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What`s New in DHF: Clinical aspect

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 is more affected than Children. 2. Expanded Dengue Syndrome or

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What`s New in DHF: Clinical aspect

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  1. 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.

  2. 1. Adults is more affected than Children

  3. 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

  4. Expanded Dengue Syndrome(EDS) • Encephalopathy: confusion, seizure, coma • Liver failure • Renal failure • Cardiac involvement: myocarditis • Other organs involvement

  5. Causes of EDS • Prolonged 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

  6. Clinical manifestations of EDS Mostly manifestations of DHF+ • Complications • Underlying diseases • Co-infections

  7. 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

  8. CXR – compare between 2 positions

  9. Early clinical diagnosis &Management 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: • DHF with superimposed bacterial infections • DHF with liver injury: hepatitis, liver dysfunction/ failure • DHF with concealed internal bleeding (mostly GI bleed)

  10. 3. Dengue Classifications 1975, 1986, 1997, 2011 2009

  11. Dengue Classification Original WHO Newly suggested WHO 1975, 1986,1997, 2011 • Undifferentiated febrile illness • Dengue Fever (DF) • Dengue hemorrhagic fever (DHF) • Dengue Shock Syndrome (DSS) • Expanded Dengue Syndrome (EDS) WHO TDR 2009 • Dengue (D) • Dengue ± Warning signs (D ± WS) • Severe Dengue (SD)

  12. Dengue virus infection 10,000 AsymptomaticSymptomatic Viral syndrome Dengue fever DHF 1,000 9,000 100 500 400 Plasma leakage • Expanded dengue syndrome • Prolonged shock: liver failure, • renal failure,…Encephalopathy… • Co-morbidities • 3. Co-infections • 4. True dengue infection - encephalitis DHF DSS 1-2

  13. Suspected dengue infections:Fever with any 2 of the followingsin dengue endemic area Original WHO Suggested New • Headache • Retro-orbital pain • Myalgia • Arthralgia/ bone pain • Rash • Bleeding manifestations (Tourniquet positive) • Leukopenia • Rising Hct 10-15% • Platelet ≤ 150,000 cels/cumm • Nausea/ vomiting • Rash • Aches and pain • Tourniquet positive • Leukopenia • Any warning signs Tourniquet positive + Leukopenia

  14. AT QSNICH OPD: Suspected dengue cases that need close observation Original Newly suggested Tourniquet positive + Leukopenia 1,500 cases Warning signs: nausea/vomiting and abdominal pain 30,000+ cases (20 times more workload)

  15. QSNICH: IPD (June – August 2009) Confirmed = 274/298 = 91.9% Kalayanarooj S. J Med Assoc Thai 2011; 94(3); s74-83.

  16. Different between the two classifications Original WHO Suggested New Emphasize on plasma leakage*and abnormal 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%) Emphasize on warning signs*: • 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

  17. Natural course of DHF Day 1 2 3 4 5 6 7 8 9 Shock Fever Pleural effusion, Ascites Hematocrit Plasma leakage Stop leakage Reabsorption Fluid overload IV fluid: NSS, DAR, DLR Colloid: 10%Dextran, 10%Haes-steril M+5% Deficit (= 4,600 ml in adult) WBC Tourniquet test + WBC 6,000-9,000 ≤5,000 Platelet count 200,000 ≤100,000 <50,000 Hct 35 38 45 (rising 20%) Albumin ≤3.5 gm% Cholesterol ≤100 mg% Professor Siripen Kalayanarooj

  18. Early diagnosis by CBC:Guide for management BP = 90/70 mmHg, P 118/min AST/AL:T = 62/59 A 20-year-old woman Good consciousness

  19. Compare between 2 classifications Plasma leakage Warning signs • 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 • 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

  20. 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

  21. Multi-country study: 18 countriesValidation study of the newly suggested classification Barniol J et al: BMC Infectious Disease 2011,11: 106

  22. Original and Newly suggested WHO Classification for Dengue Severity: 2005-2010 (total 494 patients) DHF+DSS = 152 patients DW+SD = 467 patients Narvaez F et al: PlosNTD 2011, 5: e1397.

  23. Advantages Original WHO Suggested new • 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% • 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?

  24. Disadvantages Original WHO Suggested new • Need follow up of laboratory test especially CBC and frequent Hct monitoring • Need close monitoring especially during 24-48 hours of critical period of plasma leakage • 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

  25. 4. IV fluid management in shock cases Original WHO Newly suggested • 10 ml/kg/hr in children or 300-500 ml/hr in adult • 20 ml/kg in 20 mins. and can repeat another 2 times

  26. 4. IV fluid management in non-shock (compensated shock) cases Original WHO Newly suggested • 1.5 ml/kg/hr in children or M/2 in early and adjust rate accordingly to clinical, vital signs, Hct and urine output • 5-7 ml/kg/hr

  27. 4. Others management Original WHO Newly suggested • 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. • Any colloidal solution including FFP • Platelet prophylaxis

  28. Hotline DHF:089-2045522 – M.D.089-2042255 – GN.siripenk@gmail.com

  29. Thank you !!!

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