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

• 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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• 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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• 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 (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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• 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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• 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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Hb
HCT
WBC
DC
Platelets
Day 4
13
40
3200
PS for MP -ve
Urine Routine Normal
Day 6
15
45
2200
P40, L56, E3, M1 P34, L60, E5, M1
120,000 70,000
-ve
Normal
Mother wants to know whether it is dengue and whether she should ask for dengue tests?
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• Test for confirming dengue
– NS1 Antigen, ELISA for IgG & IgM
• Need, timing, interpretation
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NS1 antigen IgM
+ve -ve
-ve/+ve
-ve
+ve
+ve
-ve/+ve
-ve
-ve
+ve
-ve
-ve
IgG
-ve
-ve
+ve low titers
Interpretation
Early (< 4dys)
Primary
Current/Recent
+ve high titer Secondary
+ve High titers Secondary
+ve low titers Past infection
Exception being congenital dengue (in 1 st 3 months of life)
• Most important for preventing morbidity and mortality is serial clinical monitoring and CBC
• Do not withhold fluid therapy pending labs/-ve labs
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• 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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Critical phase:
Falling WBC &
Platelets

Plasma leak & Rising
HCT – 3 rd spacing

Shock, organ dysf.,
Acidosis, DIC

Severe bleeding with 
HCT &
 in WBC

Severe shock, organ damage & death.
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DF grade Clinical criteria Laboratory criteria
DF
DHF I
DHF II
DHF III
(DSS)
DHF IV
(DSS)
Fever with 2 or more of following signs:
Headache, retro-orbital pain, myalgia, arthralgia
Above signs plus
+ve tourniquete test
Above signs plus spontaneous bleeding
Above signs plus circulatory failure
Profound shock with undetectable BP and pulse
Leukopenia, occasionally thrombocytopenia with no plasma leakage
HCT rise > 20% platelets < 100,000
HCT rise > 20% platelets < 100,000
HCT rise > 20% platelets < 100,000
HCT rise > 20% platelets < 100,000
Not suitable in all situation; severe dengue in absence of criteria
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Severe Dengue Dengue +/- warning signs
Without
With warning signs
1) Severe plasma leakage 2)
Severe hemorrhage 3)
Severe organ impairment
Criteria for dengue +/- warning signs
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
Criteria for severe dengue
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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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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• 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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• 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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• 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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• Includes those with warning signs:
• Abd. Pain & tenderness
• Clinical fluid accum.
• Lethargy, restlessness
• Lab:

HCT/
 in platelets
• Persistent vomiting
• Mucosal bleeds
• > 2 cm liver enlarged
• High risk for complications like pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic hemolytic diseases
• Difficult social situation (far away/living alone)
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Management of Group 2 with danger signs
5-7 ml/Kg/hr x 1-2 hr
3-5 ml/Kg/hr x 2-4 hr
Clinical/CBC monitoring
Response seen
2-3 ml/Kg/hr x 2-4 hr
Worsening
5-10 ml/Kg/hr x 1-2 hr
Clinical/CBC monitoring
Response seen Worsening
Taper over 24-48 hr Severe shock
Monitoring: Clinical q 1-4 hr; Urine output q 4-6 hr;
CBC q 6-12 hr; Organ function tests sos
Refer to 3 0 care
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• 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
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Compensated shock (systolic pressure maintained but has signs of reduced perfusion)
O2, Fluid resuscitation with isotonic crystalloid
5–10 ml/kg/hr over 1 hour
Improvement
HCT
 or high
No improvement
Check HCT
HCT low 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.
2 nd bolus
10-20 ml/Kg for 1 hr
Improvement

Fluids to
7–10 ml/kg/hr for 1–2 hours then
 further
Dr. Nitin Shah
Significant
Bleeding
– consider
Fresh whole blood transfusion
No improvement
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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 hr
IV cryst. 5–7 ml/kg/hr x 1–2 hours
3–5 ml/kg/hr x 2–4 hours
2–3 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.
HCT
 or high
No improvement
Check 1st HCT
HCT low
2 nd bolus colloid
10-20 ml/Kg for ½-1 hr
Significant
Bleeding
– Fresh whole blood transfusion
Improvement No improvement
Check 2 nd HCT
HCT low HCT
 or high
3 rd bolus colloid 10-20 ml/Kg over 1 hr
Check 3 rd HCT
Improvement
No improvement
Fluid refractory shock
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• 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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• 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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• 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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• 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
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• Symptoms--
FEVER
headache myalgia rash and eschar
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

• Interstitial Pneumonia, Pulmonary edema
• CNS-Meningoencephalitis syndrome
• Renal-ARF
• Disseminated Intravascular
Coagulation,Hepatic failure and Myocarditis.

• Hematology-TLC-is low and leucocytosis
• Platelets less in 60% ESR is high
• Hyponatremia,,Hypoalbunemia,Thrombocytop enia
• SGOT- elevated
• Weil Felix test (5-7) days
• PCR- Immunoflorescence(gold standard)

• 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

• Tetracyclin,Doxycyclin Chloromycetin,
Macrolides and Quinolines
• 5mg/kg in 2 doses min 5-7 days, and
• Supportive therapy.

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)

• 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.

• 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
Fever
Arthralgia
Backache
Headache
Infrequent Rare in adults but seen sometimes in children
Rash
Stomatitis
Photophobia
Retro-orbital pain
Oral ulcers Vomiting
HyperpigmentationExfo liative dermatitis
Diarrea
Meningeal syndrome
Acute encephalopathy

• 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

• 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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