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:

India’s Botanical Dengue Drug

India’s botanical Dengue drug is getting world wide attention. At last! India, the home of ayurvedic medicine, has begun work to develop, test and market a botanical drug to treat of dengue, with drug major Sun Pharma announcing its collaborative effort with the International Centre for Genetic Engineering and Biotechnology (ICGEB).
The move follows a March announcement of success in the drug’s initial development stage through a joint project between the ICGEB, the Department of Biotechnology (DBT).

Dengue Mosquito: Aedes Aegypti
Dengue Mosquito: Aedes Aegypti

Sun Pharma will fund entire development programme of Cissampelos pariera (Cipa), the botanical drug to treat all strains of dengue. While the pharma giant will pay royalty following commercialisation of the drug, the ICGEB will provide the technical know-how and pre-clinical expertise.
“Using the knowledge of traditional Indian medicine, we explored the indigenous herbal bio-resource to identify plants with pan-DENV inhibitory activity and identified CIPA as a safe, affordable and effective solution,” said Dr Dinakar M Salunke, director, ICGEB, New Delhi.
Given the densely-populated cities and the high prevalence of the mosquito that spreads dengue — aedes aegypti — India is home to close to 50% of the global population estimated to be at risk of dengue. Severe dengue, which can potentially kill, correlates with very high-virus load, reduction in platelet counts and haemorrhage.
The new drug is expected to reduce high-virus load and make the disease milder, leading to fewer hospitalisations. The collaboration aims to explore how the extract prepared from Cipa Linn can inhibit the replication of virus in living cells against dengue infection.
The terms of this agreement permits Sun Pharma’s access to all the intellectual properties of this drug cross 17 countries.
“In tropical countries like India, where dengue outbreaks are significantly intense, a drug for dengue is an unmet public health need. Our partnership with ICGEB aims to develop Cipa as a safe, effective & affordable botanical drug for treatment of dengue,” said Kirti Ganorkar, senior V-P, business development and portfolio management, Sun Pharma, the world’s fifth largest generic pharmaceutical company.
The ICGEB will establish assay systems for development of Cipa for treatment of dengue infection for a pre-defined period of time. The ICGEB will work exclusively with Sun Pharma for the development of this drug, and clinical treatment strategies based on botanical and phyto-pharmaceuticals. Sun Pharma will pay royalties on sales post commercialisation. Other financial details of this agreement are confidential.
Dengue is estimated to costs India over $1.1 billion (about Rs 7,260 crore) annually, with the cost of medical care being nearly $550 million and the indirect cost, in terms of lost wages, being another $550 million. Read more..