General office of the national health and family planning commission, issue guidelines for dengue version 2 (2014)
 
 
The national health and family planning commission of the People's Republic of China 
 
 
The 2014-10-11
 
 
Who invented the electric [2014] no. 66 

Provinces, autonomous regions and municipalities directly under the central government health and family planning commission, the xinjiang production and construction corps health bureau:
        To further strengthen dengue patients medical treatment, safeguard people's health and life safety, combined with the recent situation of dengue fever diagnosis and treatment, by organization developed the dengue fever clinic guide (2nd edition) 2014 "(which can be downloaded from the national health and family planning commission web site). Hereby printed and distributed to you for reference used in the clinical work of medical institutions. 

General office of national health and family planning commission
On October 11, 2014 

Dengue guidelines
 
 
Version 2 (2014) 

Dengue fever is an acute infectious disease caused by the dengue virus, mainly transmitted by aedes aegypti and aedes albopictus bites.
A, etiology,
Dengue virus belong to yellow virus flavivirus genus. Dengue virus particles are spherical, 45 ~ 55 nm in diameter. There are 4 serotype dengue virus (DENV - 1, 2 DENV DENV - - 3 and DENV - 4), four kinds of serotype all can affect people, including type 2 severe rate and case fatality rate were higher than other type.
Dengue virus is sensitive to heat, 56 ℃ for 30 minutes can be inactivated, but in 4 ℃ under the condition of its infectious can stay for several weeks. Ultrasound, uv, 0.05% formaldehyde solution, lactic acid, potassium permanganate, gentian violet can be inactivated virus. The virus the most stable at pH 7 ~ 9, in 70 ℃ or freeze drying condition can survive for a long time.
Second, the epidemiology
(a) infection. Dengue fever, recessive infected with dengue virus infection in patients with nonhuman primates and poisoned medium aedes mosquitoes.
(2) the route of transmission. Is mainly transmitted by aedes mosquito. Media mainly aedes aegypti and aedes albopictus.
(3) the vulnerable groups. People generally susceptible, but only some people after infection disease. Dengue virus infection, the human body on the same virus, lasting immunity, but could not form effective protection for different virus infections, if again alien or more different serum virus infection, the body's immune response may occur, leading to severe clinical manifestations.
(4) popular characteristics. Dengue fever epidemic in tropical and subtropical regions, especially in southeast Asia, the Caribbean and Pacific islands more than 100 countries and regions. Provinces have input case report in our country, guangdong, yunnan, fujian, zhejiang, hainan and other local endemic disease, southern provinces can be mainly in summer fall, unemployed and retired workers more at home.
Three, clinical manifestation
Dengue fever is the incubation period is commonly 3 ~ 15 days, most of the 5 ~ 8 days.
Dengue virus infection can be shown as asymptomatic recessive infection, severe infection and severe infection. Dengue fever is a systemic disease, complex and varied clinical manifestations. Typical dengue course is divided into three phases, namely acute fever period, period and recovery period. According to the illness severity, dengue fever can be divided into general dengue fever and severe dengue fever two clinical types.
(a) acute fever. Patients with acute onset, usually starting symptoms are fever, can be associated with chills, body temperature of 40 ℃ within 24 hours. Some cases of fever for 3 to 5 days after the temperature dropped to normal, 1-3 days later rise again, known as bimodal type heat. When fever associated with headache, whole body muscle, bone and joint pain, apparent lack of power, and can appear nausea, vomiting, abdominal pain, diarrhea and other gastrointestinal symptoms.
Acute fever lasts 2 ~ 7 days. In the course of 3 ~ 6 days in facial limbs congestive rash or dotted hemorrhage rash. Typical rash to tip in the limbs and bleeder "PiDao" sample performance, etc. Can appear different degree of bleeding, such as subcutaneous hemorrhage, the injection site, petechiae, ecchymoses, bleeding gums, epistaxis and arm beam test results, etc.
(2) phase. Some patients with high fever continued not ease, or after illness, fever can be caused by the increase of blood capillary permeability of plasma leakage. Serious shock and other important viscera damage can occur.
A period usually appear in the course of 3 ~ 8 days. Such as abdominal pain, vomiting severe warning indications often prompts period begins.
In front of the plasma leakage occurs, patients are often characterized by progressive leukopenia and platelet count down quickly. Patients with different degree of plasma leakage difference is very big, such as chemosis, pericardial effusion, pleural effusion and ascites. Elevated erythrocyte hematocrit (HCT), margin often reflect the severity of the plasma leakage.
If the plasma leakage cause serious lack of capacity, plasma shock patients can occur. Long time shock can occur in patients with metabolic acidosis and multiple organ dysfunction and disseminated intravascular coagulation.
A few patients without obvious leakage of plasma, but can still be severe bleeding (such as subcutaneous hematoma, gastrointestinal bleeding, vaginal bleeding, intracranial hemorrhage, haemoptysis, macroscopic haematuria, etc.).
Some cases can appear orthopnea, chest tightness, heart palpitations, dizziness, shortness of breath, difficulty breathing, headache, vomiting, lethargy, irritability, delirium, convulsions, coma, abnormal behavior, neck stiffness, lumbago, oliguria or anuria, jaundice and other serious viscera damage performance.
(3) the recovery period. After 2 ~ 3 days, patients better, gastrointestinal symptoms, into the recovery period. Some patients bleeder visible tip samples, lower limb, can have itchy skin. White blood cell count began to rise, the platelet count gradually restored.
Most patients characterized by ordinary dengue fever, but only fever period and recovery period. A few patients develop severe dengue.
Four, severe dengue fever warning indications
(a) the high risk population
1. Patients with secondary infection;
2. Accompanied by diabetes, high blood pressure, coronary heart disease, liver cirrhosis, peptic ulcers, asthma, copd, chronic kidney function not entire basic diseases;
3. The elderly or infants and young children;
4. Obesity or severely malnourished;
5. Pregnant women.
(2) clinical manifestations
1. His condition deteriorated after fever;
2. Abdominal pain;
3. Vomiting;
4. Chest tightness, palpitation;
5. Lethargy, irritability;
6. Obvious bleeding tendency;
7. The plasma leakage);
8. Hepatomegaly > 2 cm;
9. Oliguria.
(3) the laboratory indications
1. The platelet count below 50 x 109 / L;
2. The red blood cells deposited rise (up from basic value more than 20%).
Five, complications,
Can appear in viral hepatitis, myocarditis, infusion excess, electrolyte and acid-base imbalance, double infection, acute intravascular hemolysis, etc.
Six, laboratory examination
1. Blood routine: total number of white blood cells decreased, most cases of early began to decline, the course of 4 ~ 5 of heaven to the lowest point, WBC count is given priority to with neutrophils decline. Most of the cases with thrombocytopenia, the minimum can be dropped to under 10 x 109 / L.
2. Routine urine: a small protein, red blood cells, such as pipe type can occur.
3. Blood biochemical examination: more than half of the patients with elevated aminotransferase, lactate dehydrogenase, some patients CK/CK - MB, BNP, troponin, urea nitrogen and creatinine increased, etc. Alanine amino transaminase (ALT) and aspartate amino transaminase (AST) in mild-to-moderate rise, a few patients with elevated total bilirubin, serum albumin. Some patients can appear hypokalemia electrolyte disorder; The blood coagulation function checks visible fibrinogen decrease, prothrombin time and clotting enzyme live longer, severe cases of clotting factor Ⅱ, Ⅴ, Ⅶ, Ⅸ and Ⅹ reduced.
4. The etiology and serological detection: acute stage and convalescence blood samples inspection. Sick of the original testing conditions of medical institutions should test as soon as possible, without etiology detection conditions of medical institutions shall return the specimen to send designated institutions detection.
Acute dengue fever period applicable antigen (NS1) detection and virus nucleic acid detection for early diagnosis, conditional credits and virus serum separation can be performed.
First infected patients, the disease can be detected 3 ~ 5 days after the IgM antibody, reach a peak incidence after 2 weeks, can maintain 2 ~ 3 months; Disease can be detected IgG antibody after 1 week, IgG antibody can maintain several years or even a lifetime; Within 1 week, detected in serum in patients with high levels of specific IgG antibody tip secondary infection, also can be combined with capture method to detect the IgM/IgG antibody ratio of comprehensive judgment.
Seven, imaging examination
CT or chest radiograph can be found on one side or double side pleural effusion and some patients with interstitial pneumonia. Ultrasound visible liver splenomegaly, critically ill patients can also be performance was observed in the gallbladder wall thickening, and fibrin, abdominal cavity and pelvic cavity accumulates fluid performance. Computed tomography (CT) and magnetic resonance imaging (mri) can be found that the brain edema and intracranial hemorrhage, subcutaneous tissue, leakage, etc.
Eight, diagnosis and differential diagnosis
(a) the diagnosis of dengue fever.
According to the history of epidemiology, clinical manifestations and laboratory test results, can make the diagnosis of dengue fever. In the case of epidemiology history is unknown, according to clinical manifestation, auxiliary examination and laboratory test results to make the diagnosis.
Suspected cases: in line with the clinical manifestations of dengue, has a history of epidemiology (onset within 15 days prior to the dengue fever epidemic areas, or where dengue cases), or there are white blood cells and thrombocytopenia.
2. Clinical diagnosis cases: in line with the clinical manifestations of dengue, has a history of epidemiology, and white blood cell, platelet reduce at the same time, a single copy of dengue virus specific IgM antibody positive serum.
3 confirmed cases, suspected cases or clinical diagnosis cases, acute phase serum NS1 antigen or virus nucleic acid detection or isolate dengue virus or recovery of serum specific IgG antibody degrees in more than four times higher.
(2) the diagnosis of severe dengue fever.
One of the following situations:
1. Serious bleeding, subcutaneous hematoma, hematemesis, black, vaginal bleeding, macroscopic haematuria, intracranial hemorrhage, etc;
2. Shock: tachycardia, acromegaly clammy, capillary filling duration > 3 seconds, the pulse of the thin or not, pressing of arteries and veins, reduce blood pressure measurement is less than or;
3. Serious organ damage: liver damage (ALT and/or the AST > 1000 IU/L), ARDS, acute myocarditis, acute renal failure, such as encephalopathy and encephalitis.
(3) of the differential diagnosis.
The clinical manifestations of dengue fever is diversiform, pay attention to identify with the following diseases. With such as chikungunya fever associated with bleeding disease syndrome, kidney syndrome hemorrhagic fever, fever with thrombocytopenia and other identification; And fever with a rash diseases such as measles, urticaria, scarlet fever, meningitis, typhus, tsutsugamushi disease identification; Have cases of encephalopathy performance to identify with other central nervous system infection; White blood cells and platelets to reduce obviously, and blood system diseases identification.
Nine, treatment,
There is no special effects of antiviral drugs, mainly adopt measures to support and symptomatic treatment. Treatment principle is early detection, early diagnosis, early treatment, early anti-mosquito isolation. Severe cases of early recognition and timely treatment is the key to reduce the case fatality rate. Severe dengue diagnosis flow chart see attachment.
(a) general treatment.
1. Bed rest, light diet;
2. The anti-mosquito isolation to symptoms and relieving fever, shoulds not be too early activities on fields, prevent illness;
3. Monitoring consciousness, vital signs, fluid intake and urine output, platelets, HCT, electrolyte, etc. Venipuncture on platelet decreased obviously, to prevent the hemorrhage and hematoma.
(2) of symptomatic treatment.
1. : fever is given priority to with physical cooling, for patients with bleeding symptoms, avoid using alcohol to clean bath. Antipyretic analgesic drugs may appear serious complications, should be careful to use;
2. The rehydration: oral rehydration is given priority to, appropriate into the liquid food, for frequent vomiting, difficulty in feeding or low blood pressure patients, should be timely intravenous fluids;
3. Calm the pain: can give stable, cranial pain on symptomatic treatment, etc.
(3) the treatment of severe dengue fever.
In addition to the monitoring indicators which are mentioned in the general treatment, severe dengue cases should also be dynamic monitoring the change of the electrolyte. Of plasma leakage, shock, severe ARDS, severe bleeding, or other important viscera function disorder should actively take corresponding treatment measures.
1. The rehydration principle: severe dengue rehydration principle is to maintain good tissue perfusion. HCT, platelets should according to the patient at the same time, electrolyte, urine and blood flow dynamics, adjust the amount and type of rehydration in urine volume up to about 0.5 ml/kg/h, under the premise of quantity should be controlled intravenous rehydration.
2. Anti-shock treatment: a shock for liquid recovery treatment as soon as possible, the initial fluid resuscitation is given priority to with isotonic crystal liquid (such as physiological saline, etc.), to respond to initial fluid resuscitation without shock or more severe shock colloidal solution can also be used (such as albumin, etc.). At the same time actively correcting acid-base imbalances. Liquid recovery treatment unable to maintain blood pressure, vascular active drugs should be used; Severe bleeding shock, should timely infusion of red blood cells or whole blood. Conditional hemodynamic monitoring can be performed and guiding treatment.
3. The treatment of bleeding:
(1) bleeding clear, such as severe epistaxis give local bleeding. Gastrointestinal bleeding is given acid drugs. Try to avoid a gastric tube, urine tube and other invasive diagnosis and treatment;
(2) for severe hemorrhage with the hemoglobin is lower than 7 g/L, transfusion of red blood cells in time according to the condition;
(3) severe bleeding associated with platelet count below 30 x 109 / L, should be timely platelet transfusion.
Clinical blood transfusion (including red blood cells, platelets, etc.) to pay attention to the acute lung injury (TRALI) and platelet transfusion related invalid infusion, etc.
4. The important viscera damage treatment:
(1) acute myocarditis and acute heart failure
Should stay in bed for low flow oxygen, maintain defecate unobstructed, intravenous infusion and transfusion speed restrictions. There is room sex or ventricular premature beat, betaloc or amiodarone etc anti-arrhythmic drug therapy. Heart failure occurs in the first place to the diuretic treatment, and maintain daily liquid negative balance in 500 ml to 800 ml, secondly to oral isosorbide mononitrate 30 or 60 mg mg.
(2) encephalopathy and encephalitis
Cooling, oxygen, intravenous infusion volume and infusion speed control. According to the condition to give mannitol or diuretics intravenous drip to relieve cerebral edema. Encephalitis patients can give corticosteroids reduce brain tissue inflammation and swelling. Assisted ventilation support in central respiratory failure should be timely treatment.
(3) with acute renal failure
Reference standard staging acute kidney injury, blood purification treatment in a timely manner.
(4) liver failure
Some can occur in patients with severe liver damage, such as liver failure, according to liver failure of conventional processing.
5. Other treatment: prevention and timely treatment of a variety of complications.
Ten, TCM syndrome differentiation and treatment plan
Dengue belong to the category of "disease" of traditional Chinese medicine, can be reference to the science of seasonal febrile diseases "disease rash" and "wet temperature", "heat temperature" and "latent summer heat" disease and syndrome differentiation and treatment.
(a) acute fever: hot and humid depressive stem, who with the disease.
The early clinical manifestations: come on, fever, cold evil, no sweat, fatigue, tired, headache, back pain, muscle pain, thirst, visible hemorrhagic rash, with nausea and retching, poor appetite, diarrhea, red tongue, moss greasy or thick, pulse and moist slide number.
Treatment: clear heat, wet, detoxification and evil.
Reference: the formulas dew disinfection Dan, to drink to add and subtract.
Chinese mosla herb herba agastachis puerarin artemisinin (after)
notopterygium White Chloe benevolence pinellia talc (packet Fried)
Radix paeoniae rubra wormwood amomum licorice
Usage: the water decoction, a dose of day.
Add and subtract: see the rash and radix arnebiae seu lithospermi; The thirsty and hosts; Hot clear and radix bupleuri.
Proprietary Chinese medicine: it upright series preparations, etc.
Injection: can use poison ning, phlegm hot clear, clean spirit, blood will injection, etc.
(2) phase.
1. The poison stasis knot, camp move blood
Clinical performance: heat, or fever, irritability, insomnia, thirst, nausea, vomiting, is bright red blood rash, more with epistaxis, or bleeding gums, haemoptysis, stool, blood while, vaginal bleeding, red tongue, yellow moss owe jin, pulse headquarters or sink and smooth.
Treatment: detoxification of blood, clear camp cold blood
Reference: the formulas antipyretic disease and add and subtract.
Mi radix rehmanniae buffalo horn honeysuckle
Even the radix scutellariae huang Radix paeoniae rubra madder
Dan Fried mountain Zhi green artemisia licorice
Usage: the water decoction, a dose of day.
Add and subtract, was in a coma, delirium, convulsions with purple snow loose, Ann palace bezoar bolus, wang Huang, etc.
Injection: hot poison ning, phlegm heat, clean spirit, blood will injection, etc.
2. The wet heat injury Yang, qi is not taken blood
Clinical manifestations: refund or fever heat, lack of burnout, rash and faint, bruises or see the dark, or no rash, many with epistaxis, or bleeding gums, haemoptysis, stool, blood while, vaginal bleeding, tongue dark moss greasy, pulse thin weak.
Treatment: explored, replenishing qi and blood taken.
Reference: the formulas aconite decoction and loess in tonga.
Heart of the loess oven Cannon monkshood dangshen cannon ginger
Yellow Qin Herba schizonepetae carbon Fried atractylodes Main licorice
Usage: the water decoction, a dose of day.
Injection: ginseng injection, and injection, etc.
(3) the recovery: more evil, not qi and Yin.
Late clinical manifestations: come on, see more sluggish burnout, nausea, anorexia, thirsty, defecate is not adjustable, see more itchy rash, pale red tongue, white greasy moss, pulse imaginary Numbers.
Treatment: heat wet, spleen and stomach.
Reference: the formulas of bamboo leaves gypsum soup pulse-activating decoction.
Bamboo leaf radix adenophorae barley Raw yam
Pinellia phragmites communis dwarf lilyturf raw rice sprouts
Amomum villosum American ginseng licorice
Usage: the water decoction, a dose of day.
Eleven, prognosis,
Dengue fever is a self-limited disease, usually good prognosis. Factors that affect prognosis include patients with history of dengue virus infection, age, basic diseases, complications, and so on. A handful of severe dengue cases can die in important viscera function failure.
Twelve, remove anti-mosquito isolation criteria
Course of more than 5 days, and heat may be discharged back more than 24 hours.
13, discharge standard
Patients with dengue fever heat back more than 24 hours at the same time the clinical symptoms can be discharged from hospital.
 
Attachment: severe dengue diagnosis flowchart. Doc