# Presentation: 081661

## III. Clinical Manifestations of Dengue and Dengue Hemorrhagic Fever

## Dengue Clinical Syndromes

- Undifferentiated fever
- Classic dengue fever
- Dengue hemorrhagic fever
- Dengue shock syndrome

## Undifferentiated Fever

- May be the most common manifestation of dengue
- Prospective study found that 87% of students infected were either asymptomatic or only mildly symptomatic
- Other prospective studies including all age- groups also demonstrate silent transmission

- DS Burke, et al. A prospective study of dengue infections
- in Bangkok. _Am J Trop Med Hyg_ 1988; 38:172-80.

## Clinical Characteristicsof Dengue Fever

- Clinical Characteristicsof Dengue Fever

- Fever
- Headache
- Muscle and joint pain
- Nausea/vomiting
- Rash
- Hemorrhagic manifestations

## Signs and Symptoms ofEncephalitis/EncephalopathyAssociated with Acute Dengue Infection

- Signs and Symptoms ofEncephalitis/EncephalopathyAssociated with Acute Dengue Infection

- Decreased level of consciousness:   lethargy, confusion, coma
- Seizures
- Nuchal rigidity
- Paresis

## Hemorrhagic Manifestationsof Dengue

- Hemorrhagic Manifestationsof Dengue

- Skin hemorrhages:                          petechiae, purpura, ecchymoses
- Gingival bleeding
- Nasal bleeding
- Gastro-intestinal bleeding:                                hematemesis, melena, hematochezia
- Hematuria
- Increased menstrual flow

## Clinical Case Definition forDengue Hemorrhagic Fever

- Clinical Case Definition forDengue Hemorrhagic Fever

- Fever, or recent history of acute fever
- Hemorrhagic manifestations
- Low platelet count (100,000/mm3 or less)
- Objective evidence of “leaky capillaries:”
- elevated hematocrit (20% or more over baseline)
- low albumin
- pleural or other effusions

- 4 Necessary Criteria:

## Clinical Case Definition for Dengue Shock Syndrome

- 4 criteria for DHF
- Evidence of circulatory failure manifested indirectly by all of the following:
- Rapid and weak pulse
- Narrow pulse pressure ( 20 mm Hg) **OR **hypotension for age
- Cold, clammy skin and altered mental status
- Frank shock is direct evidence of circulatory failure

## Four Grades of DHF

- Grade 1
- Fever and nonspecific constitutional symptoms
- Positive tourniquet test is only hemorrhagic manifestation
- Grade 2
- Grade 1 manifestations + spontaneous bleeding
- Grade 3
- Signs of circulatory failure (rapid/weak pulse, narrow pulse pressure, hypotension, cold/clammy skin)
- Grade 4
- Profound shock (undetectable pulse and BP)

## Danger Signs inDengue Hemorrhagic Fever

- Danger Signs inDengue Hemorrhagic Fever

- Abdominal pain - intense and sustained
- Persistent vomiting
- Abrupt change from fever to hypothermia, with sweating and prostration
- Restlessness or somnolence

- Martínez Torres E. _Salud Pública Mex_ 37 (supl):29-44, 1995.

## Warning Signs for Dengue Shock

**When Patients Develop DSS:**
-   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 of
-    consciousness (irritability                                                                                                                                                                                                                                    or somnolence)

**Four Criteria for DHF:**
-   Fever
-   Hemorrhagic manifestations
-   Excessive capillary permeability
-   100,000/mm3 platelets

## Signs and Symptoms in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

- * Minimum estimate, search was not uniform for all patients
- ** Only 2 (3.5%) cases had severe hemorrhagic manifestations

- SIGNS AND SYMPTOMS    FREQUENCY*   PERCENT

- Fever					57		100 %
- Rash					27		  47.4%
- Hepatomegaly			  6		  10.5%
- Effusions				  3		    5.3%
- Frank shock				  3		    5.3%
- Coma					  2		    3.5%
- Any hemorrhage**			57		100 %

## Hemorrhagic Signs and Symptoms in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

- * Minimum estimate; the search was not uniform for all patients
- ** Percents were calculated using the number of patients among
-      whom each symptom was sought as the denominator

## Hemorrhagic Signs and Symptoms in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

- * Minimum estimate; the search was not uniform for all patients
- ** Only 2 (3.5%) cases had severe hemorrhagic manifestations

## Clinical Laboratory Analyses in 57 Hospitalized Cases of DHF, Puerto Rico, 1990 - 1991

- * Average result in the tested cases

## Profile of the Progression of Illness

- Mean Days from Onset of Symptoms, and
- Mean Value (± 2 SD) of Selected Clinical Tests

- 5		                  6		     	        7		         	        8

- DAYS AFTER ONSET

- Average admission - day 4.5
- Average discharge - day 11

- Puerto Rico, 1990-1991 (N=57 patients)

- Maximum
- Hematocrit (%)

-  45.2

- 57

- 34

****

****

- Lowest Diastolic
- (mm Hg)

- 88

- 42

- 65.6

****

****

- Platelets
- per mm3

- 99,000

- 45,980

****

- 9,000

****

- Minimum
- Hematocrit (%)

- 44

****

****

- 36.3

- 23

## Unusual Presentationsof Severe Dengue Fever

- Unusual Presentationsof Severe Dengue Fever

- Encephalopathy
- Hepatic damage
- Cardiomyopathy
- Severe gastrointestinal hemorrhage