EMERGING VECTOR-BORNE DISEASES IN CHILDREN
DR SV PATIL PROF AND HEAD PAEDIATRICS BLDE-UNIVERSITY SRI BM.PATIL MEDICAL
COLLEGE BIJAPUR
EMERGING VECTOR - BORNE DISEASES IN CHILDREN
DR SV PATIL PROF AND HEAD PAEDIATRICS
• Dengue fever• Ricketsial fever
• Chickungunya fever• Japanese encephalitis• Malaria
Dengue fever
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Case
• Rahul, 4 year male child presents with– Fever high grade, vomiting for 4 days– Treated with paracetamol but little response– Monsoon time and a case of dengue in neighborhood
reported recently – How will you proceed in such a case?
• Ask • Look • Test
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Ask for ……• Localizing symptoms:
– Cough, cold, ear ache: Tonsillitis, AOM, Sinusitis– Loose stools: Rotaviral, bloody diarrhea– Urinary symptoms: UTI– Boils: SSTI
• Without focus: – Pattern of fever, Well between fever spikes, history in
contacts, coryza, systemic symptoms (myalgia) – Vaccination: Hib, typhoid, measles, MMR
• Danger symptoms: Lethargy, refusal of feeds, irritability, oliguria, convulsion, cold extremities (Serious infections)
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Look for …..
• Vitals: Pulse, CRT, BP/Pulse pressure, Tourniquete test, Skin rash
• Focus like: – Liver/spleen/LN, ascitis – Resp: Conj congestion, Coryza, Throat/Otoscopy,
RR, Grunt, retractions, effusions – CNS: Alertness, FND, meningeal signs – Other systems
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Test for …..
• Test for (now or later?) – CBC, PS for MP (repeat if no response) – Urine analysis – culture SOS– Blood culture?? – X ray chest (If resp signs)– Repeat tests (CBC) SOS– Others: CRP, SGOT, SGPT, Widal, Dengue serology,
RMT ????
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Case continues ….
• Rahul’s tests done show: • CBC:
– Hb 13 gm%, HCT 40%, – WBC 3200, P 40, L 56 E 3, M1– Platelets: 1.2 lakhs
• PS for MP: Negative• Urine analysis: Albumin nil, Pus cells 2-3/hpf• X ray chest: Normal
DD: Malaria, Dengue, Viral fever, Enteric fever, Leptospirosis etc
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Case continues …..
• Rahul’s fever is persistent • He now has some rash on his body• He seems to have body ache and restlessness • His mother repeats his investigations
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Case continues ….Day 4 Day 6
Hb 13 15
HCT 40 45
WBC 3200 2200
DC P40, L56, E3, M1 P34, L60, E5, M1
Platelets 120,000 70,000
PS for MP -ve -ve
Urine Routine Normal Normal
Mother wants to know whether it is dengue and whether she should ask for dengue tests?
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Which laboratory tests?
• Test for confirming dengue– NS1 Antigen, ELISA for IgG & IgM
• Need, timing, interpretation
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Interpretation of dengue serologyNS1 antigen IgM IgG Interpretation
+ve -ve -ve Early (< 4dys)
-ve/+ve +ve -ve Primary
-ve +ve +ve low titers Current/Recent
-ve/+ve +ve +ve high titer Secondary
-ve -ve +ve High titers Secondary
-ve -ve +ve low titers Past infection
• Most important for preventing morbidity and mortality is serial clinical monitoring and CBC
• Do not withhold fluid therapy pending labs/-ve labs
*
* Exception being congenital dengue (in 1st 3 months of life)
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Case continues …..
• Rahul is drinking and eating though less than before
• His fever is better with paracetamol• He has passed urine 3-4 times since morning• Mother wants to know whether she should
admit Rahul in hospital?
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Course of dengue illnessCritical phase:
Falling WBC & Platelets
Plasma leak & Rising HCT – 3rd spacing
Shock, organ dysf., Acidosis, DIC
Severe bleeding with HCT & in WBC
Severe shock, organ damage & death.
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WHO classification of dengueDF grade Clinical criteria Laboratory criteria
DF Fever with 2 or more of following signs:
Headache, retro-orbital pain, myalgia, arthralgia
Leukopenia, occasionally thrombocytopenia with no plasma leakage
DHF I Above signs plus
+ve tourniquete test
HCT rise > 20%
platelets < 100,000
DHF II Above signs plus
spontaneous bleeding
HCT rise > 20%
platelets < 100,000
DHF III
(DSS)
Above signs plus
circulatory failure
HCT rise > 20%
platelets < 100,000
DHF IV
(DSS)
Profound shock with undetectable BP and pulse
HCT rise > 20%
platelets < 100,000
Not suitable in all situation; severe dengue in absence of criteria
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Suggested dengue classification
Criteria for dengue +/- warning signs
Without
With warning signs
1) Severe plasma leakage 2) Severe hemorrhage 3) Severe organ impairment
Dengue +/- warning signs Severe Dengue
Criteria for severe dengue
Probable dengue
Live in/travel to dengue endemic area. Fever and 2 of the following criteria
• Nausea, vomiting • Rash • Aches and pains • +ve tourniquete test • Leukopenia • Any warning sign
Warning signs• Abd. Pain & tenderness
• Persistent vomiting
• Clinical fluid accum.
• Mucosal bleeds
• Lethargy, restlessness
• > 2 cm liver enlarged
• Lab: HCT with rapid in platelets
Severe plasma leakage• Shock (DSS) • Fluid accumulation with respiratory distress
Severe bleeding As evaluated by clinician
Severe organ involvement • Liver: AST/ALT > 1000 • CNS: Impaired consc. • Heart & other organs
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Management principles
Step 1. Overall assessment: History, examination, labs
Step 2. Diagnose & assess phase/severity of disease
Step 3. Management:• Disease notification• Management decisions:
• Group A (to be sent home)• Group B (in-hospital management)• Group C (emergency treatment & referral)
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Case continues …..
• Rahul is drinking and eating though less than before
• His fever is better with paracetamol• He has passed urine 3-4 times since morning• Mother wants to know whether she should
admit Rahul in hospital?
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Group 1 (Home care)
• It includes those who: – Can tolerate adequate volume of oral fluids– Pass urine 4-5 times in 24 hours– No warning signs
• Rx: 5-6 glasses of ORS, Juices, other fluids, Paracetamol (NO NSAIDs/Mefenimic acid)
• FU: Daily FU till defervescence period is over at home by care taker and at clinic by medical professional for – Intake, output, repeat CBC, look for warning signs,
response to therapy, deterioration or warning signs
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Case continues …..
• Rahul is now sick looking• He has vomited several times and is not able
to drink well• He has developed cold hands and feet• He is irritable and restless • He has not passed urine for 8 hours• Mother wants to know whether she should
admit the child?
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Group 2 (In-hospital Rx)
• Includes those with warning signs:• Abd. Pain & tenderness • Clinical fluid accum. • Lethargy, restlessness • Lab: HCT/ in platelets
• High risk for complications like pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic hemolytic diseases
• Difficult social situation (far away/living alone)
• Persistent vomiting • Mucosal bleeds • > 2 cm liver enlarged
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5-7 ml/Kg/hr x 1-2 hr
3-5 ml/Kg/hr x 2-4 hr
2-3 ml/Kg/hr x 2-4 hr
Clinical/CBC monitoring
Taper over 24-48 hr
Response seen
Worsening
5-10 ml/Kg/hr x 1-2 hr
Clinical/CBC monitoring
Response seen Worsening
Severe shock
Monitoring: Clinical q 1-4 hr; Urine output q 4-6 hr; CBC q 6-12 hr; Organ function tests sos
Management of Group 2 with danger signs
Refer to 30 care
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Group 3 (Referral to tertiary care)
• Includes those with severe dengue (DSS):– severe plasma leakage leading to dengue shock
and/or fluid accumulation with respiratory distress
– severe hemorrhages– severe organ impairment (hepatic damage, renal
impairment, cardiomyopathy, encephalopathy or encephalitis)
Need access to intensive care, blood products and colloids
Dr. Nitin Shah 25
Compensated shock (systolic pressuremaintained but has signs of reduced perfusion)O2, Fluid resuscitation with isotonic crystalloid
5–10 ml/kg/hr over 1 hour
Improvement
IV crystalloid 5–7 ml/kg/hr for 1–2 hours, then:
to 3–5 ml/kg/hr for 2–4 hours; to 2–3 ml/kg/hr for 2–4 hours.Improvement - fluid further.
Monitor HCT 6–8 hourly.Not stable, act according to
HCT levels:if HCT , consider bolus
or increase fluid administration;if HCT , consider
fresh whole blood transfusion.Stop at 48 hours.
No improvement
HCT or high HCT low
Check HCT
Significant Bleeding
– consider Fresh whole
blood transfusion
2nd bolus 10-20 ml/Kg
for 1 hr
Improvement
No improvement Fluids to
7–10 ml/kg/hr for 1–2 hoursthen further
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Hypotensive shock O2, Fluid resuscitation with isotonic crystalloid
or colloid @ 20 ml/kg over 15 min
Improvement
IV cryst./colloid 10 ml/Kg x 1 hrIV cryst. 5–7 ml/kg/hr x 1–2 hours
3–5 ml/kg/hr x 2–4 hours2–3 ml/kg/hr x 2–4 hours.
Improvement - fluid further.Monitor HCT 6–8 hourly.
Not stable, act according to HCT levels:
if HCT , consider bolus or increase fluid administration;
if HCT , consider fresh whole blood transfusion.
Stop at 48 hours.
No improvement
HCT or high HCT lowCheck 1st HCT
Significant Bleeding
– Fresh whole blood transfusion
2nd bolus colloid 10-20 ml/Kg
for ½-1 hr
Improvement No improvement
Check 2nd HCTHCT or high HCT low
3rd bolus colloid 10-20 ml/Kg over 1 hr
Improvement No improvement
Check 3rd HCT
Fluid refractory shock
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Case continues …..
• Rahul was admitted in hospital and treated with IV fluids and he responded well
• His serial CBC showed platelets of only 30,000• He has some skin rash and mild epistaxis• Mother insists on giving platelet transfusion to
Rahul
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Use of blood products • At risk:
– Profound shock, hypotension, NSAIds, Trauma (procedures), liver disease
• Recognition: – Falling HCT on fluid resuscitation with unstable
hemodynamics, – Overt bleeding irrespective of HCT – Refractory/hypotensive shock, worsening metabolic
acidosis • Treatment:
– Fresh PRBC or whole blood (Rarely platelets, FFP) – No role of prophylactic platelets!!!!
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Case continues …..
• Rahul is now well• He is eating and drinking well• He is passing urine well• It is 8 days and he is afebrile for 2 days• His CBC shows Hb of 11 gm%, WBC 4200,
P40,L56, E4, Platelets of 90,000• Mother wants to know when can Rahul go
home?
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Criteria for discharge
• All of the following must be present• Clinical:
– No fever for 48 hours– Improvement in clinical status (general well-being,
appetite, haemodynamic status, urine output, no respiratory distress)
– Time frame for critical phase over
• Laboratory:– Increasing trend of platelet count– Stable hematocrit without intravenous fluids
RICKETTSIAL INFECTIONS
Rickettsial Infections
• Symptoms-- FEVER headache myalgia rash and eschar
generalized lymphnodes,and hepatosplenomegaly
RASH-PALMS AND SOLES
• GI- symptoms-Nausea,Vomiting Abd pain, Diarrhoea
• RS-Cough, Distress,• CNS-Dizziness,Disorientation, Photphobia and
Visual disturbances• Others include-periorbital edema,conjunct
congestion Epistaxis,hearing loss and arthralgia
SEVERE SYMPTOMS
• Interstitial Pneumonia, Pulmonary edema• CNS-Meningoencephalitis syndrome• Renal-ARF • Disseminated Intravascular
Coagulation,Hepatic failure and Myocarditis.
Laboratory findings
• Hematology-TLC-is low and leucocytosis• Platelets less in 60% ESR is high• Hyponatremia,,Hypoalbunemia,Thrombocyto
penia• SGOT- elevated• Weil Felix test (5-7) days• PCR- Immunoflorescence(gold standard)
Diagnosis
• Fever-PUO- Fever with rash(palms and soles)• Tick bite and exposure• Epidemiological data• Lab findings-• Defervescence with antibiotics• DD-Measles,Dengue,Inf mono,Malaria
Typhoid TSS and CVD
Treatment
• Tetracyclin,Doxycyclin Chloromycetin, Macrolides and Quinolines
• 5mg/kg in 2 doses min 5-7 days, and• Supportive therapy.
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
Case Definition of Suspected case:• - Acute onset of fever, not more than 5-7 days
duration.• - Change in mental status with/ without• New onset of seizures (excluding febrile seizures)• (Other early clinical findings . may include irritability,
somnolence• or abnormal behavior greater than that seen with
usual febrile• illness)
JE
JE- CONTD• Laboratory-Confirmed case : A suspected case with any
one of the following markers:• Presence of lgM antibody in serum and/ or CSF to a
specific virus including• JE/Entero Virus or others• Four fold difference in lgG antibody titre in paired sera• Virus isolation from brain tissue• Antigen detection by immunofluroscence• Nucleic acid detection by PCR• In the sentinel surveillance network, AES/JE will be
diagnosed by lgM Capture ELISA, and• virus isolation will be done in National Reference
Laboratory.
CHICKUNGUNYA FEVER
• Triad of fever, rash and joint manifestations• Clinically-fever>38.5,severe
arthralgia(possible)• Epidemiological-visit epidemic area 15 days
prior to symptoms.(probable)• Lab-isolation virus, PCR IgM AND IgG
(confirmed)
• Caused by-chik virus, aedes aegypti vector (human-mosq-human)-post mansoon• Monkeys rodents birds and others.• Symptoms-fever(92%),arthralgia(87%),back
ache(67%) and head ache(62%)• Differs from adults-
Common Infrequent Rare in adults but seensometimes in children
Fever Rash Photophobia
Arthralgia Stomatitis Retro-orbital pain
Backache Oral ulcers Vomiting
Headache HyperpigmentationExfoliative dermatitis
DiarreaMeningeal syndromeAcute encephalopathy
SEQUELAE
• Arthralgia resolves in 87%,3.7% episodic stiffness and 2.8% persistent stiff
• Lab diagnosis–virus isolation PCR IgM antibody and rising IgG titres
• Differential diagnosis –Leptospirosis,dengue fever,malaria,meningitis and rheumatic fever
Management
• First contact-Differential diagnosis should be thought
• Assess dehydration(severe,mild to moderate)• Total leucocyte count->10,000-leptospira, and
<50,000 –dengue fever peripheral smear-MP• Paracetamol -50-60mg/kg/day• Exercise and physiotherapy
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Thank you all!