Dengue fever and some case reports from Delhi Govt.

homoeopathic dispensaries
Dr Sudha Bala#1, Dr Gyandas G. Wadhwani#2, Dr Jithesh T.K.#3, Dr Parul G. Wadhwani#4, Dr Vandana Awasthi#5
#1 Chief Medical Officer (H) I/c Homoeo unit Sanjay Gandhi Hospital #2 Chief Medical Officer (H) I/c DGHD South Campus & Aali village #3 Chief Medical Officer (H) I/c DGHD Batla House #4 Reader (H) Deptt of Obs & Gynae NHMC & Hospital #5 Chief Medical Officer (H) I/c DGHD Mangol Puri

Introduction Dengue fever, also known as break-bone fever, is an infectious tropical disease with flu like features transmitted by the bite of an infected female Aedes mosquito. Symptoms appear in 314 days (average 47 days) after the infective bite.

The virus causing Dengue fever (DENV) is an RNA virus of the family Flaviviridae; genus Flavivirus. There are four distinct serotypes of the dengue virus (DEN 1, DEN 2, DEN 3 and DEN 4). Infection with one type usually gives lifelong immunity to that type, but only short-term immunity to the others. Subsequent infection with a different type increases the risk of severe complications. Dengue epidemiology The incidence of dengue has grown dramatically around the world in recent decades. Before 1970, only nine countries had experienced severe dengue epidemics. The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-east Asia and the Western Pacific. The American, South-east Asia and the Western Pacific regions are the most seriously affected. In India, the first epidemic of clinical dengue-like illness was recorded in Madras (now Chennai) in 1780 and the first virologically proved epidemic of dengue fever (DF) occurred in Calcutta (now Kolkata) and eastern Coast of India in 1963-1964. During the last 50 years number of dengue fever incidences increased tremendously. This year's dengue outbreak in the country was the worst in at last six years, with 55,063 cases reported till October 2013. According to health ministry data, the number of dengue cases has been steadily rising since 2008. Health specialists attribute the steady increase in dengue cases to a number of factors, including heavy rains, intense construction activity in cities and a better surveillance system that enables detection of more cases.

According to the World Health Organization (WHO): Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas. Dengue prevention and control solely depends on effective vector control measures. Dengue infection rates among people who have not been previously exposed to the virus are commonly 40% to 50% during epidemics, but may sometimes reach 80% to 90%. Approximately 2.5 billion people, or two-fifths of the world's population, are now at risk from dengue. Dengue hemorrhagic fever (DHF) is a leading cause of serious illness and death among children in some Asian countries. Approximately half-a-million people with DHF are hospitalized each year, of which many are children. About 2.5% of these patients die. DHF fatality reads may exceed 20% if untreated. If there is access to medical care with health care professionals trained in treating DHF, the death rate may be less than 1%. Vector The Aedes aegypti mosquito is the primary vector of dengue. The virus is transmitted to humans through the bites of infected female mosquitoes. After virus incubation for 410 days, an infected mosquito is capable of transmitting the virus for the rest of its life. Infected humans are the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes. Patients who are already infected with the dengue virus can transmit the infection (for 45 days; maximum 12) via Aedes mosquitoes after their first symptoms appear. The Aedes aegypti mosquito lives in urban habitats and breeds mostly in manmade containers. Unlike other mosquitoes Aedes aegypti is a daytime feeder; its peak biting periods are early in the morning and in the evening before dusk. Female Aedes aegypti bites multiple people during each feeding period. Signs and symptoms of Dengue Fever As there are different severities of dengue fever, the clinical features can vary: Mild Dengue Fever Symptoms can appear up to seven days after the bite, and usually last for a week. This form of the disease hardly ever results in serious or fatal complications. The symptoms are: Aching muscles and joints Body rash that can disappear and then reappear High fever Intense headache Pain behind the eyes Vomiting and feeling nauseous DHF Symptoms during onset may resemble mild dengue fever, but gradually worsen. DHF can result in death if not treated in time. Suggestive clinical features are: Bleeding from the mouth/gums 2

Nosebleeds Clammy skin Considerably damaged lymph and blood vessels Internal bleeding, which can result in black vomit and feces Lower number of platelets in blood Sensitive stomach Small blood spots under the skin Weak pulse

Dengue shock syndrome This is the worst form of dengue which can also result in death, again mild dengue fever symptoms may be there, but others suggestive features are: Intense stomach pain Disorientation Sudden hypotension Heavy bleeding Regular vomiting Blood vessels leaking fluid Death Warning Signs of Dengue Fever These usually occur before the onset of severe dengue fever Worsening of abdominal pain Ongoing vomiting Liver enlargement Mucosal bleeding High hematocrit with low platelets Lethargy or restlessness Diagnosing Dengue Fever The diagnosis of dengue is typically made clinically, on the basis of reported symptoms and physical examination, this applies especially in endemic areas. However, early disease can be difficult to differentiate from other viral infections. Investigations may be required to exclude other conditions that cause similar symptoms, such as malaria, leptospirosis, viral hemorrhagic fever, typhoid fever, meningococcal disease, measles, and influenza. It may be difficult to distinguish dengue fever and chikungunya, a similar viral infection that shares many symptoms and occurs in similar parts of the world to dengue. A probable diagnosis may be based on the findings of fever plus any two of the following: nausea and vomiting, rash, generalized pains, low white blood cell count, positive tourniquet test, or any warning sign. The tourniquet test is particularly useful in settings where no laboratory investigations are readily available. Inflate blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes. After deflating the cuff, wait for the skin to return to its normal color, and then count the number of petechiae visible in one inch square area on the ventral surface of the forearm. A higher number makes a diagnosis of dengue more likely with the cut off being more than 10 to 20 per 2.5 cm2 (1 inch2).

The earliest change detectable on laboratory investigations is a low white blood cell count, which may then be followed by low platelets and metabolic acidosis. A moderately elevated level of aminotransferase (AST and ALT) from the liver is commonly associated with low platelets and white blood cells. In severe disease, plasma leakage results in hemoconcentration as indicated by a rising hematocrit and hypoalbuminemia. A laboratory confirmation of diagnosis may be made by any of the following tests: 1. Isolation of virus in cell cultures 2. Detection of dengue virus genomic sequences / nucleic acid detection by Real-time PCR (Note: Virus isolation and nucleic acid detection are more accurate than antigen detection, but these tests are not widely available due to their greater cost) 3. Viral antigen detection (Platelia Dengue NS1 Ag assay) allows rapid detection of dengue on the first day of fever, before antibodies appear some 5 or more days later. 4. Detection of IgM & IgG antibodies: Both IgG and IgM are produced after 5 7 days. The highest levels of IgM are detected following a primary infection, but IgM is also produced in reinfection. IgM becomes undetectable 3090 days after a primary infection, but earlier following re-infections. IgG, by contrast, remains detectable for over 60 years and, in the absence of symptoms, is a useful indicator of past infection. After a primary infection IgG reaches peak levels in the blood after 1421 days. In subsequent reinfections, levels peak earlier and the titres are usually higher. Both IgG and IgM provide protective immunity to the infecting serotype of the virus. The detection of IgG alone is not considered diagnostic unless blood samples are collected 14 days apart and a greater than fourfold increase in levels of specific IgG is detected. In a person with symptoms, the detection of IgM is considered diagnostic. Pleural effusion or ascites may be detected by physical examination. The demonstration of fluid on ultrasound may assist in the early identification of dengue shock syndrome. The use of ultrasound is limited by lack of availability in many settings. Dengue shock syndrome is present if pulse pressure drops to 20 mm Hg along with peripheral vascular collapse. Prevention of dengue fever The emphasis for dengue prevention is on sustainable, community-bases, integrated mosquito control, with limited reliance on insecticides. It requires a coordinated community effort to increase awareness about dengue fever / DHF, how to recognise it, and how to control the mosquitoes that transmit it. Residents are responsible for keeping their surroundings free of standing water where mosquitoes can be produced. The transmission of the virus to mosquitoes must be interrupted to prevent the illness. To this end, patients are kept under mosquito netting until the second bout of fever is over and they are no longer contagious. The prevention of dengue requires control or eradication of the mosquitoes carrying the virus that causes dengue. In nations plagued by dengue fever, 4

people are urged to empty stagnant water from old tires, trash cans, and flower pots. Governmental initiatives to decrease mosquitoes also help to keep the disease in check. To prevent mosquito bites, wear long pants and long sleeves. Use mosquito netting while resting. For personal protection, use mosquito repellant sprays that contain DEET (N-diethyl-m-toluamide) when visiting places where dengue is endemic. Some case reports from Delhi Govt homoeopathic dispensaries 1. Ms S., 27yrs, consulted on 23/09/13, for fever with chills since 1week with vomitings and stool frequency 3-4 times/ day and heaviness in head. She was thirstless. She was undergoing allopathic medicines from private practitionner. When homoeopathic treatment was started she was advised her to consume plenty of fluids & hydropathy in case temperature rose. She was advised to stop all allopathic medicines. On 22/09/13, her platelet count was 35,000. Rx Gelsemium 30/2hrly/one day 24/09/13 Fever better; stool frequency decreased. Platelet count 50,000. Rx Gelsemium 30/2hrly/one day 25/09/13 Temp normal; complaining of general weakness. Platelet count 60,000 Rx China30/qid /2days 27/09/13 feeling better. Platelet count on 26th was 75,000 and today 90,000 Rx China30/qid /2days 28/09/13 no complaints; Platelet count 125,000 2. Mr S, 19 yrs, consulted on 17/09/13 for high grade fever since 5days with vomiting, bodyache and weakness. Thirst was good. His Dengue NS1Ag test was positive. Advised to consume lot off fluids & hydrotherapy if fever goes above 100F. Platelet count on 16th was 99,000 and today had come down to 85,000. Rx Arsenic alb 30/ 2hrly for 1 day 18/09/13 No Fever or vomitings. Platelet count 70,000. Rx Ars Alb 30 /qid /one day

19/09/13 General weakness. Platelet count 90,000/Rx China 30 for 2 days 20/09/13 reported with platelet count of 113,000. 3. Mr MP of 36 yrs consulted for fever (101.4 F) with headache and bodyache on 24.9.13. He complained of restlessness and sore feeling over the body esp. back and was unable to lie in one position. His head was hot and extremities cold to touch. He was advised to undergo Dengue NS1 antigen test. Rx Arnica 200 three hourly He reported with a positive Dengue NS1 Antigen test on the following day. Patient complained of persistent fever (around 101F), headache, intense pain was felt all through the body and bones on the basis of which Eupatorium perf 30 was prescribed 2hrly for two days. He was advised to montor his platelet counts daily. The Platelet count on day 3 was 92000. On fourth day the platelet count was 89000 and the patient reported with slight relief in headache and bodyache. Since the fever (101 F) was still present he was now prescribed Eupatorium perf 200 every 2hrs. On day 5 platelet count was 71000 but the headache was absent and bodyache was much better, however fever (101F) was still present. Eupatorium perf 200 was continued. On day 6 the platelet count decreased further to 60000. The patient complained of weakness fever subsided. He was then prescribed Eupatorium perf 1000, 3 doses. On day 7 the platelet count showed a increasing trend and was 66000. The patient was afebrile and asymptomatic. This increasing trend continued and the platelet count was last reported on 4.10.13 as 1.66 lac. Throughout the illness the patient was advised to increase fluid intake and maintain adequate hydration. 4.Ms MS, age 21, years presented with high fever (102F), extreme weakness, pain in lower limbs and severe retching without vomiting on 7/0/13. She was feeling hungry but eating produced severe retching. she was so weak that she had to be supported for slight movements. Her thirst was for small quantities of water at short intervals and drinking also produced retching. Ars alb 30/ 2 hourly was prescribed. Temperature came down to 100.8F on day 2 but she didn't feel better. On 9/10/13 (day 3) dengue profile was done. Dengue NS1 Ag test was positive, platelets were 4 lacs/cumm, TLC was 4000/cumm. Rx Ars alb 200/ 2 hourly was prescribed as the picture was same and patient showed response with the medicine in 30th potency but did not hold. On 12/10/13 (day 6) platelets fell down to 1.5 lacs/cumm. Temperature was 100F, retching was same, weakness was persisting but was less. Ars alb 200 was continued. By day 9 the patient was afebrile, could retain food and water without retching and do her chores without help. 6

On 16/10/13 (day 10) platelets raised upto 3.52 lacs/cumm. Patient's entire demeanour was quite good except that she was having pain and weakness in her lower limbs. Ars alb 1M/tds was prescribed for two days. 2 days later patient reported feeling much better with good thirst, appetite and sleep. 5.Ms S, 21 years presented with fever (102F), sleepiness, bodyache and severe headache since 1 day on 7/10/13 (day 2). She had lost appetite and thirst and was prescribed Gelsemium 200 three hourly. On 9/10/13 (day 4) she presented with dengue profile report Dengue NS1 Ag test was positive, platelets were 1.2 lacs/cumm, TLC was 3400/cumm. Her fever persisted (101-103F) along with all symptoms except that she did not feel sleepy anymore. She was more disturbed by pain in forehead and post-orbital region, which was not affected by movements of eyeballs but aggravated with any movement of head or neck. She was then prescribed Spigelia 200 three hourly. She was afebrile by the following morning (day 5) and reported with platelet count of 80,000. Same medicine was continued. By day 7 her headache was over, she had been afebrile for nealry 48 hours and platelet count was 1.6 lacs. Bibliography: 1. http://www.cdc.gov/dengue/ as accessed on 4-11-13 2. http://www.cdc.gov/Dengue/clinicalLab/ as accessed on 4-11-13 3. http://www.who.int/topics/dengue/en/ as accessed on 4-11-13 4. http://icmr.nic.in/ijmr/2012/september/0905.pdf as accessed on 4-11-13 5. http://www.icmr.nic.in/pinstitute/niv/DENGUE.pdf as accessed on 4-11-13 6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510884/ as accessed on 4-1113 7. http://www.nlm.nih.gov/medlineplus/ency/article/001374.htm as accessed on 4-11-13 8. http://www.medicinenet.com/dengue_fever/article.htm as accessed on 4-1113 9. http://en.wikipedia.org/wiki/Dengue_fever as accessed on 4-11-13