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Dengue Hemorrhagic Fever

Dengue Hemorrhagic Fever (DHF) are acute febrile diseases which occur in the

tropics, can be life-threatening, and are caused by four closely related virus serotypes of the

genus Flavivirus, family Flaviviridae. It is also known as breakbone fever, since it can beextremely painful. It occurs widely in the tropics, including northern Argentina, northern

Australia, Bangladesh, Barbados, Bolivia, Belize, Brazil, Cambodia, Colombia, Costa Rica,

Cuba, Dominican Republic,French Polynesia, Guadeloupe, El Salvador, Guatemala, Guyana,

Haiti, Honduras, India, Indonesia, Jamaica, Laos, Malaysia, Melanesia, Mexico, Micronesia,

Nicaragua, Pakistan, Panama, Paraguay, Philippines, Puerto Rico, Samoa, Western Saudi

Arabia, Singapore, Sri Lanka, Suriname, Taiwan, Thailand,Trinidad,Venezuela andVietnam,

and increasingly in southern China. Unlike malaria, dengue is just as prevalent in the urban

districts of its range as in rural areas. Each serotype is sufficiently different that there is no

cross-protection and epidemics caused by multiple serotypes (hyperendemicity) can occur.

Dengue is transmitted to humans by the Aedes (Stegomyia) aegyptior more rarely theAedes

albopictusmosquito, both of which feed exclusively during daylight hours.

http://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Tropical_diseasehttp://en.wikipedia.org/wiki/Tropicshttp://en.wikipedia.org/wiki/Virushttp://en.wikipedia.org/wiki/Virushttp://en.wikipedia.org/wiki/Serotypehttp://en.wikipedia.org/wiki/Flavivirushttp://en.wikipedia.org/wiki/Flavivirushttp://en.wikipedia.org/wiki/Flaviviridaehttp://en.wikipedia.org/wiki/Argentinahttp://en.wikipedia.org/wiki/Australiahttp://en.wikipedia.org/wiki/Bangladeshhttp://en.wikipedia.org/wiki/Barbadoshttp://en.wikipedia.org/wiki/Boliviahttp://en.wikipedia.org/wiki/Boliviahttp://en.wikipedia.org/wiki/Belizehttp://en.wikipedia.org/wiki/Brazilhttp://en.wikipedia.org/wiki/Cambodiahttp://en.wikipedia.org/wiki/Cambodiahttp://en.wikipedia.org/wiki/Colombiahttp://en.wikipedia.org/wiki/Colombiahttp://en.wikipedia.org/wiki/Costa_Ricahttp://en.wikipedia.org/wiki/Cubahttp://en.wikipedia.org/wiki/Cubahttp://en.wikipedia.org/wiki/Dominican_Republichttp://en.wikipedia.org/wiki/French_Polynesiahttp://en.wikipedia.org/wiki/Guadeloupehttp://en.wikipedia.org/wiki/El_Salvadorhttp://en.wikipedia.org/wiki/Guatemalahttp://en.wikipedia.org/wiki/Guyanahttp://en.wikipedia.org/wiki/Haitihttp://en.wikipedia.org/wiki/Hondurashttp://en.wikipedia.org/wiki/Hondurashttp://en.wikipedia.org/wiki/Hondurashttp://en.wikipedia.org/wiki/Indiahttp://en.wikipedia.org/wiki/Indonesiahttp://en.wikipedia.org/wiki/Jamaicahttp://en.wikipedia.org/wiki/Jamaicahttp://en.wikipedia.org/wiki/Laoshttp://en.wikipedia.org/wiki/Malaysiahttp://en.wikipedia.org/wiki/Mexicohttp://en.wikipedia.org/wiki/Micronesiahttp://en.wikipedia.org/wiki/Micronesiahttp://en.wikipedia.org/wiki/Nicaraguahttp://en.wikipedia.org/wiki/Pakistanhttp://en.wikipedia.org/wiki/Panamahttp://en.wikipedia.org/wiki/Panamahttp://en.wikipedia.org/wiki/Paraguayhttp://en.wikipedia.org/wiki/Paraguayhttp://en.wikipedia.org/wiki/Philippineshttp://en.wikipedia.org/wiki/Puerto_Ricohttp://en.wikipedia.org/wiki/Samoahttp://en.wikipedia.org/wiki/Saudi_Arabiahttp://en.wikipedia.org/wiki/Saudi_Arabiahttp://en.wikipedia.org/wiki/Singaporehttp://en.wikipedia.org/wiki/Singaporehttp://en.wikipedia.org/wiki/Sri_Lankahttp://en.wikipedia.org/wiki/Surinamehttp://en.wikipedia.org/wiki/Taiwanhttp://en.wikipedia.org/wiki/Thailandhttp://en.wikipedia.org/wiki/Thailandhttp://en.wikipedia.org/wiki/Trinidadhttp://en.wikipedia.org/wiki/Trinidadhttp://en.wikipedia.org/wiki/Trinidadhttp://en.wikipedia.org/wiki/Venezuelahttp://en.wikipedia.org/wiki/Venezuelahttp://en.wikipedia.org/wiki/Vietnamhttp://en.wikipedia.org/wiki/Vietnamhttp://en.wikipedia.org/wiki/Chinahttp://en.wikipedia.org/wiki/Malariahttp://en.wikipedia.org/wiki/Serotypehttp://en.wikipedia.org/wiki/Epidemichttp://en.wikipedia.org/wiki/Epidemichttp://en.wikipedia.org/wiki/Aedes_(Stegomyia)_aegyptihttp://en.wikipedia.org/wiki/Aedes_albopictushttp://en.wikipedia.org/wiki/Aedes_albopictushttp://en.wikipedia.org/wiki/Mosquitohttp://en.wikipedia.org/wiki/Mosquitohttp://en.wikipedia.org/wiki/Mosquitohttp://en.wikipedia.org/wiki/Tropical_diseasehttp://en.wikipedia.org/wiki/Tropicshttp://en.wikipedia.org/wiki/Virushttp://en.wikipedia.org/wiki/Serotypehttp://en.wikipedia.org/wiki/Flavivirushttp://en.wikipedia.org/wiki/Flaviviridaehttp://en.wikipedia.org/wiki/Argentinahttp://en.wikipedia.org/wiki/Australiahttp://en.wikipedia.org/wiki/Bangladeshhttp://en.wikipedia.org/wiki/Barbadoshttp://en.wikipedia.org/wiki/Boliviahttp://en.wikipedia.org/wiki/Belizehttp://en.wikipedia.org/wiki/Brazilhttp://en.wikipedia.org/wiki/Cambodiahttp://en.wikipedia.org/wiki/Colombiahttp://en.wikipedia.org/wiki/Costa_Ricahttp://en.wikipedia.org/wiki/Cubahttp://en.wikipedia.org/wiki/Dominican_Republichttp://en.wikipedia.org/wiki/French_Polynesiahttp://en.wikipedia.org/wiki/Guadeloupehttp://en.wikipedia.org/wiki/El_Salvadorhttp://en.wikipedia.org/wiki/Guatemalahttp://en.wikipedia.org/wiki/Guyanahttp://en.wikipedia.org/wiki/Haitihttp://en.wikipedia.org/wiki/Hondurashttp://en.wikipedia.org/wiki/Indiahttp://en.wikipedia.org/wiki/Indonesiahttp://en.wikipedia.org/wiki/Jamaicahttp://en.wikipedia.org/wiki/Laoshttp://en.wikipedia.org/wiki/Malaysiahttp://en.wikipedia.org/wiki/Mexicohttp://en.wikipedia.org/wiki/Micronesiahttp://en.wikipedia.org/wiki/Nicaraguahttp://en.wikipedia.org/wiki/Pakistanhttp://en.wikipedia.org/wiki/Panamahttp://en.wikipedia.org/wiki/Paraguayhttp://en.wikipedia.org/wiki/Philippineshttp://en.wikipedia.org/wiki/Puerto_Ricohttp://en.wikipedia.org/wiki/Samoahttp://en.wikipedia.org/wiki/Saudi_Arabiahttp://en.wikipedia.org/wiki/Saudi_Arabiahttp://en.wikipedia.org/wiki/Singaporehttp://en.wikipedia.org/wiki/Sri_Lankahttp://en.wikipedia.org/wiki/Surinamehttp://en.wikipedia.org/wiki/Taiwanhttp://en.wikipedia.org/wiki/Thailandhttp://en.wikipedia.org/wiki/Trinidadhttp://en.wikipedia.org/wiki/Venezuelahttp://en.wikipedia.org/wiki/Vietnamhttp://en.wikipedia.org/wiki/Chinahttp://en.wikipedia.org/wiki/Malariahttp://en.wikipedia.org/wiki/Serotypehttp://en.wikipedia.org/wiki/Epidemichttp://en.wikipedia.org/wiki/Aedes_(Stegomyia)_aegyptihttp://en.wikipedia.org/wiki/Aedes_albopictushttp://en.wikipedia.org/wiki/Aedes_albopictushttp://en.wikipedia.org/wiki/Mosquitohttp://en.wikipedia.org/wiki/Fever

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CAUSATIVE AGENT

Dengue Hemorrhagic Fever is caused due to infection with a virus of the Flaviviridae

family. The agency through which the virus travels is the aedes aegypti or the aedes albopictus

mosquito.

MODE OF TRANSMISSION

Dengue viruses are transmitted to humans through thebites of infective female Aedes mosquitoes. Mosquitoesgenerally acquire the virus while feeding on the blood of aninfected person. After virus incubation for eight to 10 days, aninfected mosquito is capable, during probing and bloodfeeding, of transmitting the virus for the rest of its life. Infectedfemale mosquitoes may also transmit the virus to their offspringby transovarial (via the eggs) transmission, but the role of thisin sustaining transmission of the virus to humans has not yetbeen defined.

Infected humans are the main carriers and multipliers of the virus, serving as a source ofthe virus for uninfected mosquitoes. The virus circulates in the blood of infected humans for twoto seven days, at approximately the same time that they have a fever; Aedes mosquitoes mayacquire the virus when they feed on an individual during this period. Some studies have shownthat monkeys in some parts of the world play a similar role in transmission.

INCUBATION PERIOD

After being bitten by a mosquito carrying the virus, the incubation period ranges fromthree to 15 (usually five to eight) days before the signs and symptoms of dengue appear

abruptly. The initial symptoms of dengue fever last about six to seven days. The fever climbsrapidly in the first 48 to 96 hours of the illness and then may break for a day before elevatingrapidly again. This second phase of the fever is often when a rash may appear on the limbs orchest.

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PERIOD OF COMMUNICABILITY

Unknown. Presumed to be on the 1st week of illnesswhen virus is still present in the blood.

SIGNS AND SYMPTOMS

The classic dengue rash is a generalised maculopapularrash with islands of sparing. Ahemorrhagic rash of characteristically bright red pinpoint spots, known as petechiae can occurlater during the illness and is associated withthrombocytopenia. It usually appears first on thelower limbs and the chest; in some patients, it spreads to cover most of the body. There mayalso be severe retro-orbital pain, (a pain from behind the eyes that is distinctive to Dengueinfections), and gastritis with some combination of associated abdominalpain, nausea, vomiting coffee-grounds-like congealed blood, or severe diarrhea.

An acute febrile infection of sudden onset with clinical manifestationof 3 stages:

First 4 daysFebrile or invasive stage starts abruptly as high fever, abdominal pain and

headache; later flushing which may be accompanied by vomiting, conjunctival infectionand epistaxis.

4th-7th daysToxic or hemorrhagic stagelowering of temperature, severe abdominal

pain, vomiting and frequent bleeding from gastrointestinal tract in the form of hematesisor melena. Unstable BP, narrow pulse pressure and shock may occur. Tourniquet testwhich may be negative due to low or vasomotor collapse.

7th-10th daysconvalescent or recovery stage generalized flushing with intervening areas

of blanching appetite regained and blood pressure already stable.

Classification

Severe, frank typewith flushing, sudden high fever, severe hemorrhage, followed by

sudden drop of temperature, shock and terminating in recovery or death.

Moderatewith high fever but less hemorrhage, no shock

Mildwith slight fever, with or without petechial hemorrhage but epidemiologically

related to typical cases usually discovered in the course of investigation of typical cases

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Grading of Dengue Fever

The severity of DHF is categorized into four grades:

Grade I, without overt bleeding but positive for tourniquet test Grade II, with clinical bleeding diathesis such as petechiae, epistaxis and hematemesis Grade III, circulatory failure manifested by a rapid and weak pulse with narrowing pulse

pressure (20 mmHg) or hypotension, with the presence of cold clammy skin andrestlessness; and

Grade IV, profound shock in which pulse and blood pressure are not detectable. It isnoteworthy that patients who are in threatened shock or shock stage, also known asdengue shock syndrome, usually remain conscious.

Grade III and IV are considered to be Dengue Shock Syndrome

LABORATORY/DIAGNOSIS

1.) Tourniquet Test (Rumpel Leads Tests) Inflate the blood pressure cuff on the upper arm t

o a point midway between thesystolic and diastolic pressure for 5 minutes

Release cuff and make an imaginary 2.5 cm square or 1 inch just below the cuff, atthe antecubital fossa

Count the number of petechiae inside the box A test is (+) when 20 or more petechiae per2.5

cm square or 1 inch square are observed.

2.) A confirmed diagnosis is established by culture of the virus, polymerasechain-reaction (PCR) tests, or serologic assays.

The diagnosis of dengue hemorrhagic fever is made onthe basis of the following triad of symptoms and signs:Hemorrhagic manifestations; a platelet count of less than 100,000 per cubic millimeter; and objective evidence of plasmaleakage, shown either by fluctuation of packedcell volume(greater than 20 percent during the course of the illness) or byclinical signs of plasma leakage, such as pleural effusion,ascites or hypoproteinemia. Hemorrhagic manifestationswithout capillary leakage do not constitute denguehemorrhagic fever.

The diagnosis of dengue is usually made clinically. The classic picture is high fever with nolocalizing source of infection, a rash with thrombocytopenia and relative leukopenia - lowplatelet and white blood cell count. Dengue infection can affect many organs and thus maypresent unusually as liver dysfunction, renal impairment, meningo-encephalitis orgastroenteritis.

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1. Fever, headaches, eye pain, severe dizziness and loss of appetite.2. Hemorrhagic tendency (positive tourniquet test, spontaneous bruising, bleeding from

mucosa,gingiva, injection sites, etc.; vomiting blood, or bloody diarrhea)

3. Thrombocytopenia (

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NURSING MANAGEMENT

Supportive and symptomatic treatment should be provided:

Promote rest

Medication

Paracetamol for fever

Analgesic (Acetaminophen (Tylenol) and codeine) for severe headache and jointand muscle pains

Aspirin and nonsteroidal antiinflammatory drugs should be avoided

Rapid replacement of body fluids is the most important treatment

Give ORESOL to replace fluid as in moderate dehydration at 75ml/kg in 46 hours orup to 23L in adults. Continue ORS intake until paients condition improves.

Intravenous fluid

For hemorrhage

Keep patient at rest during bleeding periods

For epistaxis maintain an elevated position of trunk and promote vasoconstrictionin nasal mucosa membrane through an ice bag over the forehead.

For melena ice bag over the abdomen. Provide support during the transfusiontherapy

Diet

Low fat, low fiber, nonirritating, noncarbonated

Noodle soup may be given

Observe signs of deterioration (shock) such as low pulse, cold clammy perspiration,

prostration.

For shock

Place in dorsal recumbent position to facilitate circulation

Provision of warmth through lightweight covers (overheating causes vasodilatationwhich aggravates bleeding)

HEALTH TEACHINGS

The best way to prevent dengue fever is to take special precautions to avoid contact with mosquitoes.

Eliminate vector by:

Changing water and scrubbing sides of lower vases once a week

Destroy breeding places of mosquito by cleaning surroundings

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Proper disposal of rubber tires, empty bottles and cans

Keep water containers covered

Because Aedes mosquitoes usually bite during the day, be sure to use precautionsespecially during early morning hours before daybreak and in the late afternoon before

dark.

Other precautions include:

When outdoors in an area where dengue fever has been found

Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus

Dress in protective clothinglongsleeved shirts, long pants, socks, and shoes

Keeping unscreened windows and doors closed

Keeping window and door screens repaired

Use of mosquito nets