Misconceptions on Dengue

7:53 AM

DENGUE. You will be a frog under a coconut shell (katak di bawah tempurung) if you haven't heard about it. Throw a stone randomly and it will hit at least one person who had Dengue. I had Dengue back in 2007 when I was still a student. It was bad. It was the worse fever I have ever experienced. I was aching everywhere. Thankfully it was just Dengue Fever.

Despite all the awareness campaign initiated by HE WHO SHALL NOT BE NAMED, there are still some misconceptions about Dengue.

1. Definition

Doktor, saya mau check darah. Takut kene Denggi

No fever. No myalgia and arthalgia. No headache. Not from Dengue endemic area.
In an ideal world, where resources are unlimited and chemical reagents are as cheap as a bottle of mineral water, I can kau tim and do it. Mo man tai! But the truth is, HE WHO SHALL NOT BE NAMED's resources are already stretched to its limit.

The reason why it is called Dengue FEVER or DEMAM Denggi is because...your typical presentation would be to have FEVER.
Dengue fever goes through 3 phases; febrile phase, critical phase and recovery phase.

Self explanatory diagram
Doctors will usually perform lab tests after Day 3 of fever. As per diagram, hematocrit and platelet levels will only derange after Day 3. That's it is important for patients to tell properly when they had the onset of fever instead of dah lama daaaaahhhh!!!! and ish, doktor ni mana la saya ingat!

Updated on 27/2/2014

  • Despite it being common practice to take FBC on Day 3 of fever, it IS recommended for FBC to be taken to get a baseline hematocrit and platelet. Hemoconcentration is when it is elevated more than 20% of the baseline value. Increase in hematocrit with concurrent rapid decrease in platelet IS A WARNING SIGN.

2. Viral fever and Dengue fever

MOfrust: It looks like a viral fever as the WBC is low and platelet is lowish but still within normal range. Its only Day 2 of fever and I would like to repeat another test tomorrow.

Mr X: Viral fever? Can't you tell what it is? Such a big hospital and you can't diagnose me properly?

MOfrust: At this stage it is difficult to tell.

Next morning, I get a complaint letter 

"Doktor tak kompeten dan tidak tahu memberi rawatan dan diagnosis"

The reason why most doctors will only say "suspect Dengue" is because we have a high index of suspicion and nothing else. There used to be a Dengue Rapid Test but it quickly ran out. It was also only done in the ward. For the poor doctor at the clinic and ED, there is no other test available other than full blood count. Furthermore immunoglobulins to Dengue Virus can only be detected after 4 to 5 days. Before your body develops an immune response, there is no way of confirming Dengue!

There is an option to send a blood sample for viral DNA to Institute of Medical Research for a hefty sum. On top of that the result will only be ready after more than 2 weeks. By then, it might be too late.

Updated on 27/2/2014

  • I have been made aware of a test called NS1 antigen test that can be used to detect Dengue on the first day of fever. Its detection is via enzyme linked immunosorbent assay. This test was introduced in 2006. I have personally never used this test before and it is certainly not available in my clinic located in ceruk kampung.
3. The mosquito

Doktor, saya kene gigit nyamuk kejap tadi. Saya nak check ade Dengue ke tak.

Aedes aegypti
Ask any Malaysian and they will know what this is. INI NYAMUK AEDES. But most Malaysians (even some medical students) can't get the correlation between Aedes mosquito and Dengue virus. The Aedes mosquito will only be infective if it is infected by the Dengue virus. Not ALL mosquitoes will carry this virus. 

It goes back to the basic question.....ada demam tak? Its impossible to know whether you have Dengue fever if your were bitten 2 hours ago!

However, eradication of Aedes mosquito plays a big part in controlling as these mosquitoes are the main vectors of Dengue Virus. So please, do your part in keeping your surrounding free of free standing water.

The 2nd video is very informative. Please take your time to go through it.

4. The management

Saya sudah bayar mahal mah...masuk hospital bagi drip air saja. Bukan mau kasi antibiotic ke apa. Kat ward tak habis habis cucuk darah saja.

Well sir, that air is not air paip. Normal saline actually costs a lot. And you should be thankful that you only had to intravenous fluids and not blood transfusion. If it was Dengue Shock Syndrome, you will be in ICU. The main treatment of Dengue Fever IS fluid management. Due to the nature of the disease process, plasma leakage occurs thus the body will be in a dehydrated state. Basically there is insufficient fluids in the blood vessels. That is why doctors (usually housemen) to take blood up to 4 hourly. How much fluids that go in will greatly depend on the hematocrit level. So far, there is no clinical indication for antibiotics and antivirals. Dengue is a self limiting disease. Once past the critical phase, things will be alright.

Hopefully with this post, more people will get a better understanding of Dengue Fever. Please do not barge in to the Accident and Emergency Department telling "saya sudah tunggu 2 jam di luar, nak tunggu saya mati ke?" even though demam baru EMPAT jam. For further information, read up on the Management of Dengue Infection In Adults Clinical Practice Guidelines.

Updated on 27/02/2014

  • Despite all the test and clinical evaluations I failed to mention regarding the warning signs that the public should be made aware of (thanks to Msforty5). If there is persistent fever with the following symptoms, please come and seek treatment.
  1. Abdominal pain and tenderness
  2. Persistent vomiting
  3. Mucosal bleed - gum bleed, per rectal bleed etc
  4. Restlessness and lethargy

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  1. haha betul betul lagi bagus tampal besar besar

  2. though I agree with your views MO frust, let me share this experience by a friend who has just been admitted to ICU at private hospital last nite when it was confirmed she really had dengue. Day 1-sat, she went to private clinic & the doctor assured her the fever accompanied by purging is because of food poisoning. Take the medication after third or 4th day come back if still got fever. So friend (63yo) went thru fever, nausea, tired, purging stage until day 4. She regain her appetite but still had fever despite paracetamol. Last nite we insisted she ask her adult children seek treatment at the emergency ward of private hospital, which thankfully they did, so now all we can hope is she will recover from this disease. Another friend shared her friend's mom was not so fortunate, she too had continuous fever, went to clinics (JB) the doctors prescribed panadol until almost a week later, finally seek treatment at hospital. Blood tests were taken, unfortunately she passed away the same day. I too had dengue fever last year but due to my medical history (ca) I promptly went to emergency ward of private hospital the very next day because of sudden onset of high fever & nausea with headaches. The attentive medical officer casually ask "your area got dengue cases" I wasn't sure but said maybe. So he proceeded & ask if its ok to run blood tests for dengue & H1N1. I did & less than 2hrs later I was admitted when it was confirmed as dengue +. So pls as care provider, not everyone is as knowledgeable as you all are. Some people can be very annoying with little complains they run to seek medical attention while others like the friend say, its ok the doctor say food poisoning so I should be fine.

    1. Thanx msforty5 for pointing it out. I have missed out something here, regarding warning signs. I will update after office hours

  3. I dont want to say that private care is not good but there are some who treat dengue as normal. In dengue we have this term that is close monitoring. Most privates dont do that because only Specialist see their patient twice a day and even worst once a day. Not so many MOs in private hospitals. So there is lacking of close monitoring. Severe ill cases dont send to private, instead sent them to general hospital. At least there is a doctor who always present in the ward for 24/7.

  4. Thank you for this post. I find that it is very educational to the normal laymen like myself despite the heavy usage of jargon. I had a scary experience with my son, whose temperature fluctuated for about 4 days, but it wasn't accompanied by any vomiting or the sort. Oh and he also had a slight rash and he was a little too tired all the time. Of course he cannot yet talk properly so he couldn't tell me if he had the other symptoms like sengal-sengal badan, headache and all that. Of course I was scared to death of losing him, if he was in fact, infected but due to so much complaint from doctors about people hogging the ED and KK unnecessarily, I just decided not to seek for medical help just in case I became of those hoggers. I read up and asked some people who have been infected/had family members who have been infected before and they said that their family members didn't have a fever when dengue FEVER was detected. So, I start to wonder if fever is the only indication or if that rash was just a rash or an indication of dengue without the fever? And what's up with this so called new strain of dengue, is that even true to begin with? So, you see, MOFrust, I know you are frustrated with the people as you mentioned in your post, but the rest of us aren't doctors and I think we have every right to be concerned about our health (and our loved one's as well) and that's why we need doctors to diagnose our illnesses. For people like us who don't deal with illnesses like it's run-of-the-mill kind of thing, every sign/symptom is a potential illness so I hope you will be granted patience to deal with your patients. Thank you.

  5. Yes it is patient's right to concern about their health & their loved one, but i think what mofrust trying to convey here is please make a brilliant complaint, don't complain without any knowledge & accuse doctor blindly.
    I got 1 baby which was referred to ED from KK for neonatal jaundice with Serum Bilirubin (capillary) of 250. However the parents only brought their son to ED after 24 hours. Repeated serum bilirubin was 350. The father was very angry and accuse the doctor in KK for not properly check the baby. I explained to him the differences between venous & capillary blood and also the time frame which he still cannot accept & keep accuse the doctor!

  6. Rainy season has more possibilities of getting infected with various diseases like dengue, chikungunya etc. Once should take more precautions during this season. Every country has similar issue for this mosquito spreading diseases and everyone is affected by this.

  7. thanks for so in-depth information and knowledge. Really appreciate your work.

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