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Commentary on Dengue Fever’s Symptoms, Causes, and Treatment
Dengue is a mosquito-transmitted virus disease characterized by intense muscle spasms, joint pain, and high fever which reflect the severity and duration of symptoms. Most cases of dengue fever are asymptomatic or present as mild febrile illness but severe illness and mortality can occur. The World Health Organization classifies dengue into probable dengue, dengue with warning signs, and severe dengue. Dengue fever has increased rapidly worldwide in recent decades affecting over 80 countries across all WHO regions in 2023. As of April 2024, over 7.6 million dengue cases, including 3.4 million confirmed cases, over 16,000 severe cases and over 3000 deaths, had been reported to WHO. Untreated severe dengue fever might have a fatality rate of 10% to 20%. However, with the right supportive care, the death rate can be decreased to under 1%.
Indonesia is a tropical country where both main mosquito vector species are endemic in all regions. According to data from Indonesia’s Ministry of Health, there have been 119.709 cases of dengue hemorrhagic fever and 777 deaths as of week 22nd of 2024 in Indonesia. West Java, Special Capital Region of Jakarta, East Java, Central Java, and Banten recorded the most cases. Incidence rate of dengue is 21,06% and the case fatality rate is 0,73% in 2023.
Clinical course of dengue follows three phases: febrile, critical, and recovery. Patients with severe dengue go through all three stages.
- 1.Febrile phase
- During the febrile phase, patients usually experience a sudden onset of high grade fever (reaching 40℃) and can last for 2-7 days. However, around 6% of cases may have saddleback or biphasic fever – reaching normal temperature in between phases. Common symptoms associated with this phase include facial flushing,rash, muscle soreness, joint pain, severe headache, eye redness, pain behind the eyes, swollen glands, loss of appetite, nausea, and vomiting.
- 2.ppetite, nausea, and vomiting.
2．Critical phase -
Critical phase begins at the end of the febrile phase when temperature decreases but it might begin as early as the third day after fever onset in patients who are still febrile. This phase is the period when a patient could develop severe dengue or start to recover. People with severe dengue feel restless and have additional warning symptoms such as 。
● Severe abdominal pain
● Rapid breathing
● Persistent vomiting
● Bleeding gums or nose
● Blood in vomit, stool, or urine
● Pale and cold skin
● Being very thirsty
● Decrease urine output
● Large amount of menstruation
● Feeling weakPrior to the critical phase, there is frequently a rapid decrease in platelet count, accompanied by an increase in hematocrit levels above. Increased hematocrit level more than 20 percent indicates severe dengue. If not properly treated, the critical phase can lead to shock, organ malfunction, and eventually death.
- 3.Recovery phase
-
After critical phase, the patient enters recovery phase where the patient’s condition steadily improves over the course of 2 to 3 days. During this phase, symptoms and laboratory findings are gradually improving. Sign of recovery:
● Stable pulse, blood pressure, and breathing rate
● Normal temperature
● No evidence of external or internal bleeding
● Return of appetite
● No vomiting
● No abdominal pain
● Good urinary output
● Stable hematocrit at baseline levelIn most uncomplicated cases, platelet rises to normal within 3-5 days but it’s also best to avoid traumatic activities for at least 1-2 weeks if the platelet count is not more than 50,000/mm3 when discharged from hospital.
Dengue cases have been documented in all 34 provinces of Indonesia, with all four DENV serotypes (DENV-1, -2, -3, and -4) confirmed to be circulating across the country. An infection can occur by any one or more than one of the four serotypes. Regardless of these differences, infection with each dengue serotype causes the same sickness and range of clinical symptoms. All DENV serotypes can manifest as asymptomatic dengue, dengue fever, dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS).
Previous reports show that subsequent infections with different dengue virus serotypes raise the likelihood of developing severe dengue. Studies conducted in Malaysia, India, and Brazil found that patients with concurrent DENV infection had significantly higher intensity of warning signs (90%) as well as additional severe clinical presentations (15%). Furthermore, the prevalence of patients with severe low platelet count has also been recorded. Secondary infection with another serotype or multiple infections with different serotypes leads to severe dengue. According to studies in Thailand, it is revealed that DENV-1/DENV-2 infection sequence was associated with a 500-fold higher risk of DHF than primary infection. The risk of DHF increased 150-fold for the DENV-3/DENV-2 sequence and 50-fold for the DENV-4/DENV-2 sequence.
Depending on the patient’s stage of disease, there are differences in the dengue fever treatment plan. Antipyretic and enough oral fluids can usually be used to treat individuals without warning signs as outpatients. Furthermore, it is critical to inform patients of the warning sign and urge them to get help right once if any of them appear. Hospitalization should be considered for patients presenting with warning signs of the disease, severe dengue fever, or having risk factors such as being elderly, pregnant, having diabetes mellitus, or living alone. It is particularly important to not self-medicate with nonsteroidal anti-inflammatory medication (ex. ibuprofen,aspirin), antiemetic and other drugs that are not prescribed by doctors since it can worsen liver and platelet functions.
One way to avoid contracting dengue virus is to prevent mosquito bites. You can lower the risk of getting the disease by protecting yourself especially during the day when the vectors are active by using clothes that cover as much of your body as possible, mosquito nets, window screen, and mosquito repellents. Another way is to eliminate mosquito breeding areas particularly stagnant water pools, both inside and outside the home, and always keep containers or bins covered. It is important to know that it is still possible to get bitten by a mosquito despite these precautions.
In Indonesia, it is recommended for people aged 6-45 years old to get the dengue vaccine. Dengue vaccine is indicated as prevention of dengue caused by any dengue virus serotypes. It is also reported that individuals who are infected for the second time are at greater risk of severe dengue. Dengue vaccine can also help protect against dengue in people who have had dengue in the past with recommendation to wait for a minimum of 6 months post recovery before receiving the dengue fever vaccine.
- 1.
- Tetravalent Dengue Vaccine from Takeda, TAK-003, or known by the trade name QDENGA consists of 2 injections given 3 months apart. However according to recommendation by Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI), it is contraindicated for pregnant women or planning to become pregnant at least 1 month following vaccination, breastfeeding women, and people with immunodeficiency such as HIV patients not on antiretroviral therapy, cancer patients on chemotherapy, patients undergoing high-dose steroid therapy, and patient with primary immunodeficiency.
- 2.
- Chimeric Yellow Fever Dengue (CYD-TDV), or known by brand name Dengvaxia, can be given to children who have had dengue confirmed using antigen test (NS-1 dengue rapid test or PCR). CYD vaccine consists of 3 injections given 6 months apart and can only be given to children aged 9-16 years old according to recommendation by Ikatan Dokter Anak Indonesia (IDAI).
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内科
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