Dengue Viral Infections: A Major Public Health Issue
*1Nadeem Sajjad Raja, 2Nishi Nihar Singh, 3Tahir Mehmood, 4Habib
1Department of Medical
3Medici Medical Centre (General Practice), Luton UK.
4Army Medical Corps,
5Fauji Foundation Medical Centre,
*To whom correspondence should be addressed:
Dr Nadeem Sajjad Raja
Department of Medical Microbiology,
Dengue virus infection has emerged as a major public health problem worldwide in the recent decades. The incidence of this infection has increased in tropics and subtropics. It’s estimated that approximately one third of the world population are at risk of acquiring dengue infection with 100 million case of dengue fever (DF) and half million dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) every year. Dengue is a mosquito borne infection caused by four serotypes (type 1-4) of dengue virus. Severe forms (DHF/DSS) of dengue infection are under-recognised and the lack of awareness of the clinical features especially plasma leakage can lead to delayed recognition of DHF and DSS. No antiviral agents are available to treat dengue infection at the moment. Nevertheless, attempt to control dengue vector and introduction of safe and effective vaccine remain the important preventive measure. In this review article, we describe the epidemiology, virology, risk factors, pathogenesis and pathology, clinical features and management of DF, DHF and DSS, this review is also an update of diagnostics methods such as virus isolation, serology and molecular methods employed in clinical virology laboratory for the diagnosis of dengue infection.
Keywords: Dengue, Dengue Virus, Dengue haemorrhagic fever, Dengue shock syndrome
Dengue is a widespread mosquito-borne illness in humans of the tropics and subtropics of the world (1, 2). It is thought that about 100 million cases of dengue fever, 500,000 cases of dengue hemorrhagic fever (DHF) and 12000 deaths occur worldwide annually (3, 4,5,6, 7). Aedes aegypti (A. aegypti), the mosquito vector of dengue virus is present in almost all tropics and sub-tropic of the world and it poses the greatest threat to one third of the worlds population. This infection has been expanding its endemic areas for several years. The current epidemiologic trend underscores the importance of dengue infections and there is need for appropriate understanding of presentation patterns, diagnosis, treatment and long-term improvements for disease control and surveillance of dengue infections. This article reviews the epidemiology, virology, clinical manifestations including pathogenesis and pathology, laboratory diagnosis, treatment and prevention of dengue infections.
Dengue infections have largely been endemic in Asia (
Dengue infection (also called “break bone fever”) is an important infectious disease that is caused by the dengue virus, which belongs to family flaviviridae of the genus flavivirus (3). The flaviviruses are small surrounded by a spherical lipid envelope. The Dengue virus is a single stranded RNA virus, approximately 11 kilo bases with an icosahedral nucleocapsid covered by a lipid envelope (4). The dengue virus has four closely related but distinct serotypes, DEN1 to DEN4; within which are several genotypes. The virion is composed of 3 structural proteins (known as core, membrane and envelope) and 7 non-structural (NS1, NS2a, NS2b, NS3, NS4a, NS4b AND NS5) proteins (20). As the infection with 1 dengue virus provides life long immunity, there is no cross protective immunity to the other dengue viruses, therefore all dengue virus types may infect a person living in an endemic area. Dengue is understood to be an urban disease. These viruses maintain cycle of infection that uses the mosquito, the A. aegypti as a vector to infect the human host, who in turn serves as sources of viral amplification. The A. aegypti is a small highly domesticated, black and white tropical insect that prefers to feed on humans during the daytime. There are two peaks of biting activity; early morning for 2 to 3 hours and in the afternoon for several hours before dark. It breads in artificial containers in and around homes. Female A. aegypti feeds on several persons and may transmit dengue virus to many persons in short course of time (6, 21, 8).
Humans happen to infected with dengue virus after an infected mosquito prods on the vulnerable human host. There are several other possible routes of transmission without mosquito vector such as mucocutaneous transmission by blood of infected patient with dengue, needle stick injuries, bone marrow transplant, blood transfusion, intrapartum and vertical transmission (22). The incubation period of dengue infections is from 3 to 14 days (average 4-7 days). Serotype and virulence of dengue virus, sex, age, genetic background and immune status of the host are the established risk factors in dengue infections. For example, the elderly patients are more susceptible than younger children however the risk for severity of dengue infections does however fluctuate by age (9, 18, 23). The clinical presentation of dengue infection depicts a wide spectrum of findings from asymptomatic or mild undifferentiated illness with maculopapular rash or mild self-limiting infection of DF to DHF and dengue shock syndrome (DSS) (3, 21, 24). DF is an acute febrile illness that appears after an incubation period of 4-7 days. In older patients the disease may be mild or severe with sudden onset of high-grade fever, chills, frontal headache, myalgia, arthralgia and a rash, vomiting and loss of appetite (6, 25). This febrile phase lasts for 2-7 days. Although it is a serious debilitating condition it is usually not fatal (25). Clinical presentation of dengue infections in children is different and the major symptoms include are seizure, rash, coryza, and diarrhoea and less common symptoms are vomiting, abdominal pain and headache (26). Patients with DF also describe blurred vision after seven days of onset of illness while other clinical manifestations are disappearing. Focal retinal haemorrhage, Roth like spots, retinal oedema, cotton wool spots, vasculitis, and optic neuritis are the most common ocular manifestations (27).
DHF occurs less frequently than DF. Although it is primarily a disease of young children, adults may also suffer from DHF. Its clinical presentations are dramatic with abrupt onset of high-grade fever that subsides in approximately 2-7 days. However fever in DHF gives biphasic or saddleback curve. The signs of circulatory failure appear before or about 24 hours after the temperature hits normal or below (28). Blood tests usually illustrate thrombocytopenia and hemoconcentration as evidence of vascular leak syndrome. Skin haemorrhages like purpuric lesions, petechiae and ecchymosis are obvious hemorrhagic manifestation in DHF. The tourniquet test, which indicates that patient has increased capillary fragility, may be diagnostically helpful to the physicians (8). Scattered petechiae appear on the extremities, trunk, face and other parts of the body in patients with severe DSS. More severely ill patients may have gastrointestinal bleed. Shock in dengue infection is usually caused by plasma leakage. Von willebrand factor (VWF) antigen is a macromolecular antigen that is secreted predominantly by endothelial cells and smaller amount from platelet cell. Endothelial activation or injury leads to the release of VWF antigen from endothelial cells. This injury is manifested by a spectrum of clinical effects from hypotension to lung injury. One study revealed that high levels of plasma VWF were associated with hospital deaths and a longer duration of mechanical ventilation (29). It is also thought that endothelial injury may contribute to the widespread formation of platelet micro thrombi leading to tissue ischemia and multiorgan dysfunction. The potential value of VWF antigen as a predictor of the development of acute respiratory distress has been established (5, 28, 29).
In dengue infection, viremia usually hits the peak at the time or shortly after the onset of illness and remains detectable during illness period ranging 2 to 12 days. The number of cells infected with the virus determines the severity of dengue disease and the number of cells infected is related to antibody dependent enhancement (ADE) infection of peripheral leukocytes in secondary infections. It is also hypothesised that there is an association between dengue viremia early in the course of illness and disease outcome in patients with secondary dengue virus 1 and dengue virus 2 infections. However no association has been found in patients with primary dengue virus 1 infection. It has been established that dengue virus 3 viremia (measured as dengue virus 3 genome equivalent levels) and subsequent immune activation were of greater magnitude in more severe clinical disease. The magnitude of plasma leakage was primarily linked to the magnitude of viremia. Sensitive and reproducible quantitative RT-PCR assays have been reliably used to find associations between higher and maximum viremia levels and increasing disease severity (30, 31). The clinical and laboratory parameters are summarised in Table1.
Complications in dengue infections are rare though, the reports of complications are on the rise. However severe dengue infections may give rise to complications (Table2) for example, liver failure, myocarditis, acute renal failure, haemolytic ureaemic syndrome, acute transverse myelitis, and encephalopathy and disseminated intravascular coagulation (DIC) (26, 32). Patients with persistent uncorrected shock may progress to acute respiratory distress syndrome (ARDS), abdominal compartment syndrome (ACS), neurological symptoms, diastolic dysfunction contributing to refractory shock and acute disseminated encephalomyelitis. ACS was described as abdominal distension with intra abdominal pressure >15 mmHg, and any of two signs from the following oliguria or anuria or metabolic acidosis or hypotension shock or respiratory distress (33).
of DF, DHF and DSS is less understood and controversial. Dengue virus is a
complex interplay of host and viral factors. Several risk factors for severe disease
have been established such as age (8, 23),
viral serotype (8), genotype (14) and genetic background (34). The ability to severe illness in
primary infection varies between DV serotypes but secondary infection is by a
heterologous serotype is the paramount risk factor for DHF and DSS (34, 35). Several studies have indicated that certain DEN2 and DEN3 genotypes
are associated with DF and DHF (14, 36).
There are two common theories to explain the pathogenesis of dengue infection. The “immune enhancement hypothesis” is most commonly regarded as reliable. This hypothesis elaborates that patients in second infection with a heterologus dengue virus serotype have a profound higher risk for developing DHF or DSS (38). Already present heterologus dengue antibody (from previous infection) recognises the infecting virus and establishes an antigen-antibody complex, which is bound and internalise by immunoglobulin Fc receptor on the cell membrane of leukocytes. In such, circumstances the antibody is heterologus; the virus is not neutralized and is free to replicate inside macrophages. This is known as antibody dependent enhancement (ADE) and this phenomenon boosts the infectious process and replication of the virus in the cells of the mononuclear lineage (5, 30, 38). Anti-DENV antibodies have demonstrated that they cross-react with platelets, clotting factors, and endothelial cells in humans (39). Lin et al (2005) described that anti-NS1 antibodies bind and induce apoptosis in endothelial cells and increase vascular permeability in DHF and DSS by the secretion of proinflammatory cytokines and chemokines (40). These cells are responsible for the increased vascular permeability that eventually leads to hypovolumia and shock.
theory claims that dengue virus does vary and mutates as a result of selection
pressure as they replicate in human and or mosquitoes. There are also some
virus strains that have greater epidemic potential (31). Phenotypic genetic
changes in the virus genome may contribute in virus replication and viremia,
severity of the disease and epidemic potential. Avirutnan et. al. (2006) revealed
a strong association between peak levels of viremia and progression to DHF for
circulation serotypes in
The pathology of DHF and DSS has been studied extensively. Pathological studies of tissues taken at autopsies have shown diffused petechial haemorrhages of most organs, as well as serous effusion in the pericardial, pleural and peritoneal cavities. Microscopically perivascular oedema and loss of integrity of endothelial junctions are found. There is no prominent damage to the endothelial cells or blood vessels. Midzonal necrosis and Councilman bodies are frequently found in the liver. Recent isolation of dengue virus from brain, cerebrospinal fluid and intrathecal antibody production suggest that dengue virus crosses the blood-brain barrier. There is increased proliferation of reticuloendothelial cells in the bone marrow, spleen, lymph nodes and lungs (24, 42). In a recent cohort study, Jessie and co workers revealed presence of dengue viral antigen in many tissues like liver, spleen, thymus, lung, lymph nodes, kidney and mononuclear phagocytic cells. This study also shows that B and T lymphocytes, endothelial and fibroblast cells could be probable source of infection and replication of virus. It has been established that viral replication occurs in vascular endothelial cells and it contributes to DSS (43).
The diagnosis of dengue infections is difficult on the basis of clinical grounds only because more than half of patients are either asymptomatic or have diffuse picture of fever. This diffuse picture can be attributed to other similar infection such as malaria, typhoid fever, measles, leptospirosis, Epstein-Barr virus, cytomegalovirus, rubella, rickettsial infection and HIV seroconversion illness. Leucopoenia, thrombocytopenia, raised liver function tests, and hyponateremia are important laboratories features in dengue infections (12, 44, 45). A definitive diagnosis of dengue infection can be made only in the virology laboratories. Several types of methods are currently being employed in virology labs for the definitive diagnosis of dengue infections. The methods include virus isolation, detection of viral antigen and or antibodies and genomic sequencing by nucleic acid amplification assays (46, 47). The dengue virus can be found in serum or plasma, circulating blood cells tissues from immune system between 2-7 days of onset of infection (47). Laboratory diagnostic methods are summarised in Table3.
Virus isolation is considered as gold standard methods in the establishment of dengue disease. It is useful in further virological studies and detection of serotype of dengue virus by immunofluorescence staining method. The rate of virus isolation can be improved by collection of blood sample within first six days of disease as viral load is high during first week of illness (48). There are currently four isolation systems used for the isolation of dengue viruses; intracerebral inoculation of 1-3 days old baby mice, the use of mammalian cell cultures (primarily LLC-MK2 Cells), intrathoracic inoculation of adult mosquito and use of mosquito cell structure (3, 25). All DV serotypes are isolated by intracerebellar inoculation of new born mice. This method has not been popular in recent years because of low sensitivity, long isolation time and high cost (49). On the other hand mosquito inoculation and mosquito cell cultures are the most sensitive virological methods. The former method is rarely used for virus isolation now adays. The main disadvantages are extraordinary precautions required to prevent the release of infected mosquito and hard work needed to produce large number of mosquitoes for this method. Four mosquito species such as Aedes aegypti, Aedes albopticus, Tooxorhynchities amboinensis and Tooxorhynchities splendens are used for virus isolation. Serotyping of all DV is done on the brain, salivary gland tissues of mosquito by the immunofluorescence assay (IFA) after one week of isolation at suitable temperature (50, 51). IFA is used for identification of viruses. It is a more reliable and rapid method. The different types of mosquito cell culture for example C6/36 (A. alpopictus), AP61 (A. pseudoscutellaris) and TRA 284 (Toxorhynchities amboinensis) are used for virus isolation and then serotyping. The diluted serum is introduced to the mosquito cell culture monolayer on screw cap tubes, dishes of flasks. Cytopathic effect (CPE) is often detected in within 11 days after inoculation at suitable temperature. IFA stain with all four different serotype specific monocloncal antibodies is used to determine the serotype of DV (48, 50, 51). The cell line C/636 is considered as the method of choice for routine dengue virus isolation. Mammalian cell culture like the Vero cell culture, primarily LLC-MK2 cells are not recommended for routine dengue virus isolation in the clinical laboratories. DV needs multiple passages in this cell culture in order to induce CPE.
Five basic serological techniques have been routinely used for the diagnosis infection; hemagglutination inhibition (HI), complement fixation test (CF), neutralization test (NT), immunoglobulin IgM capture enzyme linked immunosorbent assay (ELISA) and indirect IgG ELISA (1, 3, 6). Regardless of test used, serological diagnosis depends upon a significant 4-fold rise in the titre of specific antibodies between acute and convalescent serum samples. The dengue antibodies are best detected around the day 5 of the illness. It is understood that on the whole, serological techniques used in clinical laboratories have several limitations. The most important drawback is the high cross reactivity between antigens of flaviviruses including all four DV, yellow fever virus, Japanese encephalitis virus or St. Louis encephalitis virus. It also remains difficult to establish the serodiagnosis of past, recent and present dengue infection due to long standing persistence of immunoglobulin G. It is a well established factor that the diagnosis of dengue virus infection is more complicated than the diagnosis of other viral infections because the patient may have been infected with more than one serotype of DV. Infection with one serotype does not confer immunity to other three serotypes of the DV (20, 52, 53).
HI has remained the standard serological diagnostic technique in dengue viral infections due to its high sensitivity rate, reproducibility and easy of execution. It is also used to differentiate primary infection from secondary infection. In primary dengue, antibodies are detected on 5 or 6 day of onset of acute period of disease and antibodies titres are more than 1:10. The antibody titre in convalescent sera is often less than 1:640. On the contrary, the antibodies in secondary dengue can be detected soon after the appearance of clinical illness. Rapid rise in antibodies titres in early days of illness is an important diagnostic feature. In secondary infection seroconvalescent antibodies titres are higher than or equal to 1:2560. In majority of patients, the antibodies levels remain for 2 to 3 months then start to decline. HI is also used for seroepidemiological studies in several parts of the world. The disadvantages include inability to differentiate different serotypes of DV, lack of specificity and require paired samples (46, 54, 55). CF is rarely used for routine dengue diagnosis in the virology laboratories as it requires highly qualified and trained technical staff and is difficult to perform to attain reliable results (53, 54). Although NT is an expensive and tedious technique, is has high specificity for dengue virus diagnosis and it can be used to identify the infecting serotype in primary dengue infection.
Among all serological diagnostic techniques, capture IgM and or IgG ELISA is the most routinely used method for the daily diagnosis of DV infections in clinical laboratories around the world. It has high sensitivity and specificity, easy to perform, no need for sophisticated equipments as well as it provides evidence of recent infection. It also has the ability to distinguish primary dengue infection from secondary dengue infection by capturing IgM or IgG. However, it has a few drawbacks such as the existence of rheumatoid factor in patient’s serum. This may interfere with the specificity of ELISA test in IgM detection and difficulty in detecting DV specific antibody due to cross reactivity between different serotypes of dengue virus. The test is also used to detect antigens (46, 47, 56, 57). IgM appears firstly in the serum and is detectable form day 3 to 5 of illness in patients. Several studies have shown anti-dengue IgM levels reach peak levels in approximately 2 weeks time; they start disappearing to undetectable levels in 60-90 days. IgG appears shortly after the disappearance of IgM IgM titres are markedly high in primary infection as compared to secondary infection (46, 53, 54). IgG ELISA is as sensitive as HI and is used in seroepidemiological studies. It can be used for the differentiation between primary and secondary DV infection. This test is simple to perform although it is not specific, cross reacts with other flaviviruses and unable to differentiate between dengue serotypes (58).
New diagnostic techniques
In the past few years, several new modern and latest methods have been introduced for dengue infection diagnosis. These include polymerase chain reaction (PCR), hybridization probes and immunohistochemistry. These methods have proven useful in the diagnosis of virus infection (1-4, 21, 25).
There is no specific therapy and uncomplicated dengue infections are usually resolved spontaneously. Nevertheless, dengue viral infections with life threatening complications should be managed in hospital with purely supportive management (44, 45).
Dengue fever can easily be managed at home by administering analgesics and antipyretic or tepid sponging as it is a mild self limiting illness. Paracetamol (60 mg/kg/day) is the drug of choice in febrile patients. Aspirin and diclofenac sodium should be avoided because these agents pose a risk of gastric irritation and may cause bleeding. All patients should be observed closely by their general practitioner for the early detection of DHF and DSS. It is highly recommended that platelet counts and packed cells volume should be checked on daily basis. The low levels of the cells indicate the plasma leakage in dengue disease (59, 33). Antiemetic should be administered in patients with vomiting. Hospital admission is necessary if patient develops acute abdominal pain, decreased level of consciousness, cold extremities, bleeding, restless, laboratory evidence of DHF, urine output, and haemoconcentration. Patients with underlying risk factors such as age <1 years, heart disease, anaemia, massive bleeding, comatose, overweight/obese should be monitored closely (26, 60). Patients with probable diagnosis of DHF should be hospitalised in rehydration ward. As mentioned above, antipyretic therapy is given and blood tests are done daily. The fluid and its volume should be determined to the degree of dehydration and electrolyte. It is imperative to monitor the patients for the early signs of DSS. Shock usually occurs after the third day during transition from pyrexia to defervescence period. These patients have low platelet count or have significant loss of blood may require platelet transfusions (61). Patients with probable diagnosis DSS should be provided intensive unit therapy. Vital signs, haemoatocrit and platelet counts, urine output, level of consciousness and haemorrhagic manifestations need to be monitored regularly. Fluid replacement therapy plays a crucial rule in the reversal of DSS. Ringers lactate or 5% glucose at a rate of 10-20 ml/kg/hour is sufficient for infusion. It can be infused rapidly in severe shock. Dose can be raised to 20-30 ml/kg/hour. In case of persistent shock, plasma expander (10-20 ml/kg/hour) can be added (61). Fluid overload should be avoided in order to prevent pulmonary oedema, myocardial oedema and pleural effusion (62, 63). Diastolic dysfunction is an established complication in patients with persistent shock and should be investigated by echocardiography. ACS can be relieved by lowering intra abdominal pressure; hence it improves cardiopulmonary symptoms (33). Prothrombin and partial thromoboplastin times should be measures in patients with DIC and profuse bleeding. In these patients, fresh frozen plasma, platelet concentrate or cryoprecipitate is suggested (26). Management of dengue virus infection is summarised in Table4.
A good prognosis depends on the early diagnosis of the dengue infection, monitoring of the clinical condition of the patient like blood pressure, pulse, urine output, conscious level and good nursing care. The onset of plasma leakage in DHF and DSS progress rapidly and hemotocrit rises abruptly. If it is not managed quickly it may then lead to tissue hypoperfusion, tissue anoxia, metabolic acidosis and organ failure. Fluid replacement has significant role in the desirable outcome in the most dengue infections.
PREVENTION AND CONTROL
At the moment the tools available to prevent dengue infection is limited. There are no vaccines available in the market and options for mosquito control are also disappointing. In these circumstances the emphasis should be on disease prevention if the trend of emergent disease is to be reversed.
Active surveillance remains a fundamental point of dengue prevention program. The main aim of this program should be to provide an early warning or predictive capability for epidemic transmission. Thus the epidemic can be prevented by emergency mosquito control (5).
Prevention and control of dengue infections is based on controlling the mosquito vector in and around the houses, where most transmission occurs. The most effective way to control the mosquitoes is the reduction of larva by eliminating or cleaning of water holding containers that serve as the larval habitat for A. aegypti. Public involvement is necessary in order to implement mosquito control program. It can be achieved by public education and law enforcement (64). Massive media campaign against dengue should be launched in the country. All sections of the society such as school teachers, health workers, religious leaders, community leaders and school children should be encouraged to participate in dengue control program. Government should take necessary step to make people aware of dengue disease and its prevention.
An effective tetravalent vaccine remains a significant challenge. Two live attenuated dengue virus vaccines, attenuated by passing several times I non-human cells, have been developed. Trial of a tetravalent vaccine showed significant seroconversion rates (89%) against all 4 serotypes of DV after the third dose. However, two doses of this vaccine confer 80-90% protection in children (65). Other vaccine, prepared by Walter Reed Army Institute of Research, produced similar seroconversion rates in adult volunteer (60). Several risk factors are associated with live attenuated RNA vaccine such as reversal to a virulent phenotype, and short life.
Dengue virus infections are a major and emerging global health problem in present era. Since these infections are on the continuous rise, it remains important to describe and categorise the common manifestation of dengue infections, employ laboratory tests for its diagnosis and utilise all possible sources for the management and prevention of the disease.
Table1: The clinical and laboratory parameters and differential diagnosis of dengue infections 9, 12, 26, 44, 45.
Sudden onset, high grade fever, flu like illness, myalgia, retro-bulbar pain, maculopapular rash, cervical and occipital lymphadenopathy, ocular manifestations
Low white blood cells count, Low platelet count
Influenza, measles, rubella, leptospirosis, infectious mononucleosis, chickengunya, coxsackie, parovirus and rickettsial infections,
Similar as above, intermittent high grade fever, flushing, abdominal pain, vomiting, anorexia, bleeding tendencies such as petechiae, bruises, haematemesis and meleana, epistaxis, signs of circulatory failure
Low platelet count, Low white blood cells count, increased haematocrit concentration, low albumin, disturbed liver function tests and electrolytes
Viral haemorrhagic disease such as yellow fever, leptospirosis, meningococcemia, acute abdomen, hanta viral infection, chickengunya infection
As above as DF and DHF, cold extremities, signs of shock such oliguria, as low pulse, tachycardia, and hypotension, abdominal tenderness, impaired mental status, encephalopathy and coma
increased haematocrit concentration, metabolic acidosis,
Other viral haemorrhagic fevers, Septicaemia, meningococcemia,
DF, Dengue fever; DHF, Dengue haemorrhagic fever; DS, Dengue shock syndrome
Table 2: Complications of the dengue infections.26,32,33
liver failure, myocarditis, acute renal failure, haemolytic ureaemic syndrome, acute transverse myelitis, encephalopathy, disseminated intravascular coagulation, acute respiratory distress syndrome, abdominal compartment syndrome, neurological symptoms, diastolic dysfunction contributing to refractory shock, acute disseminated encephalomyelitis
Table 3: Methods used in clinical laboratory for the diagnosis tests of dengue infection. 1-4,6,25
Intracerebral inoculation in baby mice
Mammalian cell culture
Mosquito cell culture
Adult mosquito inoculation techniques
Haemagglutination inhibition test
Enzyme linked immunosorbent assay
Indirect IgG Enzyme linked immunosorbent assay
Complement fixation tests
Reverse-Transcriptase Polymerase Chain Reaction
Table 4: Management of patients with dengue infection28,46, 63
Analgesic and antipyretic (Paracetamol, aspirin is contraindicated)
Recognise early signs of DHF/DSS
Hospitalise the patient, Analgesic and antipyretic
Monitor vital signs, urine output and conscious level
Daily blood biochemistry (liver function tests, platelet, white blood cells, hematocrit concentration) for early diagnosis DHF and DSS
Increase fluid intake
Intravenous fluids to correct dehydration (Hartman’s solution, 5% dextrose saline)
Observe for haemorrhagic manifestations
· Admit in Intensive care unit
· Management as above
· nursing care
· Ringers’ acetate at a rate of 10-20 ml/kg body weight/hour, if no improvement increase 20-30 ml/kg body weight/hour and add plasma expander 10-20 ml/kg body weight/hour.
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