CME INDIA Presentation by Dr. Pratik Savaj, DNB(Medicine) FID, FNB Infectious Diseases, Infectious diseases specialist, IDCC Hospital Surat, Gujrat, India.

Dengue Ward Scenario

Case 1

Lesson learnt

1. The patient who is not able to take IV fluids and rising Haematocrit requires IV fluids.
2. If the patient is taking liquids orally and Haematocrit is stable, then there is no need for IV fluids.

Management

Out Patient Treatment

When?

• Able to take liquids orally
• No warning sign
• Vitals stable
• Haematocrit/PCV is stable

If No to above all

• Admit and IPD care

Most important point – to assess for warning sign

(Dr. Pratik Savaj. FNB Infectious Disease. Surat.)

Case 2

• 48/Male
• Dengue fever NS1 positive
• Day 5 – platelet count is 12,000
• What to do next?

Any role of papaya leaf extract?

Possible Mechanism of Action of papaya extract in Dengue

• The extracts are likely to possess membrane-stabilizing properties and protect blood cells against stress-induced destruction.
• This property may be useful in patients with dengue infection where the leaf extracts could possibly prevent platelet lysis.
• The authors postulate that this effect could be due to the presence of flavonoids and other phenolic compounds in the papaya leaves (Pharmacognosy Res. 2012 Oct; 4(4):196-202).

What is our goal?

Yes: Stable Hct

No: Not the optimal platelet count

What if early platelet transfusion to be given?

Data

• Prophylactic platelet transfusion delayed the recovery of patients, in terms of increment of platelet counts and the time to discharge Prashantha B et al. Prophylactic platelet transfusion in stable dengue fever patients: Is it really necessary? (Indian J Hematol Blood Transfus 2014;30:126-9)
• Patients receiving prophylactic platelet transfusion had a significantly higher risk of developing pulmonary oedema. (Lum LC. J Pediatr 2003;143:682-4).

Case 3

• 45/F with day 5 dengue fever
• BP- 90/60 P-110 Fever

Day 6 – expired, why??

Case 4

• 32/male
• Dengue fever diagnosed by ELISA method
• Doing well in the ward became afebrile on day 5
• On day 8 – breathlessness and 103 F was started

What is next step?

• Start IV antibiotics?
• Do PCT
• Call Expert

Why we are not taking dengue vaccine?

• Dengvaxia (Sanofi Pasteur)
• Tetravalent, live-attenuated dengue vaccine
• Three doses

Why more malaria and less dengue?

Case 5

• 48 Female
• Fever – 3 days
• Dengue NS1 positive, CBC – Normal, SGPT-32
• Day 5 – vertigo
• Cause???

General and systemic examination – WNL

• Taking 6 liter of water orally and extra 1 liter saline IV
• LDH, CRP and ferritin – N
• What could be the cause?

Sodium level – 127

• Does all patient need high oral intake?
• Who needs IV fluids

Which saline do you give to your patient?

0.9 NS as saline Major concern with 0.9 NS is supra-physiological chloride levels which can lead to hyperchloraemic metabolic acidosis Clinical effects of hyperchloremic Acidosis • persistent acidosis • delayed urination • abdominal discomfort and pain, • nausea, drowsiness, and decreased mental capacity to perform complex tasks • Williams EL. Anesth Analg 1999; 88: 999–1003

Management

If:

• Able to take liquids orally
• No warning sign
• Vitals stable
• Hct/PCV is stable

OPD based care

If NOT- Admit and IPD care

Look for Severe plasma leakage- SHOCK, Large effusion or ascites

For Bleeding- Evaluate

Look for End organ involvement- LIVER – SGPT/SGOT >1000 CNS – impaired consciousness Heart – cardiomyopathy Renal – ARF

What you do in home care?

Ask your patient to show following records everyday • water intake? • Fever chart • Input and output chart • Any warning sign observed or not (Recurrent vomiting, Abdominal pain, cutaneous bleed, breathlessness, lethargy and restlessness)

Small things to remember

• No shaving
• No intramuscular injection
• No Diclo or dexa injection
• No antibiotics (please)

Fluids to be taken by patient at home

IPD care

• Goal – optimal hydration with stable hct
• Do CBC twice a day during critical phase (day 3 to 7) which will guide you IV fluid therapy
• Assess for mucocutaneous bleed
• Two most important thing in the monitoring is vitals (pulse, BP, RR) and Hct
• How to take help of Hct to guide therapy →

Fever control Paracetamol Adult – not >3gm/day Child – 10 mg/kg/dose, not more than 3−4 times in 24 hours NO NSAIDS Dr Pratik Savaj. FNB Infectious Disease. Surat. 45

What is the marker of monitoring? Investigation for the assessment of progression

No role of

• Inj Pantoprazole etc
• Inj Ondansetron
• Antibiotic
• Inj Diclo
• Inj Dexamethasone
• Papaya leaf
• Excessive IV fluids

What is needed?

• Clinical assessment of warning sign
• Daily CBC
• Ferritin and LDH
• Early admission
• IV fluids when needed
• ID physician, nephrologist and haematologist early involvement

Ideal treatment sheet of dengue fever patient

Points to remember

1. Indication of platelet transfusions – of platelet bellow 10,000
2. Indication of steroids – If HLH is proven
3. Pregnancy associated dengue has high risk of blessings and DIC so risk is high

CME INDIA Tail-Piece:

Book Recommendation

Read this book on dengue fever for more details.

KEEP CDC Leaflets in clinic

At Present NO to Papaya Leaves

Carica papaya Leaf Juice for Dengue: A Scoping Review. The BP et al (2022) (1,2)

“A total of 28 articles (ethnobotanical information: three, in vitro studies: three, ex vivo studies: one, in vivo study: 13, clinical studies: 10) were included for descriptive analysis, which covered study characteristics, juice preparation/formulations, study outcomes, and toxicity findings. Other than larvicidal activity, this review also reveals two medicinal potentials of C. papaya leaf juice on dengue infection, namely anti-thrombocytopenic and immunomodulatory effects. C. papaya leaf juice has the potential to be a new drug candidate against dengue disease safely and effectively.”

Letter in Global Health 6(2): p e126, March 2023. (3)

“In conclusion, until descriptive research and clinical trials are carried out to ascertain its treatment effectiveness, the use of PLE for treating dengue symptoms in patients with dengue fever must be contraindicated. Insecticide-treated textiles, the use of mosquito repellent coils, the use of bed nets while in bed even during the day, and the development of the habit of wearing full-sleeve shirts and pants must all be encouraged. The general public must be informed and warned about the dangers and possible side effects of using papaya leaves during dengue fever”

References:

1. Teh BP, Ahmad NB, Mohamad SB, Tan TYC, Mohd Abd Razak MRB, Afzan AB, Syed Mohamed AFB. Carica papaya Leaf Juice for Dengue: A Scoping Review. Nutrients. 2022 Apr 11;14(8):1584. doi: 10.3390/nu14081584. PMID: 35458146; PMCID: PMC9030784.
2. Shrivastava N, Alagarasu K, Cherian S, Parashar D. Antiviral & platelet-protective properties of Carica papaya in dengue. Indian J Med Res. 2022 Sep;156(3):459-463. doi: 10.4103/ijmr.ijmr_2406_21. PMID: 36751743; PMCID: PMC10101366.
3. Nadeem, Abdullah MBBS; Tariq, Rabeea MBBS. Therapeutic potential of Carica papaya leaf extract for the treatment of dengue. International Journal of Surgery: Global Health 6(2):p e126, March 2023. | DOI: 10.1097/GH9.0000000000000126
4. https://www.cdc.gov/dengue/healthcare-providers/clinical-presentation.html

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