Dengue Hemorahagic Fever Koreksi

8/8/2019 Dengue Hemorahagic Fever Koreksi

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Dengue Hemorahagic FeverDengue Hemorahagic Fever

bybyProf.H. Azhali MS, dr., Sp.AKProf.H. Azhali MS, dr., Sp.AK

DHF :DHF : Acute febrile illnessAcute febrile illness Four serotypes of dengue virusFour serotypes of dengue virusClinically :Clinically : -- Haemorrhagic diathesisHaemorrhagic diathesis

-- Tendency to developTendency to develop

shock syndromeshock syndrome-- ThrombocytopeniaThrombocytopenia-- HemoconcentrationHemoconcentration

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Transmission chain of dengueTransmission chain of dengue

Three factors :Three factors :

-- manman

-- virusvirus-- masquitomasquito

Man :Man :

The main reservoir of the virus.The main reservoir of the virus.

Intrinsic incubation period 4Intrinsic incubation period 4--6 days6 days

Viremia: 2days before febrisViremia: 2days before febris 5 days after febris appear5 days after febris appear


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3VIRUSVIRUS

Arthropod borne virus ( Arbo virus)Arthropod borne virus ( Arbo virus)

Four serotypes DenFour serotypes Den--1,Den1,Den--2,Den2,Den--3, Den3, Den--4.4.

Partial cross protection after infection by one of themPartial cross protection after infection by one of them

VECTORVECTOR

Mosquito : Aedes AegyptiMosquito : Aedes AegyptiAedes AlbopictusAedes Albopictus

Aedes PolynesiensisAedes Polynesiensis

Aedes ScutellarisAedes Scutellaris

Female :Female : -- Bites during the day, rest in houses, lay eggsBites during the day, rest in houses, lay eggs

in clean waterin clean water-- Extrinsic incubation periodExtrinsic incubation period

88--10 days10 days

-- Multiplies in salivary glandsMultiplies in salivary glands


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Virus dengue ditransmisikan ke manusia melalui gigitan nyamukVirus dengue ditransmisikan ke manusia melalui gigitan nyamukdomestik:domestik:

Aedes aegypti, A. albopictusAedes aegypti, A. albopictus


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Manifestation of the dengue Syndrome

Dengue virus infection

Undifferentiated

fever(viral syndrome)

Dengue fever

syndrome

Asymptomatic symptomatic

Dengue Hemorrhagic

FeverPlasma leakage

Withouthemorrhage

With unusualhemorrhage

Dengue hemorrhagic

Fever (DSS)

No shock Dengue shockSyndrome(DSS)

Dengue Fever/DF

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PATHOGENESISPATHOGENESIS

1.1. ANTIBODY DEPENDENTANTIBODY DEPENDENT

ENHANCEMENTENHANCEMENT(ADE) THEORY(ADE) THEORY

2.2. CYTOKINECYTOKINE--MEDIATOR THEORYMEDIATOR THEORY

3.3. VIRUS FACTORVIRUS FACTOR VIRULENCY VIRULENCY

4.4. HOST FACTORHOST FACTOR


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Increased vascular permeability Plasma leakageIncreased vascular permeability Plasma leakage

loss of plasma hemoconcentration hypovolemialoss of plasma hemoconcentration hypovolemia

shockshockAbnormal hemostatis due toAbnormal hemostatis due to

-- vasculopathyvasculopathy

-- thrombocytopeniathrombocytopenia

-- coagulopathycoagulopathy

various hemorrhagic manifestationvarious hemorrhagic manifestation

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PATHOPHYSIOLOGIC CHANGESPATHOPHYSIOLOGIC CHANGES


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DENGUE VIRUS INFECTION

FEVERANOREXIA

VOMITING

BLEEDINGMANIFESTATION

HEPATOMEGALY INCREASEVASCULAR

PERMIABILITY

TROMBOCYTOPENIA

Plasma leakage :

Hemoconcentration

Hipoproteinemia

Pleural effusion

Ascites

Hypovolemia

Shock

Anoxia

Death

AcidosisG.I. bleeding

DIC

Dehydration

Suchitra (1993)


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CLINICAL CRITERIACLINICAL CRITERIA

ClinicalClinicala.Fever,acute,high,continous,lasting 2a.Fever,acute,high,continous,lasting 2--7 days.7 days.b.Haemorrhagic manifestationsb.Haemorrhagic manifestations

-- Positive tourniquet testPositive tourniquet test

-- Petechiae, purpura, echymosisPetechiae, purpura, echymosis

-- epistaxis, gum bleedingepistaxis, gum bleeding

-- Haematemesis and/or melaenaHaematemesis and/or melaenac.Enlargement of liverc.Enlargement of liver

d.Shock :d.Shock : -- rapid and weak pulserapid and weak pulse

-- Narrowing pulse pressure ( 20 mmHgNarrowing pulse pressure ( 20 mmHg

or less) undetectableor less) undetectable

-- Hypotension undetectableHypotension undetectable-- Cold ,clammy skin, restlessnessCold ,clammy skin, restlessness

LABORATORYLABORATORYa.Thrombocytopenia ( 100.000/mm3 or less)a.Thrombocytopenia ( 100.000/mm3 or less)

b.Hemoconcentration ( increase by 20% or moreb.Hemoconcentration ( increase by 20% or more))

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Tes bendungan ( Rumpel Leede/Torniquet test)


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Four Grades of DHFFour Grades of DHF

Grade 1Grade 1 Fever and nonspecific constitutional symptomsFever and nonspecific constitutional symptoms

Positive tourniquet test is only hemorrhagicPositive tourniquet test is only hemorrhagicmanifestationmanifestation

Grade 2Grade 2 Grade 1 manifestations + spontaneousGrade 1 manifestations + spontaneous

bleedingbleeding

Grade 3Grade 3 Signs of circulatory failure (rapid/weak pulse,Signs of circulatory failure (rapid/weak pulse,

narrow pulse pressure, hypotension,narrow pulse pressure, hypotension,cold/clammy skin)cold/clammy skin)

Grade 4Grade 4 Profound shock (undetectable pulse and BP)Profound shock (undetectable pulse and BP)

Grade 1Grade 1 Fever and nonspecific constitutional symptomsFever and nonspecific constitutional symptoms

Positive tourniquet test is only hemorrhagicPositive tourniquet test is only hemorrhagicmanifestationmanifestation

Grade 2Grade 2 Grade 1 manifestations + spontaneousGrade 1 manifestations + spontaneous

bleedingbleeding

Grade 3Grade 3 Signs of circulatory failure (rapid/weak pulse,Signs of circulatory failure (rapid/weak pulse,

narrow pulse pressure, hypotension,narrow pulse pressure, hypotension,cold/clammy skin)cold/clammy skin)

Grade 4Grade 4 Profound shock (undetectable pulse and BP)Profound shock (undetectable pulse and BP)


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Diagnosis

Anamnesis : - chief complaint- contact

Clinical manifestations

Iaboratory Findings

Confirm laboratory diagnosis :

- isolation of the virus high level of technical skills and equipment- demonstration of a rising titre of serum dengue antibodies

Hae magglution inhibition test (H I)

Complement Fixation test (C F)

Neutralization test (N T) Test todetect IgM and IgG (IgM Captured Elisa, Mac. Elisa)

-molecular biology polymerase chain rection

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Treatment

Pathophysiological abnormality

Vascular permeability leakage of plasma

hemoconcentration hypovolaemic shock

tissue anoxia, metabolic acidosis death

Haematostatic changes

- vascular changes

- thrombocytopenia

- coagulation disorders

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Warning Signs for Dengue ShockWarning Signs for Dengue Shock

When Patients DevelopDSS:

3 to 6 days after onset of

symptoms

Initial Warning Signals:

Disappearance of fever Drop in platelets

Increase in hematocrit

Alarm Signals:

Severe abdominal pain

Prolonged vomiting

Abrupt change from fever

to hypothermia

Change in level ofconsciousness (irritability

or somnolence)

Four Criteria for DHF:

Fever

Hemorrhagic manifestations Excessive capillary

permeability

e 100,000/mm3 platelets


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Unusual manifestationsUnusual manifestations

-- Dengue encephalopathyDengue encephalopathy

-- Acute liver failureAcute liver failure

-- Myocarditis, cardiomyopathyMyocarditis, cardiomyopathy

-- Severe gastrointestinal bleedingSevere gastrointestinal bleeding

-- Dengue encephalopathyDengue encephalopathy

-- Acute liver failureAcute liver failure

-- Myocarditis, cardiomyopathyMyocarditis, cardiomyopathy

-- Severe gastrointestinal bleedingSevere gastrointestinal bleeding


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Suspect Dengue Infection

Emergency + Emergency -

Tourniquet + Tourniquet -

Thrombocyte100.000/ul

hospitalized Out patient

Suspect Dengue infection : fever, acute, high, continuous,

Lasting 2 7 days

Emergency + : sympthoms of shock, vomiting, convulsions,

unconciousness, hematemesis, melena

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DHF GRADE I AND IIWithout hemoconcentration

By mouth

vomiting vomiting +

Observed

Clinical and laboratoriumIntravenous fluid infusion

improvement No improvement improvement No improvement

Out patient In patient

Out patient in patient

-

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DHF GRADE I AND IIWith hemoconcentrafion

Intravenous fluid infusion

RL 6 7 ml / kg bw / h

improvement no improvement

RL 3 ml / kg bw / h RL 10 15 ml / kg bw / h

24 48 hours stop no improvementColloid 20 30 ml / kg bw / h

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DHF GRADE III AND IV

02

RL 20 ml / kg bw / h

RL 10 ml / kg bw / h

RL 5 ml / kg bw / h

RL 3 ml / kg bw / h

Shock - Shock +

24 hours 1 hour

Shock - Shock +

Ad colloid 10 ml/kg bw / h

colloid 20 ml/kg bw / h

1 hour

Shock - Shock +stop

ICU

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Criteria of discharged

1. Clinical improvement

2. No fever within 24 hours without antipyretic

3. No respiratory distress4. Stabiliting of hematocrit

5. Tendency of thrombocyte increase (>50.000/ul

6. Three days after shock overcone

7. Increasing of appetite


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Dengue Hemorahagic Fever Koreksi

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