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Dengue Fever

Dengue fever is common arthropod-borne viral disease caused by the dengue virus, a single-stranded RNA virus.


Presentation

Individuals with dengue generally have a history of either living in or travelling recently to areas that have been denoted as endemic [5]. The incubation period for the condition is 3-14 days.

Symptoms that occur two weeks after departure of the individual from an endemic area may not be due to the dengue virus.

Most patients experience erythematous mottling of the skin, chills and facial flushing. Facial flushing can be regarded as one of the most specific indicators of dengue fever. The chills may last for 2-3 days. Maculopapular rash and nonspecific febrile syndrome is often seen in children that are younger than 15 years of age.

Standard cases of dengue begin with onset of fever, chills, aching of the back, head, extremities and other symptoms [6]. The fever generally lasts for 2-7 days and so fever longer than 10 days may not be due to dengue.

Other findings may include injected conjunctivae, inflamed pharynx, Lymphadenopathy, nausea and vomiting, dry or non-productive cough, tachychardia and brachychardia.

Fever
  • This is a pattern that is known as saddleback fever. The saddleback fever is more commonly seen in dengue hemorrhagic fever cases. Thrombocytopenia, lymphopenia and leukopenia are equally common with dengue fever.[symptoma.com]
  • Dengue fever is a virus-caused disease that is spread by mosquitoes. Dengue fever is caused by 1 of 4 different but related viruses.[nlm.nih.gov]
  • This paper reviews the changing epidemiology of dengue and dengue hemorrhagic fever by geographic region, the natural history and transmission cycles, clinical diagnosis of both dengue fever and dengue hemorrhagic fever, serologic and virologic laboratory[ncbi.nlm.nih.gov]
  • That shows that dengue fever should be considered for people returning from a tropical location with fever in the absence of malaria. In 2012 a large outbreak of the dengue fever occurred in Madeira.[flexikon.doccheck.com]
High Fever
  • He just came back home from a travel to Southeast Asia 1 week ago and had presented with chill, high fever (temperature, 39.6 C), arthralgia, myalgia, and skin rash a few days before.[ncbi.nlm.nih.gov]
  • Dengue fever begins with a sudden high fever, often as high as 105 F (40.5 C), 4 to 7 days after the infection. A flat, red rash may appear over most of the body 2 to 5 days after the fever starts.[nlm.nih.gov]
  • The acute phase of the illness causes extreme muscle pains and high fevers. These may last up to two weeks. A particular syndrome of the illness called Dengue hemorrhagic fever (DHF) usually affects children younger than 10 years.[indianexpress.com]
  • It begins with a sudden onset of high fever that usually lasts between 3-5 days, and is accompanied by the following symptoms: High fever, possibly as high as 106 F (41 C) Severe headache Possible bleeding from the mouth and nose Retro-orbital pain (pain[pacificmedicalacls.com]
Fatigue
  • Other symptoms include: Fatigue Headache (especially behind the eyes) Joint aches (often severe) Muscle aches (often severe) Nausea and vomiting Swollen lymph nodes Cough Sore throat Nasal stuffiness Tests that may be done to diagnose this condition include[nlm.nih.gov]
  • Recovery phase Fatigue and depression may last for weeks, particularly in adults.[patient.info]
  • "Post-infectious fatigue syndrome in dengue infection." Journal of Clinical Virology 38 (2007): 1-6. postinfection_fatigue_syndrome.pdf . Shepherd, Suzanne Moore. "Dengue." Medscape.com. Oct. 5, 2015. . Switzerland. World Health Organization.[medicinenet.com]
  • Warning signs usually occur three to seven days after the first symptoms, and include a decrease in fever, bleeding from nose or gums, fatigue, severe abdominal pain, persistent vomiting and difficulty breathing.[travel.gc.ca]
Chills
  • He just came back home from a travel to Southeast Asia 1 week ago and had presented with chill, high fever (temperature, 39.6 C), arthralgia, myalgia, and skin rash a few days before.[ncbi.nlm.nih.gov]
  • Most patients experience erythematous mottling of the skin, chills and facial flushing. Facial flushing can be regarded as one of the most specific indicators of dengue fever. The chills may last for 2-3 days.[symptoma.com]
  • The disease is typified by the sudden onset of a severe fever, chills, headache, pain behind the eyes (retro-orbital pain), photophobia, and joint and muscle pain.[web.archive.org]
  • The patient has chills or chilly sensations, a fever, exhaustion, diarrhea, and/or vomiting. Pain behind the eyeballs (postorbital) occurs on moving the head. The head, lower back, legs and joints ache. The patient feels very weak.[rarediseases.org]
  • The disease manifests as a sudden onset of severe headache, chills, pain upon moving the eyes, and low backache.[denguevirusnet.com]
Lymphadenopathy
  • Dandy fever: An acute mosquito- borne viral illness of sudden onset that usually follows a benign course with headache, fever, prostration, severe joint and muscle pain, swollen glands (lymphadenopathy) and rash.[medterms.com]
  • Dengue, a major public health problem throughout subtropical and tropical regions, is an acute infectious disease characterized by biphasic fever, headache, pain in various parts of the body, prostration, rash, lymphadenopathy, and leukopenia.[ncbi.nlm.nih.gov]
  • SUMMARY Dengue, a major public health problem throughout subtropical and tropical regions, is an acute infectious disease characterized by biphasic fever, headache, pain in various parts of the body, prostration, rash, lymphadenopathy, and leukopenia.[doi.org]
Splenomegaly
  • Tender hepatomegaly is observed in all patients and splenomegaly in some. Shock, plasma leakage and marked thrombocytopenia are more common in children, whereas internal haemorrhage is more frequent as age increases ( Hammond et al., 2005 ).[ncbi.nlm.nih.gov]
  • Tender hepatomegaly is observed in almost all patients and splenomegaly may be seen in some.[doi.org]
Sputum
  • A sputum smear revealed leukocytes with phagocytized gram-positive cocci in clusters, and grew an isolate Staphylococcus aureus sensitive to semi-synthetic penicillin; he was treated successfully with ceftriaxone and cephalexin.[ncbi.nlm.nih.gov]
Nausea
  • On the evening of the embryo transfer the patient started with headache and retro-orbital pain, followed by fever and nausea. Two days later she started with vomiting and diarrhea and epistaxis. The tourniquet test was positive.[ncbi.nlm.nih.gov]
  • There may also be gastritis with some combination of associated abdominal pain, nausea, vomiting, or diarrhea.[denguevirusnet.com]
  • Other symptoms include: Fatigue Headache (especially behind the eyes) Joint aches (often severe) Muscle aches (often severe) Nausea and vomiting Swollen lymph nodes Cough Sore throat Nasal stuffiness Tests that may be done to diagnose this condition include[nlm.nih.gov]
  • Some people get a rash and have nausea and vomiting. It sounds awful, but most people recover in a week or so. But if the symptoms get worse and you don't see a doctor, it can become life threatening.[webmd.com]
Abdominal Pain
  • Rectus sheath hematoma is an uncommon and often clinically misdiagnosed cause of abdominal pain.[ncbi.nlm.nih.gov]
Hypotension
  • On admission physical examination revealed fever, dry mucosa, moderate hypotension and tachycardia. In the laboratory test results, leukopoenia, thrombocytopoenia and elevated transaminases were observed.[ncbi.nlm.nih.gov]
  • Hypotension is a more frequent complication of DHF than severe hemorrhage. Bibliography CDC. Imported dengue —United States, 1999 and 2000. MMWR Morbid Mortal Wkly Rep 2002; 5:281-3. Ellerin T, Hurtado R, Lockman S, Baden L.[web.archive.org]
  • The temperature rises quickly as high as 40 C, with relative low heart rate (bradycardia) and low blood pressure (hypotension).[denguevirusnet.com]
  • However, once hypotension develops, systolic blood pressure rapidly declines, and irreversible shock and death may ensue despite resuscitation.[wwwnc.cdc.gov]
Tachycardia
  • On admission physical examination revealed fever, dry mucosa, moderate hypotension and tachycardia. In the laboratory test results, leukopoenia, thrombocytopoenia and elevated transaminases were observed.[ncbi.nlm.nih.gov]
  • […] epigastralgia (pain in the upper abdomen) Bleeding of the nose, mouth or gums Bleeding or bruising under the skin Hematemesis (vomiting blood) and vomiting without blood Dry skin and mucous membranes Excessive thirst Dehydration Insomnia and restlessness Tachycardia[pacificmedicalacls.com]
  • Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation.[doi.org]
Red Eye
  • Dengue fever virus patients found to have red eyes need to be carefully followed and treated, as these eyes might develop thinning of the sclera that could lead to rupture of the globe, thereby resulting in blindness.[ncbi.nlm.nih.gov]
  • Symptoms of the disease appear suddenly and include high fever, chills, headache, eye pain, red eyes, enlarged lymph nodes, a red flush to the face, lower back pain, extreme weakness, and severe aches in the legs and joints.[encyclopedia.com]
Retroorbital Pain
  • The commonest form has an incubation period of 5-8 days followed by the onset of a fever, violent headache, chills, retroorbital pain, with a rash developing after 3-4 days.[web.archive.org]
  • Other signs and symptoms may include severe headache; retroorbital pain; muscle, joint, and bone pain; macular or maculopapular rash; and minor hemorrhagic manifestations, including petechiae, ecchymosis, purpura, epistaxis, bleeding gums, hematuria,[wwwnc.cdc.gov]
Petechiae
  • An 8-year-old girl was admitted with fever, myalgia and petechiae. Dengue virus IgM antibodies were positive. She recovered completely, but her thrombocytopenia persisted. Six weeks later she became pancytopenic.[ncbi.nlm.nih.gov]
  • The test is considered positive when 20 petechiae per 2.5 cm 2 are seen. Even in profound shock it can be negative or just mildly positive.[patient.info]
  • The dengue rash is characteristically bright red petechiae and usually appears first on the lower limbs and the chest (see figure 2). The glands (lymph nodes) in the neck and groin are often swollen.[denguevirusnet.com]
Flushing
  • Dengue is an arboviral infection that classically presents with fever, joint pain, headaches, skin flush and morbilliform rashes.[ncbi.nlm.nih.gov]
  • Most patients experience erythematous mottling of the skin, chills and facial flushing. Facial flushing can be regarded as one of the most specific indicators of dengue fever. The chills may last for 2-3 days.[symptoma.com]
  • […] infection is endemic in more than 100 countries, particularly the South East Asia region, western Pacific region, and the Americas The incubation period is 3-14 days (average 7 days) Clinical features include fever, headache, myalgia/arthralgia, and skin flushing[doi.org]
  • The illness often begins with a sudden rise in temperature accompanied by facial flush and other flu-like symptoms. The fever usually continues for two to seven days and can be as high as 41 C, possibly with convulsions and other complications.[denguevirusnet.com]
  • The victim may appear flushed at the onset of the fever and a rash may appear on the torso after 3-4 days and spread to the rest of the body. Lymph nodes are often inflamed.[web.archive.org]
Myalgia
  • An 8-year-old girl was admitted with fever, myalgia and petechiae. Dengue virus IgM antibodies were positive. She recovered completely, but her thrombocytopenia persisted. Six weeks later she became pancytopenic.[ncbi.nlm.nih.gov]
Arthralgia
  • A 60-year-old Sri Lankan man presented with a history of fever, arthralgia, and generalized malaise of 2 days duration.[ncbi.nlm.nih.gov]
Back Pain
  • The back pain is characteristic of the infection. Diagnosis A doctor may be able to diagnose dengue fever based on symptoms and any history a patient provides about travel and exposure to mosquitoes.[news-medical.net]
  • Headache, back pain and muscle aching may be so severe as to require narcotics.[web.archive.org]
  • Some individuals may develop a sore throat , vomiting , nausea , abdominal and/or back pain , and loss of appetite.[emedicinehealth.com]
  • Symptoms of the disease appear suddenly and include high fever, chills, headache, eye pain, red eyes, enlarged lymph nodes, a red flush to the face, lower back pain, extreme weakness, and severe aches in the legs and joints.[encyclopedia.com]
Headache
  • Dengue is an arboviral infection that classically presents with fever, joint pain, headaches, skin flush and morbilliform rashes.[ncbi.nlm.nih.gov]
  • It's one of the world's most common mosquito-borne viruses, with severe symptoms including headaches, rashes and leaking blood vessels. The makers of the vaccine are confident it can reduce cases in the Philippines by 24% over the next five years.[web.archive.org]
Dysarthria
  • Clinical examination revealed a scanning dysarthria and marked horizontal nystagmus with bilateral dysmetria, dysdiadokokinesia and incordination more prominent on the right.[ncbi.nlm.nih.gov]
Dysmetria
  • Clinical examination revealed a scanning dysarthria and marked horizontal nystagmus with bilateral dysmetria, dysdiadokokinesia and incordination more prominent on the right.[ncbi.nlm.nih.gov]
Ataxia
  • The first patient was a 53-year-old previously healthy Singhalese woman who developed acute-onset slurring of speech and ataxia with altered sensorium 1 day after recovery from a critical period of dengue hemorrhagic fever.[ncbi.nlm.nih.gov]

Workup

The signs and symptoms of dengue fever are nonspecific [7]. Therefore attempting a laboratory confirmation of the dengue infection is vital. Criteria to be met in the laboratory for diagnosis to be confirmed include:

  • Detection of viral genomic sequences in autopsy tissue, serum, or cerebral spinal fluid (CSF) samples through polymerase chain reaction (PCR)
  • Demonstration of dengue virus antigen in autopsy tissue via immunohistochemistry or immunofluorescence or in serum samples via enzyme immunoassay (EIA)
  • Demonstration of a fourfold or greater change in reciprocal immunoglobulin G (IgG) or immunoglobulin M (IgM) antibody titers to one or more dengue virus antigens in paired serum samples
  • Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy samples

The following laboratory tests equally have to be performed:

  • Metabolic panel
  • Complete blood count (CBC)
  • Serum protein and albumin levels
  • Liver panel and disseminated intravascular coagulation (DIC) panel

Dengue fever characteristically shows thrombocytopenia with platelet count < 100 x 109/L. Leukopenia and mild or moderate increases in level of alanine aminotransferase values can also be found [8].

Treatment

Dengue fever is usually a self-limited illness. As there is presently no antiviral drug available, treatment is supportive, with analgesics, fluid replacement, and bed rest.

Prognosis

The dengue fever condition is a self-limiting one and the mortality rate is less than 1%. When adequately treated, dengue hemorrhagic fever has a mortality rate of 2-5%. If left untreated, dengue hemorrhagic fever has a mortality rate which is as high as 50% [9].

Etiology

Dengue fever is caused by the DENV (dengue virus). This virus is a single-stranded RNA virus of the family Flaviviridae and genus Flavivirus. The type specific virus is yellow fever [3]. The dengue virus has 4 stereotypes that are antigenically distinct. Each of the stereotypes have several different genotypes and disease severity is affected by the sequence of infection with different serotypes.

An important risk factor for infection is living in endemic areas of the tropics where the vector mosquito thrives. The explosive global population growth and poorly planned urbanization is what brings the human host and mosquito close to each other.

Increase in air travel also makes it easy for infectious diseases to be transported between different groups.

Epidemiology

United States

In the U.S dengue occurs principally in travellers who have just returned from areas marked as endemic. According to the CDC, 244 confirmed cases of travel related dengue were reported in the U.S within 2006 to 2008.

Over the past 20 years, there has been an increase in the cases of Dengue amongst returning U.S travellers. The condition is also responsible for majority of febrile illnesses in individuals returning from South America, Asia and the Caribbean [2].

International

500,000 cases of dengue hemorrhagic fever and 50-100 million cases of dengue fever occur worldwide each year with an approximated 22,000 deaths recorded yearly too. 40% of the world’s population are at risk of dengue infection (an estimated 2.5-3 billion people spread across 112 tropical and subtropical countries around the world).

The only continents where dengue transmission is not experienced are Antarctica and Europe. The WHO rates dengue as the most important viral disease transmitted by mosquito in the world. Dengue has continued to pose a challenge to world health as it has increased 30 fold over the past 30 years.

Sex distribution
Age distribution

Pathophysiology

As mentioned above, dengue fever is a mosquito-borne viral disease that is caused by one of four dengue virus types [4]. Homotypic immunity is conferred on an individual after infection by one type of this virus. There is also brief period of partial heterotypic immunity. It is possible for several serotypes to be in circulation in the event of an epidemic.

Dengue fever develops like majority of bacterial and viral illnesses. Fever sets in on the third day of illness and may last for 5-7 days. It abates with the end of viremia. In children, the fever is intermittent, abating for a day before recurring. This is a pattern that is known as saddleback fever. The saddleback fever is more commonly seen in dengue hemorrhagic fever cases.

Thrombocytopenia, lymphopenia and leukopenia are equally common with dengue fever. It is believed that this happens due to the direct destructive actions of the virus on bone marrow precursor cells.

Prevention

There are not yet any vaccines to prevent infection and the most effective protective measures are those that avoid mosquito bites.

Summary

Dengue fever is a mosquito-borne tropical disease that is caused by the dengue virus. It is also referred to as breakbone fever. 

Dengue fever is transmitted by the A. aegypti mosquito. The dengue virus is of 5 types. When an individual is infected with one type, he or she gets lifelong immunity to that type. Infection also brings immunity to the other virus forms, albeit temporary [1]. Infection by another type of the virus after an earlier case leads to an increased risk of severe complications.

There are no commercially available vaccines. Therefore prevention is achieved by reducing or destroying the mosquito habitat and also limiting the exposure of individuals to bites.

Dengue vascualopathy or Dengue hemorrahgic fever brings about vascular leakage in patients and this often results in serous effusions and hemoconcentration which may lead to a collapse of the circulatory system. This happens in conjuction with severe hemorrhagic complications leading to dengue shock syndrome, a condition with greater risk of fatality.

Patient Information

Individuals who have suffered dengue fever in the past should avoid mosquito bites through the use of repellants and other domestic vector control techniques especially when travelling to areas that are endemic [10]. This is because such individuals are at risk of developing the dengue shock syndrome or dengue hemorrhagic fever if they get infected with a different dengue strain in the future.

References

Article

  1. Normile D. Surprising new dengue virus throws a spanner in disease control efforts. Science 2013 342 (6157): 415.
  2. Whitehorn J, Farrar J. Dengue. Br. Med. Bull. 2010 95: 161–73.
  3. Bhatt S, Gething PW, Brady OJ, et al. (April 2013). "The global distribution and burden of dengue". Nature 496 (7446): 504–7.
  4. Kyle JL, Harris E. Global spread and persistence of dengue. Annu Rev Microbiol. 2008;62:71-92.
  5. Statler J, Mammen M, Lyons A, Sun W. Sonographic findings of healthy volunteers infected with dengue virus. J Clin Ultrasound. Sep 2008;36(7):413-7.
  6. Gubler DJ. Cities spawn epidemic dengue viruses. Nat Med. Feb 2004;10(2):129-30.
  7. Wilder-Smith A, Gubler DJ. Geographic expansion of dengue: the impact of international travel. Med Clin North Am. Nov 2008;92(6):1377-90, x.
  8. Halstead SB. Dengue. Lancet. Nov 10 2007;370(9599):1644-52.
  9. Chowell G, Torre CA, Munayco-Escate C, Suárez-Ognio L, López-Cruz R, Hyman JM. Spatial and temporal dynamics of dengue fever in Peru: 1994-2006. Epidemiol Infect. Dec 2008;136(12):1667-77.
  10. Guzman MG, Halstead SB, Artsob H, et al. (December 2010). "Dengue: a continuing global threat". Nature Reviews Microbiology 8 (12 Suppl): S7–S16.

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Last updated: 2019-07-11 22:23