Box 8a: Diagnosis of dengue fever and dengue haemorrhagic fever’ Dengue fever Probable diagnosis Acute febrile illness with two or more of the following’ headache, retro-orbital pain, myalgia, arthralgia/bone pain, rach, haemorthagic manifestations, leucopenia (whe <5000 colle/mm?), thrombocytopenia (platelet count <150 000 celis/mm*), rising haematocrit (5 — 10%); and at least one of following: Confirmed diagno: supportive serology on single serum sample: titre >1280 with haemagglutination inhibition test. comparable IgG titre with enzyme-linked immunosorbent assay, or tasting positive in IgM antibody test, and ‘occurrence at the same location and time as confirmed cases of dengue fever. Probable case with at least one of the following: isolation of dengue virus from serum, CSF or autopsy samples. fourfold or greater increase in serum IgG (by haemaggjutination inhibition test) or increase in IgM antibody specific to dengue virus. detection of dengue virusor antigen in tissue, serum or cerebrospinal fluid by immunohistochemisty, immunefluorescence or enzyme-linked immunosorbent assay. detection of dengue virus genomic sequences by reverse transcription-polymerase chain reaction. Traci on dscnsons and recmmenitions ofthe Consitatne Meeting on Dengue Case Casication an Case Management hed in Banghok, Thaland, on 7-8 October 2010, The paticipans included experts from SEARO and WPRO countries and one observer ‘and sectetarat from the WHO Collaborating Centre or Case Management of Dengue/DHF'DSS, QSNICH @angkok, Thailand. ‘Studies have shown that im endemic areas ace fons nese with a postive TT anc levcopania(WEC= S000 calm’ nasa goed ponte precicive value of 70% 1 80% In stone wher eoogy cnok alse, ewe ate Ue fr ety Geteton oderme Box All of following": acute onset of fever of two to seven days duration. haemorrhagic manifestations, shown by any of the following: positive tourniquet test, petechiae, © platelet count =100 000 celisimm? © objective evidence of plasma leakage” due to increased vascular permeability shown by any of 8b: Dengue haemorrhagic fever ‘ecchymoses or purpura, or blooding from mucosa, gastrointestinal tract, injoction sites, or other locations. the following Rising haematocrithaemoconcentration >20% from baseline or decrease in convalescence| or evidence of plasma leakage such as pleural effusion, ascites or hypoproteinaemia| albuminaemia.* Box Criteria for dengue haemorrhagic fever as above with signs of shock including: &c: Dengue shock syndrome tachycardia, cool extremities, delayed capillay refill, weak pulse, lethargy or restlessness, which may be a sign of reduced brain perfusion. pube pressure <20 mmHg with increased diastolic pressure, e.g. 100/80 mmHg. hypotension by age, defined ac systolic prescure <80 mmHg for those aged <5 years or 80 to ‘90 mmbg for olcer children and adults. These "four ceria re met, the sensitivity and specificity is 62% and 92% rexpecivey. Anon 5. et a. Dengue Hemonhagic Fever: sty and Specfcty ofthe World Health Organation Defntion fr Idenbfcation of Severe Cazes of Dengue in Thalnd, 19942005 Cin. In! Dis. 2010: 50,@) 1135-5. If fever and sigfcant plasma leshage are decursented a clnicl diagnosis of DHF is mot likely even if there is no bleeding or thrombecytopenia. Figure 5: Approximate tim and secondat virus infections and the slag Sure: Wo. Deer Caine be ge, Peet enon sd Cone Ne en 208 THO cenaTable 4: WHO classification of dengue infections and grading of severity of DHF Fever with two of the following: Leucopenia (whe <5000 oo ' aa . oe © Retro-orbital pain. . Unvombo vropenia (Platelet © Myalgia. <150 000 cells/mm). © Arthtralgia/bone pain. © Rising haematocrit © Rash. (5% 10% ). Senin © No evidence of plasma loss. manifestations. © No evidence of plasma leakage. DHF 1 ee eee roc (positive tourniquet test) and mm®; HCT rise > 20% nce of plasma leakage DHF 1 As in Grade | plus spontaneous Thrombocytopenia bleeding, <100 000 cellsimm!; HCT rise >20%. DHFF MW Asin Grade or Il plus circulatory Thrombocytopenia failure <100 000 cellsimm?; HCT rise =20%. (weak pulse, narrow pulse pressure ($20 mmHg), hypotension, restlessness). DHFF v ‘As in Grade III plus profound shock Thrombocytopenia with undetectable BP and pulse < 100 000 cells/mm*; HCT rise > 20%. Source: http:/\wiw.who inYcsresources/publications/dengue/Denguepublication/ery |: DHE Ill and IV are DSSTable 5: Expanded dengue syndrome (Unusual or atypical manifestations of dengue) Gastrointestinal/hepatic Renal Cardiac Respiratory Musculoskeletal Lymphoreticular/bone marrow Eye Others Febrile seizures in young children. Encephalopathy. Encephalitis/aseptic meningitis. Intracranial haemorrhages/thrombosis. Subdural effusions. Mononeuropathies/polyneuropathies/Cuillane-Barre Syndrome. Transverse myelitis. Hepatitisfulminant hepatic failure. Acalculous cholecystitis. ‘Acute pancreatitis. Hyperplasia of Peyer’s patches. Acute parotitis. ‘Acute renal failure. Hemolytic uremic syndrome. Conduction abnormalities. Myocarditis. Pericarditis. Acute respiratory distress syndrome. Pulmonary haemorrhage. Myositis with raised creatine phosphokinase (CPK). Rhabdomyolysis. Infection associated haemophagocytic syndrome. jocytosis (HLH), idiopathic IAHS or Haemophagocytic lymphol thrombocytopenic purura (ITP). Spontaneous splenic rupture. Lymph node infarction. Macular haemorrhage. Impaired visual acuity. Optic neuritis. Post-infectious fatigue syndrome, depression, hallucinations, psychosis, alopecia. Source: Gulati S., Manesnwari A. Atypical manitestations of dengue. Trop Med int Healtn. 2007 Sep.; 12(2):1087 ~ 95.Figure 1.4 Suggested dengue case classi DENGUE = WARNING SIGNS ST] ad CRITERIA FOR DENGUE +: WARNING SIGNS. Probable dengue live tn /ravel to dengue endemic area. Fat ond 2 ofthe alowng enero: + Nausea, voting Rath «Aches and pone Toumiquet tt poste Leukepis| + An womina son Laboratory-confirmed dengue Iparon nto nf pass ‘Waming signs” + Abdominal pan or endemess eon voting * Clint ful accumulation « Mucosal bleed + Uahargy,rsfetness 4 Liver enlaramert 22 cm laborer: increase In HOT congmeniwih opi decrease in pli! court *qunng et stsraten ard medal ieee ction and levels of severity SEVERE DENGUE ets een See uc ES Si i 2 Ki} CRITERIA FOR SEVERE DENGUE Severe plasma leckage leading to: «Shock Bs) +» Fluid accumulation wath respiratory diese Severe blesding ‘as evaluated by clinickan Severe organ involvement Lise ASTer ALT s=1000 + CNS: Impotied consciousness Hert ond ah pans Box 11: Warning signs No clinical improvement or worsening of the situation just before or during the transition to afebrile phase or as the disease progresses. Persistent vomiting, not drinking. Severe abdominal pain. Lethargy and/or restlessness, sudden behavioural changes. Bleeding: Epistaxis, black stool, haematemesis, excessive menstrual bleeding, dark- coloured urine (haemoglobinuria) or haematuria. Giddiness. Pale, cold and clammy hands and feet. Lessino urine output for 4-6 hours.Box 9: Steps for OPD screening during dengue outbreak Sereaning: History & Worning signs Observe = Emergency/ercen channel Box 10: Suggested triage pathwayManagement of convalescence Convalescence can be recognized by the improvement in clinical parameters, appetite and general well-being. Haemodynamic state such as good peripheral perfusion and stable vital signs should be observed. Decrease of HCT to baseline or below and dieresis are usually observed. Intravenous fluid should be discontinued. In those patients with massive effusion and ascites, hypervolemia may occur and diuretic therapy may be necessary to prevent pulmonary oedema. Hypokalemia may be present due to stress and diuresis and should be corrected with potassium-rich fruits or supplements. Bradycardia is commonly found and requires intense monitoring for possible rare complications such as heart block or ventricular premature contraction (VPC), Convalescence rash is found in 20%-30% of patients. Signs of recovery Stable pulse, blood pressure and breathing rate. Normal temperature. No evidence of external or internal bleeding. Retum of appetite. No vomiting, no abdominal pain. Good urinary output. Stable haematocrit at baseline level. Convalescent confluent petechiae rash or itching, especially on the extremities. Criteria for discharging patients Absence of fever for at least 24 hours without the use of anti-fever therapy. Retumn of appetite. Visible clinical improvement. Satisfactory urine output. ‘A minimum of 2-3 days have elapsed alter recovery from shock. No respiratory distress from pleural effusion and no ascites, Platelet count of more than 50 000/mm’. If not, patients can be recommended to avoid traumatic activities for at least 1-2 weeks for platelet count to become normal. In most. uncomplicated cases, platelet rises to normal within 3-5 days.Figure 8: Rate of infusion in non-shock cases Raed W ima) Shock tine Iv Adjust nonsneck gre i Mo €€[ Day = el AMA, Leeere peers | Rate of ICV fluid for children (Rate for adults) Te [oneal | Source: Kslayanarooj S. and Nimmannitya S. ‘Medical Publisher, Bangkok 2003 * In: Cuidelines for Dengue and Dengue Haemorrhagic Fever Management. BangkokFigure 9: Rate of infusion in DSS case I Adjust on shock grade 1 soon BW. hg Me ovina sm $2 mone seer Lee ‘eaiaghe «VO (omieicoy Het) Source: Kalayanarooj S. and Nimmannitya S. In: Guidelines for Dengue and Dengue Haemorthagic Fever Management. Bangkok Medical Publsher, Bangkok 2003Box 15: Volume replacement flow chart for patients with DSS* ‘UNSTABLE VITAL SIGNS: Urine output falls ‘Signs of shock (DHF Grade i Oxygen va face maskor nasal catheter Immediate, rapid vlumereplacement initiate V therapy 10. Agr isotonic crystalloid solution for 1-2hour Improvernent "Wo improvement Check for ACS and correct Reduce rate fom LOmiIg/he 107.5, 3,15 mi/g/r. respectively bette tril = ‘further reducing to keep vein open | Further improvamant IV Callotd (Dexwan 80} flood transfusion 10 mi/a/br | Whole blsod 10 mil/tg/ or paced red cll Sel /ke Discontinue I therapy for Improvement 248i Reduce rate rom 10mi/eg/te 10 7,5,3,1.5 mifegf,respectvely and then keep vein open and dlscontine IV for 24-48 hours “tn case wth prelonged/profound shock (OFF grade IV) ratelVis 20 mig for 10-15 minutes. Or Lunt BP isrestored, then reduce the rate to 10 mi/ig/he