Transcript THAI BOY 12 YEARS

WHAT`S NEW IN DHF:
CLINICAL ASPECT
Professor Siripen Kalayanarooj,
Director, WHO Collaborating Centre for
Case Management of Dengue/DHF/DSS,
Queen Sirikit National Institute of Child Health.
1. ADULTS
CHILDREN
IS MORE AFFECTED THAN
2. Expanded Dengue Syndrome
or
Unusual Manifestations of Dengue
 Infant
< 1 year old
 Commonly found in adults
 In newly outbreak countries
 In endemic countries where there
are limited laboratory facilities
EXPANDED DENGUE SYNDROME
(EDS)
 Encephalopathy:
 Liver
confusion, seizure, coma
failure
 Renal failure
 Cardiac involvement: myocarditis
 Other organs involvement
CAUSES
OF
 Prolonged
EDS
shock: Liver, renal, respiratory
and other organs (unrecognized at the
very beginning)
 Dengue infections in patients with
underlying diseases: DM, HT, Heart
diseases, Thalassemia, Liver and renal
diseases, etc…
 Co-infections with other microbial
agents:
 Dengue virus virulence: encephalitis, liver
failure
CLINICAL
MANIFESTATIONS OF
EDS
Mostly manifestations of DHF +
Complications
 Underlying diseases
 Co-infections

CLUES TO DIAGNOSE EDS
Detection of plasma leakage (early when the
patients present to the healthcare facilities):
 Rising Hct ≥ 20%
 Pleural effusion: clinical, CXR – right lateral
decubitus, ultrasound
 Ascites: clinical, ultrasound
 Hypoalbuminemia: serum albumin ≤ 3.5 gm% in
normal nutritional status
Other evidence of DHF:
 Thrombocytopenia especially when platelet
count < 50,000 cells/cumm.
 Clinical bleeding
CXR –
COMPARE BETWEEN
2
POSITIONS
EARLY CLINICAL
MANAGEMENT
DIAGNOSIS
&
Suspected EDS in patients with thrombocytopenia
(platelet count ≤ 100,000 cells/cumm.) or clinical
bleeding or shock with high fever (probably with
encephalopathy)
 Look for evidence of plasma leakage, if positive
more likely to have DHF with complication:
1. DHF with superimposed bacterial infections
2. DHF with liver injury: hepatitis, liver
dysfunction/ failure
3. DHF with concealed internal bleeding (mostly
GI bleed)
3. DENGUE CLASSIFICATIONS
1975, 1986, 1997,
2011
2009
DENGUE CLASSIFICATION
Original WHO
WHO 1975, 1986,1997, 2011





Undifferentiated febrile
illness
Dengue Fever (DF)
Dengue hemorrhagic fever
(DHF)
Dengue Shock Syndrome
(DSS)
Expanded Dengue Syndrome
(EDS)
Newly suggested
WHO TDR 2009
 Dengue (D)
 Dengue ± Warning
signs (D ± WS)

Severe Dengue (SD)
Dengue virus infection
10,000
Asymptomatic
Symptomatic
1,000
9,000
Viral syndrome Dengue fever
500
DHF
100
400
Expanded dengue syndrome
1. Prolonged shock: liver failure,
renal failure,…Encephalopathy…
2. Co-morbidities
3. Co-infections
4. True dengue infection - encephalitis
Plasma leakage
DHF
DSS 1-2
SUSPECTED DENGUE INFECTIONS:
FEVER WITH ANY 2 OF THE FOLLOWINGS
IN DENGUE ENDEMIC AREA
Original WHO









Headache
Retro-orbital pain
Myalgia
Arthralgia/ bone pain
Rash
Bleeding manifestations
(Tourniquet positive)
Leukopenia
Rising Hct 10-15%
Platelet ≤ 150,000
cels/cumm
Suggested New
Nausea/ vomiting
 Rash
 Aches and pain
 Tourniquet positive
 Leukopenia
 Any warning signs

Tourniquet positive
+ Leukopenia
AT QSNICH OPD: SUSPECTED
DENGUE CASES THAT NEED CLOSE OBSERVATION
Original
Tourniquet positive +
Leukopenia
1,500 cases
Newly suggested
Warning signs:
nausea/vomiting and
abdominal pain
30,000+ cases
(20 times more
workload)
QSNICH: IPD
(JUNE – AUGUST 2009)
Confirmed dengue
DF
DHF + DSS
Dengue
D with WS + SD
180
72 + 22
85
160 + 29
180
94
85
189
Non- Dengue
DF
DHF + DSS
Dengue
D with WS + SD
19
5+0
10
13 + 1
19
5
10
14
Total clinical suspected dengue cases
DF
DHF + DSS
Dengue
D with WS + SD
199
99
95
203
Confirmed = 274/298 = 91.9% Kalayanarooj S. J Med Assoc Thai 2011; 94(3); s74-83.
DIFFERENT BETWEEN THE TWO
CLASSIFICATIONS
Original WHO
Suggested New
Emphasize on
Emphasize on
plasma leakage* and abnormal
warning signs*:
hemostasis (platelet count ≤
100,000 cells/cumm):




Rising Hct ≥ 20%
Pleural effusion: PE, CXR
(right lateral decubitus,
ultrasound)
Ascites: PE, ultrasound
Hypoalbuminemia (Alb ≤ 3.5
gm%)

Abdominal pain or tenderness

Persistent vomiting

Clinical fluid accumulation

Mucosal bleed

Lethargy, restlessness

Liver > 2 cm

Lab.: increase in Hct
concurrent with rapid
decrease in Platelet count
*Need close monitoring
Natural course of DHF
Day 1
2
3
4
5
6
7
8
Shock
Fever
Pleural effusion,
Ascites
Hematocrit
Plasma leakage
IV fluid: NSS, DAR, DLR
Colloid: 10%Dextran,
10%Haes-steril
M+5% Deficit
(= 4,600 ml in adult)
W
B
C
WBC
6,000-9,000
Platelet count 200,000
Hct
Albumin
Cholesterol
Stop leakage
35
≤5,000
≤100,000
38
<50,000
45 (rising 20%)
≤3.5 gm%
≤100 mg%
Professor Siripen Kalayanarooj
Reabsorption
9
EARLY DIAGNOSIS BY CBC:
GUIDE FOR MANAGEMENT
Date
HCT
WBC
PLT
Day 2
41
6,500
160,000
Day 3
43
4,200
143,000
Day 4
47
2,300
90,000
Day 5
39
BP = 90/70 mmHg, P 118/min
70,000
AST/AL:T = 62/59
A 20-year-old woman
Good consciousness
COMPARE
BETWEEN
2
CLASSIFICATIONS
Plasma leakage
Follow up platelet and
frequent Hct (at least q 6
hours) at critical period
 Can prevent shock
and severe cases
with complications of
organs failure

Warning signs
Follow warning signs
which are non-specific
 Shock cannot be
prevented. Organs
failure as a
consequence of
prolonged shock are
detected late with
overt manifestations
and poor prognosis

LAHORE EXPERIENCED (SEP.-NOV. 11)
 Total
suspected cases : 600,000+ cases
 Confirmed 20,000 cases (< 4%)
 At the peak: 4,000-6,000 patients/day
 Admission 500-600 cases/day
 Death 10-15 cases per day
MULTI-COUNTRY STUDY: 18 COUNTRIES
VALIDATION STUDY OF THE NEWLY SUGGESTED
CLASSIFICATION
Revised
not
classified
Dengue
without
Warning
Signs
Dengue
With
Warning
Signs
Severe
dengue
Total
Not
classify
23
57
159
29
268
DF
7
551
684
75
1,317
DHF
2
8
240
39
289
DSS
0
0
12
76
88
Total
32
616
1,095
219
1,962
Barniol J et al: BMC Infectious Disease 2011,11: 106
ORIGINAL AND NEWLY SUGGESTED WHO
CLASSIFICATION FOR DENGUE SEVERITY:
2005-2010 (TOTAL 494 PATIENTS)
Narvaez F et al: PlosNTD 2011, 5: e1397.
DHF+DSS = 152 patients
DW+SD = 467 patients
ADVANTAGES
Original WHO



Proven in reducing CFR
Can prevent shock so less
severe cases and less
complications
No need for confirmed
dengue laboratories (PCR,
NS1Ag, IgM/IgG tests):
diagnosis DHF/DSS by
clinical criteria correct >
90%
Suggested new
Easy and friendly use
 Use only clinical
especially warning
signs.
 No need for any
laboratory tests to
follow up: CBC
 Increase number of
cases report so may
be more effective
control?

DISADVANTAGES
Original WHO
Need follow up of
laboratory test
especially CBC and
frequent Hct
monitoring
 Need close monitoring
especially during 2448 hours of critical
period of plasma
leakage

Suggested new





More workload to healthcare
personnel, at least 20 times
at OPD and 2 times for IPD
More complication of fluid
overload (admit and observe
early with IV fluid infusion)
More severe cases with EDS
Need dengue confirm labs.
except those with shock, with
complication of fluid overload
Increase in CFR
4. IV FLUID MANAGEMENT IN
SHOCK CASES
Original WHO

10 ml/kg/hr in
children or 300-500
ml/hr in adult
Newly suggested

20 ml/kg in 20 mins.
and can repeat
another 2 times
4. IV FLUID MANAGEMENT IN
NON-SHOCK (COMPENSATED
Original WHO

1.5 ml/kg/hr in
children or M/2 in
early and adjust rate
accordingly to clinical,
vital signs, Hct and
urine output
SHOCK) CASES
Newly suggested

5-7 ml/kg/hr
4. OTHERS
MANAGEMENT
Original WHO
Colloidal solution: only
plasma expander
(hyper-oncotic) - 10%
Dextran-40 in NSS
 No platelet
prophylaxis except in
adults with underlying
HT and Plt < 10,000
cells/cumm.

Newly suggested


Any colloidal solution
including FFP
Platelet prophylaxis
HOTLINE DHF:
089-2045522 – M.D.
089-2042255 – GN.
[email protected]
Thank you !!!