Facultad De Medicina

Humana
Escuela Profesional De
Medicina Humana

Medical English

CURSE : Medical English

TEACHER : Dra. Rosa Gonzáles Llontop

CONTENT : Modern Medical Care

GROUP VI :
• ALCOSER ARCILA ALONSO
• DE LA CRUZ RUIZ LENIN
• MENDOZA MEGO BORIS
• LUMBRE YUPTON CESAR
• QUEVEDO MORI ARTURO
• REGALADO ROCHA WILINTON

CYCLE : 2010-I

Lambayeque, Perú
September 2010
 I.-EPIDEMIOLOGY

Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A.

albopictus. The first recognized Dengue epidemics occurred almost simultaneously
in Asia, Africa, and North America in the 1780s, shortly after the identification and
naming of the disease in 1779. A pandemic began in Southeast Asia in the 1950s,
and by 1975 DHF had become a leading cause of death among children in the
region. Epidemic dengue has become more common since the 1980s. By the late
1990s, dengue was the most important mosquito-borne disease affecting humans
after malaria, with around 40 million cases of dengue fever and several hundred
thousand cases of dengue hemorrhagic fever each year. Significant outbreaks of
dengue fever tend to occur every five or six months.

The cyclical rise and fall in numbers of dengue cases is thought to be the result of
seasonal cycles interacting with a short-lived cross-immunit for all four strains in
people who have had dengue. When the cross-immunity wears off the population
is more susceptible to transmission whenever the next seasonal peak occurs. Thus
over time there remain large numbers of susceptible people in affected populations
despite previous outbreaks due to the four different serotypes of dengue virus and
the presence of unexposed individuals from childbirth or immigration.

There is significant evidence, originally suggested by S.B. Halstead in the 1970s

that dengue hemorrhagic fever is more likely to occur in patients who have
secondary infections by another one of dengue fever's four serotypes.

One model to explain this process is known as antibody-dependent enhancement

(ADE), which allows for increased uptake and virion replication during a secondary
infection with a different strain. Through an immunological phenomenon, known as
original antigenic sin, the immune system is not able to adequately respond to the
stronger infection, and the secondary infection becomes far more serious.
Reported cases of dengue are an under-representation of all cases when
accounting for subclinical cases and cases where the patient did receive medical
treatment.

There was a serious outbreak in Rio de Janeiro in February 2002 affecting around
one million people and killing sixteen. On March 20, 2008, the secretary of health
of the state of Rio de Janeiro, Sérgio Côrtes, announced that 23,555 cases of
dengue, including 30 deaths, had been recorded in the state in less than three
months. Côrtes said, "I am treating this as an epidemic because the number of
cases is extremely high." Federal Minister of Health, José Gomes Temporão also
announced that he was forming a panel to respond to the situation. Cesar Maia,
mayor of the city of Rio de Janeiro, denied that there was serious cause for
concern, saying that the incidence of cases was in fact declining from a peak at the
beginning of February. By April 3, 2008, the number of cases reported rose to
55,000.

In Singapore, there are 4,000–5,000 reported cases of dengue fever or dengue

haemorrhagic fever every year. In the year 2004, there were seven deaths from
dengue shock syndrome.
 II.- DENGUE ETIOLOGY

The causal agent is a virus of the family Flaviviridae: arbovirus (arthropod-point)

similar to that of the Yellow Fever. It is a question of virus wrapped (sensitive
therefore to the destruction for physical and chemical agents), of 40-50 nm of
diameter, with icosahedra capsid and genome of monocatenary RNA, not
segmented, of positive polarity. The virus adheres to the cells eukaryotes, deposits
them for viropexis, one answers in the cytoplasm and is assembled in the reticulum
endoplasmic. His genome codifies a polyprotein that is processed then in 10
polypeptides: 3 structural (a protein of nucleocapsid C, a membranous prM and a
glycoprotein of wrapper E: hemaglutinante and of adherence) and 7 not structural,
of which we stand out NS1, that it can induce, since E, an immune protective
response.

They are recognized by variation of the protein E 4 types antigenic (so called
DEN1, DEN2, DEN-3 and DEN 4) on the base of tests of neutralization of the effect
citopatico. Heterogeneity of vine-stocks exists inside every type, which is
correlated by variety of RNA's sequences, which identification in prM, E and NS1
has epidemiological usefulness. The possibilities of wide variation and survival of
these virus would be minor that for others virus RNA, because of his strict
adjustment to 2 different inn-keepers.
 III.-AEDES AEGYPTI´S CICLE

The transmission cycle of the Dengue virus from the Aedes Aegypti mosquito
starts with a dengue-infected person (Person 1) who has a circulating virus in his
/her blood, a state called as viremia, usually lasting for 5 days. Once an uninfected
Aedes Aegypti bites or feeds on the dengue-infected person, it now ingests the
virus-contaminated blood from the person.
This in turn paves way for the virus to
replicate within the mosquito. Consequently,
an unwilling human victim (person 2), when
bitten by the infected Aedes Aegypti, is
transmitted the fatal viral disease. A barrage
of symptoms is produced thereafter,
appearing in about 4-7 days as the virus
replicates itself in the person's blood.
See the diagram below for a more detailed transmission of the disease cycle.

(1)The virus is introduced into humans with the mosquito’s saliva via it’s bite.
(2)The virus stays and spreads in various target organs e.g liver, lymph nodes
(3)The virus, once released from these tissues spreads in the white blood cells and
other lymphatic tissues
(4)The virus then releases itself form the tissues and circulates in the blood
(5)A 2nd mosquito ingests the virus in it’s blood
(6)That 2nd mosquito is then inoculated with the virus and therby affecting it’s
salivary glands
(7)The virus replicates in the salivary glands and when this mosquito bites on an
unwilling victim ,the cycle continues.

IV.-SIGNS AND SYMPTOMS

The disease manifests as fever of sudden onset associated with headache, muscle
and joint pains (myalgias and arthralgias—severe pain that gives it the nickname
break-bone fever or bonecrusher disease), distinctive retro-orbital pain, and rash.
The classic dengue rash is a generalized maculopapular rash with islands of
sparing. A hemorrhagic rash of characteristically bright red pinpoint spots, known
as petechiae can occur later during the illness and is associated with
thrombocytopenia. It usually appears first on the lower limbs and the chest; in
some patients, it spreads to cover most of the body.

There may also be severe retro-orbital pain, (a pain from behind the eyes that is
distinctive to Dengue infections), and gastritis with some combination of associated
abdominal pain, nausea, vomiting coffee-grounds-like congealed blood, or
diarrhea. Some cases develop much milder symptoms which can be misdiagnosed
as influenza or other viral infection when no rash or retro-orbital pain is present.
Febrile travelers from tropical areas may transmit dengue inadvertently to
previously Dengue free populations of Aedes (Stegomyia) Aegypti mosquitoes,
having not been properly diagnosed for Dengue. Patients only transmit Dengue
when they are febrile and bitten by Aedes (Stegomyia) Aegypti mosquitoes, or
(much more unusually) via blood products

The classic dengue fever lasts about two to seven days, with a smaller peak of
fever at the trailing end of the disease (the so-called "biphasic pattern"). Clinically,
the platelet count will drop until after the patient's temperature is normal. Cases of
DHF also show higher fever, variable hemorrhagic phenomena including bleeding
from the eyes,nose,mouth and ear into the gut, and oozing blood from skin pores, ,
and hemoconcentration. When Dengue
infections proceed to DHF symptoms,
DHF causes vascular leak syndrome
which includes fluid in the blood vessels
leaking through the skin and into spaces
around the lungs and belly. This fluid loss
and severe bleeding can cause blood
pressure to fall, then Dengue Shock
Syndrome (DSS) sets in, which has a high mortality rate.

V.-DIAGNOSTIC

There are two types of dengue, the classic and hemorrhagic. After an incubation
period of 2-8 days, where you can look like a blue box without fever, the classical
form is expressed with the above symptoms. In infants and school children these
symptoms are benign and may go unnoticed. The fever lasts 3-5 days. Clinically,
recovery is usually accompanied by fatigue, lymphadenopathy and decreased
white blood cells with relative lymphocytosis. The platelet count will drop until the
patient's temperature is normal. In some cases, there are thrombocytopenia (less
than 100,000 platelets per mm3) and increased aminotransferases.
The cases of dengue hemorrhagic fever with show greater incidence of bleeding,
thrombocytopenia and hemoconcentration. In a small proportion of cases is
experienced dengue shock syndrome (DSS) which, without medical attention, can
cause death within 4-8 hours. The WHO definition of dengue haemorrhagic fever
has been in use since 1975. The four criteria necessary to diagnose the disease:

 Fever

 Hemorrhagic tendency (positive tourniquet test, spontaneous bruising,

bleeding of mucous membranes, gums, the site of injection, etc., vomiting
blood or bloody diarrhea) and thrombocytopenia (less than 100,000 platelets
per mm3 or the estimate by less than 3 platelets per field high resolution
microscopic observation).

 Evidence of plasma leakage (hematocrit more than 20% higher than

expected, or drop in hematocrit of 20% or more from baseline after the
infusion of intravenous fluids as a result of pleural effusion, ascites, and
hypoproteinemia).

 dengue shock syndrome (DSS), which is defined as dengue haemorrhagic

fever plus:

 Weak or rapid pulse,

 Reduction of pulse pressure (less than 20 mm Hg)

 Cold, clammy skin and restlessness.