Dengue and Bedside US: What Could Help You More Than Blood Test Rathachai Kaewlai, MD Division of Emergency Radiology, Dept of Radiology Ramathibodi Hospital, Bangkok, Thailand WINFOCUS Ultrasound Enhanced Life Support, Chulalongkorn Hospital University, 10 Jan 2016
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Dengue and Bedside US: ���What Could Help You More Than Blood Test
Rathachai Kaewlai, MD Division of Emergency Radiology, Dept of Radiology Ramathibodi Hospital, Bangkok, Thailand WINFOCUS Ultrasound Enhanced Life Support, Chulalongkorn Hospital University, 10 Jan 2016
Outline
Dengue infection
Traditional means of diagnosis Bedside ultrasound – evidence so far
Dengue: Major Public Health
3.9 billion people in 128 countries at risk 390 million dengue infections per year
Dengue: Major Public Health
Average annual number of DF and DHF cases reported to WHO, and of countries reporting dengue, 1955-2007
Dengue Infection
Flavivirus infection
Four serotypes: DEN-1, DEN-2, DEN-3, DEN-4 Several possible vectors: Aedes aegypti, Aedes albopictus Incubation period 3-14 days (average 4-7 days)
Most severe infections = co-infection of two different serotypes
Images from ucanr.edu and virology.wisc.edu
Dengue Infection: ���Primary or Secondary Primary: infection with any serotype inducing immune
response protecting re-infection by that serotype Mostly children
Secondary: infection by another serotype Mostly adults or elderly A/W significant morbidity and occasional death
Dengue Infection
Wide spectrum of clinical presentations
Often unpredictable clinical evolution and outcome Infection may be asymptomatic, self-limiting febrile
illness or
Small number of cases – severe/life-threatening characterized by plasma leakage w/wo hemorrhage
Dengue: Course of Illness
WHO: ���Focus on First Level of Care Recognize that the febrile patient could have dengue
Notify public health authorities Manage patients in early febrile phase Recognize early stage of plasma leakage or critical phase
and initiate fluid therapy Recognize patients with warning signs needing referral
or admission
Recognize and manage severe plasma leakage and shock
Dengue: Confusing With Classification? Think of it as the same disease of different severity
Asymptomatic ! Mild ! Severe ! Lethal Fever ! Leakage/hemorrhage
Viral syndrome ! DF ! DHF ! DSS (WHO SEAsia) Dengue wo warning ! w warning ! Severe (WHO)
Symptomatic Rx ! Admission ! ICU
Dengue: Beware
Even dengue patients without warning signs may develop severe dengue (“DHF is not a continuum of DF”)
Expanded dengue syndrome
Unusual or atypical manifestations Uncommon but increasing reports Neurological, hepatic, renal and other isolated organ involvement (complications of severe profound shock or a/w underlying host diseases)
Dengue: Role of Ultrasound
Detect plasma leakage
Ascites Pleural effusion
Gallbladder wall edema is a/w plasma leakage and may precede clinical detection of plasma leakage
Helpful for diagnosis of severe dengue/DHF in patients with anemia, severe hemorrhage, no baseline Hct or rise in Hct <20% because of early IV therapy
Dengue: Role of Ultrasound
Identify patients at risk of progression to severe dengue
Detect subclinical plasma leakage by daily US Ascites and/or pleural effusion found in 27/66 cases: 31% in non-severe dengue vs 91% in severe dengue
PPV 35%, NPV 90% Thickened GB wall for predicting severe dengue PPV 21%, NPV 91%
Michels M, et al. PLoS Negl Trop Dis 2013
Dengue: Role of Ultrasound
Raise a possibility of this diagnosis in unsuspected cases:
Atypical presentation Limited resources in lab testing