DENGUE,

CHIKUNGUNIA,
MALARIA &
LEPTOSPIROSIS
DR. MUHAMMAD IHTISHAMUL HAQUE
MBBS, D-CARD, MD
ASSOCIATE PROFESSOR
FACULTY OF MEDICINE
MAHSA UNIVERSITY
 • Female Aedes aegypti (most common), A.
albopictus, A. polynesiensis, and A. scutellaris
mosquitoes
• Dengue virus 1, 2, 3, and 4. Part of the
Flaviviridae family.
• Incubation:3 to 4 days
• Natural course:
DENGUE Febrile phase: High fever, nausea, myalgia,
rash, flushed face for 2-7 days.
Critical phase: Plasma leakage, abdominal
pain, hypotension, liver tenderness for 24-48
hours.
Convalescent phase: Increased appetite, rash,
normotension, bradycardia, decreased Hct.
A maculopapular or macular
confluent rash over the face,
thorax, and flexor surfaces,
with islands of skin sparing.
Petechiae spots on full body
except face, from day 3-4.
May turn hemorrhagic. Rash
disappears under pressure.
 • Fever: Sudden onset and occasionally biphasic pattern.
1-2 days of fever, remission for 1-2 days, relapse for 1-2
days. aka "break bone fever" due to accompanying joint
and muscle pain.
• Jaundice: Only 2% of DSS patients.
• Arthralgia: Mild joint pain, specially in febrile phase.
Usually of the knees and shoulders.
DENGUE • Myalgia: Severe muscular pain, especially of the lower
back, arms, and legs. And especially in febrile phase.
• Headache: Common. Retro-orbital pain.
• Nausea: Yes.
• Other findings: Mild hemorrhagic manifestations (eg,
petechiae, bleeding gums, epistaxis, menorrhagia,
hematuria). Altered taste sensation. Anorexia.
Lymphadenopathy.
 INVESTIGATIONS:
DIAGNOSTIC TESTS FOR DENGUE AND SPECIMENS:

≤7 DAYS AFTER >7 DAYS POST

DIAGNOSTIC TEST SYMPTOM ONSET SYMPTOM ONSET SPECIMEN TYPES

Molecular Tests
(Nucleic Acid Amplification Test for ✓ — Serum, plasma, whole blood,
confirm diagnosis) cerebrospinal fluid*

Dengue Virus Antigen Detection (NS1) ✓ — Serum

Serologic Tests
IgM Antibody Capture Enzyme-Linked
✓ ✓ Serum, cerebrospinal fluid*
Immunosorbent Assay (MAC-ELISA)

Tissue Tests
Immunohistochemical (IHC) Analysis ✓ ✓ Fixed tissue
for Fixed Tissue Specimens
 • Female Aedes aegypti (more prevalent during the
day) and Aedes albopictus mosquitoes
• Incubation: 3-7 days
• Natural course:
Acute infection phase (1-14 days): High grade
fever for 3-5 days. Polyarthralgia (10+ joints) begins
CHIKUNGUN 2-5 days after onset of fever.
YA Persistent symptoms phase: Skin manifestation
(40-75%) macular or maculopapular rash. The
polyarthralgia becomes more severe and can
become polyarthritis, sometimes with tenosynovitis
and carpal tunnel syndrome. May complicate to
Raynaud's phenomenon (20%).
  Fever: Sudden onset of high fever (up
to 40°C) for 1-2 days, remission for 1-2
days (defervescence), relapse for 1-2
days. With chills.
 Jaundice: Mild
CHIKUNGUN  Arthralgia: Severe small joint pain and
YA arthritis (joint swelling), polyarticular,
bilateral, and symmetric. Begins two to
five days after onset of fever. 80%+.
 Myalgia: Severe muscle pain
 Headache: Common
CHIKUNGUNY
A: Over face, chest
from day 1-3 for 3-7
days, non-
hemorrhagic.
Maculopapular rash,
similar to dengue.
Occurs early in illness.
40-75%.
INVESTIGATI ELISA: IgM and IgG anti-chikungunya
antibodies. IgM antibody levels are
ONS: highest 3 to 5 weeks after the onset of
CHIKUNGUNY illness and persist for about 2 months.
(Samples collected during the first week
A after the onset of symptoms).
RT–PCR (Samples collected during the
first week after the onset of symptoms).
 Female Anopheles mosquito (more prevalent
during the night, dawn, and dusk)
Plasmodium parasites: P. falciparum (common
and severe, 50%), P. vivax (43%), P. ovale, P.

MALAR malariae and P. knowlesi.

Incubation: 2 weeks, other sources: 10-21+
days
IA Skin: Sweating
Fever:
 With or without chills. Recurrent (36-48 hrs) or
continuous fever in P. falciparum.
 Tertian fever (every 2 days) in P. vivax and P. ovale.
 Quartan fever (every 3 days) for P. malariae.
 Thick and thin blood smears (Gold
standard).
MALARIA: Rapid diagnostic test: Antigen testing
INVESTIGATI Molecular test : PCR
ONS Serology (ELISA): Antibody test
 P Falciparum: Quinine-based therapy is
with quinine (or quinidine) sulfate plus
doxycycline or clindamycin or
pyrimethamine- Sulfadoxine; alternative
therapies are artemether-lumefantrine,
MALARIA: atovaquone-proguanil, or mefloquine
TREATMENT P vivax, P ovale: Chloroquine plus
primaquine. But recently there's some
evidence for combination of
dihydroartemisinin-piperaquine with
primaquine.
 Spirochete bacteria in the genus Leptospira.
 Leptospires are spread by the urine of infected
animals (rodents, dogs, livestock, pigs, horses,
wildlife).
LEPTOSPIRO People can be infected through:
SIS:  Direct contact with the urine or reproductive fluids
TRANSMISSI from infected animals
 Contact with urine-contaminated water (floodwater,
ON rivers, streams, sewage) and wet soil
 Ingestion of food or water contaminated by urine or
urine-contaminated water
Transmission occurs through mucous membranes,
conjunctiva, and skin cuts or abrasions.
 Incubation period: is 2–30 days; most illnesses occur
5–14 days after exposure.
1st phase (acute or septicemic phase): 3–7 days.
Asymptomatic phase: 3-4 days. Symptoms
LEPTOSPIRO disappear. Bacteria in blood. Leptospira antibodies
appear.
SIS:NATURA 2nd phase: Fever returns. Hallmark: meningitis.
L COURSE Severe phase (10%): Liver damage (causing
jaundice), kidney failure, and bleeding ( Weil's
disease).
Can complicate to severe pulmonary hemorrhage
syndrome, which is fatal in 50% despite treatment.
SKIN: Usually
over legs, from
day 4-6,
hemorrhagic.
 Confirmatory Diagnostic Tests:
1. Microscopic agglutination test (MAT) — Serum
samples collected 7–14 days part is ideal.
2. Polymerase chain reaction (PCR) –
LEPTOSPIRO Recommended samples:
SIS:  Whole blood collected in the first week of illness (in the first 4

INVESTIGATI days is ideal)

 Urine (collected at least 1 week after symptom onset is ideal)
ONS  Cerebrospinal fluid from a patient with signs of meningitis
 Fresh frozen kidney and/or liver (if available from deceased
patients) — kidney preferred
3. Pathology (immunohistochemistry) —Formalin-
fixed tissues: from the kidney (preferred), liver,
lung, heart, or spleen.
 SUPPORTIVE DIAGNOSTIC TESTS:
• IgM-based commercial assays, such as
LEPTOSPIRO  ELISA IgM
 ImmunoDOT
SIS:  Lateral flow tests
INVESTIGATI • IgM assays are screening tests and results should be
ONS confirmed using one of the confirmatory methods
below.
  Mild symptoms:
 Doxycycline is the drug of choice (100 mg
orally, twice daily
 Azithromycin (500 mg orally, once daily),
LEPTOSPIR  Ampicillin (500-750 mg orally, every 6 hours),
OSIS:TREA  Amoxicillin (500 mg orally, every 6 hours).
TMENT  Severe disease:
 IV penicillin is the drug of choice (1.5 MU IV,
every 6 hours), and
 Ceftriaxone (1 g IV, every 24 hours) can be
equally effective. .