The Sundaytimes Sri Lanka

Dealing with Dengue

With the number of reported cases and also deaths on the rise, Dr. LakKumar Fernando discusses with Kumudini Hettiarachchi the vital steps in detection and treatment

Dengue does not strike anyone like a bolt from the blue, bringing death instantly. The signs and symptoms are clear and evident.
Be it a man, woman or child, the warning signs and symptoms should be heeded and acted upon immediately, stresses dengue expert Dr. LakKumar Fernando who is attached to the Negombo General Hospital, dispelling recent speculation that this disease which seems to spell doom in Sri Lanka comes upon people suddenly.

A child undergoing treatment at the Negombo Hospital. Pic by M.A. Pushpa Kumara

The most important symptom is fever, MediScene understands and by the second day of fever, the first culprit that needs to be suspected is the dengue virus. A blood test will be a must on Day 3.With not only the number of dengue patients but also deaths on the rise just half-way into the year and intermittent showers a frequent occurrence, MediScene contacted this Consultant Paediatrician to help arm Sri Lankans against this scourge.

“If anyone gets fever these days, the first suspect should be dengue,” he reiterates. It is a must to take the temperature with a thermometer. Sometimes the person may think he is having only a headache but if a headache lasts more than a day and the temperature is checked, he is sure to be running a fever.

The “normal” temperature of a human is 37 oC or 98.6 oF.Don’t be scared about the fever, urges this Paediatrician, advising that it is very important to give the patient only paracetamol, until dengue is ruled out. Parents are so terrified of fever, which is just a symptom of another underlying cause, that they beg doctors to give their children ‘something’ to get rid of it.

Here lies the danger, he explains, for if non-steroidal anti-inflammatory drugs (NSAIDS) are used to bring the fever down and the cause of the fever is dengue, the consequences would be disastrous. The fever should be managed with paracetamol and sponging with warm water.

However, if a person has fever for more than two days, don’t delay thinking it’s the flu, seek medical attention from a competent doctor who is concerned about dengue, says Dr. Fernando, pointing out that it is very important to check the temperature with a thermometer and keep a record of it to help the doctor. Both Paediatricians and Physicians are well-equipped to handle all strains of the dengue virus.
Just because someone has a cold, sore throat or cough, don’t be complacent, as these could also mask the fact that the person is having dengue, he says.

Dengue is spread by a hardly-visible female mosquito with white dots on its legs from both the Aedes aegypti and Aedes albopictus groups. Usually a day-biter it is more likely to bite in the morning between 6 and 10 and early afternoon-evening between 3 and 6.
Two to seven days after being bitten by an infected mosquito, the person may be struck down by dengue, MediScene understands.

The symptoms will include:
•    Acute onset of high fever
•    Severe body (joint and muscle) aches
•    Severe headache
•    Retro-orbital pain (pain behind the eye-ball)
•    Nausea and vomiting
•    Flushing

There are four strains of dengue – DEN-1, DEN-2, DEN-3 and DEN-4, according to this Dengue Specialist. Anyone of these can cause either Dengue Fever (DF) or the more dangerous Dengue Haemorrhagic Fever (DHF). “Just because you get one strain doesn’t mean that you have immunity and won’t get another strain. If you have had one strain, the antibodies created in your body by the first infection will make the second attack more severe.”

Whatever the reason, if you have fever, it is vital to rest, according to this Paediatrician who advises parents to refrain from sending their children to school and tuition. “If your child is having fever, forget the rat-race you and your child are part of to pass examinations. Ensure that the child rests while giving him adequate fluid including fruit juices and Jeevani.”

“Adequate” means the amount of fluid the person requires for normal, daily urine output. After Day 3, giving too much fluid, especially force-feeding a child could sometimes be dangerous, for if he is having DHF he can start leaking fluid anytime between Day3 and Day 7. During this period, giving too much fluid may aggravate the leaking as well, MediScene learns.

Dr. Fernando

There is a fine line between giving too much and too little fluid, warns Dr. Fernando, explaining that too little could also be dangerous. The best way to judge would be to ensure that the child or the adult maintains the normal daily urine output. “It’s not the frequency of passing urine but the volume that is passed. If too much fluid has been given the volume will be heavy and too little, the volume will be less.”

If the fever has not subsided after Day 2, seek medical help, it is stressed.It is then that doctors will distinguish between DF and DHF which look like twins in the first two days of fever. Underscoring the fact that DF will never turn into DHF, Dr. Fernando says that while almost all DF patients will recover, the danger lies with DHF which if neglected would end in death.

The “red flag” of DHF is plasma leakage from the blood vessels to body cavities such as the abdominal (peritoneal) cavity and chest (pleural) cavity. There is no plasma leakage in DF, he says.

Clearing the confusion, Dr. Fernando explains that although a drop in the platelet count will give a strong indication to the doctor that the patient is having dengue, it is essential to perform an ultrasound or do an X-ray as well as a haematocrit count to determine whether it’s DHF. Tests such as serum albumin and cholesterol will also aid in differentiating between DF and DHF.

The ultrasound or X-ray, without doubt, will provide objective evidence whether there is fluid in the chest or abdomen cavities, it is learnt. A blood test with the packed cell volume (PCV) reading is more speculative and occasionally can even be misleading
If found to be DHF, the patient’s life is definitely in the doctor’s hands — as clinical management is the key to saving lives.

Three phases of DHF

Febrile (fever) phase – The sudden onset of high fever lasting between 2-7 days, with flushing of the face, skin redness or rash, muscle and joint pain and headache. The patient could also develop a sore throat, infected pharynx and conjunctival (eye) infection. Nausea and vomiting are common. Although these features will be present in both DF and DHF, a tender liver will indicate a tendency towards DHF.

Critical phase – Lasting between 24 and 48 hours, this phase comes towards the end of the febrile stage. Almost never occurring in the first two days of the disease, the patient could get into the critical phase any time from Day 3, commonly on Day 4 or Day 5 or even as late as Day 7. The fever may come down rapidly but the patient’s general condition will not improve, unlike in other viral infections. Sometimes he may improve if there has been minimal or no plasma leak. However, the leakage of a large volume of plasma will make the patient critically ill.

Recovery phase – Lasts 3-5 days but may be longer in adults. The plasma leakage stops and the fluid that leaked out during the critical phase is re-absorbed. The patient’s well-being and appetite improve. The movement of blood stabilizes and urine output starts increasing. A recovery rash which has white areas on a red background, along with generalized itching may occur. A rise in the platelet count will be preceded by a rise in the white blood cell count.

Having treated many a child suffering from DHF and saving them from an untimely death, Dr. Fernando shares his experiences through a day-by-day management plan.

Day 1 & 2 — the patient should be hydrated, reversing any losses due to vomiting. If there is vomiting, he should be given fluids only to maintain the usual body functions. It is unlikely that the patient will get into the critical phase. Day 3 — if the patient has DHF, large amounts of fluid being given freely should be avoided to prevent an overload. It is better to restrict fluids to some degree only to maintain a “just” adequate urine output.

CRITICAL STAGE — A platelet count of less than 100,000, an increase of haematocrit (packed red blood cells in a proportion of blood) by 20%, low albumin or cholesterol detected by frequent blood tests and/or the presence of fluid in body cavities detected through X-rays and ultrasound scanning will alert the doctors.

Fluid leakage will be there for a minimum period of 24 and a maximum period of only 48 hours. Some patients, particularly neonates and infants, will have such leakage for 24 hours, after which it will cease. Therefore, it is vital for the doctor managing the patient to evaluate the physical signs and other factors to check whether leakage has stopped.

If it has stopped, fluid therapy should be halted, otherwise there will be an overload. The fluid infusions should be continued only if there is evidence that the patient is continuing to leak even after 24 hours.

Dealing with the importance of close monitoring, Dr. Fernando explains that when the patient peaks the leakage stage and shock is detected, the fluid infusion rate should be increased rapidly. Otherwise, the patient will die. With many patients appearing conscious and very alert until the last stage of shock, there is a misconception that they are doing well. The early signs of shock may be ascertained through the pulse and blood pressure taken frequently.

The four essential criteria in the clinical definition of DHF are fever or recent history of acute fever, haemorrhagic manifestations and low platelet count – 100,000/mm3 or less, aided by objective evidence of leaky capillaries – elevated haematocrit (20% or more over baseline), low albumin/cholesterol and pleural or other effusions.

At a glance

n    Don’t rule out dengue just because someone is having a runny nose, cold, cough or loose stools. Fever lasting two days is the danger signal – record the fever with a thermometer and after Day 2 go to a doctor and get a blood test done.
n    DF is not dangerous – it’s DHF which kills. The Gold Standard to prove whether it’s DHF is the ultrasound scan of the chest or abdomen to look for fluid leakage.
n    A majority of DHF patients have suffered the dengue infection more than once. But uncommonly it can also occur in the first infection.
n    NSAIDS such as ibuprofen, mefenamic acid, diclofenic sodium and also aspirin should be avoided from Day 1 of fever. NSAIDS could cause mild gastric erosion and if the patient is having DHF, with the progression of the disease, cause major bleeding from these eroded sites, sending him into shock faster.
Diclofenac suppositories such as Diclo-Denk, Almiral, Jonac, Remathan and Voltaren may derange the coagulatory system which will lead to bleeding even with relatively high platelet counts, says Dr. Fernando.
n    If paracetamol does not bring the fever down, sponge the patient with warm water and not room-temperature tap water or cool or iced water. When sponging what happens is the water on the skin absorbs the heat of the body to reach evaporation point, bringing the fever down. Warm water will reach this evaporation point sooner, while also expanding the surface of the vessels, allowing more heat to get out from the body. So dip a towel in warm water and sponge down the patient.
n    Too much or too little fluid therapy is dangerous. To save DHF patients the right amount is a must.

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