Neurologic Complications of Dengue

Dengue Shock Syndrome

What is Dengue Shock Syndrome?

Dengue Shock Syndrome is a collection of symptoms resulting from a dengue infection. Its symptoms – including hemorrhaging – resemble those you’d see after an accident, when someone is ‘in shock’. Typically, older children or adults suffer 2–7 days of high fever and show two or more of the following symptoms:

  • severe headache,
  • retro-orbital eye pain,
  • myalgias,
  • arthralgias,
  • a diffuse erythematous maculo-papular rash, and
  • mild hemorrhagic manifestation.
  • Subtle, minor epithelial hemorrhage, in the form of petechiae, are often found on the lower extremities (but may occur on buccal mucosa, hard and soft palates and or subconjunctivae as well), easy bruising on the skin, or the patient may have a positive tourniquet test.
  • Other forms of hemorrhage such as epistaxis, gingival bleeding, gastrointestinal bleeding, or urogenital bleeding can also occur, but are rare.
  • Leukopenia is frequently found and may be accompanied by varying degrees of thrombocytopenia.
  • Children may also present with nausea and vomiting.
  • Patients with DF do not develop substantial plasma leak (hallmark of DHF and DSS, see below) or extensive clinical hemorrhage.
Dengue virus image
Dengue virus: Dengue Shock Syndrome

Serological testing for anti-dengue IgM antibodies or molecular testing for dengue viral RNA or viral isolation can confirm the diagnosis, but these tests often provide only retrospective confirmation, as lab results are typically not available until well after the patient has recovered.

Clinical presentation of DF and the early phase of DHF are similar, and therefore it can be difficult to differentiate between the two forms early in the course of illness. With close monitoring of key indicators, the development of DHF can be detected at the time of defervescence so that early and appropriate therapy can be initiated.

The key to successfully managing patients with dengue infection and lowering the probability of medical complications or death due to DHF or DSS is early recognition and anticipatory treatment(For more detailed guidance on management for DF please see the recommended treatment courses for DHF in the links listed below.)

Dengue Hemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS): The third clinical presentation results in the development of DHF, which in some patients progresses to DSS. Vigilant is critical for identifying warning signs of progressing illness and early symptoms of DHF which are very similar to those of DF. Case Definitions Page

There are three phases of DHF:

  1. the Febrile Phase;
  2. the Critical (Plasma Leak) Phase; and
  3. the Convalescent (Reabsorption) Phase.

The Febrile Phase: Early in the course of illness, patients with DHF can present much like DF, but they may also have hepatomegaly without jaundice (later in the Febrile Phase). The hemorrhagic manifestations that occur in the early course of DHF most frequently consist of mild hemorrhagic manifestations as in DF. Less commonly, epistaxis, bleeding of the gums, or frank gastrointestinal bleeding occur while the patient is still febrile (gastrointestinal bleeding may commence at this point, but commonly does not become apparent until a melenic stool is passed much later in the course). Dengue viremia is typically highest in the first three to four days after onset of fever but then falls quickly to undetectable levels over the next few days. The level of viremia and fever usually follow each other closely, and anti-dengue IgM anti-bodies increase as fever abates.

The Critical (Plasma Leak) Phase: About the time when the fever abates, the patient enters a period of highest risk for developing the severe manifestations of plasma leak and hemorrhage. At this time, it is vital to watch for evidence of hemorrhage and plasma leak into the pleural and abdominal cavities and to implement appropriate therapies replacing intravascular losses and stabilizing effective volume. If left untreated, this can lead to intravascular volume depletion and cardiovascular compromise. Evidence of plasma leak includes sudden increase in hematocrit (≥20% increase from baseline), presence of ascites, a new pleural effusion on lateral decubitus chest x-ray, or low serum albumin or protein for age and sex. Patients with plasma leak should be monitored for early changes in hemodynamic parameters consistent with compensated shock such as increased heart rate (tachycardia) for age especially in the absence of fever, weak and thready pulse, cool extremities, narrowing pulse pressure (systolic blood pressure minus diastolic blood pressure <20 mmHg), delayed capillary refill (>2 seconds), and decrease in urination (i.e., oliguria). Patients exhibiting signs of increasing intravascular depletion, impending or frank shock, or severe hemorrhage should be admitted to an appropriate level intensive care unit for monitoring and intravascular volume replacement. Once a patient experiences frank shock he or she will be categorized as having DSS. Prolonged shock is the main factor associated with complications that can lead to death including massive gastrointestinal hemorrhage. Interestingly, many patients with DHF/DSS remain alert and lucid throughout the course of the illness, even at the tipping point of profound shock. CDC:

Doctors: See case definition for DHF and DSS. Adobe PDF fileExternal Web Site IconThere are no good videos about dengue shock syndrome, but this text video might help:

Dengue in the USA

Dengue in the USA

Dengue in the USA is here to stay. With the Department of Health of Hawaii confirming two locally-acquired dengue fever cases in the state, two video bloggers have decided to share their own struggles dealing with the tropical disease to help raise public awareness.

Hawaii State health officials are investigating a dengue fever cluster. Thirty-three people on Hawaii’s Big Island have become sick with dengue since September – the first locally transmitted outbreak of the viral illness on the Big Island and the first outbreak in the state since five people were infected on Oahu in 2011. Twenty-five of those infected in this current outbreak are residents of the Big Island, while eight are visitors. Four children are among those who have become ill. All patients have recovered or are recovering.

Allie Wesenberg and Charles Trippy feature prominently on an ongoing web series known as “Internet Killed Television” on the YouTube channel CTFxC.

For the past seven years, the channel, which caters to more than 1.5 million subscribers, has been uploading adventure clips of the duo taken in different parts of the world.

On one of their recent trips dated on Oct.13, Wesenberg and Trippy visited several popular spots in Hawaii, including South Kona’s Honaunau, the Volcanoes National Park and South Point.

However, by the time they got back from their Big Island trip, Wesenberg suddenly fell ill and was taken to the hospital on Oct. 22. Yep, dengue in the USA is a reality. Now watch the video:

Dengue in India

Dengue in India

Dengue Mosquito: Aedes Aegypti
Dengue Mosquito: Aedes Aegypti

Dengue has been endemic in India for decades now, and has been reporting the highest number of cases globally. The incidence of the disease has been rising rapidly. Moreover, according to the National Vector-borne Disease Control Programme (NVBDCP), the nodal agency for prevention and control of vector borne diseases such as dengue, the scale of the outbreak changes from year to year.

In 2009, 15,535 dengue cases and 96 deaths were reported. In 2010, the numbers increased to 28,292 cases and 110 deaths were reported. In 2011, the caseload dropped to 18,860 cases but the death rates remained high at 169. In 2012, once again there was a major outbreak and 50222 dengue cases were reported and 242 deaths. In 2013 the incidence of dengue was even more severe with 75808 cases being reported and 193 deaths. In 2014, the numbers reduced to 40571 and 137 deaths.

This year, too, the dengue outbreak was reported in all states in the country. However, the situation according to the NVBDCP is still not under control and the incidence is very high in some states.

Delhi has so far reported the 3,791 cases and 17 deaths, the highest number in the country. Karnataka has reported 3,586 cases and 4 deaths so far; Kerala reported 2,985 cases and 19 deaths; Tamil Nadu reported 2,343 cases and 5 deaths; Arunachal Pradesh, 1,720 cases and one death; Andhra Pradesh, 1,397 cases but no deaths. Gujarat reported 1,490 cases and one death while Maharashtra reported 1,365 cases and four deaths so far. Other states, which reported far fewer cases and deaths, are Telengana with 901 cases and two deaths; Uttar Pradesh with 195 cases and three deaths; and West Bengal with 658 cases and one death. All other states have reported even fewer cases, which by no means is lesser cause for worry given the ubiquity of the root causes.

Delhi counts among the most affected states because the public health response has been poor. Common strategies that are formulated for managing dengue fever and outbreaks have not been implemented.

Dr. Ravindran, who heads the Emergency Cell at the Health Ministry and has managed several outbreaks and health crises in disaster prone areas for many years across the country, says that building public awareness prior to the emergence of dengue is crucial so that people are better prepared to handle the situation. It makes a big difference if people are aware about early warning signs that can help them approach health facilities for timely treatment.

Paying attention to children

Dr. Puneet Bedi, a gynaecologist and health activist, also says public health so far has not been a priority for ruling Delhi government. The Health Ministry has put together extensive strategies but they have not been implemented, especially in public health.

Dengue is not just a normal viral disease. It needs special attention,

Dengue deluge in Mumbai leads to bed crisis in hospitals

MUMBAI: Every fourth hospital bed in the city seems to be occupied by a fever, dengue, malaria or typhoid patient. The deluge of monsoon-related ailments long after the rains has made it daunting to find beds in both private and public hospitals.

Mumbai has around 40,000 hospital beds, with the private sector contributing 50% while the state and BMC-run hospitals constituting 22% and 28% respectively. All the three civic hospitals—KEM, Sion and BYL Nair, are overflowing with patients. The BMC has, therefore, decided to keep the special monsoon ward functional even though rains are officially over. The three hospitals have together seen over 4,000 hospitalizations over the past one month.

Andheri resident Taher Kapasi (35) faced the crisis first hand on Friday when he was advised hospitalization following a  dengue diagnosis and his platelets dropping to 80,000. “We first went to Holy Spirit Hospital that was dealing with a heavy rush of patients. We then approached three other hospitals, including a five-star hospital in Andheri, but came back with the same response,” said Taher’s father Hakim, a chemist.

Shoab Memon echoed the helplessness after his son (6) and 10-month-old daughter tested positive for dengue. “We were panicking and searching for beds. Nowhere could we find two beds,” he said. After two days, he finally managed to admit his children to the civic-run Shatabdi Hospital in Kandivli.

Sion Hospital dean Dr Avinash Supe said dengue cases will continue till November-end or till there is a dip in temperature. “We have 160 fever patients admitted with us, almost double the ward’s capacity,” he said. Two resident doctors from the hospital continue to be treated in the ICU for dengue.

“There is a waiting period for not-so critical patients even in south Mumbai hospitals. For critical patients, ICU beds can be arranged,” said Dr Om Srivastava, head of Jaslok Hospital’s infectious disease department.

Physician Dr Vijay Dalal, who consults in four western suburb hospitals, said there was a crunch of beds as there were several dengue cases. Physician Dr M K Dave, who consults at Karuna Hospital in Borivli, said 99 out of 100 fever cases are turning out to be dengue. She said people from extended suburbs like Palghar are also flocking to city hospitals for dengue treatment, adding to the load. Dalal, however, cautioned that many get admitted out of fear, though dengue can be treated at home.

Yes, there’s a real dengue deluge in Mumbai! Read more here

And watch this video at dengue central in Mumbai:

 

 

 

 

 

 

 

Dengue App

There’s an app for dengue: the dengue app that maps dengue

The Gates Foundation has been helping fund some dengue research. One of the side benefits of the research on dengue is a new app created by one of the researchers that lets everyone with a smart phone send in dengue reports that automatically use the phone’s GPS to target breeding areas, new cases of dengue, and so on. Very cool! Will people use it? It will still mean a lot of public education to make it part of people’s consciousness. Here’s the story:

Leah Katzelnick was all set for a career as an anthropologist until she contracted dengue fever. She was in hospital for a week with severe symptoms. It changed her life. She is now the only scientist focusing solely on dengue fever at the University of Cambridge, working in partnership with the National Institutes of Health to map the interaction between different strains of the virus, all enabled by a Gates Cambridge Scholarship.

Dengue outbreaks are common in many developing countries. Four billion people live in areas with the disease, although mortality is relatively low. There are 400m infections a year. Only 500,000 people develop severe infection symptoms and approximately 25,000 of these die. However, it places a huge burden on the health services of countries where there are major outbreaks. “Epidemics can swamp public health and intensive care services,” says Leah [2012]. “It creates fear even if there is a low likelihood of death and in many countries virtually everyone knows someone who has died from it, most of whom are children.”

For her PhD she has been working with both human and non-human primate sera.  Isolates from some of the main strains of the dengue virus are injected and Leah studies the immune sera to chart the complex inter-relationship between the four main strains of the virus. Dengue only causes mild infection in the non-human primates she works with.

Early years
Leah, from Madison, Wisconsin, was not sure what she wanted to study at university initially. She was interested in maths, music and history and was a keen participant in musical theatre at school. She was also interested in social justice issues and organised a teach-in about Darfur after getting to know the Sudanese husband of a local pastor.

At Williams College, where she did her undergraduate studies, she joined up with a friend who was interested in Uganda and the two organised several initiatives for eastern Africa, including book drives. She also joined Students for Social Justice and was involved in a hunger banquet and an alternative gift fair.

Leah had thought she would study pre-med and major in maths, but she found anthropology and English captured her imagination more. However, although she graduated with a major in anthropology she did pre-med throughout and became more and more interested in science, particularly virology.

In her second year she travelled to Nicaragua to hear people’s stories and try to understand the kind of issues they were facing. She had been studying a course on dilemmas around humanitarian interventions and how well-meaning interventions had failed due to a lack of understanding of the lives of those in receipt of aid.

In her third year she did a study abroad summer fellowship programme on international health to learn about different health systems and beliefs about health. It involved talking to people in NGOs about their aims and talking to people on the ground about how the NGOS were perceived. She travelled to Nicaragua again and lived with a family there who had good contacts with people working in international organisations. She started contacting different organisations and talking to people in the community.

Dengue
Then she contracted dengue fever and became very sick. “I was wandering Managua by myself talking to people asking them what the problems were with international organisations which seemed quite strange since I was a white North American. People were understandably quite suspicious of me and I came to a sad realisation that I might not be able to overcome that, read more…

Finally, an App that Allows you to report Dengue Breeding Sites

Each year 22,000 people die from dengue fever, many of them children. More than 100 million people contract it each year, almost entirely from carrier mosquitoes. About 2.5 billion people live in areas where dengue infection is a risk.

“The real problem with dengue is it occurs in an epidemic fashion, so it can paralyse healthcare systems when it comes through a big city, causing thousands of hospitalisations,” says Gavin Screaton, at Imperial College, London. The only prevention is mosquito repellent or spraying mosquito spawning areas.

Now a team of developers in Costa Rica have created a free app to allow the public to easily report the standing water that acts as mosquito hatcheries, and allow the government to quickly spray these areas with pesticides.

Costa Rica experienced more than 50,000 cases of dengue fever in 2013, twice as many as 2012, costing the country more than $800,000 in disability payments, and causing one death. This was despite the government investing $6m in spraying initiatives.

The health ministry worked with Geotecnologias, a local web-mapping company, to create an app to enable them to crowdsource mosquito hatcheries. The app, Reporte Criaderos Dengue, was built on the ArcGIS online mapping software that works in the cloud, donated by the creators ESRI.

Luis Araya, business manager at Geotecnologias, explains: “We have a tool that everyone can use to publish and show places where the mosquito can grow. The best part of the solution is that it is in real time, and that everyone can access the reports and info of the raised ticket.”

Users can log on at a suspected mosquito location and upload pictures, and any breeding classification information, as well as leave their contact details for more information. The app also includes a module explaining preventative measures, as well as the contact details of the health ministry and Geotecnologias. More

Dengue Podcast, Video

Really Great Dengue Podcast, Video

The BBC’s Discovery Program is a wonderful source of scientific information. So’s the California Academy of Sciences. Here’s a description of their dengue podcast and video. At the end of the blurb are links to the  program so you can listen and watch at your leisure.

Dengue fever is carried in the tropics all around the world by the mosquito Aedis aegypti. The disease passes from person to person via these mosquitoes. Dengue doesn’t exist in forests and fields, only where people live, so it’s particularly prevalent in towns.

Dengue is endemic in Brazil. The only weapon against it is chemical spray. But it’s hard to catch the mozzies as they lurk in the tiniest pool of water. Also, once you get infected with Dengue (symptoms ranging from mild-flu-like to bedridden ‘breakbone fever’) all subsequent infections just get worse. It’s why the Brazilians are desperate to find a new way of stopping Dengue – for which there is no vaccine.

That’s the reason Brazil is the first country in the world to run a GM mosquito public health programme. They already have facilities for producing vast numbers of sterile mosquitoes – though they produce them via irradiation. Last summer we reported on caged outdoor trials in Mexico of mosquitoes genetically modified to fight Dengue.

In Brazil in February this year, UK company Oxitec, in collaboration with the University of Sao Paolo and a company called Moscamed in Brazil, started doing test releases in the city of Juazeiro, in Bahia province of N E Brazil. (Juazeiro is close to Brazil’s major tropical fruit exporting city of Petrolina). The test was to see whether the GM mozzies would survive and do their job in the wild, which they seemed to.

Check out this great Podcast

And here’s the great dengue video to go with it: