Diagnosis and management of dengue
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4338 (Published 18 November 2009) Cite this as: BMJ 2009;339:b4338
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The review on dengue was comprehensive (1). Although the
review does mention about the hepatic involvement in this
infection, it fails to mention the propensity of the virus
to cause hepatic failure. Numerous reports have appeared
implicating dengue in severe hepatic involvement resulting
in acute liver failure. At least in some countries, dengue
has been reported as the most common cause of acute hepatic
failure (2). Studies from India also indicate that dengue is
an important cause of hepatic failure (3). The authors
mention about possibility of encephalopathy in dengue
infection; in such cases acute hepatic failure should be
ruled out as a cause of altered sensorium (4).
1.Teixeira MG, Barreto ML. Diagnosis and management of
dengue. BMJ 2009; 39: b4338.
2.Poovorawan Y, Hutagalung Y, Chongsrisawat V, Boudville I,
Bock HL. Dengue virus infection: a major cause of acute
hepatic failure in Thai children. Ann Trop Paediatr.
2006;26:17–23.
3.Kumar R, Tripathi P, Tripathi S, Kanodia A, Venkatesh V.
Prevalence of dengue infection in north Indian children with
acute hepatic failure. Ann Hepatol 2008;7:59-62.
4.Giri S, Agarwal MP, Sharma V, Singh A. Acute hepatic
failure due to dengue: A case report. Cases J 2008;1:204.
Competing interests:
None declared
Competing interests: No competing interests
There is a typo in this article: dengue virus is a member of the Flaviviridae (not Flaviridae). This family derives its name from the Latin word for yellow (flavus) which refers to yellow fever virus, the prototypical virus of this family and of the Flavivirus genus. Yellow fever, in turn, derives its name from its propensity to cause jaundice in sufferers.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
I read Teixeira et al’s article on Dengue (1) with great
interest. The article has nicely covered diagnosis,
pathophysiology and management aspects but there are
some old and incomplete epidemiological data presented
in this review.
The Worldwide mapping of Aedes aegypti in page
number two shows Nepal as a clean country which is
wrong. Nepal reported dengue cases for the first time in
November 2006 (2).
Currently, there are nine districts that carry the risk of
Dengue in Nepal (3). They are mainly low lying i.e nearer
to India where it is prevalent and it has been well
highlighted here in this article. The geographical
mapping of Dengue Outbreak in Nepal is given in the
map here Figure 1.:
http://www.searo.who.int/Image/oth_dengue_dfoutbrea
k_nepal_06.gif
.gif)
Figure 1. Dengue Outbreak in Nepal: a geographical
mapping.
Thank you!
Dr Matiram Pun
University of Calgary,
Canada
References:
1. Teixeira MG, Barreto ML. Diagnosis and management
of dengue. BMJ 2009; 39: b4338.
2.http://www.searo.who.int/en/Section10/Section332_11
01.htm
3.http://www.searo.who.int/en/Section10/Section332/Se
ction2277_13402.htm
Competing interests:
I had been participating in
Tropical Medicine
workshop and research
priority in Nepal.
Competing interests: No competing interests
The article ‘Diagnosis and management of dengue’ gives a
comprehensive review of dengue, detailing cause, transmission, clinical
features, treatment and prevention (1). With respect to prevention, the
authors discuss about vaccine development, community involvement strategy,
vector control using chemicals, biologicals and traps. According to the
authors, the strategy to control vector population is centred mainly on
the use of chemicals, a counterproductive measure. Therefore, efforts
should focus on community involvement to control Aedes aegypti, the
principal vector, which breeds in discarded containers (that collect
rainwater) and in other water storage containers.
When DDT had been widely in use about 41 years ago (2) Aedes aegypti
had almost disappeared from many countries. With diminished use of DDT,
the menace of DHF has now returned (2). The problem has become more
pronounced with urban expansion, increased use of non-biodegradable
products (that can hold rain water and allow mosquitoes to lay eggs), lack
of water supply via pipes (this makes water storage in containers and
tanks a necessity) among other factors (2).
A community involved environmental management for dengue prevention
study carried out in Guantanamo, Cuba showed Aedes infestation reduction
by 50-75% (3). However, as the authors suggest (1), this study did not
investigate the effect of the intervention on dengue virus transmission
(1). Notwithstanding this, persistent reduction in vector infestation is
bound to reduce dengue virus transmission.
Cans, plastic bottles, tires, car batteries (4) and flower containers
in cemeteries have been found to be good breeding places. Latex collection
cups, in rubber growing countries, cocoa pods, coconut shells, tree holes,
plant stumps, mud pots, flower pots, grinding stones, water tanks etc are
good breeding ground for mosquitoes (5). Care needs to be taken to turn
latex collection cups upside down during rainy season to prevent vector
breeding. Use of flower holding vases with drain holes or bronze vases, in
cemeteries, has been suggested to limit mosquito spread (6).
Community participation programme focusing on eradicating or reducing
breeding containers at homes, weekly emptying of storage containers
(weekly emptying can disrupt mosquito life cycles, since newly hatched
larvae require 9 days under favorable conditions to develop into the adult
stage or complete the cycle), encouraging larval control by using
larvicide (temephos or Abate 1% sand granules), introducing larvivorous
fish into water containers, covering larger containers with lids to
prevent egg laying by mosquitoes and encouraging the use of predacious
copephods of the genus Mesocyclops as a biological control agent will help
stop the spread of dengue and DHF (7,8). A novel insecticide delivery
instrument named the Mossie-Buster has been developed to control mosquito
larvae from urban breeding places in Townsville, Australia (9).
References
1. Teixeira GM, Barreto ML. Diagnosis and management of dengue. BMJ
2009;339:b4338
2. Vu SN, Nguyen TY, Kay BH, Marten GG, Reid JW. Eradication of Aedes
aegypti from a village in Vietnam, using copepods and community
participation. Am J Trop Med Hyg. 1998; 59:657-60.
3. Vanlerberghe V, Toledo ME, Rodríguez M, Gomez D, Baly A, Benitez
33 JR, et al. Community involvement in dengue vector control: cluster
randomised. BMJ 2009;338:1959b.
4. Mazine CA, Macoris ML, Andrighetti MT, Yasumaro S, Silva ME,
Nelson MJ, Winch PJ. Disposable containers as larval habitats for Aedes
aegypti in a city with regular refuse collection: a study in Marilia, Sao
Paulo State, Brazil. Acta Trop. 1996; 62:1-13.
5 Thenmozhi V, Hiriyan JG, Tewari SC, Philip Samuel P, Paramasivan R,
Rajendran R, Mani TR, Tyagi BK. Natural vertical transmission of dengue
virus in Aedes albopictus (Diptera: Culicidae) in Kerala, a southern
Indian state. Jpn J Infect Dis. 2007;60:245-9.
6. O'Meara GF, Gettman AD, Evans LF Jr, Scheel FD. Invasion of
cemeteries in Florida by Aedes albopictus. J Am Mosq Control Assoc. 1992
;8:1-10.
7. Effectiveness of dengue control practices in household water
containers in Northeast Thailand.Trop Med Int Health. 2005;10:755-63.
8. Vu SN, Nguyen TY, Tran VP, Truong UN, Le QM, Le VL, Le TN, Bektas
A, Briscombe A, Aaskov JG, Ryan PA, Kay BH. Elimination of dengue by
community programs using Mesocyclops(Copepoda) against Aedes aegypti in
central Vietnam. Am J Trop Med Hyg. 2005;72:67-73.
9. Canyon DV, Hii JL. The Mossie-Buster: a hose-driven insecticide
delivery tool for the control of container-breeding mosquitoes. J Am Mosq
Control Assoc. 1997 ;13:389-94.
Competing interests:
None declared
Competing interests: No competing interests
I read with interest Teixeira et al’s recent excellent clinical
review on the 'Diagnosis and management of dengue'. [1] However, when
Texeira et al under the subheading of ‘How might dengue be prevented?’
state that the reduction of the vector population has ‘low or no
effectiveness in reducing levels of dengue transmission’, they perhaps
leave the impression that vector control measures- that are aimed at
keeping the mosquito population at a low level- are ineffective in
reducing the incidence of dengue infections.
Indeed, the Aedes aegypti mosquito, the main vector for dengue, is
well adapted to living in urban environments and natural breeding habitats
are created as quickly as they are eliminated, and there is no evidence
that the use of chemical insecticides in an area after cases have already
been detected are effective. However, the experience in Singapore shows
that a well-conducted vector control system based on entolomogic
surveillance and larval source reduction aiming to control the mosquito
population before disease is detected in an area can be successful. [2] In
this instance, this strategy of keeping the vector population low was
successful in bringing about a 15-year period of low dengue incidence.
Dengue infections are currently on a rapid rise globally. This has
been attributed to population growth, a proliferation of breeding sites
for mosquitos with uncontrolled urbanization, difficulties in implementing
successful vector control and a rapid increase in international travel.
[3] In fact, the recent resurgence in Singapore itself has been partly
attributed to the shift in the emphasis in prevention from vector
surveillance towards responding to detected cases of dengue, and
increasing travel. [2} With treatment for dengue fever and dengue
haemorrhagic fever being at best supportive and an effective vaccine still
at the stage of phase III trials, [4] then continued diligence towards
holistic and effective vector control measures aimed at keeping the Aedes
aegypti population low cannot and should not be neglected.
References
1. Teixeira MG, Barreto ML. Diagnosis and management of dengue. BMJ
2009; 39: b4338.
2. Ooi EE, Goh KT, Gubler DJ. Dengue prevention and 35 ears of vector
control in Singapore. Emerg infect Dis 2006; 12(6): 887-93.
3. Kyle JL, Harris E. Global spread and persistence of dengue. Annu
Rev Microbiol 2008; 62: 71–92.
4. Webster DP, Farrar J, Rowland-Jones S. Progress towards a dengue
vaccine. Lancet Infect Dis. 2009 Nov;9(11):678-87.
Competing interests:
None declared
Competing interests: No competing interests
Plaque reduction neutralization test for dengue virus is more sensitive test but expensive
Dengue hemorrhagic fever is characterized by systemic vascular
leakage, disordered haemostasis and may develop after infection with any
of four dengue viral subtypes. Between 2,50,000-5,00,000 cases of DHF, mainly in children, are reported by WHO annually with mortality rate 1-5%
among patients with Dengue hemorrhagic fever shock. In West Bengal
provinces of India, on average around 1064 cases of dengue occurs each
years with maximum infections are detected in kolkata district around 600
cases followed by in N-24 parganas , S-24 parganas and ,Howrah districts
and total death from DHF is 10-12. Usually the diagnosis of dengue
infection is made with use of Dengue DUO IgM capture and IgG capture
enzyme linked immunosorbant essays in paired sample. Coagulation profile
is also done for PT, APTT, fibriongen level by serum quantitative assay
besides quantitative platelet count. The serotype of dengue virus is
distinguishable by Plaque reduction neutralization test.
The plaque
reduction neutralization test is one of the most specific and sensitive
tests for dengue virus and can be used to identify the virus serotype in
primary dengue infection. The secondary and tertiary infection however the
infecting viral serotype can not be reliably done because of long
neutralizing antibodies. This test can also be linked for sero
epidemiology. The disadvantages of this test are it is highly expensive,
technical difficulty and need live virus in the lab.
Authors_:
Professor Pranab kumar Bhattacharya MD(cal), FIC path(Ind.) ,
Professor of Pathology, In charge of Histopathology Unit, in charge Blood
Bank &VCCTC, Cytogenetics. Institute of Post Graduate Medical Education
& Research, 244a AJC Bose Road, Kolkta-20, West Bengal, India; **Mr.
Ritwik Bhattacharya, B.Com(cal); ***Mr. Rupak Bhattacharya BSc(Cal)MSc(JU)
of 7/51 Purbapalli, Sodepur, Dist 24 parganas(North) ,Kol- 110, West
Bengal, India; ****Mrs Dahlia Mukherjee BA(hons) Cal, Swamiji Road, Habra
N-24 parganas, W.B, India, *****Miss Upasana Bhattacharya of Mahamyatala,
Garia kol-86,Daughter of Prof. Bhattacharya Dr. Hriday Ranjan Das MD,
DTM&H( Cal) Medical officer, Nephrology, IPGMER, KOl-20, Dr. Sumit
Chaudhury MD(cal)Asst.Prof.Dept of Medicine IPGMER Dr. Tarun Biswas
MaBBS(cal), Dept. Of Pathology, Institute of Post Graduate Medical
Education & Research, 244a AJC Bose Road, Kolkta-20, West Bengal,
India
Competing interests:
None declared
Competing interests: No competing interests