Special FeatureDengue fever: Report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine☆
Introduction
Dengue is a self-limiting viral infection transmitted mainly by the Aedes aegypti species of mosquito and to a lesser extent the Aedes albopicto, which is found in tropical and subtropical regions The virus belongs to the family Flaviviridae and has four serologically distinct serotypes (DEN-1, DEN-2, DEN-3, and DEN-4) [1]. Following infection with one strain, lifelong immunity to that serotype occurs and may also produce limited cross-immunity to the other serotypes. The WHO has stated that the global incidence of dengue has grown dramatically in recent decades with an estimated 390 million (95% credible interval 284–528) infections occurring per year. Of these, 96 million (67–136) of varying severity are actually diagnosed [2]. It is estimated that 3.9 billion people in 128 countries are at risk of infection [3] representing approximately one half of the world's population. Dengue is endemic in regions of Africa, the Americas, the Eastern Mediterranean, South-East Asia and the Western Pacific. Of the possible 400,000 cases of dengue haemorrhagic fever, occurring annually the case fatality is approximately 5% if untreated, but with appropriate therapy it can reduce to < 1% [4]. Admission APACHE II and SOFA scores, arterial lactate and serum albumin may predict mortality and outcome of high risk patients [5], [6].
Section snippets
Pathogenesis
Following a bite from an infected mosquito the virus spreads via the lymphatics to the lymph nodes where it replicates prior to the development of viremia. Infection with any of the four serotypes DEN-1, DEN-2, DEN-3, and DEN-4, is associated with a variety of clinical manifestations ranging from mild fever to severe fatal hemorrhage and shock. Recovery from infection by one strain and a subsequent infection with another serotype can potentially lead to dengue hemorrhagic fever and dengue shock
Clinical features
The incubation period is 4–10 days after the bite of an infected mosquito. Dengue virus can produce various clinical presentations with an unpredictable evolution and outcome [16]. Most patients recover after a self-limiting disease, while a small proportion progress to severe Dengue. Clinical features include fever, nausea, vomiting, rash, headache, retroorbital pain, myalgia, arthralgia, petechiae, positive tourniquet test, and leukopenia [17]. Two other arboviral diseases, Chikungunya and
Laboratory diagnosis
Early and accurate diagnosis allows effective medical care, identification of severe cases, and differentiation of dengue from other tropical illnesses. The laboratory diagnosis is made by detecting the virus and its components or by serology (Fig. 3). Detection of the non-structural protein 1 (NS1 antigen) using an enzyme linked immunosorbent assay (ELISA) or rapid kits is useful in early diagnosis and can be positive within days 1–5 of illness. The diagnostic sensitivity of NS1 in the febrile
Management
Management is based on the severity of infection. Patients who have no complications and are able to take fluids orally can be monitored in the community with instructions to return in the event of bleeding or the appearance of warning signs suggestive of vascular leak (group A), Those with warning signs require admission and parenteral hydration if oral intake is inadequate (group B). Patients in the critical phase of the disease (group C) with severe capillary leak, hemorrhage and organ
Vaccines
Live attenuated and inactivated viruses, recombinant proteins, and DNA vaccines are being developed. One dengue vaccine has been registered in several countries (CYD-TDV, or Dengvaxia®); this is a live attenuated (recombinant) tetravalent vaccine. CYD-TDV has been evaluated in two Phase 3 clinical trials [53], [54].
Conclusion
Vector control of Aedes aegypti which is predominantly found in urban areas in the tropics is an important means of reducing the global burden of Dengue. DHF and DSS is a precarious illness that can rapidly progress to death. Diagnosis though previously primarily clinical, has improved with the current laboratory tools. No specific therapy has yet been proven to be of value, and the mainstay of management continues to be careful fluid resuscitation. Thrombocytopenia is not uncommon in dengue
Task force planning
Jean-Louis Vincent (Belgium)
John Marshall (Canada)
Janice Zimmerman (USA)
Pravin Amin (India)
Djillali Annane (France)
Lluís Blanch, CIBERES-ISCIII (Spain)
Guillermo Castorena (Mexico)
Bin Du (China)
Edgar Jimenez (USA)
Younsuck Koh (Korea)
John Myburgh (Australia)
Masaji Nishimura (Japan)
Paolo Pelosi (Italy)
Álvaro Réa-Neto (Brazil)
Arzu Topeli (Turkey)
Sebastian Ugarte (Chile)
Financial support
None.
Conflict of interest disclosures related to this manuscript
None declared.
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On behalf of the Council of the World Federation of Societies of Intensive and Critical Care Medicine.