DENGUE HEMORRHAGIC FEVER

Dengue hemorrhagic fever is a severe, potentially deadly infection spread by certain species of
mosquitoes (Aedes aegypti).

Causes, incidence, and risk factors

Four different dengue viruses are known to cause dengue hemorrhagic fever. Dengue hemorrhagic fever
occurs when a person catches a different type dengue virus after being infected by another one sometime
before. Prior immunity to a different dengue virus type plays an important role in this severe disease.
Worldwide, more than 100 million cases of dengue fever occur every year. A small number of these
develop into dengue hemorrhagic fever. Most infections in the United States are brought in from other
countries. It is possible, but uncommon, for a traveler who has returned to the United States to pass the
infection to someone who has not traveled.
Risk factors for dengue hemorrhagic fever include having antibodies to dengue virus from prior infection
and being younger than 12, female, or Caucasian.

Symptoms
Early symptoms of dengue hemorrhagic fever are similar to those of dengue fever, but after several days
the patient becomes irritable,restless, and sweaty. These symptoms are followed by a shock -like state.
Bleeding may appear as tiny spots of blood on the skin (petechiae) and larger patches of blood under the
skin (ecchymoses). Minor injuries may cause bleeding.
Shock may cause death. If the patient survives, recovery begins after a one-day crisis period.
Early symptoms include:

Decreased appetite

Fever

Headache

Joint aches

Malaise

Muscle aches

Vomiting

Acute phase symptoms include:

Restlessness followed by:

o

Ecchymosis

Generalized rash

Petechiae

Worsening of earlier symptoms

Shock-like state
o

Cold, clammy extremities

Sweatiness (diaphoretic)

Signs and tests

A physical examination may reveal:
Enlarged liver (hepatomegaly)

Low blood pressure

Rash

Red eyes

Red throat

Swollen glands

Weak, rapid pulse

Tests may include:

Arterial blood gases

Coagulation studies

Electrolytes
Hematocrit

Liver enzymes

Platelet count

Serologic studies (demonstrate antibodies to Dengue viruses)

Serum studies from samples taken during acute illness and convalescence (increase in titer to
Dengue antigen)

Tourniquet test (causes petechiae to form below the tourniquet)

X-ray of the chest (may demonstrate pleural effusion)

Treatment
Because Dengue hemorrhagic fever is caused by a virus for which there is no known cure or vaccine, the
only treatment is to treat the symptoms.

A transfusion of fresh blood or platelets can correct bleeding problems

Intravenous (IV) fluids and electrolytes are also used to correct electrolyte imbalances

Oxygen therapy may be needed to treat abnormally low blood oxygen

Rehydration with intravenous (IV) fluids is often necessary to treat dehydration

Supportive care in an intensive care unit/environment

Expectations (prognosis)
With early and aggressive care, most patients recover from dengue hemorrhagic fever. However, half of
untreated patients who go into shock do not survive.

Complications

Encephalopathy

Liver damage

Residual brain damage

Seizures

Shock

Tourniquet Test for Dengue

In a tourniquet test for dengue, the blood capillaries are examined for their ability to withstand
increased pressure. This gives a good indication for assessing the blood vessels and whether it will
lead to Dengue Shock Syndrome (DSS) or Dengue Hemorrhagic Fever (DHF). This test involves
checking what are known as petechiae, i.e. small red spots under the surface of the skin. These
petechiae are formed when blood leaks from capillaries into the skin. Pressing the petechiae does not
have any effect on its appearance.
Performing the Dengue Tourniquet Test

Pump up a blood pressure cuff on one of the arm to more than venous pressure (70 mm Hg).

Keep it for 5 minutes and then ease the pressure.

Examine the extremity of the pressure for petechiae.

If there are more than 2 petechiae, the test is positive.

This test is not considered to be completely reliable for confirming dengue. Factors that can influence
the results are premenstrual and postmenstrual period in women and sun damaged skin in people.
This is because all such people are sure to have relatively fragile capillaries. Dengue Tourniquet Test
does have its use in diagnosis of dengue. It is useful in monitoring a patients condition when he is
suffering fromDengue Shock Syndrome (DSS) or Dengue Hemorrhagic Fever (DHF).
The World Health Organization (WHO) has defined this test as one of the necessary requirements

fordengue fever diagnosis. In case of Dengue Haemorrhagic Fever (DHF), the test generally gives a
sure positive result with 20 or more petechiae per square inch. Since the test does not have high
specificity i.e. ability to confirm the infection, the interfering conditions must be taken into
consideration.
Premenstrual women, postmenstrual women who are not taking hormonal supplements, women
having skin damaged by sun must not take this test as they have high capillary fragility due to
altogether different reasons. Since dengue infection is typical of a tropical and sub-tropical country,
the tourniquet test is used to evaluate the possibility of dengue infection immediately in such
countries. There are 36 million symptomatic cases of dengue worldwide with 2.1 million severe cases
reported in the year 2010. With a tourniquet test, people suspected of having contracted the
infection can be immediately hospitalised for treatment and further diagnosis.

Chikungunya
Key facts

Chikungunya is a viral disease that is spread by mosquitoes. It causes fever and severe
joint pain. Other symptoms include muscle pain, headache, nausea, fatigue and rash.
The disease shares some clinical signs with dengue, and can be misdiagnosed in areas
where dengue is common.
There is no cure for the disease. Treatment is focused on relieving the symptoms.
The proximity of mosquito breeding sites to human habitation is a significant risk factor
for chikungunya.
The disease occurs in Africa, Asia and the Indian subcontinent. In recent decades
mosquito vectors of chikungunya have spread to Europe and the Americas. In 2007, disease
transmission was reported for the first time in Europe, in a localized outbreak in north-eastern
Italy.
Chikungunya is a mosquito-borne viral disease first described during an outbreak in southern
Tanzania in 1952. It is an alphavirus of the family Togaviridae. The name chikungunya derives
from a root verb in the Kimakonde language, meaning "to become contorted" and describes the
stooped appearance of sufferers with joint pain.
Signs and symptoms
Chikungunya is characterized by an abrupt onset of fever frequently accompanied by joint pain.
Other common signs and symptoms include muscle pain, headache, nausea, fatigue and rash. The
joint pain is often very debilitating, but usually ends within a few days or weeks. Most patients
recover fully, but in some cases joint pain may persist for several months, or even years.
Occasional cases of eye, neurological and heart complications have been reported, as well as
gastrointestinal complaints. Serious complications are not common, but in older people, the

disease can contribute to the cause of death. Often symptoms in infected individuals are mild and
the infection may go unrecognized, or be misdiagnosed in areas where dengue occurs.
Transmission
The virus is transmitted from human to human by the bites of infected female mosquitoes. Most
commonly, the mosquitoes involved are Aedes aegypti andAedes albopictus, two species which
can also transmit other mosquito-borne viruses, including dengue. These mosquitoes can be
found biting throughout daylight hours, although there may be peaks of activity in the early
morning and late afternoon. Both species are found biting outdoors, but Ae. aegypti will also
readily feed indoors.
After the bite of an infected mosquito, onset of illness occurs usually between four and eight
days but can range from two to 12 days.
Diagnosis
Several methods can be used for diagnosis. Serological tests, such as enzyme-linked
immunosorbent assays (ELISA), may confirm the presence of IgM and IgG anti-chikungunya
antibodies. IgM antibody levels are highest three to five weeks after the onset of illness and
persist for about two months. The virus may be isolated from the blood during the first few days
of infection. Various reverse transcriptasepolymerase chain reaction (RTPCR) methods are
available but are of variable sensitivity. Some are suited to clinical diagnosis. RTPCR products
from clinical samples may also be used for genotyping of the virus, allowing comparisons with
virus samples from various geographical sources.
Treatment
There are no specific drugs to cure the disease. Treatment is directed primarily at relieving the
symptoms, including the joint pain. There is no commercial chikungunya vaccine.
Prevention and control
The proximity of mosquito vector breeding sites to human habitation is a significant risk factor
for chikungunya as well as for other diseases that these species transmit. Prevention and control
relies heavily on reducing the number of natural and artificial water-filled container habitats that
support breeding of the mosquitoes. This requires mobilization of affected communities. During
outbreaks, insecticides may be sprayed to kill flying mosquitoes, applied to surfaces in and
around containers where the mosquitoes land, and used to treat water in containers to kill the
immature larvae.
For protection during outbreaks of chikungunya, clothing which minimizes skin exposure to the
day-biting vectors is advised. Repellents can be applied to exposed skin or to clothing in strict
accordance with product label instructions. Repellents should contain DEET (N, N-diethyl-3methylbenzamide), IR3535 (3-[N-acetyl-N-butyl]-aminopropionic acid ethyl ester) or icaridin
(1-piperidinecarboxylic acid, 2-(2-hydroxyethyl)-1-methylpropylester). For those who sleep
during the daytime, particularly young children, or sick or older people, insecticide treated
mosquito nets afford good protection. Mosquito coils or other insecticide vaporizers may also
reduce indoor biting.
Disease outbreaks

Chikungunya occurs in Africa, Asia and the Indian subcontinent. Human infections in Africa
have been at relatively low levels for a number of years, but in 1999-2000 there was a large
outbreak in the Democratic Republic of the Congo, and in 2007 there was an outbreak in Gabon.
Starting in February 2005, a major outbreak of chikungunya occurred in islands of the Indian
Ocean. A large number of imported cases in Europe were associated with this outbreak, mostly in
2006 when the Indian Ocean epidemic was at its peak. A large outbreak of chikungunya in India
occurred in 2006 and 2007. Several other countries in South-East Asia were also affected. In
2007 transmission was reported for the first time in Europe, in a localized outbreak in northeastern Italy.
More about disease vectors
Both Ae. aegypti and Ae. albopictus have been implicated in large outbreaks of chikungunya.
Whereas Ae. aegypti is confined within the tropics and sub-tropics,Ae. albopictus also occurs in
temperate and even cold temperate regions. In recent decades Ae. albopictus has spread from
Asia to become established in areas of Africa, Europe and the Americas.
The species Ae. albopictus thrives in a wider range of water-filled breeding sites than Ae.
aegypti, including coconut husks, cocoa pods, bamboo stumps, tree holes and rock pools, in
addition to artificial containers such as vehicle tyres and saucers beneath plant pots. This
diversity of habitats explains the abundance ofAe. albopictus in rural as well as peri-urban areas
and shady city parks. Ae. aegypti is more closely associated with human habitation and uses
indoor breeding sites, including flower vases, water storage vessels and concrete water tanks in
bathrooms, as well as the same artificial outdoor habitats as Ae. albopictus.
In Africa several other mosquito vectors have been implicated in disease transmission, including
species of the A. furcifer-taylori group and A. luteocephalus. There is evidence that some
animals, including non-primates, may act as reservoirs

Symptoms and Treatment

Chikungunya virus infection can cause a debilitating illness, most often characterized by fever,
headache, fatigue, nausea, vomiting, muscle pain, rash, and joint pain. The term chikungunya
means that which bends up in the Kimakonde language of Mozambique.
Acute chikungunya fever typically lasts a few days to a few weeks, but as with dengue, West
Nile fever and other arboviral fevers, some patients have prolonged fatigue lasting several
weeks. Additionally, some patients have reported incapacitating joint pain, or arthritis which may
last for weeks or months. The prolonged joint pain associated with chikungunya virus is not
typical of dengue. No hemorrhagic cases related to chikungunya virus infection have been
conclusively documented in the scientific literature. Co-circulation of dengue fever in many
areas may mean that chikungunya fever cases are sometimes clinically misdiagnosed as dengue
infections, therefore the incidence of chikungunya fever could be much higher than what has
been previously reported.
The incubation period (time from infection to illness) can be 2-12 days, but is usually 3-7 days.
Silent chikungunya virus infections (infections without illness) do occur, but how commonly

this happens is not yet known. Chikungunya virus infection (whether clinically apparent or
silent) is thought to confer life-long immunity. Fatalities related to chikungunya virus are rare.
Pregnant women can become infected with chikungunya virus during all stages of pregnancy and
have symptoms similar to other individuals. Most infections occurring during pregnancy will not
result in the virus being transmitted to the fetus. The highest risk for infection of the fetus/child
occurs when a woman has virus in her blood (viremic) at the time of delivery. There are also rare
reports of first trimester abortions occurring after chikungunya infection. Pregnant women
should take precautions to avoid mosquito bites. Products containing DEET can be used in
pregnancy without adverse effects. Currently, there is no evidence that the virus is transmitted
through breast milk.
There is no vaccine or specific antiviral treatment currently available for chikungunya fever.
Treatment is symptomatic and can include rest, fluids, and medicines to relieve symptoms of
fever and aching such as ibuprofen, naproxen, acetaminophen, or paracetamol. Aspirin should be
avoided. Infected persons should be protected from further mosquito exposure (staying indoors
in areas with screens and/or under a mosquito net) during the first few days of the illness so they
can not contribute to the transmission cycle