DENGUE IN CHILDREN

-Dr.Apoorva.E PG,DCMS

EPIDEMIOLOGY

• Dengue is the most rapidly spreading mosquito-borne viral disease in the world

• Increase in incidence by over 30-fold in the last 50 years

• Currently endemic in all continents except Europe

ETIOLOGYTHE VIRUS

• DEN- family flaviviridae genus flavivirus

• Has four distinct serotypes (DEN1 – 4)

• DEN-2 and DEN-3 cause severe disease

• Cleaved by host and viral proteases into 3 structural proteins and 7 nonstructural proteins(NS)

THE VECTOR

• Transmitted by infected Aedes mosquitoes

• Highly urbanized,

fresh water,

day feeding mosquito

THE HOST

• Humans are the primary host of the virus

• Severity depends upon factors like gender,secondary infection,age and chronic diseases (sickle cell anemia, asthma , DM)

• Vertical transmission and through infected blood products +

PATHOGENESIS

Capillary damage

Fluid leaks into extravascular spaces

Hemoconcentration Hypovolemia

Increased cardiac work Tissue hypoxia,metabolic acidosis

THROMBOCYTOPENIA

+

LIVER DAMAGE

+

DIC

DENGUE HAEMORRHAGIC FEVER

ANTIBODY DEPENDENT

ENHANCEMENT

• Specific antibodies start appearing around day 5 of illness.

• Infection with one serotype gives lifelong immunity to that type, but only short term protection against the other three.

• Secondary infection with DEN-2, DEN-3 is associated with dengue haemorrhagic fever.

CLINICAL MANIFESTATIONS

• Multisystem disease with a wide clinical spectrum

• Incubation period – 4 to 10 days

• Illness begins abruptly following the IP,divided into three phases

FEBRILE CRITICAL RECOVERY

FEBRILE PHASE

• High grade fever lasting for 2-7 days

• Accompanied by facial flushing,rash,myalgia,arthralgia,headache,nausea,vomiting,anorexia,sore throat,injected pharynx and conjunctiva.

• Petechiae,epistaxis,gum bleed may be seen.

CRITICAL PHASE

• Usually occurs on days 3-6 of the illness

• Lasts for 24-48 hours

• Progressive leukopenia,increasing hematocrit levels,decrease in platelet count precede plasma leakage

Ascites Pleural effusion Shock

• Prolonged shock leads to DIC which leads to severe haemorrhage

-Decrease in hematocrit

-GI bleeding usually

• Organ hypoperfusion can lead to hepatitis,myocarditis,encephalitis

RECOVERY PHASE

• Reabsorption of the fluid from extravascular compartment occurs

• General well-being improves,appetite returns,hemodynamic status stabilizes,urine output becomes normal,GI symptoms abate

• Generalized pruritus,bradycardia ++

CLINICAL PROBLEMS ENCOUNTERED DURING

DIFFERENT PHASES

DENGUE CASE PROBABLE DENGUE (live in/travel to endemic area+fever+any of the following

two criteria : rash,nausea/vomiting,aches,positive tourniquet test,leukopenia,any warning sign)

WARNING SIGNS

NEGATIVE POSITIVE

DENGUE WITH SEVERE WARNING SIGNS DENGUE

DENGUE WITHOUT WARNING SIGNS

WARNING SIGNS

SEVERE DENGUE

FEVER OF 2-7 DAYS PLUS ANY OF THE FOLLOWING FEATURES :

1.EVIDENCE OF PLASMA LEAKAGE

2.SIGNIFICANT BLEEDING

3.ALTERED LEVEL OF CONSCIOUSNESS

4.SEVERE GI INVOLVEMENT

5.SEVERE ORGAN INVOLVEMENT

DENGUE SHOCK SYNDROME

COMPENSATED DECOMPENSATED

SHOCK SHOCK

(pulse pressure<20mmHg,

cold clammy extremities,

feeble rapid pulse)

DENGUE HAEMORRHAGIC FEVER

GRADING OF DENGUE FEVER

MANAGEMENT

• HISTORY – Time of fever onset,associated symptoms,warning signs,urine output,family or neighbourhood dengue

• PHYSICAL EXAMINATION – Assess hydration,hemodynamic status,tender abdomen,ascites,hepatomegaly,pleural efffusion,bleeding manifestations,mental state,tourniquet test

• INVESTIGATIONS – CBP with HCT,other organ function tests as indicated(USG,CXR,LFT,RFT,PT APTT INR,BLOOD GLUCOSE,SERUM ELECTROLYTES,ABG)

• SPECIFIC DIAGNOSTIC TESTS – NS1 Ag detection IgM IgG detection Viral isolation PCR to detect viral genome

DENGUE WITHOUT WARNING SIGNS - TREATMENT

DENGUE WITH WARNING SIGNS - TREATMENT

SEVERE DENGUE(COMPENSATED SHOCK) - TREATMENT

HYPOTENSIVE SHOCK - TREATMENT

DISCHARGE CRITERIA

• No fever for 48hours

• Improvement in general well-being,appetite,U/O,hemodynamic status

• Increasing platelet count

• Stable HCT without IVF

D/D

• CONDITIONS THAT MIMIC FEBRILE PHASE :

Influenza,

measles,

chikungunya,

scarlet fever,

meningococcal infection,

drug reactions,

G.E

• CONDITIONS THAT MIMIC CRITICAL PHASE :

Acute GE,

malaria,

viral hepatitis,

acute abdomen,

DKA,

lactic acidosis,

acute leukemia,

platelet disorders,

leptospirosis

THANK YOU !