Day: July 29, 2019

The Dengue Dance?

Patient Presentation
“My friend Usha, finally came back to school today,” began the dinner conversation with a pediatrician’s daughter.
“She went to India to visit her family, and got some disease. It made her really sick with a fever and they had to stay with their family until she got better,” the girl went on.
“Do you know what it was?” asked the pediatrician.
“I don’t know but she had a bad fever and it sounds like the name of a dance,” she replied.
The pediatrician offered, “We’ll it could be many things. Was it malaria?”
“No that doesn’t sound right,” she answered.
“Maybe Dengue?” said the pediatrician.
“That sounds right! It sounds funny to me like some type of music or dance,” the daughter said.
“I think you are thinking of Merengue,” she parleyed.
“Yeah. Merengue – Dengue, they sound like something you should move to,” the daughter laughed.
“Merengue is great Caribbean music, but Dengue could be really bad. I’m really glad that Usha is much better,” the pediatrician commented.

Discussion
Dengue is an important arboviral infection that affects about 40% of the world population. It is found mainly in topical and subtropical areas of the world mainly in developing countries but it range is spreading including the United States. A review of common arboviruses can be found here. It is a flaviavirus with 4 distinct serotypes named DENV-1 through DENV-4 and is spread by A. aegypti a day biting mosquito. Infection with one serotype confers immunity to that serotype but not the others. It does offer some protection for cross-infection but this only lasts a few months. Incubation period is 3-14 days with an average of 7 after exposure.

A primary infection is usually benign. A second infection with another serotype or multiple infections with different serotypes can cause severe infections.
Dengue fever (DF) presents with skin flushing and abrupt high fever (often biphasic 39.4-40.5C) but could also usually be lower that lasts for 5-7 days. Myalgia and pain especially headache or retroorbital pain is generally constant but remits in a few days. Anorexia, nausea, emesis or abdominal pain occur. Fatigue, lethargy or restlessness are also common. A maculopapular, blanching rash over the body occurs often on day 3-4 of fever and fades with time. DF is sometimes referred to as break-bone fever because of the intense fever.

Dengue hemorrhagic fever or Dengue shock syndrome (DHF/DSS) are different in that patients have the same symptoms but start to have signs of underlying serious infection particularly plasma leakage. Laboratory testing start to show leukopenia, shifting from neutrophils to lymphocytes, and thrombocytopenia which can be severe. Increased hematocrit, hypoalbuminemia and increased liver function tests occur which are part of the plasma leak. Patients will show increased abdominal tenderness, emesis, fluid accumulation including pleural effusions or ascites, mucosal bleeding, mental status changes including lethargy or restlessness, and hepatomegaly. Other signs of plasma leakage and hemorrhage occur with more severe disease including petechiae (e.g. positive tourniquet test), mucosal bleeding, and menorrhagia.

Viral antigen detection testing is available for diagnosis.

Tropical diseases associated with fever include:

  • Anthrax
  • Brucellosis
  • Carrion’s disease/Oroya fever
  • Chikungunya
  • Ebola
  • Human immunodeficiency virus
  • Japanese encephalitis
  • Lassa fever and other arenaviral infections
  • Leptospirosis
  • Lyme disease
  • Murray Valley encephalitis
  • Plague
  • Poliomyelitis
  • Q fever
  • Rabies
  • Rat lungworm
  • Relapsing fever/Borrelia
  • Rickettsioses
  • Riff Valley fever and other bunyaviral infections
  • Rubella
  • Scrub typhus
  • Typhus, endemic and epidemic
  • Sleeping sickness
  • Tetanus
  • Tick-born encephalitis
  • Toxoplasmosis
  • Yellow fever
  • Zika

A review of health affects of climate change can be found here.

Learning Point
There are 3 infection phases for Dengue:
1. Febrile
2. Critical – where patients will deteriorate and have symptoms of plasma leak and hemorrhage occurring for about 24-48 hours often (but not always) as the fever starts to subside (often day 3-7 but not always)
3. Convalescent – when patients improve with resolution of laboratory values and generally without health problems but they may have post-viral fatigue syndrome.


Most patients recover and mortality is 0.8-2.5% with children at increased risk especially those <5 years of age.

There is no specific treatment for Dengue. Treatment is only supportive. Patients who are overall well, able to maintain hydration and have no warning signs of impending hemorrhage are usually treated outpatient. Authors note that oral rehydration fluids work well but fluids that are red or brown in color should not be used as these could be mistaken for gastric hemorrhage. For patients with underlying health problems they are monitored in the hospital and treated accordingly. For patients with DHF/DSS they are treated aggressively for hemorrhage with fluid resuscitation and other measures meant to maintain organ function. Also non-steroid anti-inflammatory drugs should be avoided as they can increase the risk of bleeding.

Mosquito bite prevention is the primary prevention. Dengvaxia® vaccine was approved for use in the United States in May 2019 for persons living in endemic areas such as the US Territories of American Samoa, Puerto Rico and US Virgin Islands. Vaccines can be given to children 9-16 years. The dosing schedule is 3 doses each given 6 months apart. In other countries this vaccine can be given from ages 9-45 years.

Questions for Further Discussion
1. What are good travel health resources to find current information about specific destinations?
2. What are some health affects due to climate change? A review can be found here.
3. What patient education information do you provide to patients traveling internationally?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Dengue

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Kularatne SA. Dengue fever. BMJ. 2015 Sep 15;351:h4661.

Khetarpal N, Khanna I. Dengue Fever: Causes, Complications, and Vaccine Strategies. J Immunol Res. 2016;2016:6803098.

Scaggs Huang FA, Schlaudecker E. Fever in the Returning Traveler. Infect Dis Clin North Am. 2018 Mar;32(1):163-188.

Centers for Disease Control. Dengue Fever. Available from the Internet at https://www.cdc.gov/dengue/ (rev. 5/3/19, cited 5/16/19).

Centers for Disease Control. Dengue Vaccine. Available from the Internet at https://www.cdc.gov/dengue/prevention/dengue-vaccine.html (rev. 5/3/19, cited 5/16/19).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa