Dengue 4 is less
fatal: IMA
It’s not an
epidemic yet: IMA
IMA today released
dengue guidelines and said not to panic. The present serotype is less fatal
than the one whish was in 2013.
Addressing a press
meet here Dr K K Aggarwal, Padma Shri Awardee and Honorary secretary General
IMA said that only suspected severe dengue cases needs medical attention and
admission. Most can be managed as OPD care. IMA said NO to platelet transfusion
unless patient has active bleed and count less than 10,000.
Platelets counts by
machine readings are bot reliable and can have an error of upto 40,000.
The reliable test is
haematocrit and not platelet count. Most cases can be manages without testing
by only measuring difference between upper and lower blood pressure. The pulse
pressure should be kept over 40 mm Hg.
IMA also appealed to
the public not to panic and do not force doctors to admit you unless it is
important.
“ do bot fill beds
with patients not requiring admission. Make beds available for sever dengue
cases” added Dr Aggarwal.
Co-addressing the
press Dr V K Monga and Dr R N Tandon from IMA said that most dengue patients
can be managed with oral fluids.
New strain of
dengue
·
Dengue normally is Den1, Den2, Den 3 and Den4
serotypes.
·
1 and 3 serotypes are less dangerous as compared
to 2 and 4 serotypes.
·
This year its 2 and 4 serotypes which are
prevalent.
·
As per AIIMS the type 4 strain of
the disease has emerged as the dominant type for the first time in the capital,
along with dengue type 2
·
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.
·
Barring stray cases in 2003, the
type 4 strain of the virus has never been isolated in Delhi
·
Doctors were expecting the strain
to change this year, given the large number of cases. Doctors were not
expecting type 4 because it has never been actively circulating in Delhi.
·
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. However the type 4 strain had
never even shown a significant presence. A new serotype will always end
up with an epidemic like situations
·
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.
·
AIIMS lab is also suspecting a new serotype this
year in addition. Is it Den 5 ?. Researchers screening dengue viral
samples found a virus collected during an outbreak in Malaysia's Sarawak state
in 2007 that they suspected was different from the four original serotypes.
They sequenced the virus and found that it is phylogenetically distinct from
the other four types. Experiments found that monkey antibodies produced against
the new type differ significantly from those resulting from the previously
known dengue viruses. So far, dengue 5
has been linked to only one outbreak in humans.
·
In 1996, when an outbreak of the
disease was reported in Delhi with over 10,000 cases, the relatively severe
type 2 strain of the virus was identified as the most common one.
·
In 2003, when a sharp rise in
dengue cases was again reported, type 3, a mild strain, emerged as the most
common type.
·
In 2013, with over 5,500 cases,
type 2 returned as the common strain in the capital.
Most dengue
patients are not serious
·
Dengue is both preventable and manageable
·
The risk of complications is in less than one per cent of dengue
cases and, if warning signals are known to the public, all deaths from dengue
can be avoided.
·
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.
·
Classic dengue fever is
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.
·
Most complications of
dengue occur after the fever is over. The two 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
Only these needs admission
"Warning
signs" – World Health Organization (WHO) guidelines recommend attention to
clinical warning signs for severe dengue
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
Severe
dengue
Early
recognition
·
Dramatic plasma leakage often develop 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
·
NS 1 of >600 ng/mL suggests
severe dengue
·
Coexisting medical conditions, such as pregnancy, infancy, old
age, obesity, diabetes mellitus, renal failure, and chronic hemolytic disease
may increase the risk of severe dengue and/or 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 or with timely
self-referral should complications develop (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, as long as close clinical observation is assured. Daily
outpatient visits may be needed to permit serial assessment of blood pressure,
hematocrit, and platelet count.
Government
may clarify: is it an epidemic
1. Recent
government circulars say: Postpone routine surgeries to accommodate dengue
patients/ Postpone routine admissions/ Make provision of extra beds/ Do not
refuse any patient who needs admission
2. These all
are done when an epidemic is announced
3. Ina n
epidemic all cases are presumed to be dengue, no confirmatory testing are done,
a triage announcement is done, clear cut directions are announce regarding
which patients are to be admitted and
which patients re not to be admitted’
Management
of significant bleeding
—
Gastrointestinal bleeding, epistaxis, or menorrhagia in patients
with severe dengue (and occasionally in patients with dengue fever) can be severe
enough to require blood transfusion.
—
Blood replacement should be performed with 5 mL/kg of packed red blood cells (or 10 mL/kg whole blood).
—
Platelet transfusions have not been shown to be effective at
preventing or controlling hemorrhage but may be warranted in patients with
severe thrombocytopenia (<10,000/mm3) and active bleeding.
—
Prophylactic platelet transfusions in patients with severe
thrombocytopenia but without active bleeding are not recommended
Fluid
requirement
1. 20 ml/kg
body weight as bolus
2. 10 mL/kg over the next first hour
3. 7 mL/kg/hour for next two hours
4. 5 mL/kg/hour for next four hours
5. 3 mL/kg/hour for next 8 hours
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
When to
discharge
—
In the absence of complications from prolonged hypotension or from
medical interventions, most patients with severe dengue recover within a few
days of admission
—
No fever for at least 24 hours
—
Two days have passed after an episode of shock
—
Patient is clinically well
—
Normal normal appetite,
urine output, and hematocrit.
No aspirin
Patients with dengue should be
cautioned to maintain their fluid intake to avoid dehydration and to take
paracetamol as needed for fevers and myalgias. Aspirin or nonsteroidal
antiinflammatory agents should generally be avoided.
