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  • Snapshot
    • 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.
  • Introduction
    • 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
  • Presentation
    • 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
  • Studies
    • 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
  • Differential
    • 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
  • Treatment
    • 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
  • Complications
    • Shock
    • Death
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