Dengue Hemorrhagic Fever

Dengue hemorrhagic fever is a dengue virus infection that is transmitted to humans through the bite of infected female Aedes aegypti and Aedes albopictus mosquitoes. Dengue fever is caused by four serotypes of dengue virus (DENV), namely DENV-1, DENV-2, DENV-3, and DENV-4 which are generally widespread in tropical and subtropical climates, including Indonesia. The incidence of dengue fever has increased dramatically over the past few decades. About half of the world's population is now at risk of dengue hemorrhagic fever with an estimated 100–400 million infections occurring each year.

The incubation period for dengue virus infection is 4-10 days. Dengue virus infection can cause a spectrum of diseases ranging from asymptomatic, flu like syndrome, dengue fever, dengue hemorrhagic fever, dengue shock syndrome to death. The course of dengue fever/dengue hemorrhagic fever is closely related to calculating the days of the fever, because by knowing the days of the fever we can estimate that the patient is in a certain phase.

• After the incubation period

sufferers will experience 3 phases of the disease, namely the fever phase, critical phase and recovery phase.

• Critical phase (fever days 4-6)

The beginning of the critical phase is generally marked by a decrease in body temperature, and generally occurs on days 3-7 of the course of the disease. It is called the critical phase because in this phase plasma leakage occurs (usually lasts 24-48 hours). In this phase, it is very important to monitor the emergence of bleeding and plasma leakage into the pleural and abdominal cavities, apply appropriate therapy, and stabilize the fluid volume in the body. Signs of plasma leakage include hemoconcentration (sudden increase in hematocrit ≥20% from baseline), presence of ascites, pleural effusion, low serum albumin or protein. If not treated properly, this condition can cause intravascular volume depletion and cord.

• Convalescence phase (reabsorption)

This third phase begins when the critical phase ends, which is marked by the cessation of plasma leakage and the start of fluid reabsorption. During this phase, fluids that leaked from the intravascular space (plasma fluid and intravenous fluid) during the critical phase are reabsorbed. Indicators that show that the patient is entering the convalescence phase are the patient feeling that he has improved, appetite increases, vital signs begin to stabilize, bradycardia, hematocrit levels return to normal, increased urine output, and the appearance of convalescence rash of dengue.

Most dengue fever sufferers have mild symptoms or no symptoms at all and will recover in 1-2 weeks. If symptoms appear, they usually begin 4–10 days after infection and last for 2–7 days. Symptoms of dengue fever that are often encountered include high fever (40°C), severe headache, pain behind the eyes, muscle and joint pain, nausea, vomiting, enlarged glands, and a rash. Meanwhile, symptoms of severe dengue fever often appear after the fever disappears, including severe abdominal pain, continuous vomiting, shortness of breath, bleeding gums or nose, vomiting blood or bloody stools, restlessness, pale and cold skin.

Signs and symptoms of dengue hemorrhagic fever are not specific, so laboratory confirmation of dengue infection is very important. Laboratory examination to detect the dengue virus is by examining virus isolation. Even though it is definitive, this examination is not practical, because it takes a long time. This limitation led to the introduction of molecular methods using Polymerase Chain Reaction (PCR). In addition to detecting the virus itself, viral proteins such as non-structural protein 1 (NS1) are used for DENV diagnosis. Apart from viruses or virus products, dengue can be confirmed based on the host's immune response, namely by examining immunoglobulin G (IgG) or immunoglobulin M (IgM) antibodies. This examination can also differentiate primary or secondary dengue infection. Typical laboratory examination findings in dengue hemorrhagic fever are thrombocytopenia (platelet count < 100 x 10^9/L), leukopenia, and mild to moderate increases in aspartate aminotransferase and alanine aminotransferase values. An increase in hematocrit levels of more than 20% is a sign of hemoconcentration and precedes shock. Hematocrit levels should be monitored at least every 24 hours and every 3-4 hours in cases of severe dengue hemorrhagic fever or dengue shock syndrome.

To reduce the death rate due to dengue fever and control the severity of the disease, early diagnosis is important for effective disease management. Currently, there is no antiviral drug for dengue fever. Some recommendations for treating dengue fever include rest, antipyretics to control fever, analgesics to help relieve pain, and fluid or electrolyte therapy to help with hydration.

With the high number of dengue fever cases worldwide, vaccine development has great potential in controlling dengue fever infections. Dengue hemorrhagic fever has 4 different serotypes, after recovering from one serotype, infected individuals have long-term immunity against subsequent infections with the same DENV serotype, but not with different serotypes.  The tetravalent dengue vaccine provides protection against all four DENV serotypes simultaneously. This vaccine can reduce the risk of hospitalization and reduce the severity of dengue fever symptoms.

 

 

 

Referensi :

1. WHO Regional Office for South-East Asia. Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever. India: WHO Regional Office for South-East Asia; 2011
2. World Health Organization. Dengue and severe dengue fact sheet. WHO. 2024
3. Pedoman Nasional Pelayanan Kedokteran (PNPK). Kemkes.go.id n.d. Available from: https://www.kemkes.go.id/id/pnpk-2020---tata-laksana-infeksi-dengue-pada-dewasa.
4. Wang WH, Urbina AN, Chang MR, et al. Dengue hemorrhagic fever – A systemic literature review of current perspectives on pathogenesis, prevention and control. J Microbiol Immunol Infect [Internet]. 2020;53(6):963–78. Available from: https://doi.org/10.1016/j.jmii.2020.03.007
5. Bhatt P, Sabeena SP, Varma M, Arunkumar G. Current understanding of the pathogenesis of dengue virus infection. Curr Microbiol [Internet]. 2021 [cited 2024 Mar 27];78(1):17–32. Available from: http://dx.doi.org/10.1007/s00284-020-02284-w