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General Information

General InformationGeneral Information

Description

  • acute febrile illness due to dengue virus (an arbovirus) infection and transmitted by Aedes mosquitoes1
  • infection may be asymptomatic or present with symptoms ranging from mild fever to shock and death1

Also called

  • 2009 World Health Organization terms used to classify illness1
    • undifferentiated fever
    • dengue fever (DF)
    • dengue hemorrhagic fever (DHF)
      • subcategorized into 4 severity grades
      • grades III and IV are defined as dengue shock syndrome (DSS)
    • previously classified into 3 classifications of DF, DHF, and DSS which are still widely used
  • break-bone fever
  • dandy fever
  • review of early use of term break-bone fever in Spanish (quebranta huesos) and use of term dengue can be found in 9715945Am J Trop Med Hyg 1998 Aug;59(2):272OpenInNew

Definitions

World Health Organization (WHO) case definitions

  • controversy exists over use of 1997 and 2009 WHO case definitions, with 1997 often preferred for pathogenesis research, and 2009 definitions preferred for disease surveillance and reporting in endemic areas (mnh22668442paph111193052pa9h111193052pbyh111193052pbeh111193052pcxh111193052pmdc22668442pPaediatr Int Child Health 2012 May;32 Suppl 1:5OpenInNew)
  • 2009 WHO case definitions1
    • probable dengue without warning signs (can still lead to severe dengue)
      • living in or travel to endemic area
      • fever
      • ≥ 2 of following
        • nausea or vomiting
        • rash
        • aches and pains
        • positive tourniquet test
        • leukopenia
    • probable dengue with warning signs
      • same as above but also have any of following
        • abdominal pain or tenderness
        • persistent vomiting
        • fluid accumulation on physical exam
        • mucosal bleeding
        • lethargy or restlessness
        • liver enlargement > 2 cm
        • increase in hematocrit with rapid decrease in platelet count
    • severe dengue (may develop even without warning signs)
      • severe plasma leakage leading to shock or fluid accumulation with respiratory distress
      • severe bleeding
      • severe organ impairment
        • alanine aminotransferase or aspartate aminotransferase ≥ 1,000 units/L
        • impaired consciousness
        • involvement of other organs such as heart
    • laboratory confirmed dengue - laboratory confirmation of illness (important when no signs of plasma leakage)
  • 1997 WHO case definitions
    • probable dengue
      • defined as both of
        • acute febrile illness with ≥ 2 of
          • headache
          • retro-orbital pain
          • myalgia
          • arthralgia
          • rash
          • hemorrhagic manifestations
          • leukopenia
        • supportive serology or occurrence at same time and location as other confirmed cases
    • confirmed dengue defined as case confirmed by laboratory findings, including
      • virus isolation
      • ≥ 4-fold change in reciprocal immunoglobulin G (IgG) or immunoglobulin M (IgM) antibody titers in paired samples
      • identification of viral antigen
      • detection of genomic sequences by polymerase chain reaction (PCR)
    • reportable dengue defined as any probably or confirmed case
    • dengue hemorrhagic fever defined as presence of all 4 of
      • fever, or history of acute fever, 2-7 days in length, may be biphasic
      • hemorrhagic tendencies evidence by ≥ 1 of
        • positive tourniquet test
        • petechia, purpura, or ecchymoses
        • bleeding from mucosa, gastrointestinal tract, injection sites, or other locations
        • hematemesis or melena
      • thrombocytopenia (≤ 100,000 cells/mm3)
      • evidence of plasma leakage by at least 1 of
        • ≥ 20% rise in hematocrit above average for age, sex, and population
        • ≥ 20% drop in hematocrit after volume-replacement treatment
        • signs of plasma leakage, such as pleural effusion, ascites, and hypoproteinemia
    • dengue shock syndrome defined as 4 criteria for dengue hemorrhagic fever plus evidence of circulatory failure manifesting as 1 of
      • weak and rapid pulse with narrow pulse pressure (< 20 mm Hg [2.7 kPa])
      • hypotension for age plus restlessness and cold, clammy skin
    • Reference - WHO guidelines on dengue hemorrhagic fever (WHO 1997OpenInNew)
    • DynaMed commentary -- Dengue shock often occurs at or shortly after fever resolution.
  • most appropriate classification system for dengue remains a matter of debate
    • revised (2009) WHO case definitions may predict need for major interventions better than previous (1997) classification system (level 2 [mid-level] evidenceOpenInNew)
      studySummary2
      • based on prospective cohort study without validation Cohort Study
      • 2,259 patients with suspected dengue in 7 countries in Southeast Asia and Latin American 2006-2007 evaluated
      • 1,734 patients with laboratory confirmed disease included in analysis (majority recruited from inpatient setting)
      • 230 of 1,585 requiring hospital admission underwent major intervention (such as resuscitation for shock or transfusion)
      • with respect to need for major intervention
        • classification of dengue hemorrhagic fever (DHF) had sensitivity of 70%, specificity of 100% (previous system)
        • classification of either DHF or dengue shock syndrome (DSS) had sensitivity of 76%, specificity of 54% (previous system)
        • classification of severe dengue had sensitivity of 96%, specificity of 97% using revised classification system
      • PubMed21624014Tropical medicine & international health : TM & IH20110801Trop Med Int Health168936936 Reference - 21624014Trop Med Int Health 2011 Aug;16(8):936OpenInNewfull-textOpenInNewhttp://www.ncbi.nlm.nih.gov/pubmed/21624014?dopt=AbstractTrop Med Int Health 2011 Aug;16(8):936http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3156.2011.02793.x/abstract;jsessionid=E92BE3C4B421DA330BB54785F02804AE.f04t03
    • 2009 WHO case definition may have higher sensitivity and similar specificity for compared to 1997 WHO case definition for identification of severe dengue (level 2 [mid-level] evidenceOpenInNew)
      studySummary2
      • based on systematic review without reporting of individual study quality measures Systematic Review
      • systematic review of 12 cohort studies comparing 2009 vs. 1997 WHO case definitions in adults and children
      • performance of WHO dengue case definitions for identification of severe dengue in 5 studies
        • 2009 WHO case definition had
          • sensitivity 59%-98%
          • specificity 41%-99%
        • 1997 WHO case definition had
          • sensitivity 25%-90%
          • specificity 25%-100%
      • 2009 WHO case definition associated with easier clinical application in 2 studies
      • no studies found comparing 2009 vs. 1997 WHO case definitions for dengue surveillance, reporting, or research
      • PubMed24957540The American journal of tropical medicine and hygiene20140901Am J Trop Med Hyg913621621 Reference - mnh24957540pcxh98132467pmdc24957540pAm J Trop Med Hyg 2014 Sep;91(3):621OpenInNewhttp://www.ncbi.nlm.nih.gov/pubmed/24957540?dopt=AbstractAm J Trop Med Hyg 2014 Sep;91(3):621
    • no clinically relevant difference found between previous and revised classification systems based on a retrospective review of 132 returned travellers with probable or laboratory confirmed dengue (22686428Trop Med Int Health 2012 Aug;17(8):1023OpenInNew); commentary can be found in 21832264Clin Infect Dis 2011 Sep;53(6):563OpenInNew
    • DynaMed commentary -- Broader definitions of severe dengue, dengue with warning signs, and dengue without warning signs in revised case definitions might lead to overhospitalization in some settings, particularly in resource limited settings that may not be able to handle increased patient loads.

References

General references used

  1. World Health Organization (WHO) and the Special Programme for Research and Training in Tropical Diseases (TDR). Dengue guidelines for diagnosis, treatment, prevention and control 2009OpenInNewPDFPictureAsPdf
  2. Guzman MG, Harris E. Dengue. Lancet. 2015 Jan 31;385(9966):453-65OpenInNew
  3. Paessler S, Walker DH. Pathogenesis of the viral hemorrhagic fevers. Annu Rev Pathol. 2013 Jan 24;8:411-40OpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • J Martin Rodriguez, MD, FACP, FIDSA (Professor of Medicine and Public Health, Division of Infectious Diseases, University of Alabama; Medical Director of Spain Wallace S9 General Medicine Inpatient Unit, Director of UAB Travel Clinic, and Co-director of UAB Undiagnosed Diseases Program, University of Alabama Health System; Alabama, United States)
  • Dr. Rodriguez declares no relevant financial conflicts of interest.
  • Amir Qaseem, MD, PhD, MHA, FACP (Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network (GIN); Germany)
  • Dr. Qaseem declares no relevant financial conflicts of interest.
  • Vito Iacoviello, MD, FIDSA (Deputy Editor of Infectious Diseases, Immunology, and Rheumatology; Assistant Professor of Medicine, Harvard Medical School; Chief of the Division of Infectious Diseases, Mount Auburn Hospital; Massachusetts, United States)
  • Dr. Iacoviello declares no relevant financial conflicts of interest.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116824, Dengue; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116824. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

    • Prevention

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • KeyboardArrowRight

      Definitions

      • World Health Organization (WHO) case definitions

  • KeyboardArrowRight

    Epidemiology

    • KeyboardArrowRight

      Incidence/Prevalence

      • Endemic areas

      • Dengue infection

      • Dengue outbreaks (non-United States)

      • Dengue outbreaks (United States)

      • Incidence in travelers

    • Risk factors

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Pathogen

    • Transmission

    • KeyboardArrowRight

      Pathogenesis

      • Immune response

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • HEENT

      • Lungs

      • Abdomen

  • KeyboardArrowRight

    Diagnosis

    • KeyboardArrowRight

      Making the diagnosis

      • World Health Organization (WHO) criteria for diagnosing dengue

    • Differential diagnosis

    • Testing overview

    • Clinical prediction rules

    • KeyboardArrowRight

      Blood tests

      • General laboratory tests

      • KeyboardArrowRight

        Dengue-specific testing

        • World Health Organization recommendations

        • Culture

        • Nucleic acid detection

        • Antigen testing

        • Serology

        • Comparative performance

    • Imaging studies

    • Tourniquet test

    • Other diagnostic testing

  • KeyboardArrowRight

    Treatment

    • Treatment overview

    • Treatment setting

    • KeyboardArrowRight

      Fluid and electrolytes

      • Oral fluids

      • IV fluids

    • KeyboardArrowRight

      Medications

      • Pain relievers

      • Blood products

      • Anti-D immune globulin

      • Corticosteroids

      • Other medications

      • Medications which appear ineffective

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • KeyboardArrowRight

      Prevention

      • Dengue vaccines

      • Mosquito control and avoidance

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • Canadian guidelines

      • Asian guidelines

      • Central and South American guidelines

      • Australian and New Zealand guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
J Martin Rodriguez MD, FACP, FIDSA
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Affiliations

Professor of Medicine and Public Health, Division of Infectious Diseases, University of Alabama; Alabama, United States; Medical Director of Spain Wallace S9 General Medicine Inpatient Unit, Director of UAB Travel Clinic, and Co-director of UAB Undiagnosed Diseases Program, University of Alabama Health System; Alabama, United States

Conflicts of Interest

Dr. Rodriguez declares relevant financial relationships with Finch, Seres, and Syneos (Grant/Research Support).

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
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Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Vito Iacoviello MD, FIDSA
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Affiliations

Deputy Editor of Infectious Diseases, Immunology and Rheumatology, Dynamed; Massachusetts, United States; Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States; Chief of the Division of Infectious Diseases, Mount Auburn Hospital; Massachusetts, United States

Conflicts of Interest

Dr. Iacoviello declares no relevant financial conflicts of interest.

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Retinal hemorrhages and cotton-wool spots

Retinal hemorrhages and cotton-wool spots

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