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Dengue

Aka: Dengue, Break-bone fever, Dandy fever, Duengero fever, Seven-day fever, Dengue Hemorrhagic Fever, Dengue Fever

I. Epidemiology

  1. Incidence
    1. Worldwide: 50-100 million cases/year (with 500,000 hospitalizations and 12,500 deaths)
    2. United States: Few hundred cases/year
      1. Travel to endemic area (esp. Thailand, India, Indonesia, Brazil) or
      2. Hawaii or Texas-Mexico border

II. Pathophysiology

  1. Transmitted by Aedes aegypti MosquitoSaliva (bites during daytime)
  2. Arbovirus in the Flavivirus genus
    1. Related to West Nile Virus and Yellow Fever virus (same Flavivirus genus)
    2. Single stranded RNA virus
  3. Infects reticuloendothelial system (RBC and platelet production organs)
    1. Liver
    2. Spleen
    3. Lymph nodes
    4. Thymus
  4. Dengue Serotypes (one Mosquito may carry multiple serotypes)
    1. DENV 1
    2. DENV 2
    3. DENV 3
    4. DENV 4
  5. Endemic areas (over 100 tropical countries with >40% of world population at risk)
    1. Southeast Asia
    2. Central America
    3. South America
    4. Caribbean

III. Symptoms

  1. Incubation
    1. Travel to endemic area within prior 14 days
    2. Abrupt symptom onset 3-15 days (typically 4-8 days) after Mosquito Bite
  2. Febrile stage (days 3-7)
    1. Undulant Fever
      1. High fever falls after Day 3
      2. Fever may rise again later
    2. Severe frontal or retro-orbital Headache
    3. Nausea or Vomiting
    4. Musculoskeletal pain
      1. Myalgias
      2. Arthralgias
      3. Bone pain
    5. Rash
      1. Red Morbilliform, petechial punctate rash
      2. Rash starts on hands and feet
      3. Rash spreads to trunk
  3. Severe Dengue (1% of cases)
    1. Follows febrile stage in a subset of patients
    2. Associated with prior infection and immunity to one Dengue serotype followed by infection with a second, new serotype
    3. Herald symptoms of severe disease
      1. Abdominal Pain or tenderness
      2. Persistent Vomiting
      3. Third-spacing (edema, Pleural Effusion, Ascites)
      4. Mucosal bleeding
      5. Lethargy
      6. Hepatomegaly
      7. Heamtocrit increases with significant Thrombocytopenia
    4. Dengue Hemorrhagic Fever (DHF)
      1. Hemorrhage
      2. Thrombocytopenia
      3. Plasma leak (hypoproteinemia, effusions)
    5. Dengue shock syndrome (DSS) - lasts 48-72 hours, and has significant mortality risk
      1. Narrow Pulse Pressure (<20 mmHg)
      2. Hypotension
      3. Respiratory distress
      4. Abnormal Liver Function Tests (AST, ALT >1000)
      5. Altered Level of Consciousness
      6. Mortality rates approach 25-50% (however <1% with early and aggressive management)

IV. Exam: Tourniquet test

  1. Inflate Blood Pressure cuff to midway between systolic and diastolic Blood Pressure readings
  2. Leave Blood Pressure cuff inflated for 5 minutes
  3. Observe for distal Petechiae
    1. More than 20 Petechiae/inch of skin suggests capillary fragility or Thrombocytopenia

V. Differential Diagnosis

  1. Yellow Fever (Rare in U.S. travelers)
    1. Infects 200,000 people worldwide per year (with 30,000 deaths)
    2. Hyperbilirubinemia and Jaundice distinguish from Dengue Fever
  2. Leptospirosis
  3. Typhoid Fever
  4. Viral Hepatitis
  5. Rickettsial disease
  6. Bacterial Sepsis
  7. Malaria
  8. Leishmaniasis

VI. Labs

  1. Complete Blood Count
    1. Leukopenia (common)
    2. Hematocrit and Hemoglobin increased (>10% increase predicts severe disease)
    3. Thrombocytopenia (often severe)
      1. Observe for bleeding complications
  2. Specific tests (confirm diagnosis, but Dengue Fever is a clinical diagnosis)
    1. Dengue IgM (after day 4) or Dengue IgG (after day 7) with 4-fold or higher increase in titers
    2. Dengue reverse transcriptase PCR (within first 5 days)
    3. Dengue non-structural protein type 1 (NS1) detection
      1. Decreased Test Sensitivity in those exposed to other Flavivirus (e.g. Yellow Fever)

VII. Management

  1. No effective treatment or Vaccine
  2. General measures
    1. Maintain hydration
    2. Lower fever with Acetaminophen
    3. Avoid NSAIDS or Aspirin due to risk of Hemorrhage
    4. Daily monitoring of Hematocrit and Platelet Count
  3. Hospitalization indications
    1. Infants, elderly and pregnant women
    2. Serious comorbidity (Diabetes Mellitus, unreliable social situation)
    3. Findings suggestive of impending severe Dengue
  4. Severe Dengue management
    1. Aggressive supportive care
    2. Intravenous Fluid initial protocol
      1. NS or LR 5-7 cc/kg/h for 1-2 hours
      2. then 3-5 ml/kg/h for 2-4 hours
      3. then 2-3 ml/kg/h

VIII. Course

  1. Incubation: 3-15 days (typically 4-8 days)
  2. Usually benign and self-limited course lasting <7 days

IX. Prevention

  1. Limit Mosquito contact (DEET, protective clothing, bed nets)
    1. See Vector borne infection

X. References

  1. Anderson (2014) Crit Dec Emerg Med 28(7): 11-9
  2. Feder (2013) Am Fam Physician 88(8): 524-30 [PubMed]
  3. Mangold (2013) Pedr Emerg Care 29(5): 665-9 [PubMed]
  4. Wilder-Smith (2005) N Engl J Med 353(9): 924-32 [PubMed]

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Ontology: Dengue Fever (C0011311)

Definition (CHV) An acute, infectious tropical disease caused by an arbovirus transmitted by mosquitoes
Definition (CHV) An acute, infectious tropical disease caused by an arbovirus transmitted by mosquitoes
Definition (CHV) An acute, infectious tropical disease caused by an arbovirus transmitted by mosquitoes
Definition (MSH) An acute febrile disease transmitted by the bite of AEDES mosquitoes infected with DENGUE VIRUS. It is self-limiting and characterized by fever, myalgia, headache, and rash. SEVERE DENGUE is a more virulent form of dengue.
Definition (MEDLINEPLUS)

Dengue is an infection caused by a virus. You can get it if an infected mosquito bites you. Dengue does not spread from person to person. It is common in warm, wet areas of the world. Outbreaks occur in the rainy season. Dengue is rare in the United States.

Symptoms include a high fever, headaches, joint and muscle pain, vomiting, and a rash. In some cases, dengue turns into dengue hemorrhagic fever, which causes bleeding from your nose, gums, or under your skin. It can also become dengue shock syndrome, which causes massive bleeding and shock. These forms of dengue are life-threatening.

There is no specific treatment. Most people with dengue recover within 2 weeks. Until then, drinking lots of fluids, resting and taking non-aspirin fever-reducing medicines might help. People with the more severe forms of dengue usually need to go to the hospital and get fluids.

To lower your risk when traveling in dengue-prone countries

  • Wear insect repellent with DEET
  • Wear clothes that cover your arms, legs and feet
  • Close unscreened doors and windows

NIH: National Institute of Allergy and Infectious Diseases
Definition (NCI) An acute infection caused by Dengue virus. Signs and symptoms include sudden onset of fever, headache, rash, arthralgia, and myalgia. It is transmitted through mosquitoes.
Definition (CSP) acute infectious, eruptive, febrile disease caused by four antigenically related but distinct serotypes of the dengue virus; transmitted by the bite of infected Aedes mosquitoes, especially A. aegypti; classical dengue (dengue fever) is self-limiting and characterized by fever, myalgia, headache, and rash; dengue hemorrhagic fever is a more virulent form of dengue virus infection.
Concepts Disease or Syndrome (T047)
MSH D003715
ICD9 061
ICD10 A90
SnomedCT 154345006, 266194002, 38362002
LNC LA10451-5
English Dengue, Fever, Dengue, Dengue fever [classical dengue], breakbone fever, Dengue fever (diagnosis), Dengue fever virus infection, Dengue [Disease/Finding], Classical Dengues, Classical Dengue Fever, Dengue, Classical, Classical Dengue Fevers, Dengue Fever, Classical, Classical Dengue, dengue fever, Break-bone fever, Break-bone Fever, Break Bone Fever, Breakbone Fever, Fever, Breakbone, Break-Bone Fever, Fever, Break-Bone, Dengue fever, Breakbone fever, Dengue (disorder), dengue, breakbone; fever, dandy fever, dandy; fever, dengue; fever, fever; Aden, fever; breakbone, fever; dandy, fever; dengue, Aden; fever, Dengue Fever
Dutch denguekoortsvirusinfectie, dengue, Aden; koorts, breakbone; fever, dandy; fever, dengue; koorts, fever; breakbone, fever; dandy, koorts; aden, koorts; dengue, Dengue-koorts [klassieke dengue], denguekoorts, Dengue, Knokkelkoorts
French Infection par le virus de la dengue, Fièvre rouge, Dengue classique, Fièvre dengue classique, Dengue, Fièvre dengue
German Dengue-Fieber-Virusinfektion, Dengue-Fieber [Klassische Dengue], Dengue-Fieber, Denguefieber, Dengue
Italian Infezione da virus della febbre dengue, Febbre dengue, Dengue
Portuguese Infecção por vírus de dengue, Febre Quebra-Ossos, Dengue, Febre da Dengue
Spanish Infección por virus de la fiebre dengue, dengue (trastorno), dengue, fiebre dengue, fiebre quebrantahuesos, Dengue, Fiebre Dengue
Japanese デング熱ウイルス感染, ﾃﾞ�ｸﾞﾈﾂｳｲﾙｽｶ�ｾ�, ﾃﾞ�ｸﾞﾈﾂ, デング熱, H熱
Swedish Dengue
Czech dengue, Hore�ka dengue, Dengue, Infekce virem hore�ky dengue
Finnish Dengue
Russian DENGE LIKHORADKA, ДЕ�ГЕ ЛИХОР�ДК�
Korean 뎅기열[전형� 열]
Croatian DENGA
Polish GorÄ…czka denga
Hungarian Dengue, Dengue láz vírus fertőzés, dengue láz
Norwegian Dengue, Denguefeber
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Severe Dengue (C0019100)

Definition (MSH) A virulent form of dengue characterized by THROMBOCYTOPENIA and an increase in vascular permeability (grades I and II) and distinguished by a positive pain test (e.g., TOURNIQUET PAIN TEST). When accompanied by SHOCK (grades III and IV), it is called dengue shock syndrome.
Definition (NCI) A serious condition caused by Dengue virus infection. Patients present with an acute febrile illness followed by restlessness, irritability, and bleeding. It may lead to hemorrhagic shock and death.
Concepts Disease or Syndrome (T047)
MSH D019595
ICD10 A91
SnomedCT 186599009, 186598001, 20927009
English Hemorrhagic Fever, Dengue, DHF - Dengue haemorrhag fever, Dengue hemorrhagic fever (diagnosis), Thai Hemorrhagic Fever, Fever, Philippine Hemorrhagic, Philippine Hemorrhagic Fever, Hemorrhagic Dengue, Singapore Hemorrhagic Fever, Hemorrhagic Dengues, Fever, Singapore Hemorrhagic, Fever, Thai Hemorrhagic, dengue haemorrhagic fever, dengue fever haemorrhagic, dengue hemorrhagic, dengue hemorrhagic fever, haemorrhagic dengue fever, hemorrhagic dengue fever, dengue fever hemorrhagic, Severe Dengue, Dengue Hemorrhagic Fever, Dengues, Severe, Severe Dengues, Dengue, Severe, Dengue haemorrhagic fever (disorder), Severe Dengue [Disease/Finding], Dengue hemorrhagic fever, DHF - Dengue haemorrhagic fever, DHF - Dengue hemorrhagic fever, Dengue haemorrhagic fever, Dengue hemorrhagic fever (disorder), bangkok hemorrhagic; fever, Philippine; hemorrhagic fever, dengue (virus); fever, hemorrhagic, dengue; hemorrhagic fever, dengue; hemorrhagic, Singapore; hemorrhagic fever, Thailand; hemorrhagic fever, fever; bangkok hemorrhagic, fever; dengue (virus), hemorrhagic, hemorrhagic fever; Philippine, hemorrhagic fever; Singapore, hemorrhagic fever; Thailand, hemorrhagic fever; dengue, hemorrhagic; dengue, virus; dengue, hemorrhagic fever, Bangkok; hemorrhagic fever, hemorrhagic fever; Bangkok
Dutch dengue hemorragische koorts, Bangkok; koorts, Filippijns; hemorragische koorts, Singapore; hemorragische koorts, Thailand; hemorragische koorts, dengue; hemorragische koorts, dengue; hemorragisch, dengue{virus}; koorts, hemorragisch, hemorragisch; dengue, hemorragische koorts; Filippijns, hemorragische koorts; Singapore, hemorragische koorts; Thailand, hemorragische koorts; dengue, koorts; Bangkok, koorts; dengue{virus}, hemorragisch, virus; dengue, hemorragische koorts, Bangkok; hemorragische koorts, hemorragische koorts; Bangkok, Dengue-hemorragische koorts, Hemorragische denguekoorts, Koorts, dengue-hemorragische
French Fièvre hémorragique Dengue, Fièvre hémorragique thaï, Dengue grave, Dengue hémorragique, Fièvre hémorragique des Philippines, Dengue sévère, Fièvre hémorragique de Singapour
German Dengue-Haemorrhagisches Fieber, Haemorrhagisches Dengue-Fieber, Hämorrhagisches Dengue-Fieber, Hämorrhagisches Fieber, Dengue
Italian Febbre emorragica dengue, Febbre emorragica di dengue, Forma emorragica di dengue
Portuguese Febre hemorrágica de dengue, Not Translated[Severe Dengue], Febre Hemorrágica da Dengue, Dengue Hemorrágica
Spanish Fiebre dengue hemorrágica, Fiebre hemorrágica de dengue, Not Translated[Severe Dengue], Fiebre Hemorrágica Dengue, dengue hemorrágico, fiebre hemorrágica del dengue, fiebre hemorrágica dengue (trastorno), fiebre hemorrágica dengue, fiebre quebrantahuesos hemorrágica, Dengue Hemorrágico
Swedish Dengue-blödarfeber
Japanese ﾃﾞ�ｸﾞｼｭｯｹﾂﾈﾂ, デング性ショック症候群, デング出血性熱, 出血熱-デング, デング熱ショック症候群, デングショック症候群, デング出血熱
Czech hemoragická hore�ka dengue, Hemoragická hore�ka dengue
Finnish Verenvuotoinen dengue
Russian DENGE GEMORRAGICHESKAIA LIKHORADKA, GEMORRAGICHESKAIA LIKHORADKA DENGE, DENGE SHOKOVYI SINDROM, ГЕМОРР�ГИЧЕСК�Я ЛИХОР�ДК� ДЕ�ГЕ, ДЕ�ГЕ ГЕМОРР�ГИЧЕСК�Я ЛИХОР�ДК�, ДЕ�ГЕ ШОКОВЫЙ СИ�ДРОМ
Korean 뎅기출혈열
Polish Gorączka krwotoczna dengue, Gorączka krwotoczna denga, Zespół wstrząsowy dengue
Hungarian Dengue haemorrhagiás láz
Norwegian Hemoragisk denguefeber, Denguefeber, hemoragisk
Derived from the NIH UMLS (Unified Medical Language System)

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