Management of Dengue fever with co-infections and co-morbid illnesses

M3 India Newsdesk Oct 04, 2018

Management of dengue patients become harder especially when they present with comorbidities and coinfections, and among pregnant, neonate, and infant patients. The recent national guidelines provide a step-by-step protocol for treating dengue during in specific cases.

Management of DF co-morbid illness

Hypertension, diabetes, thyroid, liver, heart, and renal diseases may worsen severe manifestations in DF.

  1. Dengue hepatitis: Dengue may cause impairment of LFTs. The aspartate aminotransferase/alanine aminotransferase (AST/ALT) level may be raised and PT may be prolonged. Low albumin may worsen severe DHF and bleeding. GI bleeding is common and the patient worsens into severe DSS. The patient should be managed carefully with hepatic failure regimen with appropriate fluid and blood transfusion. IV vitamin K1 may be given if PT is prolonged.
  2. Dengue myocarditis: Dengue infection rarely causes acute myocarditis and development of DSS. Management of shock with IV fluids may be difficult due to myocardial dysfunction. Pulmonary oedema due to improper fluid management may be seen. CAD patients on aspirin and other antiplatelet agents may worsen if these are stopped during dengue infection. CCF or biventricular failure may develop and should be treated cautiously for lowered morbidity and mortality outcomes.
  3. DF in diabetes: Patient’s blood sugar may go out of control and insulin therapy may provide better management.
  4. Renal involvement in DF: If fluids are not given timely, acute tubular necrosis (ATN) may develop during DSS resulting in acute kidney injury (AKI). Kidney injury may become chronic if not addressed properly. Urine output monitoring is vital. Microscopic and macroscopic haematuria are checked in DHF patients. Blood urea, creatinine, electrolytes, glomerular filtration rate (GFR), arterial blood gas (ABG) are checked in patients with severe dengue/DHF. Fluid overload and pulmonary oedema should be avoided. Pre-existing chronic kidney diseases may worsen DF or severe DHF.
  5. CNS involvement in DF: Some conditions such as shock, DSS, electrolyte imbalance (from persistent vomiting), fluid overload (delusional hyponatremia or other electrolytes), or hypoglycaemia may alter sensorium. The central nervous system (CNS) may also be affected by the dengue virus. Acute encephalopathy or encephalitis may occur in severe dengue. Dengue CSF serology for IgM antibody detection can confirm dengue encephalopathy or encephalitis.

Management of DF with co-infections

  1. Malaria: It is prevalent across India and transmission coincides during the same period/season. It should be excluded early and managed specifically with anti-malarials.
  2. Chikungunya: Acute chikungunya complications are sometimes severe in DF. It should be investigated and properly managed if joints are mainly involved in the presentation.
  3. TB: Breathlessness and massive haemoptysis in pulmonary TB may be seen. Moderate-to-massive pleural effusion and acute respiratory distress syndrome (ARDS) may also develop. Respiratory/pulmonary complications should be closely monitored in DF in the presence of TB and anti-TB treatment (ATT) to prevent morbidity and mortality.
  4. HIV: Dengue patients may develop DHF, DSS, significant bleeding, and organ involvement among HIV/AIDS patients. In severely immunocompromised patients with opportunistic infections and very low CD4 counts, the outcome of DF is poor. Multi-organ involvement with high-mortality is common in DF. Managing DF in HIV and AIDS patients is best with a HIV specialist consultation.
  5. Enteric fever: The DF patient with typhoid is more complicated if antibiotic treatment is given late. Blood culture to confirm diagnosis should be done. Widal test may be negative till 2 weeks of fever.

Dengue management in pregnancy

DF increases the risk of bleeding, foetal complications, low-birth-weight and premature birth in pregnancy. Pleural effusion, ascites, hypotension may also occur. Lungs and liver are also commonly affected. Massive pleural effusion and high serum glutamic-oxaloacetic transaminase (SGOT) and serum glutamic-pyruvic transaminase (SGPT) may be seen due to liver involvement. Fluid replacement should be done cautiously to avoid pulmonary oedema.

Frequent BP checks, regular platelet count and coagulation profile tests should be done. As fulminant hepatic failure, ARDS and acute renal failure may be seen with dengue infection in pregnancy, and it should be managed seriously to reduce morbidity and mortality in both mother and foetus.

Neonatal dengue management

Newborns may go into shock. A history of febrile illness during pregnancy may help to diagnose DSS among neonates and infants. Close observation, symptomatic, and supportive treatment are vital.

Dengue management in infants

  • Dengue with no warning signs: Oral rehydration solution (ORS), fruit juice, and fluids with electrolytes and sugar are given with breastfeeding or formula feeding. Parents or caregivers should be advised about fever control with antipyretics and tepid sponging, with advice to visit the nearest hospital immediately if any warning signs develop.
  • Dengue with warning signs: When warning signs present, IV fluid therapy should be started. Isotonic crystalloid solutions such as Ringer’s lactate (RL), Ringer’s acetate (RA), or 0.9% saline solution should be given. In 24-48 hours, the capillary leaks usually resolve spontaneously.

Severe dengue: Treatment of shock

In infants, volume should be promptly replaced during the period of effervescence.

Management of dengue in an outbreak situation

During an outbreak, patient turnover rises exceptionally. Emergency hospitalisation facilities and an effective use of hospital and treatment facilities should be planned in all hospitals situated in endemic areas in the event of an outbreak.

Criteria for admission of a patient

Any DF patient with significant bleeding from any site, hypotension, persistent high-grade fever, rapid fall of platelet count, sudden drop in temperature is a candidate for hospital admission. Patients with evidence of organ involvement and warning symptoms and signs should also be admitted for proper monitoring and management.

Criteria for discharge of patients

Discharge criteria for hospitalised patients who had acute dengue infection include:

  • No fever for at least 24 hours
  • Normal BP
  • Adequate urine output
  • No respiratory distress
  • Persistent platelet count >50,000/mm3
  • Indications of platelet transfusion

Prophylactic platelet transfusion may be given when platelet levels are <10,000/mm3 in absence of bleeding manifestations but there is usually no need to give prophylactic platelets even at <20,000/mm3. In prolonged shock with coagulopathy and abnormal coagulogram, platelets may be given. In massive systemic bleeding, platelets may be needed in addition to red cell transfusion.

Also read National guidelines for clinical management of Dengue fever in India

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