• DENGUE

    (Dengue is derived from a Spanish word meaning dandy, so named because patient affected with dengue have such a peculiar walk)

    DEFINITION
    Acute viral infection transmitted by aedes Aegypti mosquito, characterized by saddle back high fever, intense, headache, bodyache, rash, generalized lymphadenopathy and hemorrhages.

     

    CLINICAL FEATURES
    Dengue (break bone) fever

    Symptoms:

    • Onset: Abrupt.
    • Fever: High fever with chill.
    • severe Distressing pain (justifies the name break bone fever)
    • Location: Severe frontal headache, over eye balls retro orbital pain back loins limbs, joints
    • Aggravation: movement turning in the bed Distressing joint and muscle pain.
    • Intense prostration.
    • Anorexia.
    • Nausea
    • Vomiting
    • Coryza
    • Lachrymation
    • Delirium.
    • Eruptions appear on the 4th or 6th day with a second rise of fever. Disappear in order of their appearance by scaly desquamation Urine Scant and high coloued.

    Signs:

    • Posture: restless.
    • Facies anxious.
    • Eyes congested.
    • Tongue: Coated yelloowish white.
    • Cervical lymph glands often enlarged.
    • Temperature.
    • Biphasic saddle back pattern: Sudden onset of fever, which remains high (103-105 of ) for first two or three days followed by gradual decline of temperature, which again suddenly shoots up the 4th or 5th day This Second ary rise is followed by complete remission by two days Total duration of fever is 6-7 days.
    • Respiration: fast.
    • Pulse: relative bradycardia.
    • Blood pressure: low
    • Rashes: Maculo-papular, Appears on 6th day,Disappears after 3-5 days.
    • Generalized lymphadenopathy.
    • Liver: Enlarged,Soft,Tender
    • Hess's capillary fragility test: Positive

    Complications

    • Hyperpyrexia.
    • Severe haemorrhage.

    Dengue haemorrhagic fever

    The cut off between dengue fever is the evidence of plasma leakge, which will not be present in the former but invariable in the later this is important in differentiating dengue fever with hemorrhagic form of dengue haemorrhagic fever.

    Symptoms:

    • Onset: abrupt.
    • High fever with chill
    • Distressing joint muscle pain Intense prostration
    • Epistaxis.
    • Bleeding from gums
    • Haematemesis.
    • Malaena

    Signs:

    • Facies: Sunken
    • cold extremities
    • respiration
    • Hurried
    • Shallow
    • Pulse: Fast, Thready
    • Blood pressure : Low
    • Generalised lymphadenopathy
    • petechiae.
    • purpura
    • Liver: Enlarged,soft,Tender
    • Hess,s capillary fragility test
    • Positive (It is performed by inflating blood pressure cuff to a point between systolic and the diastolic pressures for five minutes A test is cconsidered positive when 10 or more pete chiae per 2.5 cm-2 inch are observed. in dengue haemorrhagic fever, the- test usually gives a definipive positive result (i.e.,, > 20 petechiae). the test may be negative or mildly positive during the phase of profound shock)

    Dengue Shock Syndrome Summary:
    Dengue haemorrhagic fever is a problem manifestation of dengue Syndrome with haemorrhagic manifestapion having the following features:
    - Features of dengue fever at initial stage.
    - Haemorrhagic manifestation evidence through one or more of the following:

    • Positive tourniquet test.
    • Petechiae / ecchymosis/ purpura.
    • Mucosal bleeding; epistaxis, gums bleed ing.
    • . Bleeding from injection or other sites.
    • Hematemesis, melena, hematuria, PV bleeding.
    • Thrombocytopenia with platelets 100,000/mm or less.
    • - Any evidence of plasma leakage due to in creased capillary permeability, manifested by one or more of the following:
      . A 20% rise in hematocrit for age and sex.
      . A _>2o% drop in hematocrit following treatment with fluids as compared to base line.
      . Pleural effusion/Ascites/hypoproteinemia.

    COMPLICATION
    Dengue shock syndrome.
    The Dengue shock Syndrome:
    Dengue shock syndrome is a presentation of dengue syndrome when a case of dengue hemorrhagic syndrome manifests circulatory failure with one or more of the following features.
    1. Hypotension for age.
    2. Cold clammy skin, restlessness, rapid, weak pulse.
    3. Narrow pulse pressure (< 20 mm of Hg.)
    4. Profound shock.

      • Note; Grades III and IV are also called Dengue Shock Syndrome (DSS).

    INVESTIGATIONS:
    Blood (CBC):
    - TLC: leucopenia.
    - DLC: relative lymphocytosis.
    - Platelets: low (less than 100,000 / cu mm).
    - Haemoconcentration: haematocrit increased by 20%.
    - Albumin level: low.
    Serology
    - Virus isolation.Note:
    Once clinically suspected, leucocytes and platelet counts plus hematocrit level should be done atleast once per day.

    PROGNOSIS
    - Guarded.

    MIASMATIC CLEAVAGE
    - Acute recurrent miasmatic disorder.

    THERAPEUTIC AIM
    - To cure.
    - To prevent complications.
    - To prevent spread.

    GENERAL MANAGEMENT

    • Bed rest.
    • Antipyretic therapy for fever above 39 0C.
    • Cold sponging during fever.
    • Food; according to appetite. Prefer fresh fruit juice. Liquid, well balanced and easily digest ible diet.
    • Avoid commercially available fruit juice because these contain preservatives.
    • Oral rehydration therapy withers or its equiva lents if patient develops moderate dehydration due to vomiting and high fever.
    • Relief of pain.
    • I.V. replacement of fluids and electrolytes.
    • Platelet transfusion, if haemorrhage.

    MANAGEMENT OF DENGUE FEVER /DHF/DSS
    Do’s for Doctors:

    • Suspect dengue fever in cases of fever of short duration with redness of face, rash, congested eyes and bodyache after ruling out other infections.
    • Investigate all such patients for TLC/DLC/Platelet count and hematocrit (PCV):- Report all such patients with bleeding manifestations from any site, or thrombocytopenia to the health authorities (MCD).

    Manage these patients with cold sponging, lots of fluids and juice. (Allopaths can prescribe paracetamol).

    • All patients with platelet count <1 Lakh or bleeding or Hot > 36.4
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      or tourniquet test positive, may be referred to the nearby hospital for further management.

    Don’t’s:

    • Don’t use aspirin (if the patient is using aspirine/NSAIDS, stop the same if taking) in the management of fever in all suspected cases of DF/DHF/DSS.
    • Antibiotics/steroids has no role in the treatment of dengue.
    • Don’t use IV fluids indiscriminately; as it cause fluid overload.
    • Treat the bleeding manifestations and not the platelet count; as platelet count has no direct correlation with bleeding manjfestations.
    • Don’t use whole blood transfusion or platelet concentrates indiscriminately as they have got limited role in the routine management of such cases.

    Guideline for Indoor patients:

    • All patients with DHF without bleeding can be observed and managed with lots of fluid like ORT/Juice /Fîome made fluids.
    • Only patients with rising Hot/bleeding manifestations or/and evidence of plasma leakage (ascites or pleural effusion) and narrow pulse pressure (<20 mm Hg)/shock should be admit ted and put on IV fluid.
    • Ringer lactate/normal saline / or 0.45 normal saline are ideal fluids for management of DHF/DSS cases.
    • In case of no response to crystalloids within 24 hours of managing shock patients, shift to colloid, (Dextran 40) etc.- Whole blood transfusion is to be given only in cases of massive bleeding leading to falling hematocrit levels, provided patient is not in fluid overload.
    • Platelet concentrates are required only if plate let levels fall below 10,000 per cumrn.
    • All shock patient should be managed on the guidelines for shock.

    Afebrile Phase; Dengue fever:
    Constitutional symptoms in patients with DF after the fall of fever are similar during the febrile phase most patients will recover without complications. The following manifestations may be present:
    . Improvement in general condition.
    . Platelet/Hernatocrit normal.
    . Appetite rapidly regained.

    Management is more or less same; continue bed rest, check platelet and hematocrit. Orally fruit juices, oral fluids and electrolyte therapy.

    Convalescent Phase Dengue Fever:

    The duration of convalescence phase is 7-10 days after the febrile phase. During this phase further improvement in general condition and return of appetite occur. Bradycardia and confluent petechial rash with white center and or itching may persist. Weakness ìnay remain upto another week or two. No special advice is necessary. Also no restriction is needed. Normal diet and effort for adjusting to normal life style and work are necessary.

    PROPHYLACTIC MEASURES

    - Use of mosquito repellants, protective clothing and bed nets.
    - Environmental sanitation.
    - Intermittent drying of water stores.

    HOMOEOPATHIC TREATMENT

    Dengue fever:
    Aconite: Sudden onset of fever, with chilliness, throbbing pulses and great restlessness from anxiety. A remedy of cold, dry weather, winter winds.

    Bryonia Alb: White tongue: thirst for much cold fluid. Worse; from every movement, every noise, attacked with dry heat. Wants to lie quite still, and be let alone. Headaches and pain all better by pressure and worse by movement. The anxiety, dreams and delirium of Bryonia are of business; in delirium he “wants to go home”. Pains in head from coughing. Irritable.

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    Eupatorium perfoliaturn: Intense aching limbs and back, as if bones were broken. Aching in all bones with soreness of flesh. Bones feel broken, dislocated, as if would break. Bursting headache. Shivering, chills in back. Chill begins 7 to 9 a.m. Eyeballs sore. Vomiting of bile.

    Gelsemium: Heaviness and tiredness of body and limbs. Head heavy, eyelids heavy and limbs are also heavy. Colds and fevers of mild winters (opp. to Aeon.). Chills in back; chills and heats chase one another.” Bursting headache, from neck, over head to eyes, and forehead; relieved by copious urination. No thirst.

    Rhus Toxicodendron: Stiff, lame and bruised. Restlessness and uneasiness drive him to move. Illness from cold, damp weather; from cold damp when perspiring. Anxiety, fear; worse at night. Restlessness, intense fever, thirst and great prostration. Severe aching in bones. A mental symptom of rhus is fear of being poisoned.

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    Dengue haemorrhagic fever:
    Camphor: Patient goes into a state of collapse; icy coldness of body but aversion of being covered. Deathly paleness due to haemorrhages of black, coagulated blood. Chilliness with chattering of teeth but no desire to cover. Pulse small, weak and slow. Absence of perspiration, scanty. discharges. Cramps in calf muscles. Pains disappear from thinking of them or concentrating on them. There is a mental anguish and patient fears to be alone.

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    Veratrum Album: Perfect picture of collapse with extreme weakness, coldness and blueness of surface of body with internal burning. Profuse, cold sweat. Patient is depressed; sullen indifference. Rapid, feeble pulse. Skin is cold, clammy, blue, inelastic and wrinkled. Patient is aggravated in wet, cold weather and better by warmth.

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    Arsenic Album: Remedy useful for all forms of dengue. Intermittent paroxysmal fever with marked periodicity in cases of relapse. During fever intense, unquenchable thirst. Severe bodyache with mental and physical restlessness. Great anguish and lack of peace. Cannot sit still or lie down peacefully but inability to move because of the extreme pains and exhaustion. Restless sleep or patient may present with insomnia. The rash is red, papular, dry and rough with itching and burning of skin; urticarial rash. At the peak of temperature patient becomes delirious, very fearful, especially of death, is suicidal, thinks it is useless to take medicine; hallucinations of sight and smell, despite the delirium patient is very sensitive to disorder. Fever may be complicated with haemorrhages and later collapse. Epistaxis with burning in the nose, gastritis with bleeding from the bowels and burning around the anus, unhealthy, easily bleeding gums, etc. Later patient may go into collapse, unaccountable exhaustion and prostration, unconsciousness leading to immobility. All complaints; fever, pain, restlessness, and delirium — worse at midnight and patient is better by warmth.

    - Crotalus horridus.
    - Lachesis.
    - Millefolium
    - Phosphorus.

    Dengue Shock Syndrome
    - Arsenicum album.
    - Camphora.
    - Carbo vegetabilis.
    - Veratrum album.

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