Summary Guidelines for Dengue Fever

Summary Guidelines for Dengue Fever

The Indian Medical Association has released dengue guidelines and has asked citizens not to panic. Some of the important points to note are listed below:

1.    General: The present serotype is less fatal than the one in 2013. Of the new serotype of dengue (Den1, Den2, Den 3 and Den4),serotypes 1 and 3 are less dangerous as compared to 2 and 4.  This year serotypes 2 and 4 are prevalent. The type 4 strain of the disease has emerged as the dominant type for the first time in Delhi, along with dengue type 2.

2.    Symptoms: Symptoms of type 4 dengue include fever with shock and a drop in platelets. Type 2 causes a severe drop in platelets, haemorrhagic fever, organ failure and dengue shock syndrome.Every strain carries the risks of hemorrhagic fever, but type 4 is less virulent than type 2. Risk of severe dengue is highest with dengue-2 viruses.

Symptoms include the onset of an acute febrile illness accompanied by headache, retro orbital pain, and marked muscle and joint pains.

          Symptoms typically develop between four and seven days after the bite of an

          infected mosquito. The incubation period may range from three to 14 days.

          Fever typically lasts for five to seven days. The febrile period may also be

          followed by a period of marked fatigue that can last for days to weeks,

          especially in adults.

          Joint pain, body aches, and rash are more common in females.

Important points for citizens to note

1.    Dengue is causes by a virus transmitted to humans through mosquito bites.

Adopt multiple measures to avoid the mosquito breeding and bites.

2.    Do not panic. Most dengue patients are not serious, dengue is both preventable and manageable.

3.    The risk of complications is less than 1 per cent of dengue cases and, if warning signals are known to the public, all deaths from dengue can be avoided.

4.    The more reliable test for dengue complications is haematocrit rather than test for platelet count.

5.    Especially crucial are 1-2 days after the last episode of the fever are crucial and during this period, a patient should be encouraged to take plenty of oral fluids mixed with salt and sugar.

The main complication is leakage of capillaries and collection of blood outside the blood channels leading to intravascular dehydration. Giving fluids orally or by intravenous routes, if given at a proper time, can save fatal complications.

6.    A platelet transfusion is not needed unless patient has active bleeding (other than petechiae) and platelet counts are less than 10,000.

          Unnecessary platelet transfusion can cause more harm than good.

7.    'Warning signs': Need for admission-

                                          Severe abdominal pain or tenderness.

                                          Persistent vomiting, lethargy or restlessness.

                                          Abrupt change from fever to hypothermia.

                                          Bleeding, pallor.

                                          Cold /clammy extremities.

                                          Liver enlargement on physical exam.

                                          Abnormal mental status.

Early recognition:  Dramatic plasma leakage often develops suddenly; therefore, substantial attention has been placed on early identification of patients at higher risk for shock and other complications.

The period of maximum risk for shock is between the third and seventh day of illness. This tends to coincide with resolution of fever. Plasma leakage generally first becomes evident between 24 hours before and 24 hours after defervescence.

An elevation of the hematocrit is an indication that plasma leakage has already occurred and that fluid repletion is urgently required.

Low platelet count usually precedes overt plasma leakage.

Mild elevations in serum SGOT and SGPT levels are common. Bit in severe dengue the levels are very high with SGOT > SGPT levels.

A normal SGOT levels is a strong negative predictor of severe dengue even in the first three days of illness.

Coexisting medical conditions and chronic hemolytic disease may complicate management. Referral for hospitalization is recommended for such patients, regardless of other findings. Additionally, hospitalization should be considered for patients who may have difficulties with outpatient follow-up (eg, patients who live alone or who live far from a healthcare facility without a reliable means of transport).

Patients with suspected dengue who do not have any of the above indicators probably can be safely managed as outpatients. Daily outpatient visits may be needed to permit serial assessment of blood pressure, hematocrit , and platelet count.

Patient assessment

     Must pass urine every three hours.

      Duration of extra fluids.

      The fluids that are lost into potential spaces (eg, pleura, peritoneum) during the period of plasma leakage are rapidly reabsorbed. Intravenous fluid supplementation should be discontinued once patients have passed the period of plasma leakage.

        Usually no more than 48 hours of intravenous fluid therapy are required.

        Excessive fluid administration after this point can precipitate hypervolemia and pulmonary edema.

Miscellaneous precautions

1. Use paracetamol as needed for fevers and myalgias. Aspirin or nonsteroidal antiinflammatory agents should generally be avoided.

2.  Patients should be cautioned to maintain their fluid intake to avoid dehydration.

Some more facts

When the dominant strain remains the same for a long period, a significant population develops immunity to it, and fewer patients are diagnosed with the virus.

Infection with one of the four serotypes of dengue virus (primary infection) provides lifelong immunity to infection with a virus of the same serotype.

However, immunity to the other dengue serotypes is transient, and individuals can subsequently be infected with another dengue serotype (secondary infection).

Subsequent infection with a second type increases the likelihood of serious illness.

The risk for severe dengue appears to decline with age, especially after age 11 years.

Patients' Guide to ILDs

       Interstitial lung disease (ILD) comprises of a group of several diseases of different causes but similar features. It is classified as either Primary (or idiopathic) and Secondary (Secondary to some other disease). Secondary ILD commonly occurs in patients with pre-existing diseases such as rheumatoid arthritis, systemic sclerosis, sarcoidosis and occupational disorders. Hypersensitivity pneumonitis is a group of common ILDs which occur on exposure to organic dusts which happens during farming, keeping birds, manufacturing cheese, air-conditioning etc. ILD can also develop following viral infections, administration of certain drugs, high-dose radiation and radiotherapy.

       Primary or idiopathic ILD is the more serious type whose cause is not identifiable. Of various kinds of idiopathic ILDs, idiopathic pulmonary fibrosis (IPF) is most important. There are a few other types of idiopathic ILDs importantly, non-specific interstitial pneumonia (NSIP), organizing pneumonias (OP), desquamative interstitial pneumonia and acute interstitial pneumonia.

Common complaints  

1.       Breathlessness especially on exertion. Patient may feel completely fine at rest.

2.       Dry cough which is quite hacking and troublesome, often not relieved with routine cough suppressants.

3.       Generalized weakness, malaise, fatigue and tiredness.

4.       Loss of appetite.

5.       Weight loss.

6.       Blueness of fingers and nails during exercise.

7.       Symptoms of underlying disease such as joint pains, skin rashes or other manifestations.

Investigations required for confirmation of diagnosis

1.       Routine blood tests: hematological, biochemical and immunological as considered important

by the physician.

2.       Chest X-Ray

3.       Pulmonary function tests – spirometry. Sometimes, blood gases assessment.

4.       High resolution CT Chest

5.       ECG and Echocardiography

6.       Fiberoptic bronchoscopy and lung biopsy as decided by the physician.

7.       Occasionally, lung biopsy with thoracoscopy or open surgery is required to establish the diagnosis.

Other tests may be required for identification and exclusion of a secondary cause of ILD such as for rheumatoid arthritis, sarcoidosis, occupational disorder or hypersensitivity pneumonitis. Serological tests may be required for hypersensitivity pneumonias.

Treatment of ILD 

       There is no efficacious therapy for ILDs. Treatment of IPF remains elusive. Patients and clinicians are faced with four options: (i) no treatment, (ii) corticosteroids and cytotoxic agents, (iii) anti-fibrotic drugs, (iv) other miscellaneous agents. 

       Based on the evidence available immunosuppression with corticosteroids and cytotoxic agents is not helpful for IPF. These drugs are helpful in secondary ILDs such as CTD associated ILD, sarcoidosis and some other forms of IIP (NSIP, COP and DIP). Pirfenidone is the one agent which may provide some benefit in IPF. It is an anti-fibrotic drug which is shown to decrease the decline in lung function parameters. Several other drugs are also employed, but not very useful in improving the condition.

        Most patients with IPF continue to experience an inexorable progression to death, with lung transplantation being the only measure shown to prolong survival. Currently, lung transplantation has been associated with improved lung function, exercise capacity, quality of life, and survival in this group of patients. The treatment is available at very few centres in India and the cost is prohibitive. Most importantly, there is very limited availability of organs.  Lungs for transplantation can be retrieved only from a brain-dead individual with fully informed consent of the family following compliance of all the requisite legal and medical guidelines. 

       Thus, the primary objectives of treatment in IPF are essentially to provide symptomatic relief of symptoms, oxygen therapy for desaturation and pulmonary rehabilitation. One also needs to treat the complications which occur either secondary to the disease per se, or the toxicity of drugs.

Prognosis Natural history of ILD 

       Most forms of ILDs are progressive in nature. There is no permanent cure. Patient’s condition is likely to deteriorate with time. IPF is the worst form of ILD which carries a poor prognosis with an average survival of 3-5 years. Other ILDs have variable natural history which is modifiable with treatment. 

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Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com    Website: jindalchest.com

Ph.  Clincis: +91 172 4911000