical evaluation?

B. What would be your next course of action?

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 Management of dengue
Step 1: History taking

Step 2: Clinical examination: 5-in-1 magic touch

Step 3: Investigations

Step 4: Diagnosis with dengue phase and severity

Step 5: Management decision

Group A Group B Group C

• Send home • Refer for in- • Require

hospital emergency
management treatment and
urgent referral

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DENCO Slide

Management decisions depend on clinical manifestations and other circumstances.

Patients may:
Be sent home – Group A
Be referred for in-hospital management – Group B
Require emergency treatment and urgent referral – Group C

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 Outpatient management: Group A
Patients who are able to
“drink enough to pee enough”

Group A – Send home if

patient meets all of the
following 1. Give anticipatory guidance
before sending home
Intake: Getting adequate
volume of oral fluids (see patient handout)
Output: Passing urine at least
1. Follow up daily
once every 4 to 6 hours
Does not have any warning 2. Do serial CBCs
signs
3. Identify warning signs
Has stable haematocrit and early
hemodynamic status
Does not have co-existing
conditions
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 Keys to good home care

1. Bed rest

2. Encourage oral intake

What is adequate oral intake?
6 to 8 glasses of fluid for adults and accordingly in children

What types of fluid?

Milk, coconut water, fruit juice (caution with diabetes patient), oral rehydration
solution, barley water, rice water, clear soup
Water alone may cause electrolyte imbalance.

3. Manage fever
Give paracetamol if fever is higher than 38°C
Adult - not more than 4 g per day
Child - 10 mg/kg/dose, not more than 4 times a day
Tepid (lukewarm water) sponging
Do not give ibuprofen or aspirin (or other non-steroidal anti-inflammatory drugs)

What should be done at home?

•Adequate bed rest
•Encourage oral intake
•Take acetaminophen only as needed if fever or pain (NOT MORE THAN
package insert  risk of liver toxicity as virus replicates in liver). [Note: Some
patients will have severe pain and may need a narcotic.]
•Tepid (lukewarm water) sponging

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 Keys to good home care (cont.)

4. Reduce breeding habitats around the home and kill adult mosquitoes

5. Return to hospital IMMEDIATELY if no improvement or warning signs

appear

Frequent vomiting, unable to drink or scanty urine

Severe abdominal pain
Severe tiredness, drowsiness, mental confusion or seizures
Bleeding:
Red spots or patches on the skin
Bleeding from nose or gums
Vomiting blood
Black coloured stools
Heavy menstruation or vaginal bleeding
Pale, cold or clammy hands and feet
Breathing difficulty

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• Eliminate mosquitoes (as probably infected and do not want everyone sick
in household), and breeding places in and around home
• Patient should be in a screened room or under a bed net while febrile (to
prevent further spread of disease; common to see cases clustered in
households and neighbourhoods).

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 Mosquito breeding sites around the home
Tray under dish rack

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Other sites would include pet water dishes, plant pots, etc.
 Mosquito breeding sites around the home

Tarpaulins
Flower pots

Roof gutters Roadside gutters

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 Pearls in home care
What should be avoided?
• Steroids
• Non-steroidal anti-inflammatory drugs (NSAIDs), e.g. acetylsalicylic acid
(aspirin), mefenamic acid (Ponstan), and diclofenac (Voltaren) tablets,
injections or suppositories.
• Antibiotics unless you suspect patient may have leptospirosis or dual infection

Why are steroids contraindicated in dengue?

• Not recommended by the World Health Organization (WHO)
• Limited number of studies in children with dengue shock syndrome in 1970s
and 1980s
• Three recent reviews find no evidence of efficacy and recommended not
using steroids routinely *
• No convincing physiological rationale for use
• Multiple potential side-effects: gastrointestinal bleeding, hyperglycaemia,
immunosuppression
* Rajapakse S. Trans Royal Soc of Trop Med Hyg (2009) 103: 122; Panpanich et al. Cochrane Database Syst Rev (2006) 19: CD003488; Tam et al.
Clin Infect Dis (2012) 55: 1216 31
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Group A Home Care

What should be avoided at home?

• Do not take steroids or NSAIDs, e.g. acetylsalicylic acid (aspirin) and
ibuprofen.
– If the patient is already taking these medications, the prescribing
doctor should be consulted.
• Antibiotics are not necessary in uncomplicated dengue fever cases (unless
unclear if leptospirosis or dengue).

Why steroids are contraindicated in dengue

Studies of practitioners in Puerto Rico and elsewhere indicate between 25% and 43%
of physicians (depending on the level of training) report giving steroids routinely to
patients with dengue. Presumably, they are used to enhance capillary permeability,
dampen immunological response and reverse shock.
WHO does not recommend steroid use for dengue. There have been only studies on
steroid use in children with dengue shock syndrome in the 1970s and 1980s.
Two recent reviews found no evidence of efficacy and recommend not using steroids

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routinely.
There is no convincing physiological rationale for use.
Multiple potential side-effects include GI bleed, hyperglycemia and
immunosuppression.
___________________
[NOTE TO SPEAKER: Current WHO/PAHO/CDC recommendations make no mention of
use of steroids. All clinical trials of steroids have been conducted among children with
DSS. Combined results show no evidence of effectiveness, and the Cochrane
Collaboration and others have advocated against using steroids except in the clinical
trial setting. Steroids are used in sepsis because of adrenal suppression and relative
deficiency of endogenous steroids. Studies in sepsis patients have shown increased
mortality with steroid administration to patients with normal or high levels of
cortisol, which is the situation in DHF. Steroids are a risk factor for developing stress
ulceration and upper gastrointestinal bleeding in critically ill patients; they increase
risk of secondary infection and can derange glucose homeostasis (hyperglycemia
associated with poor outcome in ICU patients).]

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