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For further information, see CMDT Part 32-04: Viral Hemorrhagic Fevers

Key Features

Essentials of Diagnosis

  • Incubation period 7–10 days

  • Sudden onset of high fever, chills, severe myalgias and arthralgias, headache, and retro-orbital pain

  • Severe dengue is defined by the presence of plasma leakage, hemorrhage, or organ involvement

  • Signs of hemorrhage such as ecchymoses, gastrointestinal bleeding, and epistaxis appear later in the disease

General Considerations

  • Has four distinct serotypes that can cause infection; infection with one serotype does not confer immunity to the other serotypes

  • Dengue is transmitted primarily from human to human by the bite of the Aedes mosquito

  • Healthcare-associated transmission (needlestick or mucocutaneous exposure) and vertical transmission occur rarely

  • WHO reports that dengue is currently endemic in more than 100 countries, mostly in tropical and subtropical regions

  • An estimated 390 million cases of dengue fever occur annually (with 96 million manifesting clinical disease including at least 500,000 with severe disease and up to 20,000 deaths

  • The surge of cases is associated with climatic factors, travel, and urbanization

  • When the virus is introduced into susceptible populations, usually by viremic travelers, epidemic attack rates range from 50% to 70%

  • Dengue is the second overall cause of a febrile illness (after malaria and excluding common upper respiratory viral infections) in travelers returning from developing countries

Clinical Findings

Symptoms and Signs

  • Incubation period is usually 7–10 days

  • After the incubation period, febrile phase begins abruptly with

    • Nonspecific symptoms

    • High fever

    • Chills

    • Facial flushing

    • Malaise

    • Retro-orbital eye pain

    • Generalized body pain

    • Arthralgia

  • Some patients might have maculopapular rash, sore throat, and conjunctival injection

  • Not all patients have all symptoms or fever

  • Mild hemorrhagic manifestations can be seen

  • Most of the patients will recover and fever is usually cleared by day 8

  • A subset of patients may progress to severe dengue, which is defined by the presence of plasma leakage, hemorrhage, or organ involvement

    • Plasma leakage may be indicated by

      • Hematocrit drop

      • Increasing liver size

      • Persistent vomiting

      • Severe abdominal pain

    • Signs of hemorrhage such as ecchymoses, gastrointestinal bleeding, and epistaxis appear

    • Severe organ involvement may develop such as hepatitis, encephalitis, and myocarditis

  • Shock develops when a critical volume of plasma is lost through leakage; the following should raise concern for shock:

    • Decrease in the level of consciousness

    • Hypothermia

    • Hypoperfusion resulting in metabolic acidosis

    • Progressive organ impairment

    • Disseminated intravascular coagulation leading to severe hemorrhage

  • Acute kidney injury in dengue largely occurs with shock syndrome and shows a high mortality

Differential Diagnosis

  • Chikungunya

  • Arboviral encephalitides

  • Influenza

  • Malaria

Diagnosis

  • Leukopenia is characteristic

  • Elevated transaminases are found frequently

  • Thrombocytopenia, fibrinolysis, and hemoconcentration occur more often in the hemorrhagic form of the disease

  • Erythrocyte sedimentation rate is normal in most cases

  • The nonspecific nature of the illness mandates laboratory verification for diagnosis, usually with ...

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