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SynopsisDengue fever, also known as breakbone fever, is caused by an RNA-containing flavivirus transmitted to humans by day-biting mosquitoes, notably Aedes aegypti, in tropical areas of the Caribbean, the Pacific Islands, Central America, South America, Southeast Asia, the Middle East, and Africa. There are estimated to be 50 million cases of dengue fever each year worldwide, and 2.5 billion people are now at risk. Travelers can present once home due to a 2- to 7-day incubation period. Clinical manifestations vary and include asymptomatic infection (75% of cases), mild dengue, classic dengue, and dengue hemorrhagic fever.
In classic dengue fever, there is a biphasic pattern to symptoms. During the first phase, there is an abrupt onset of fever for 2-5 days, malaise, chills, severe headache, myalgias, and retro-orbital and lumbosacral pain. The fever may climb as high as 41°C (105.8°F) but is not associated with an increased pulse. There can be a faint, transient diffuse morbilliform macular rash during the first few days.
During the next several days, there is defervescence despite the onset of nausea, vomiting, possible cough, rhinitis, and sore throat. Leukopenia, thrombocytopenia, and hemorrhagic manifestations are possible.
In young children with dengue fever, nonspecific symptoms such as refusing to accept oral fluids and foods, restlessness, abdominal pain, skin mottling, cold sweat, and low urine output may present early in the disease course.
Incidence is associated with increased urbanization in endemic areas. There is increased severity and 10%-30% mortality in children.
In October 2013, discovery of a new dengue virus serotype, dengue 5, was announced; it is thought to be phylogenetically distinct from the other 4 types.
Transmission of dengue virus via allogeneic blood cell transplantation has been documented, and patients with sickle cell disease or trait may be at increased risk of death from dengue.
The hemorrhagic form, dengue hemorrhagic fever (DHF), is believed to be more likely to occur during a second infection with the dengue virus, especially if the second infection involves a different serotype. DHF affects approximately 500 000 people annually and is most common in children younger than 15 years.
DHF typically begins with the abrupt onset of high fever (40°C-41°C [104°F-105.8°F]), facial flushing, circumoral cyanosis, and headache. Sore throat, anorexia, weakness, abdominal pain, nausea, and vomiting are common. This febrile phase lasts for 2-7 days and may be accompanied by a maculopapular rash, similar to dengue fever. DHF can be distinguished from dengue fever by accompanied petechiae and nonpalpable purpura present on the extremities, trunk, and face, as well as potential bleeding from the nose, gums, and gastrointestinal (GI) tract. Moderate cases will resolve after the fever subsides. However, after a few febrile days, the critical stage of plasma leakage may occur following a rapid drop in temperature. Circulatory failure accompanied by diaphoresis with cool extremities and shock may herald dengue shock syndrome (DSS). Death rates of up to 20% are reported and usually occur within 24 hours of DSS.
A90 – Dengue fever [classical dengue]
38362002 – Dengue
Differential Diagnosis & PitfallsThe differential depends on history and epidemiology.
- Viral exanthem
- Trench fever
- Yellow fever
- Rift Valley fever
- Epidemic typhus
- Endemic typhus
- West Nile virus
- Bacterial sepsis
- Marburg Filoviridae virus infection
- Lassa fever
- Hantavirus hemorrhagic fever with renal syndrome
- Rocky Mountain spotted fever
- Brazilian purpuric fever
- Other hemorrhagic viral fevers (eg, Argentine, Bolivian)
- Viral hepatitis (eg, hepatitis A, B, C)
- Toxin exposure
- Kyasanur Forest disease
- Fulminant hepatic necrosis