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Diseases
Gatot Sugiharto, MD, Internist
Internal Medicine Department
Faculty of Medicine, Wijaya Kusuma
University Surabaya
DENGUE FEVER/DENGUE
HEMORHAGIC FEVER
Introduction(1)
Dengue fever is a clinical illness with
symptoms ranging from a nonspecific viral
syndrome such as fever, severe headache,
sore throat, rash, and muscle pain, and
joint pain, to severe and fatal hemorrhagic
Primarily a disease of the tropics, and the
viruses that cause it are maintained in a
cycle that involves humans and Aedes
aegypti, a domestic, day-biting mosquito
that prefers to feed on humans
Introduction(2)
Dengue is one of the most important
mosquito-born viral diseases affecting
humans.
Viral life cycle involves humans and the
mosquito vector Aedes aegypti, some others
by Aedes albopictus
The disease is caused by 4 serotypes of the
Dengue virus, a member of the genus RNAFlavivirus: DEN-1, DEN-2, DEN-3, DEN-4.
Infection with the DEN virus can result in
Dengue Fever (DF), Dengue Hemorrhagic
Fever (DHF) and Dengue Shock Syndrome
History
The first suspected epidemics of dengue
fever being reported during 1779 to 1780
in Asia, Africa, and North America.
The dengue virus was first isolated in
Japan in 1943, but this work was not
immediately published.
At the same time, Dr. Albert Sabin, working
with the U. S. Army Commission on dengue
and sandfly Fever, identified the dengue
virus.
FOUR VIRUSES
Life time immunity follows infection to
one type.
Second, third and possibly four
infections are possible.
CHILDREN first infections are mild,
largely inapparent.
ADULTS - first infections may produce
DF, some viruses more overt than
others.
Pathogene
sis
Pathogenesis
Symptoms
A sudden onset of fever 3 5 days after bitten by a dengueinfected mosquito, usually continues for 2 to 7 days and can be
as high as 104 to 106
Severe headache, muscle pain, joint pain, conjunctivitis, severe
orbital pain, backache, anorexia, and nausea and vomiting
Other symptoms : rash, minute reddish/purplish spots, nose
bleeds, or bleeding gums.
Hemorrhagic manifestations usually occur about the time that
the body temperature falls back to or below normal
During the hemorrhagic, signs of circulatory failure may appear.
Evidence of a capillary leak syndrome : reduced blood volume
(hypovolemia), shock, and death can follow.
Prolonged fatigue and depression continue through the recovery
stage.
Day 2
Day 3
EXPOSUR
E
Day 4
Day 5
Day 6
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Day 8
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18 June 2001
Day 11
Day 12
Day 13
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Diagnosis
Clinical picture
Detection of anti-dengue immunoglobulin
(Ig) M or IgG antibody in a patient's blood
serum
Isolated from human blood after
mosquito inoculation, or from mosquito
cell cultures, by immunofluorescence
using serotype-specific monoclonal
antibodies (MAbs).
Detection of dengue virus by culture is
the definitive diagnostic test, but
practical limitation its use
18 June 2001
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Clinical spectrum
There are actually four dengue clinical
syndromes:
1.Undifferentiated fever;
2.Classic dengue fever;
3.Dengue hemorrhagic fever, or DHF;
and
4.Dengue shock syndrome, or DSS.
Dengue shock syndrome is actually a
severe form of DHF.
Diagnostic criteria
Clinical Definition for Dengue Fever :
Acute febrile viral disease frequently
presenting with headaches, bone or joint
pain, muscular pains, rash, and leucopenia
Clinical Definition for Dengue Hemorrhagic
Fever :
Fever, or recent history of acute fever
Hemorrhagic manifestations
Low platelet count (100,000/mm3 or less)
Objective evidence of leaky capillaries
elevated hematocrit (20% or more over
baseline)
low albumin
pleural or other effusions
criteria
Diagnostic
Clinical Definition for Dengue Shock
Syndrome :
4 criteria for DHF + evidence of
circulatory failure manifested indirectly
by all of the following:
Rapid and weak pulse
Narrow pulse pressure (< 20 mm
Hg) OR
hypotension for age
Cold, clammy skin and altered
mental status
Frank shock is direct evidence of
Grades of DHF
Grade 1
Fever and nonspecific constitutional symptoms
Positive tourniquet test is only hemorrhagic
manifestation
Grade 2
Grade 1 manifestations + spontaneous
bleeding
Grade 3
Signs of circulatory failure (rapid/weak pulse,
narrow
pulse
pressure,
hypotension,
cold/clammy skin)
Grade 4
Profound shock (undetectable pulse and BP)
Grades of DHF
Treatment
Supportive care
Keep patient hydrated to prevent shock
Hospitalization of patients with advanced
symptoms
Symptomatic treatment : antipyretic
For complete treatment protocol refer to the
following reference:
Dengue hemorrhagic fever: diagnosis,
treatment, prevention and control. World
Health Organization. 2006
18 June 2001
27
Fluid
replaceme
nt
Shock
Manageme
nt in
Dengue
HIV / AIDS
Gatot Sugiharto, MD, Internist
Internal Medicine Department
Faculty of Medicine, Wijaya Kusuma
University Surabaya
30
INTRODUCTION(1)
Human Immunodeficiency Virus
H = Infects only Human beings
I = Immunodeficiency virus weakens the immune
system and increases the risk of infection
V = Virus that attacks the body
INTRODUCTION(2)
The HIV : virus that causes AIDS.
HIV attacks the immune system by destroying
CD4 positive (CD4+) T cells, a type of white
blood cell that is vital to fighting off infection
vulnerable to other infections, diseases and
other complications.
AIDS is the final stage of HIV infection.
AIDS is diagnosed when someone has one or
more opportunistic infections, such as
pneumonia or tuberculosis, and has a
dangerously low number of CD4+ T cells (less
than 200 cells/cmm blood).
HIV
Class of viruses : retroviruses, RNA virus
HIV uses an enzyme called reverse
transcriptase to convert its RNA into DNA
(deoxyribonucleic acid) and then proceeds to
replicate itself using the cell's machinery.
HIV belongs to a subgroup lentiviruses, or
"slow" viruses having a long time period
between initial infection and beginning of
serious symptoms unaware of HIV infection,
can spread the virus to others.
Similar versions of HIV : feline
immunodeficiency virus (FIV) in cats and simian
immunodeficiency virus (SIV) in monkeys and
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HIV
structur
e
HIV/AIDS transmission
1.
Sexual transmission
Heterosexual
Homosexual
2. Blood and blood products
IV drug use
Transfusions
Haemophilia
Other (knives, needle)
3.
Vertical transmission
During pregnancy
During birth
Breastfeeding
Insect bites
Touching, hugging
Water, food
Kissing
Public baths
Handshakes
Work or school contact
Using telephones
Sharing cups, glasses, plates, or other utensils
DR. S.K CHATURVEDI
Pathogenesis
HIV destroys CD4 positive (CD4+) T cells, which
are crucial for the human immune system.
less equipped to fight off infection and disease
resulting in the development of AIDS.
Most people who are infected can carry the
virus for years before developing any serious
symptoms until the number of CD4+ T cells
decline
Antiretroviral help reduce the amount of virus in
the body, preserve CD4+ T cells and
dramatically slow the destruction of the
immune system.
HIV
Replicati
on Cycle
Progression to AIDS
The immune system eventually
deteriorates to the point that the human
body is unable to fight off other infections.
The HIV viral load in the blood dramatically
increases while the number of CD4+ T cells
drops to dangerously low levels
HIV-infected person is diagnosed with AIDS
when he or she has one or more
opportunistic infections, such as pneumonia
or tuberculosis, and has fewer than 200
CD4+ T cells per cubic millimeter of blood.
Early symptoms
In the initial stages of HIV infection, most people
will have very few, if any, symptoms. Within a
month or two after infection, individuals may
experience a flu-like illness, including:
Fever, headache , tiredness
Enlarged lymph nodes in the neck and groin area
These symptoms usually disappear within a week
to a month and are often mistaken for another viral
infection, such as influenza (flu).
However, during this period people are highly
infectious because HIV is present in large quantities
in genital fluids and blood.
Some people infected with HIV may experience
more severe symptoms initially or a longer
Later Symptoms
HIV spectrum
Virus can be transmitted during each
stage
Seroconversion : Infection with HIV,
antibodies develop
Asymptomatic : No signs of HIV,
immune system controls virus
production
Symptomatic : Physical signs of HIV
infection, some immune suppression
AIDS : Opportunistic infections, endstage disease
DR. S.K CHATURVEDI
ABC Approach
The ABC Approach to prevent sexual
transmission of HIV
Abstain
Be faithful
Use a Condom
Limits of the ABC-Approach
Lack of resources
Gender inequality
Treatment
Antiretroviral drugs (ARVs)
Are not a cure
Slow down the process of replication of HIV in the
human body
Prevent and treat Opportunistic Infections
Prevent mother-to-child-transmission
During pregnancy and delivery
Safer infant feeding
Access to services / availability of drugs
Availability, Coverage, Impact
Treatment
Important role of institutions (hospitals, clinics,
VCT centres)
Conditions to support treatment
Medication adherence plan
Living positively
Adopt a healthy diet
Exercise regularly
Avoid alcohol and tobacco, or certainly minimize their
consumption
Reduce stress
Avoid all forms of infection (when possible) because
they may compromise your health and further weaken
ones immune system
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Prevention
Currently, there isno vaccine to prevent HIV
infection nor is there acure for HIV/AIDS. To
reduce risk of becoming infected with HIV or
transmitting the virus to others:
Consistent use of male latex condoms can help
protect against HIV infection.
Get tested regularly for HIV
Practice abstinence
Remain faithful to your spouse or partner
Consistently use male latex or female
polyurethane condoms
Do not share needles