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==Overview== | ==Overview== | ||
Dengue virus infection has a wide spectrum of clinical manifestations, ranging from asymptomic infection, to symptoms of non-severe disease (such as [[flu]]-like symptoms, [[fever]], retro-orbital [[headache]], [[fatigue]], [[arthralgia]], [[myalgia]], [[nausea]], [[vomiting]], or [[lymphadenopathy]]), and to severe complications including signs of plasma leakage (such as [[pleural effusion]] or [[ascites]]), [[hemorrhage|hemorrhagic tendencies]] (such as [[petechiae]], [[ecchymoses]], [[purpura]], [[bruising|easy bruising]] at [[venipuncture|venipuncture sites]], [[mucosa|mucosal]] [[bleeding]], [[gastrointestinal bleeding]], [[hematemesis]], or [[melena]]), and [[organ failure]] associated with [[shock]]. | |||
==History and Symptoms== | |||
{| style="float: right; width: 350px;" | |||
| [[File:The course of dengue illness.png|400px|thumb|none|Adapted from ''Dengue: guidelines for diagnosis, treatment, prevention and control''. © World Health Organization 2009<ref name=WHO2009>{{cite web | title = Dengue: guidelines for diagnosis, treatment, prevention and control | url = http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf?ua=1 }}</ref>]] | |||
|- | |||
! style="font-size: 85%; background: #DCDCDC;" | Warning Signs Requiring Strict Observation and Medical Intervention | |||
|- | |||
| style="font-size: 85%; background: #F5F5F5;" | | |||
:* [[Abdominal pain]] or [[tenderness]] | |||
:* Persistent [[vomiting]] | |||
:* Clinical fluid accumulation (eg, [[pleural effusion]] or [[ascites]]) | |||
:* [[Mucosa|Mucosal]] [[bleed]] | |||
:* [[Lethargy]], [[restlessness]] | |||
:* [[Hepatomegaly|Liver enlargment]] >2 cm | |||
:* [[Hemoconcentration|Increase in hematocrit]] concurrent with rapid [[thrombocytopenia|decrease in platelet count]] | |||
|- | |||
! style="font-size: 85%; background: #DCDCDC;" | Complications in Febrile, Critical, and Recovery Phases of Dengue | |||
|- | |||
| style="font-size: 85%; background: #F5F5F5;" | | |||
:* '''''Febrile phase''''' | |||
::* [[Dehydration]] | |||
::* [[Altered mental status|Neurologic disturbances]] and [[febrile seizure]]s in young children | |||
:* '''''Critical phase''''' | |||
::* Severe plasma leakage resulting in [[shock]] | |||
::* Severe [[hemorrhage]] | |||
::* Severe [[organ failure|organ impairment]] | |||
:* '''''Recovery phase''''' | |||
::* [[Hypervolemia]] due to excessive [[intravenous fluid|intravenous fluid administration]] | |||
::* [[Pulmonary edema|Acute pulmonary edema]] | |||
|} | |} | ||
== | After an [[incubation period]] of 4–10 days, the illness begins abruptly and is followed by the three phases — the '''Febrile Phase''', the '''Critical Phase''', and the '''Recovery Phase'''.<ref name="Thong1998">{{cite journal|last1=Thong|first1=Meow-Keong|title=Dengue shock syndrome and acute respiratory distress syndrome|journal=The Lancet|volume=352|issue=9141|year=1998|pages=1712|issn=01406736|doi=10.1016/S0140-6736(05)61496-1}}</ref> | ||
<br><br> | |||
[[Image:Symptoms Dengue Fever.png|400px]]<br><br> | |||
===Febrile Phase=== | |||
* The febrile phase is characterized by an abrupt onset of high [[fever]] which usually lasts 2–7 days, with a smaller peak at the trailing end of the [[fever]] (the so-called ''biphasic pattern''). Accompanying symptoms include [[facial flushing]], [[erythema|skin erythema]], [[generalized body aches]], [[myalgia]], [[arthralgia]], retro-orbital [[eye pain]], [[photophobia]], [[rubella|rubeliform]] [[exanthem]] and [[headache]]. The joint pain can be excruciating, hence the name ''[[breakbone fever]]'' or ''[[bonecrusher disease]]''. Some patients may have [[sore throat]], [[inflammation|injected]] [[pharynx]] or [[conjunctiva]], [[lymphadenopathy|swollen lymph nodes]], [[anorexia]], [[nausea]], or [[vomiting]]. | |||
=== | * Mild hemorrhagic manifestations such as [[petechiae]] and [[mucosal]] membrane [[bleeding]] (e.g. of the [[nose]] and [[gums]]) may be seen. [[bruising|Easy bruising]] and [[bleeding]] at [[venipuncture|venipuncture sites]] are present in some cases. The [[petechial rash]] usually appears first on the lower extremities and the chest and may spread to other parts of the body. Massive [[vaginal bleeding]] in women of childbearing age and [[gastrointestinal bleeding]] occur less commonly in this phase.<ref name="KalayanaroojVaughn1997">{{cite journal|last1=Kalayanarooj|first1=S.|last2=Vaughn|first2=D. W.|last3=Nimmannitya|first3=S.|last4=Green|first4=S.|last5=Suntayakorn|first5=S.|last6=Kunentrasai|first6=N.|last7=Viramitrachai|first7=W.|last8=Ratanachu‐eke|first8=S.|last9=Kiatpolpoj|first9=S.|last10=Innis|first10=B. L.|last11=Rothman|first11=A. L.|last12=Nisalak|first12=A.|last13=Ennis|first13=F. A.|title=Early Clinical and Laboratory Indicators of Acute Dengue Illness|journal=The Journal of Infectious Diseases|volume=176|issue=2|year=1997|pages=313–321|issn=0022-1899|doi=10.1086/514047}}</ref> A positive tourniquet test in the febrile phase indicates an increased probability of dengue.<ref name="KalayanaroojVaughn1997">{{cite journal|last1=Kalayanarooj|first1=S.|last2=Vaughn|first2=D. W.|last3=Nimmannitya|first3=S.|last4=Green|first4=S.|last5=Suntayakorn|first5=S.|last6=Kunentrasai|first6=N.|last7=Viramitrachai|first7=W.|last8=Ratanachu‐eke|first8=S.|last9=Kiatpolpoj|first9=S.|last10=Innis|first10=B. L.|last11=Rothman|first11=A. L.|last12=Nisalak|first12=A.|last13=Ennis|first13=F. A.|title=Early Clinical and Laboratory Indicators of Acute Dengue Illness|journal=The Journal of Infectious Diseases|volume=176|issue=2|year=1997|pages=313–321|issn=0022-1899|doi=10.1086/514047}}</ref><ref name="MayxayPhetsouvanh2011">{{cite journal|last1=Mayxay|first1=Mayfong|last2=Phetsouvanh|first2=Rattanaphone|last3=Moore|first3=Catrin E|last4=Chansamouth|first4=Vilada|last5=Vongsouvath|first5=Manivanh|last6=Sisouphone|first6=Syho|last7=Vongphachanh|first7=Pankham|last8=Thaojaikong|first8=Thaksinaporn|last9=Thongpaseuth|first9=Soulignasack|last10=Phongmany|first10=Simmaly|last11=Keolouangkhot|first11=Valy|last12=Strobel|first12=Michel|last13=Newton|first13=Paul N.|title=Predictive diagnostic value of the tourniquet test for the diagnosis of dengue infection in adults|journal=Tropical Medicine & International Health|volume=16|issue=1|year=2011|pages=127–133|issn=13602276|doi=10.1111/j.1365-3156.2010.02641.x}}</ref> | ||
* These clinical features do not predict the severity of dengue fever. Therefore, it is crucial to monitor for warning signs and other clinical parameters in order to recognize progression to the critical phase. | |||
* The earliest abnormality in the [[complete blood count]] is [[leukopenia]], which should alert the physician to a high probability of dengue. The [[platelet]] count usually begins to drop when the temperature is returning to normal. | |||
* When no [[rash]] is present, mild symptoms of dengue fever may be misdiagnosed as [[influenza]] or other [[virus|viral]] infection. Travelers from endemic areas may inadvertently pass on dengue in their home countries, having not been properly diagnosed at the height of their illness. Patients with dengue can only pass on the infection through [[mosquitoes]] or [[blood product]]s while they are still [[fever|febrile]]. | |||
===Critical Phase=== | ===Critical Phase=== | ||
During the critical phase of the | {{Details|Dengue fever classification|'''Dengue Hemorrhagic Fever''' and '''Dengue Shock Syndrome'''}} | ||
* During the transition from the febrile to afebrile phase, patients without an increase in [[capillary]] permeability will improve without going through the critical phase. Instead of improving with the subsidence of [[fever]], patients with increased [[capillary]] permeability may manifest with symptoms indicative of plasma leakage and enter what is termed the critical phase. | |||
* The critical phase is heralded by the development of warning signs. These patients become worse around the time of defervescence, when the temperature drops to 37.5–38°C or less and remains below this level, usually on days 3 through 8 of the illness. Progressive [[leukopenia]] (≤5000 cells/mm<sup>3</sup>) with a rapid [[thrombocytopenia|decline in platelet count]] to about 100,000 cells/mm<sup>3</sup> typically precedes plasma leakage and the [[capillary leak syndrome]]. | |||
* A rising [[hematocrit]] above baseline may be one of the earliest signs of plasma leakage. The extent of [[hemoconcentration]] reflects the severity of plasma leakage. However, this may be abated by early [[intravenous fluid]] administration. Frequent [[hematocrit]] determinations are essential for guiding [[intravenous fluid|intravenous fluid therapy]]. [[Pleural effusion]] and [[ascites]] may be clinically detectable only after [[intravenous fluid|intravenous fluid therapy]], unless plasma leakage is significant.<ref name="SrikiatkhachornKrautrachue2007">{{cite journal|last1=Srikiatkhachorn|first1=Anon|last2=Krautrachue|first2=Anchalee|last3=Ratanaprakarn|first3=Warangkana|last4=Wongtapradit|first4=Lawan|last5=Nithipanya|first5=Narong|last6=Kalayanarooj|first6=Siripen|last7=Nisalak|first7=Ananda|last8=Thomas|first8=Stephen J.|last9=Gibbons|first9=Robert V.|last10=Mammen|first10=Mammen P.|last11=Libraty|first11=Daniel H.|last12=Ennis|first12=Francis A.|last13=Rothman|first13=Alan L.|last14=Green|first14=Sharone|title=Natural History of Plasma Leakage in Dengue Hemorrhagic Fever|journal=The Pediatric Infectious Disease Journal|volume=26|issue=4|year=2007|pages=283–290|issn=0891-3668|doi=10.1097/01.inf.0000258612.26743.10}}</ref> | |||
* In addition to plasma leakage, hemorrhagic manifestations such as [[easy bruising]] and [[bleeding]] at [[venipuncture|venipuncture sites]] occur frequently. | |||
* [[Shock]] occurs when there is a dramatic [[hypovolemia|volume loss]] due to plasma leakage. With profound and/or prolonged [[shock]], [[hypoperfusion|tissue hypoperfusion]] results in [[metabolic acidosis]], progressive [[organ failure|organ impairment]], and [[disseminated intravascular coagulation]]. This in turn leads to severe [[hemorrhage]] causing the [[hematocrit]] to decrease in severe [[shock]]. Rather than [[leukopenia]], [[white cell]] count may increase as a [[stress response]] in patients with severe [[bleeding]]. | |||
===Recovery Phase=== | ===Recovery Phase=== | ||
* As the patient survives the 24–48 hours of the critical phase, a gradual reabsorption of fluid from the extravascular compartment takes place in the following 48–72 hours. [[Appetite]] returns, [[gastrointestinal]] symptoms abate, [[hemodynamic|hemodynamic status]] stabilizes, and [[diuresis]] ensues. | |||
* Some patients have a confluent [[erythema|erythematous]] or [[petechial rash]] with small areas of normal skin termed as ''isles of white in the sea of red''. Some may experience generalized [[pruritus]]. [[Bradycardia]] and other [[electrocardiographic]] changes are common during this stage. | |||
* The [[hematocrit]] normalizes or may be lower than the baseline value due to [[hemodilution]]. The [[white cell]] count usually starts to rise soon after defervescence, while the recovery of the [[platelet]] count is typically delayed. | |||
* [[Respiratory distress]] from massive [[pleural effusion]] and [[ascites]], [[pulmonary edema]], or [[congestive heart failure]] may occur during the recovery phase if excessive [[intravenous fluid]]s have been administered. | |||
{| | |||
| [[File:Manifestations of dengue virus infection.png|800px|thumb|none|Adapted from ''Dengue haemorrhagic fever: diagnosis, treatment, prevention and control''. © World Health Organization 1997 <ref name=WHO1997>{{cite web | title = Dengue haemorrhagic fever: diagnosis, treatment, prevention and control | url = http://apps.who.int/iris/bitstream/10665/41988/1/9241545003_eng.pdf }}</ref>]] | |||
|} | |||
== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
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[[Category:Flaviviruses]] | [[Category:Flaviviruses]] | ||
[[Category:Hemorrhagic fevers]] | [[Category:Hemorrhagic fevers]] | ||
[[Category:Insect-borne diseases]] | [[Category:Insect-borne diseases]] | ||
[[Category:Neglected diseases]] | [[Category:Neglected diseases]] | ||
[[Category:Tropical disease]] | [[Category:Tropical disease]] | ||
[[Category:Viral diseases]] | [[Category:Viral diseases]] | ||
[[Category:Emergency medicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
[[Category:Hematology]] | |||
[[Category:Cardiology]] | |||
[[Category:Gastroenterology]] | |||
Latest revision as of 21:16, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]
Overview
Dengue virus infection has a wide spectrum of clinical manifestations, ranging from asymptomic infection, to symptoms of non-severe disease (such as flu-like symptoms, fever, retro-orbital headache, fatigue, arthralgia, myalgia, nausea, vomiting, or lymphadenopathy), and to severe complications including signs of plasma leakage (such as pleural effusion or ascites), hemorrhagic tendencies (such as petechiae, ecchymoses, purpura, easy bruising at venipuncture sites, mucosal bleeding, gastrointestinal bleeding, hematemesis, or melena), and organ failure associated with shock.
History and Symptoms
 |
| Warning Signs Requiring Strict Observation and Medical Intervention |
|---|
|
| Complications in Febrile, Critical, and Recovery Phases of Dengue |
|
After an incubation period of 4–10 days, the illness begins abruptly and is followed by the three phases — the Febrile Phase, the Critical Phase, and the Recovery Phase.[2]
Febrile Phase
- The febrile phase is characterized by an abrupt onset of high fever which usually lasts 2–7 days, with a smaller peak at the trailing end of the fever (the so-called biphasic pattern). Accompanying symptoms include facial flushing, skin erythema, generalized body aches, myalgia, arthralgia, retro-orbital eye pain, photophobia, rubeliform exanthem and headache. The joint pain can be excruciating, hence the name breakbone fever or bonecrusher disease. Some patients may have sore throat, injected pharynx or conjunctiva, swollen lymph nodes, anorexia, nausea, or vomiting.
- Mild hemorrhagic manifestations such as petechiae and mucosal membrane bleeding (e.g. of the nose and gums) may be seen. Easy bruising and bleeding at venipuncture sites are present in some cases. The petechial rash usually appears first on the lower extremities and the chest and may spread to other parts of the body. Massive vaginal bleeding in women of childbearing age and gastrointestinal bleeding occur less commonly in this phase.[3] A positive tourniquet test in the febrile phase indicates an increased probability of dengue.[3][4]
- These clinical features do not predict the severity of dengue fever. Therefore, it is crucial to monitor for warning signs and other clinical parameters in order to recognize progression to the critical phase.
- The earliest abnormality in the complete blood count is leukopenia, which should alert the physician to a high probability of dengue. The platelet count usually begins to drop when the temperature is returning to normal.
- When no rash is present, mild symptoms of dengue fever may be misdiagnosed as influenza or other viral infection. Travelers from endemic areas may inadvertently pass on dengue in their home countries, having not been properly diagnosed at the height of their illness. Patients with dengue can only pass on the infection through mosquitoes or blood products while they are still febrile.
Critical Phase
- During the transition from the febrile to afebrile phase, patients without an increase in capillary permeability will improve without going through the critical phase. Instead of improving with the subsidence of fever, patients with increased capillary permeability may manifest with symptoms indicative of plasma leakage and enter what is termed the critical phase.
- The critical phase is heralded by the development of warning signs. These patients become worse around the time of defervescence, when the temperature drops to 37.5–38°C or less and remains below this level, usually on days 3 through 8 of the illness. Progressive leukopenia (≤5000 cells/mm3) with a rapid decline in platelet count to about 100,000 cells/mm3 typically precedes plasma leakage and the capillary leak syndrome.
- A rising hematocrit above baseline may be one of the earliest signs of plasma leakage. The extent of hemoconcentration reflects the severity of plasma leakage. However, this may be abated by early intravenous fluid administration. Frequent hematocrit determinations are essential for guiding intravenous fluid therapy. Pleural effusion and ascites may be clinically detectable only after intravenous fluid therapy, unless plasma leakage is significant.[5]
- In addition to plasma leakage, hemorrhagic manifestations such as easy bruising and bleeding at venipuncture sites occur frequently.
- Shock occurs when there is a dramatic volume loss due to plasma leakage. With profound and/or prolonged shock, tissue hypoperfusion results in metabolic acidosis, progressive organ impairment, and disseminated intravascular coagulation. This in turn leads to severe hemorrhage causing the hematocrit to decrease in severe shock. Rather than leukopenia, white cell count may increase as a stress response in patients with severe bleeding.
Recovery Phase
- As the patient survives the 24–48 hours of the critical phase, a gradual reabsorption of fluid from the extravascular compartment takes place in the following 48–72 hours. Appetite returns, gastrointestinal symptoms abate, hemodynamic status stabilizes, and diuresis ensues.
- Some patients have a confluent erythematous or petechial rash with small areas of normal skin termed as isles of white in the sea of red. Some may experience generalized pruritus. Bradycardia and other electrocardiographic changes are common during this stage.
- The hematocrit normalizes or may be lower than the baseline value due to hemodilution. The white cell count usually starts to rise soon after defervescence, while the recovery of the platelet count is typically delayed.
- Respiratory distress from massive pleural effusion and ascites, pulmonary edema, or congestive heart failure may occur during the recovery phase if excessive intravenous fluids have been administered.
 |
References
- ↑ "Dengue: guidelines for diagnosis, treatment, prevention and control" (PDF).
- ↑ Thong, Meow-Keong (1998). "Dengue shock syndrome and acute respiratory distress syndrome". The Lancet. 352 (9141): 1712. doi:10.1016/S0140-6736(05)61496-1. ISSN 0140-6736.
- ↑ 3.0 3.1 Kalayanarooj, S.; Vaughn, D. W.; Nimmannitya, S.; Green, S.; Suntayakorn, S.; Kunentrasai, N.; Viramitrachai, W.; Ratanachu‐eke, S.; Kiatpolpoj, S.; Innis, B. L.; Rothman, A. L.; Nisalak, A.; Ennis, F. A. (1997). "Early Clinical and Laboratory Indicators of Acute Dengue Illness". The Journal of Infectious Diseases. 176 (2): 313–321. doi:10.1086/514047. ISSN 0022-1899.
- ↑ Mayxay, Mayfong; Phetsouvanh, Rattanaphone; Moore, Catrin E; Chansamouth, Vilada; Vongsouvath, Manivanh; Sisouphone, Syho; Vongphachanh, Pankham; Thaojaikong, Thaksinaporn; Thongpaseuth, Soulignasack; Phongmany, Simmaly; Keolouangkhot, Valy; Strobel, Michel; Newton, Paul N. (2011). "Predictive diagnostic value of the tourniquet test for the diagnosis of dengue infection in adults". Tropical Medicine & International Health. 16 (1): 127–133. doi:10.1111/j.1365-3156.2010.02641.x. ISSN 1360-2276.
- ↑ Srikiatkhachorn, Anon; Krautrachue, Anchalee; Ratanaprakarn, Warangkana; Wongtapradit, Lawan; Nithipanya, Narong; Kalayanarooj, Siripen; Nisalak, Ananda; Thomas, Stephen J.; Gibbons, Robert V.; Mammen, Mammen P.; Libraty, Daniel H.; Ennis, Francis A.; Rothman, Alan L.; Green, Sharone (2007). "Natural History of Plasma Leakage in Dengue Hemorrhagic Fever". The Pediatric Infectious Disease Journal. 26 (4): 283–290. doi:10.1097/01.inf.0000258612.26743.10. ISSN 0891-3668.
- ↑ "Dengue haemorrhagic fever: diagnosis, treatment, prevention and control" (PDF).