1
Approach to Infectious Diseases and their prevention
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2
Antibiotic stewardship practices
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3Community-Acquired Infections
4
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Health Care?Associated Infections
5
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Gram-Positive Bacteria (part-1)6
Gram-Positive Bacteria (part-2)
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7
Gram-Negative Bacteria (part-1)
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8Gram-Negative Bacteria (part-2)
9
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Spirochetal Diseases
10
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Diseases Caused by Atypical/Miscel aneous Bacterial Infections11
Revision-cum-exam on bacteria (Must to know type)
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12
Infections Due to DNA Viruses
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113
Infections Due to RNA Viruses (part 1)
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14
Infections Due to RNA Viruses (part 2)
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15HIV/AIDS ? part 1
16
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HIV/AIDS ? part 2
17
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Fungal Infections18
Parasitic Infections (part 1)
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19
Parasitic Infections (part 2)
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20Revision-cum-exam on Virus, Fungal, and Parasite (Must to know type)
Family
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Common
virus
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PicornaviridaePolio
Entero
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Calciviridae
Noro
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ReoviridaeRota
Orthomyxviridae
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Influenza
Paramyxoviridae Measle
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MumpsParainfluenza
Coronaviridae
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SARS
MARS
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TogaviridaeRubel a
Chikungunya
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Flaviviridae
Dengue
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West nileFiloviridae
Ebola
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Rhabdoviridae
Rabies
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BunyaviridaeHanta
Nairo (CCHF)
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Retroviridae
HIV
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RABIES
? Zoonotic infection that occurs in a variety of mammals throughout the world
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except in Antarctica and on some islands? Canine rabies continues to be a threat to humans; others ? bat/raccoon rabies
? IP: 20?90 days but in rare cases is as short as a few days or >1 year
? usually transmitted to humans by the bite; rarely aerosol, transplantation, human
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-human possibly
? Neuronal dysfunction--rather than neuronal death--is responsible; microglial
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nodules called Babes nodules & Negri bodies (eosinophilic cytoplasmicinclusions)
? Disease usually presents as atypical encephalitis with relative preservation of
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consciousness
? Prodromal ? nonspecific, sometimes earliest specific neurologic symptoms that
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include paresthesias, pain, or pruritus near the site of the exposure? Acute neurologic ? encephalitic (furious) in 80% and paralytic in 20%.
? Comatose -
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? Autonomic dysfunction is commonand may result in hypersalivation,
gooseflesh, cardiac arrhythmia, and
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priapism
? Episodes of hyperexcitability are
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typical y followed by periods ofcomplete lucidity that become shorter
as the disease progresses
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? Early brainstem involvement
(hydrophobia, aerophobia)
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? In paralytic type, commonlymisdiagnosed as Guil ain-Barre
syndrome
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? Diagnosis should be considered in patients presenting with acute atypical encephalitis
or acute flaccid paralysis, including those in whom Guillain-Barre syndrome is suspected
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? Diagnostically useful specimens include serum, CSF, fresh saliva, skin biopsy samples
from the neck, and brain tissue
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? Presence of rabies virus?specific antibodies in the CSF suggests rabies encephalitis,regardless of immunization status
? Other methods: RT-PCR, Direct fluorescent antibody
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? DD: Anti-N-methyl-d-aspartate receptor (anti-NMDA) encephalitis, Postinfectious(immune-mediated) encephalomyelitis, psychiatric disorder (Rabies hysteria)
? There is no established treatment for rabies
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? There are seven well-documented cases of survival from rabies? Postexposure Prophylaxis (PEP) ?
? Healthy dogs, cats, or ferrets may be confined and observed for 10 days
? If an animal escapes after an exposure, it must be considered rabid, and PEP must be initiated
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? Includes local wound care and both active and passive immunization? If anatomically feasible, the entire dose of RIG (20 IU/kg) should be infiltrated at the site of the
bite
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? Vaccines; Four 1-mL doses of rabies vaccine should be given IM in the deltoid area (NOTgluteal) ? 0, 3, 7, and 14
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Zoonotic viruses: Arthropod-Borne andRodent-Borne Virus Infections
? Extrinsic incubation, typically lasts 1?3 weeks in mosquitoes; Arboviruses infect their vectors
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after ingestion of a blood meal from vertebrate; some arthropods by saliva-activated
transmission, Rarely transovarial transmission
? Intrinsic incubation, as per type of infections
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? Seven families: Arenaviridae, Bunyaviridae, Flaviviridae, Orthomyxoviridae, Reoviridae,Rhabdoviridae, and Togaviridae
? Arena and hanta viruses are rodent borne viruses
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? Diagnosis; recognized history of mosquito bite or tick bite (more diagnostic) or rodentexposure; serology; PCR;
Hantavirus infections differ from other viral infections in that severe acute disease is
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immunopathologic;SYNDROMES - grouped into one of five broad categories
ARTHRITIS AND RASH
? D/D - hepatitis B, parvovirus B19 infection, and rubella, and occasionally due to
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adenoviruses, enteroviruses, herpesviruses, and mumps virus
? Chikungunya:
? Aedes albopictus was identified as the major vector with IP ? 2-10 DAYS
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? Abrupt onset of Fever (often severe) with a saddleback pattern and severe arthralgiaaccompanied by chills and constitutional symptoms and signs, such as abdominal
pain, anorexia, conjunctival injection, headache, nausea, and photophobia
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? Migratory polyarthritis mainly affects the smal joints of the ankles, feet, hands, and
wrists; rarely large joints
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? Rashes often coincides with defervescence; Children also often develop a bullousrather than a maculopapular/petechial rash
? Maternal?fetal transmission has been reported
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? petechiae are occasionally seen and epistaxis is not rare, but chikungunya virus shouldnot be considered a VHF agent
? Mildly decreased platelet counts may be seen
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? Nonsteroidal anti-inflammatory drugs and sometimes chloroquine for refractory arthritisENCEPHALITIS
? Seasonal diseases, commonly occurring in the warmer months
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? Japanese encephalitis is the most important viral encephalitis inAsia
? The virus is particularly common in areas of irrigated rice fields
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(attract the natural avian vertebrate hosts and provide abundant
breeding sites for mosquitoes such as Culex tritaeniorhynchus)
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? Additional amplification host by pigs and horses? Unspecific febrile presentation (nausea, vomiting, diarrhea,
cough)
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? aseptic meningitis,
? meningoencephalitis,
? acute flaccid paralysis,
? severe encephalitis.
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? Common findings in JE are cerebellar signs, cranial nerve palsies, andcognitive and speech impairments
? Diagnosis by CSF/serum PCR study along with clinical features
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? Symptomatic treatment only? Usually two intramuscular doses of the vaccine are given 28 days apart
Chandipura virus seems to be an emerging in India
? It is transmitted among hedgehogs by mosquitoes and sandflies
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? It is characterized by high lethality in childrenWest Nile virus is the primary cause of arboviral encephalitis in the United
States
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? Few cases are reported from IndiaFEVER AND MYALGIA
? Typically begins with the abrupt onset of fever, chills, intense myalgia, and
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malaise; "influenza-like" symptoms
? The most clinically important flaviviruses that cause this syndrome are
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dengue viruses 1?4Hantavirus syndrome: It was in 1966 that Thottapalayam
virus, the first indigenous hantavirus species was isolated.
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The Old World hantaviruses cause haemorrhagic feverwith renal syndrome (HFRS) in Asia and Europe while the
New World hantaviruses cause hantavirus
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cardiopulmonary syndrome (HCPS) in the America.
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Dengue
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Agent- Dengue Virus? Single stranded RNA Virus
? Family: Flaviviridae
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? Genus: Flavivirus
? 4 serotypes: DENV-1, DENV-2,
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DENV-3 and DENV-4Vector- Mosquito
?Aedes aegypti , Aedes albopictus
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?Day feeders, Recurrent biter,
Anthropophilic1
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?Fresh water mosquitoes?White bands or scale patterns on its
legs and thorax
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Gubler Djet al. New York: CAB International; 1997. p. 1?22.
DENV- Dengue virus
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Dengue- An emerging disease
Mosquito
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Travel
Temperature
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UrbanizationSource: WHO-TDR Guidelines for diagnosis, management, prevention and control of dengue 2009
Ref: Gubler DJ, Trop Med Health. 2011 December; 39(4 Suppl): 3?11
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Dengue- Seasonal Trends
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2013-14
2014-15
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2015-16Source: Dengue Trends, https://www.google.org/denguetrends/intl/en_us/
Man-Mosquito-Man Cycle
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Mosquito
Intrinsic incubation period
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with nowithin the mosquito
dengue virus
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8-12 days
Dengue infected
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mosquito bitesMosquito bites
healthy person and
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and gets dengue
transmits the virus
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virus in blood mealExtrinsic incubation period
in the infected person
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3-14 days
Febrile viremia in
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a boy infectedwith dengue virus
Ref: WHO and TDR, Handbook for clinical management of dengue 2012.
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Immune-pathogenesisThe Original Antigenic Sin
The First Dengue Infection
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T and B memory cells
Reinfection
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B cells- Ab production &T cell activation
Antibody dependent enhanced
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replication
Chemical mediators
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Ag-Ab complex formation withCytokine
complement activation
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Mast cell mediated
Storm/Tsunami
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Deposition on various tissues,vascular pathology
vessels and platelets
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Increased vascular
pathology
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Thrombocytopenia bleedingVasculopathy capillary leakage
Ref: Mongkolsapaya J et al. 2003. Nat Med 9: 921?927
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Mathew A et al. 2008. Immunol Rev 225: 300?313
Day of illness 0 1 2 3 4 5 6 7 8
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9 10Course of Dengue
Febrile
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Critical
Recovery
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40CTemperature
38C
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Dehydration
Reabsorption and
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BleedingFluid Overload
Potential
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clinical
Shock
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problemsOrgan Dysfunction
Capillary permeability
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Platelet
Laboratory
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parametersWBC
Hematocrit
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IgM/IgG
Virology &
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ViremiaSerology
Ref: WHO-TDR Guidelines for diagnosis, management, prevention and control of dengue 2009
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Dengue Case classification (2009)
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Dengue +/- warning symptomsSevere Dengue
1. Severe plasma
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with
leakage
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warning2. Severe
signs
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haemorrhage
Without
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3. Severe organimpairment
Criteria for Severe
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Criteria for Dengue +/- warning symptoms
Dengue
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Probable dengueSevere plasma leakage
live in /travel to dengue endemic Warning signs*
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leading to:
area.
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? Abdominal pain or tenderness? Shock (DSS)
Fever and 2 of the following
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? Persistent vomiting
? Fluid accumulation with
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criteria:? Clinical fluid accumulation
respiratory distress
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? Nausea, vomiting
? Mucosal bleed
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? Rash? Lethargy, restlessness
Severe bleeding as evaluated
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? Aches and pains
? Liver enlargement >2 cm
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by clinician? Tourniquet test positive
? Laboratory: increase in HCT
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? Leukopenia
concurrent with rapid decrease
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Severe organ involvement? Any warning sign
in platelet count
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? Liver: AST or ALT >=1000
? CNS: Impaired
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Laboratory-confirmed dengue *(requiring strict observation andconsciousness
(important when no sign of plasma
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medical intervention)
leakage)
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? Heart and other organsDSS-Dengue shock syndrome
Ref: WHO-TDR Guidelines for diagnosis, management, prevention and control of dengue 2009
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Clinical Features
Tourniquet test
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? +ve when 10 or more petechia per? Midpoint between SBP and 1 square inch area over forearm
DBP
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? Definite positive test with 20
petechiae or more
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? 5 minutesSBP- systolic blood pressure
Ref: National guidelines for clinical management of Dengue ,NVBDCP, 2014.
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DBP- diastolic blood pressure
Confirming a case of Dengue
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Isolation of Virus
Up to 6 days of
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Have to process the sampleonset of illness
without delay.
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Definite test
Takes 7-10 days
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PCRUp to 6 days of
RT-PCR, one step nested RT-
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onset of illness
PCR, NASBA, real time RT-
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PCRELISA and Dot blot for Up to 6 days of
EM and NS1 Ag
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onset of illness
MAC ELISA
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From day5 till day60
IgG ELISA
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Represents past infection
Hemagglutination
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Not commonly usedInhibition Test
Neutralisation test
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Not commonly usedRapid diagnostic tests
For anti dengue IgM, IgG,
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NS1.high false positive
PCR- polymerase chain reaction, ELISA- Enzyme
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linked immunosorbent assay, NASBA-Management of Dengue
Group A- Sent Home
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Group B
Group C
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(all of the following)(any of the following)
(any of the following)
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?Getting adequate volumes of ?Has warning signs
?Severe plasma leakage
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oral fluids?Has coexisting conditions-
leading to dengue shock
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?Passing urine at least once
diabetes mellitus, renal
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and/or fluid accumulationevery six hours
failure, pregnant, infant or
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with respiratory distress
?No warning signs
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elderly?Severe haemorrhages
?Stable hematocrit
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?Has social circumstances:
?Severe organ impairment
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?Hemodynamically stableLiving alone or living far
(hepatic damage, renal
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away without reliable
impairment,
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methods of transportcardiomyopathy,
encephalopathy or
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encephalitis)
1.Oral fluids- ORS, fruit
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1.Inpatient care1.Emergency treatment with
juices
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2.Monitor Hct and
intesive care facility and
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2.Paracetamolhemodynamic stability
blood transfusion
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3.Anticipatory guidance to
3.Use IV fluids judiciously
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2.Fluid resuscitationcaregivers
4.Correct acidosis and
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4.Follow up daily
electrolyte disturbances
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5.Serial hemograms6.Identify Warning signs
Ref: WHO and TDR, Handbook for clinical management of dengue 2012.
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early
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Use of Hematocrit
Hematocrit should be interpreted alongside clinical condition of the
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patient
Observe closely for 24
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VitalsNo
hrs, Hct should start
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stable
requirement
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of IV fluidsto fall as plasma
leakage resolve
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Rising
Active
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HemodynamicFurther fluid
instability
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plasma
leakage
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replacementHematocrit
Hemodilution
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Reduce IV fluids in a
Vitals
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?Reabsorptionstepwise manner to
stable
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of extravasated
prevent pulmonary
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fluidsedema
Falling
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Immediate
Hemodynamic
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Majorinstability
Hemorrhage
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blood
transfusion
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Ref: WHO and TDR, Handbook for clinical management of dengue 2012.IV Fluids
? When to start?
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? In critical phase for 24-48 hrs
? In presence of features of shock
? In febrile phase if oral fluids are insufficient
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? What fluids to be used?? Isotonic solutions like Ringer lactate and Normal saline
? Colloids used to restore blood pressure immediately
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? Which IV fluids to be avoided?? Hypotonic saline, FFP, Dextrose solution, albumin solutions
? How much fluids to give and how fast?
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? Compensated shock: 5 to 10 ml/kg over one hour
? Hypotensive shock: 10 to 20 ml/kg over 15-30 minutes
? Maintenance fluids according to Holliday- Segar formula
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? 4ml/kg/hour for first 10 kg body weight? 2ml/kg/hour for next 10 kg body weight
? 1ml/kg/hour for onward each kg body weight
Ref: WHO and TDR, Handbook for clinical management of dengue 2012.
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FFP- Fresh frozen plasma
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Discharge criteria
? All of the following conditions must be present:
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? Clinical? No fever for 48 hours
? Improvement in clinical status (general well-being, appetite,
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haemodynamic status, urine output)
? No respiratory distress
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? Laboratory? Increasing trend of platelet count
? Stable haematocrit without intravenous fluids
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Fever patient with history, symptoms and signs
of Dengue
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Natural course of Dengue fever- Temperature,Potential clinical problems, Lab parameters,
Virology/ Serology
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Criteria for Dengue: Confirm the case, ?Warning
signs and coexisting conditions
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Classify into Groups A, B, C for managementManagement according to protocol
IV fluids <48hrs
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Dengue Vaccine
? Most promising candidate is CYD-TDV vaccine/Dengvaxia
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? Approval by WHO in Dec 2015
? Each engineered to express surface envelope and membrane proteins of 4
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serotypes of dengue virus? Administered as 3 doses (0/1/6 months)
? Striking benefit of reduction in hospitalizations among children > 9 years of age
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? Short term safety profile encouraging
? Recently withdrawn from Philippines after 14 children death
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Cure for Dengue?THANK YOU