Tropical Diseases, Neglected Tropical Diseases, Dengue Dr. Noorulhaque Shaikh

1. Tropical Diseases
Dr. Noorulhaque Shaikh
MBBS; DA; DNB(Anaesthesia)
Fellow Critical Care Medicine
SMBT Institute of Medical Sciences & Research Centre
Dhamangaon, Nashik
Moderator: Dr. Ruchira Khasne
HOD Critical Care Medicine
SMBT IMS & RC
Dhamangaon, Nashik

3. Introduction
 Tropical diseases are diseases that are prevalent in or unique to
tropical and subtropical regions.
 The diseases are less prevalent in temperate climates, due in part to the occurrence of a
cold season, which controls the insect population by forcing hibernation..
 Insects such as mosquitoes and flies are by far the most common disease carrier, or vector.
 These insects may carry a parasite, bacterium or virus that is infectious to humans and
animals.
 Most often disease is transmitted by an insect "bite", which causes transmission of the
infectious agent through subcutaneous blood exchange.
 Vaccines are not available for most of the diseases, and many do not have cures.
 Human exploration of tropical rainforests, deforestation, rising immigration and increased
international air travel and other tourism to tropical regions has led to an increased incidence
of such diseases to non-tropical countries.

4. Introduction
 Caused by diverse pathogens,majority being parasites
 Associated with: poverty and deprived environments in Tropics
Most are ancient and have plagued humanity for centuries
• Disappearing as living conditions and hygiene improving
• Mostly affect people living in: Remote rural areas or Urban slums of tropical countries
• Found in places with Low Socio-Economic progress, where:
 Substandard Housing,
 Lack of access to safe Water and Sanitation
 Filthy Environments
 Abundant Insects and other Vectors contribute to efficient transmission of infection

5. Tropical Diseases Common in India
● Dengue: Dengue fever is a mosquito-borne tropical disease caused by the
dengue virus transmitted by species of Aedes mosquitoes, principally A. aegypti
● Helminths: parasitic worms, are large multicellular organisms, which can
generally be seen with the naked eye when they are mature (eg.Tapeworm,
Schistosomiasis, Ascariasis, filariasis)
● Leishmaniasis: caused by protozoan parasites of the genus Leishmania, and
transmitted by the bite of certain species of Sand Fly.
● Leprosy(or Hansen's disease):chronic infectious disease caused by Mycobacterium
leprae. Leprosy is primarily a granulomatous disease of the peripheral nerves and
mucosa of the upper respiratory tract; skin lesions are the primary external symptom

6. Tropical Diseases Common in India
● Lymphatic Filariasis: parasitic disease caused by thread-like parasitic filarial
worms called nematodes, all transmitted by mosquitoes.
● Malaria: Caused by a Protozoan parasites transmitted by female Anopheles
mosquitoes
● STD: Sexually transmitted infections (notably Syphilis, Gonorrhoea,
Chlamydia, Trichomoniasis, Hepatitis B, HSV, HIV and HPV)
● Tuberculosis:
● TB-HIV coinfection

7. NTD: Neglected Tropical Diseases
 Term refers to group of mainly chronic, debilitating and often stigmatizing diseases
that primarily affect the poorest of the poor.
 Living in remote rural and deprived urban settings of tropical and subtropical
countries.

8. Spectrum of NTD
HELMINTH INFECTIONS
● Ascariasis
● Trichuriasis
● Hookworm
● Schistosomiasis
● Lymphatic Filariasis
● Onchocerciasis
● Dracunculosis
PROTOZOAN
INFECTIONS
● Leishmaniasis
● Chagas Disease
● African
Trypanosomiasis
BACTERIAL INFECTIONS
● Trachoma
● Leprosy
● Buruli Ulcer

9. DENGUE

10.  Dengue Fever, also known as BreakBone Fever, is
an infectious tropical diseases caused by the dengue
virus.
 Dengue virus belongs to Flaviviridae Family.
The flaviviridae are Positive Sense, Single Stranded
RNAviruses.

11. AEDES MOSQUITO
 Dengue is transmitted by several
species of mosquito within the genus
aedes principally Aedes Aegypti
 Distinct feature is black and white
stripes on its body and legs
 Bites during the Day.

12.  Ae. aegypti females will often feed on several persons during
a single blood meal and, if infective, may transmit dengue
virus to multiple persons in a short period of time even if
they only probe without taking blood.
 Ae. aegypti prefers to lay its eggs in artificial water
containers, to live in close proximity to humans, and to
feed on people rather than other vertebrates.
 Desert coolers, Drums, Jars, Pots, Buckets, Flower
vases, Plant saucers, Tanks, Cisterns, Bottles, Tins,
Tyres, Roof gutters, Refrigerator drip pans, Cement
blocks

13.  With increasing spread of the vector mosquito
throughout the tropics and sub tropics, large areas
of the world have become vulnerable to the
introduction of dengue viruses.
 An infection can be acquired via a single bite. A
female mosquito that takes a blood meal from a
person during the initial 2-10 days of dengue
infection, becomes itself infected with the virus in
the cells lining of its Gut

14.  About 8–10 days later, the virus spreads to other
tissues including the mosquito's salivary glands and
is subsequently released into its saliva. The virus
seems to have no detrimental effect on the
mosquito, which remains infected forlife.
 The virus has four different types (DEN1, DEN2,
DEN3 & DEN4); infection with one type usually
gives lifelong immunity to that type, but only
short-term immunity to the others. Subsequent
infection with a different type increases the risk of
Severe Complications

15. Factors ResponsibleFor The Resurgence
Of Dengue
 Population growth
 Unplanned and uncontrolled urbanization
 Inadequate & Interrupted water supply-- leading
to storage of water
 Deficient waste watermanagement
 Failure of effective mosquito controlmeasures

16. Risk Factors
 Virus strain (DENV 2 and 3)
 Pre-existing anti-dengue antibody 
Immuneenhancement
 Previous infection
 Maternal antibodies in infants
 Hyperendemic transmission: Two or more serotypes circulating
simultaneously at high levels
 Endemic: only one serotype prevalent in the area
 Age: more severe in children
 Ethnicity: Africans have less severe illness
 Chronic diseases (bronchial asthma, sickle cell anaemia and diabetes
mellitus)

17. Pathophysiology
2main pathophysiological changes:
Increased vascular permeability
Haemostatic Disorder:
 Vascular Changes
 Thrombocytopenia
 Coagulopathy

18. PERSONS EXPOSED TO DENGUE VIRUS
SERUM ANTI BODIES NEUTRALIZE THE VIRUS OF SAME TYPE.
SUBSEQUENT INFECTION -- ANTIBODIES FORM COMPLEXES
BUT DO NOT NEUTRALIZE THE NEW VIRUS.
THESE COMPLEXES FACILLITATES THE ENTRY OF THE VIRUS
INTO THE MONONUCLEAR CELLS BY BINDING WITH THE Fc
RECEPTORS.

19. Increased Vascular Permeability
Infected monocytes
Vasoactive mediators
Increased vascular permeability
Hemorrhagic manifestations DHF, DSS

20. Thrombocytopenia
 Infection of human haematopoietic cellsinhibits
megakaryocytopoieses
 Increased peripheral destruction of antibody coated
platelets
 Platelet destruction in the liver and spleen.
 Platelet dysfunction(Qualitative defect)

21. HemorrhageinDengue
 Vasculopathy
 Thrombocytopenia
 Platelet dysfunction
 DIC
 Coagulopathy

22. WHO 1997/2011 CASE DEFINITION OF DENGUE AND
LEVELS OF SEVERITY
DENGUE FEVER
 Probable
An acute febrile illness with 2 or more of the following:
1. Headache
2. Retro-Orbital pain
3. Arthralgia
4. Rash
5. Hemorhagic manifestations
6. Leukopenia AND
Supportive serology (a antibody titre ≥ 1280), a comparable IgG
assay ELISA titer or (+) IgM antibody on a late course or acute
convalescent phase serumspecium.
 Confirmed: by Lab Criteria

23. DENGUE HEMORRHAGIC FEVER
 Fever, or history of fever lasting for 2-7 days
 Hemorrhagic tendencies evidenced by at least one of
the following
1. Positive Tourniquet Test
other
2. Petechiae, Ecchymosis, Purpura
3. Bleeding from the mucosa, GIT, injection sites or
location.
4. Hematemesis orMalena
Thrombocytopenia (≤1,00,000 cells/cumm)

24. Evidence of Plasma Leakage due to increase vascular
permeability manifested by atleast one of the following:
1. a rise in hematocrit ≥20% above average for age sex
and population.
2. a drop inthe hematocrit following volume
replacement treatment ≥20% ofbaseline.
3. signs of plasma leakage such as Pleural Effusion,
Ascites and Hypoproteinemia.

25. DENGUE SHOCK SYNDROME
All of the four criteria for DHF must be present plus evidence
of circulatory failure manifested by
Rapid and weak pulse, &
Narrow Pulse Pressure(<20mmHG)
OR
Hypotension for age &
Cold clammy skin and restlessness

26. CLINICAL FEATURES

27. Tourniquet test
 Blood pressure (BP) cuff should be inflated on the upper
arm of the patient to a point mid way between systolic and
diastolic pressure for 5 min, and the number of resulting
petechiae in 2.5 cm2 on the volar aspect of the forearm just
distal to the antecubital fossa should be counted
 A test is considered positive when 20 or more
petechiae are observed in the 2.5 cm2
 Test reflects both capillary fragility and
thrombocytopenia
 May not be positive in severe shock associated with DSS
 Earlier DHF, now part of DF without warning signs

28. Unusual Manifestations ofDengue
 Acute liver failure and encephalopathy which
may be present even in the absence of plasma
leakage
 Cardiomyopathy and Myocarditis
 Encephalitis and rarely AIDP(Acute Inflamatory
Demyelinating Polyradiculopathy)
 Severe Gastrointestinal hemorrhage

29. Disease Course
FEBRILE PHASE
 Sudden onset high grade fever.
 Non specific constitutional symptoms like
headache, myalgia, arthralgia, facial flushing etc.
 It lasts for2-7 days.
 Mild hemorrhagic manifestation may occur.
 Monitor for the warning signs.

30. CRITICAL PHASE
 The warning signs marks the beginning of
the critical phase (plasma leakage)
 Patients condition worsens when the
Temperature drops to 37.5- 38C.
 It usually lasts for 24-48 hours.
 Progressive leucopenia, thrombocytopenia are
present.

31. RECOVERYPHASE
 Gradual reabsorption of fluid in 48-72 hours.
 Bradycardia are common during this stage.
 WBC count usually starts to rise before platelet
count improves.
 Signs of fluid overload (respiratory distress
from massive pleural effusion and ascites,
pulmonary edema or congestive heart failure)

32. STEP-WISE APPROACH
STEPI
• Overall assessment
• History-physical exam-routine lab-denguespecific lab
• Assess disease phase and severity
STEP II
STEP III
• Notification
• Management decision (A/B/C)

33. Laboratory Manifestations
 Hematocrit / Packed cell volume:
 Measured by capillary centrifugation or automated
analyzers
 Crude estimate = Hb× 3
 Capillary values may be 5-10% higher than venipuncture
values
 May be altered by bleeding/volume replacement
Increase in Hct by 20%  DHF or plasma leakage
When previous value NA > 45% is significant

34. Other Manifestations
 Peripheral Smear and TLC
 Normal, Leukocytosis Leukopenia
 Lymphocytosis and Atypical lymphocytes
 Thrombocytopenia
 Automated Platelet Counters : Giant platelets;
pseudothrombocytopenia (EDTA induced
platelet aggregates).
 between day 3 - 8 following the onset of illness

35. Other Manifestations
 Hypoalbuminemia
 Hyponatremia
 Mild increase in AST, ALT upto200-250
 > 1000 Hepatic involvement and Severe Dengue
 ↑ PT,APTT
 ↑ Urea / Creatinine
 Mild albuminuria
 Reduced Serum Complement

36. Role of Ultrasonoraphy in Dengue
 Fluid accumulation:
 Pleural effusion: Right side or B/L
 Ascites
 Pericardial effusion
 Acalculous Cholecystitis
 GB wall thickening and pericholecystic fluid
>3mm ↑ severity
 Hepatosplenomegaly

37. Diagnosis of Dengue virus infection

38. Laboratory criteria for confirmation of dengue fever
 Isolation of the dengue virus from serum or autopsy
samples
 Demonstration of a fourfold or greater change in IgG or IgM
antibody titres to one or more dengue virus antigens in paired
serum samples
 Demonstration of dengue virus antigen in autopsy tissue,
serum or CSF samples by immunohistochemistry,
immunofluorescence or ELISA
 Detection of dengue virus genomic sequences in autopsy
tissue serum or cerebrospinal fluid samples by polymerase
chain reaction (PCR).

39.  Serological tests for dengue are not much helpful for the
clinical management except in a minority of cases where
the diagnosis is in doubt. It is mostly done to establish the
diagnosis for epidemiological information.

40. Dengue NS-1Antigen
 NS-1 is a non structural protein associated with
intracellular organalles and transported to the
surface by secretory pathways.
 More efficient with acute phase sera of primary
infection as compared to secondary dengue
infection
 Soluble hexameric form found to circulate in the
blood of patients with acute dengue
 ELISA has been developed for specific detection
of Dengue NS-1 typeAntigen.

42. Serological tests available for Dengue
 Hemagglutination inhibition (HI) test
 Neutralization test
 Indirect immunofluorescent-antibody test
 Complement fixation
 Dot blotting
 Western blotting
 Rapid immunochromatography test
 ELISA

43. MAC-ELISA ( IgM-Antibody Capture ELISA )
 Cross reactivity between other circulating
flaviviruses.
 Can not be used to determine the type of virus.
 Antigens used for this assay are derived from
the denguevirus envelope protein
 MAC-ELISA has a sensitivity and specificity of
approximately 90% and 98%, respectively but
only when used five or more days after onset of
fever.

44. IgG ELISA
 Utilizes the same viral antigens as the MAC ELISA
 Similar principle
 10 Dengue: negative IgG in the acute phase and a
positive IgG in the convalescent phase of the infection
 20 Dengue: positive IgG in the acute phase and a four
fold rise in IgG titer in the convalescent phase
 Requires paired sera with at least 7 day interval
between the two samples

45. Hemagglutination inhibition (HI) test

46. Hemagglutination inhibition (HI) test
 Requires paired sera with at least 7 day interval
between the 2 samples
 Cross reaction with other flaviviruses
 HI assay does not differentiate between IgM and IgG
 10 dengue: low-undetectable levels in acute sera
HI titer < 1:1280
 20 dengue: 4 fold rise between 2 samples with peak
titers > 1:2560

47. Rapid Tests
 Various tests are available
 Most based on “Immunochromatography”
 Give results in 30-60 minutes.
 Various commercial kits are available
 Variable sensitivity and specificity
 Accuracy in testing for IgM antibodies is lower
than ELISA.
 However, their accuracy in testing for IgG
antibodies seems to be greater than ELISA
 Can not be used for reporting or in surveillance

48. 10 Dengue vs 20 Dengue
10 Dengue 20 Dengue
NS-1 High Low
IgM High Low /undetectable
IgM/IgG ratio >1.2 <1.2
HI titer < 1:2560 > 1:2560
IgG paired sample
ELISA
-ve  +ve Both sample +ve
with 4 fold rise

49. Final Interpretation of Diagnostic tests
Highly suggestive
IgM + in a single serum sample
IgG + in a single serum sample with a HI titre of 1280 or greater
Confirmed
PCR +
Virus culture +
IgM seroconversion in paired sera
IgG seroconversion in paired sera; or
Fourfold IgG titer increase in paired sera

50. Treatment
 Management is relatively simple, inexpensive and
very effective in saving lives so long as correct and
timely interventions are instituted.
 Main Pathological Abnormality is Loss of plasma
volume from the vascular compartment because of
increased capillary permeability.
 Early and effective replacement of plasma losses with
plasma expander or fluid and electrolyte solution results
in a favorable outcome in most cases.

51. TREATMENT PRINCIPLE
MONITOR
VITAL PARAMETERS
HEMATOCRIT PLATELETCOUNTS

52. Management Decisions
 Depending on the clinical manifestations and
other circumstances,
GroupA: Sent Home
Group B: In-hospital management
Group C: Require emergency
treatment

53. Group A Outpatient treatment
Who?
Able to take orally
Pass urine adequately once every 6 hrs
No warning signs particularly at defervescence of fever
What to do
Review daily for disease progression ( TLC, Hct and warning
signs)
ORS, juice and other fluids
Paracetamol (max 3gm/day)
Instruct to come back in case of warning signs or decreasing
urine output

54. Group B In hospital management
 Warning Signs
 Abdominal pain or
tenderness
 Persistent vomiting
 Clinical fluid accumulation:
Plu.Eff, Ascites
 Mucosal bleed
 Lethargy, restlessness
 Liver enlargement >2 cm
 ↑ Hct with
thrombocytopenia
 Co-existing Conditions:
 Pregnancy, Diabetes, renal
failure, infancy, old age,
obesity, chronic hemolytic
diseases.
 Social Circumstances

55. Dengue without warning signs
Encourage oral fluids
Start NS orRLat
maintenance rate
If not tolerated
Give minimum volume requiredto
Maintain good perfusion
and urine output
*IV fluids for fewhrs
*switch to oral fluids as
soon aspossible
Continue IV fluid as per next slide
No warning
signs
patient
improving
Warning signs or
↑ Hct

56. 3–5 ml/kg/hr for 2–4hr
isotonic solutions such as NS or RL
5–7 ml/kg/hr for 1-2 hrs
Obtain Hct
2–3 ml/kg/hr
Obtain Hct and reassess
clinically
Hct same or
rising minimally
2–3 ml/kg/hr for 2-4 hrs
Minimum fluid to maintain
good perfusion and urine
output =0.5 ml/kg/hr.
Reduce IV fluid as Hct decreases
and patient improves
*IVFluid for24-48hrs
Vital signs
worsening;
Hct rising

57. Monitoring
 Vital signs and peripheral perfusion 1–4 hourly
 Urine output 4–6 hourly
 Hematocrit before and after fluid replacement,
then 6–12 hourly
 Blood glucose, and other organ functions as indicated
Till the patient is out of critical period

58. Group C: Require urgent treatment
in a high dependency unit
 Early presentation with shock (on days 2 or 3 of illness)
 Severe plasma leakage and/or shock
 Undetectable pulse and blood pressure
 Severe bleeding
 Fluid overload
 Organ impairment (such as hepatic damage,
cardiomyopathy, encephalopathy, encephalitis)

59. Fluid Resuscitation
 Fluid resuscitation in severe dengue is different from fluid
administration.
 Larger volumes of fluids administered for a limited period
 Goal is to improve central and peripheral circulation and
maintain end-organ perfusion.
 Degree of intravascular volume deficit in dengue shock varies.
 Input/output ratio is of no utility for judging the adequacy
of fluid resuscitation.
 Instead of 5-7ml/kg/hr give @ 10-20 mkl/kg/hr, if HCT dec
consider BT, if same, then maintenance dose of IVF, if increas
then give bolus again.

60. Hypotensive Shock
isotonic crystalloid or colloid 20 ml/kg for 15 min
Clinical Improvement
Crystalloid/colloid 10 ml/kg/hr
for 1 hour
IV crystalloid 5–7ml/kg/hr for1–
2hrs
3–5 ml/kg/hr for 2–4hrs
2–3 ml/kg/hr for 2–4hrs
Patient improves, Hct
stable:
↓IVF to maintenance
level stop after 48hrs
Monitor Hct 6 hrly
YES NO
Review HCT
HCT ↑orhigh
2nd Bolus: Colloid10-
20ml/kg over 30 min to 1hr
Improvement
NO
Repeat 2nd HCT
HCT ↑orhigh
3rd Bolus: Colloid 10-
Consider occult/
significant bleed
BT
HCT ↓
HCT ↓
20ml/kg over 1hr
NO
Repeat Hct

61. Monitoring of patient in severe
Dengue (DSS)
 Alertnesss level and comfort
 Vital signs and peripheral perfusion: 15–30
minutes 1–2 hourly
 Urine output: hourly 1–2 hourly
 Hematocrit: before and after fluid boluses until stable
and then 4-6 hrly
 ABG: 30 min to 1 hrly until stable and then as indicated
 Blood glucose: before fluid resuscitation and repeat
as indicated
 KFT, LFT as indicated

62. Interpretation of Hematocrit
 ↑ Hct + Unstable vitals  Active Plasma Leakage
 ↑ Hct + stable vital signs  no need for extra IV
fluids
 ↓ Hct + stable vitals + adequate output
haemodilution and/or reabsorption
 ↓ Hct + unstable vitals  Continued hemorrhage

63. Fluids to be used in Dengue
 Crystalloids: use isotonic solutions
 NS ( Osm= 308mOsm/L)
 suitable option for initial fluid resuscitation
 large volumes hyperchloraemic acidosis
 RL ( Osm= 273mOsm/L)
 may not be suitable for resuscitation of patients with
severe hyponatremia
 Can be used after initial fluid resuscitation with NS
 avoid in liver failure and in patients taking metformin

64. Fluids to be used in Dengue
Colloids
Dextran
Starch
Gelatin
Haemaccel
Benefits:
Distributed in vascular compartment
Increase oncotic pressure
Disadvantages:
May effect coagulation (vWF/Factor VIII)
Allergic reactions
May cross into the interstitium Reverse osmosis

65. WHO-2012:
 Use Crystalloids first ( NS preferred as
initial resuscitation fluid over RL).
 Colloids may be used in hypotensive patients
who do not respond to a bolus of crystalloids or
PP<10mmHg.
 Colloids may also be used in patients with
obvious fluid overload but vital signs are
not stable and high Hct.
 Avoid hypotonic fluids like 5% D, N/2

66. When to stop IV fluids
 IV Fluid therapy can be stopped when Hct drops to
45% in adults, 40% in children and adult females and
35% in infants.
 Stable blood pressure, pulse and peripheral perfusion
 Afebrile for more than 24–48 days (without the use
of antipyretics)
 Resolving bowel/abdominal symptoms
 Improving urine output

67. Risk factors of major bleeding
 Prolonged/refractory shock;
 Hypotensive shock and renal or liver failure and/or
severe and persistent metabolic acidosis;
 Use of NSAIDs
 Pre-existing peptic ulcer disease
 Anticoagulant therapy
 Any form of trauma, including intramuscular injection.

68. Clinical indicators of severe bleeding
 Persistent and/or severe overt bleeding in the presence
of unstable haemodynamic status
 ↓ Hct + unstable vitals after fluid resuscitation
 Refractory shock that fails to respond to consecutive
fluid resuscitation of 40-60 ml/kg
 Hypotensive shock with low/normal hematocrit
before fluid resuscitation

69. Treatment of haemorrhagic
complications
 5–10ml/kg of fresh-packed red cells
 Or 10–20 ml/kg of fresh whole blood (FWB)
 Fresh Whole blood is preferred
 Where possible  Use fresh blood/Packed Cells
In cases of severe bleeding, use of blood is
preferable instead of platelets and FFP

70. Issues in Platelet transfusion
Platelet rich plasma (PRP) when managing
thrombocytopenia
Platelets present a strong antigenic stimulus
Evoking an exaggerated immune response
Further immune mediated platelet destruction

71. Criteria for Platelet Transfusion
 Platelet counts of dengue patients fluctuate in
an unpredictable manner despite platelet
transfusion
 Prophylactic platelet transfusions are not
necessary
 Stable patients with Platelet Count <10,000/cc*
 Patients with Platelet Count < 20,000/cc with
minor bleeding
 Patients with Platelet Count < 50,000/cc with
significant bleeding

72. Platelet Concentrate vs Apheretic
Platelets
Platelet Concentrate(Random Donor) Apheretic Platelet(SDP)
5 x 1010/unit 3.5 x 1011
1 unit increases by 5k-10k/µL 1 unit increase by 30k-60k
Loss of platelet function little loss of platelet function
Differential centrifugation from freshly
drawn blood units
by platelet-pheresis technique
Cheaper Costly
More exposure to TTI Less exposure to TTI

73. Dose of Platelet Transfusion
 If using Platelet Concentrate:
 10-20 ml/kg or 4 units/m² BSA over 1 hour
 If using apheretic platelet:
 1 unit of apheretic platelet over 1 hr
WHO does not recommend use of FFP in bleeding in
Dengue

74. Fluid Overload: Causes
 Excessive and/or too rapid intravenous fluids
 Incorrect use of hypotonic rather than isotonic
crystalloid solutions
 Inappropriate use of large volumes of intravenous fluids
in patients with unrecognized severe bleeding
 Inappropriate transfusion of FFP, PRP and Cryoprecipitate
 Continuation of intravenous fluids after plasma leakage
has resolved
 Co-morbid conditions: CHD, IHD, COPD,CKD

75. Fluid Overload: Recognition
 Early:
 Respiratory Distress
 Tachypnea
 Wheezing
 Large Pleural
Effusion
 TenseAscites
 ↑ JVP
 Late :
 Pulmonary oedema
 Irreversible shock

76. Management of fluid overload
O2 Inhalation
Critical Phase
Out of Critical
Phase
Hemodynamic
ally stable
Reduce IV
fluids
Avoid diuretics
Shock with
low Hct
May have occult
bleeding slow
cautious BT
Reduce IV fluids
May give furosemide
0.1–0.5 mg/kg OD or BD
Shock with
high Hct
Consider
colloids

77. Criteria for discharging inpatients
 Absence of fever for at least 24 hours without the use
of antipyretic therapy
 Return of appetite
 Visible clinical improvement
 Good urine output
 Stable haematocrit
 Passing of at least 2 days after recovery from shock
 No respiratory distress from pleural effusion or ascites
 Platelet count >50 000 per mm3.

78. Prevention of mosquito bite
• Install Iron Mesh at doors and
Window
• Sleep under mosquito net
• Use mosquito repellant coil
/mats
• Apply mosquito repellant oil/
cream on skin
• Cover your body with clothes as
much as possible
• Allow indoor insecticide spray
by health staff
• tetravalent, live attenuated,
recombinant vaccine, which is
currently in Phase III clinical
trials.

79. Thank You