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  • A 44-year-old woman presents to the emergency room for high fever, chills, headache, and nose bleed. She had recently traveled to Taiwan for 3 days, where she enjoyed both city-life and tropical tourism. She had been bit by mosquitoes throughout her trip. Severals days after returning to the USA, she developed a high fever, joint and muscle pain, and nose bleeds. On physical exam, there is a confluent erythematous macular rash on her trunk. There is also some gingival bleeding. She is admitted for monitoring and supportive care.
  • Classification
    • dengue virus 
      • an enveloped, positive-sense, single-stranded RNA flavivirus
    • transmission
      • Aedes mosquitoes
  • Epidemiology
    • incidence
      • tropical and subtropical areas of the world
    • risk factors
      • prior infection with dengue virus predisposes patients to severe dengue hemorrhagic fever
  • Pathogenesis
    • virus replicates in and destroys the bone marrow
    • plasma leakage is caused by increased capillary permeability
  • Associated conditions
    • dengue hemorrhagic fever or dengue shock syndrome
  • Prognosis
    • symptoms occur after 4-10 days
    • if untreated, mortality rates can be 20%
    • if treated, mortality rate is 2-5% in severe cases
  • Symptoms 
    • headache
    • myalgais and arthralgias
    • altered sense of taste
  • Physical exam
    • high fever
    • blanching confluent erythematous maculopapular rash
    • lymphadenopathy
    • may have pleural effusions
    • minor hemorrhage
      • petechiae
      • bleeding mucosa
      • epistaxis
    • in severe cases, plasma leakage occurs
      • bleeding from sites of trauma
      • gastrointestinal bleeding
      • severe abdominal pain
      • blood vomiting
    • positive tourniquet test
      • petechiae observed below the cuff after a tourniquet (commonly an inflated blood pressure cuff) is left on for 5 minutes
  • Labs
    • antibodies to the dengue virus in the serum
    • detection of RNA in tissue, serum, or cerebral spinal fluid
    • lab abnormalities
      • thrombocytopenia
      • leukopenia
      • mild transaminitis
      • decreased fibrinogen
    • urinalysis
      • hematuria
    • guaiac stool testing
      • occult blood
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
  • Yellow fever
    • distinguishing factor
      • may also be hemorrhagic but often affects the liver as well and manifests as jaundice, scleral icterus, and hepatomegaly
  • Zika virus infection
    • distinguishing factors
      • may also present with prodrome and rash, but typically does not have any hemorrhage
      • pregnant patients may give birth to infants with microcephaly and intracranial calcifications
  • Chikungunya 
    • distinguishing factor
      • may also present with flu-like symptoms, joint pain, and rash, but typically does not have any hemorrhage
  • Management approach
    • the disease is typically self-limited and mainstay for treatment is supportive care
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • rehydration
        • close monitoring
        • pain control
  • Shock
  • Death

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