Dengue part 2

                         Additional dengue information
dengue fever the African subcontinent is credited with the inception of life on earth. Whether it was the swinging predecessors of the homo sapiens from tree to tree or the various kinds of viruses like chikungunya they all seem to have their place of birth as the sub Sahara. Further there is no difference of opinion regarding the guest viruses of this article i.e the Dengue viruses, four of their kind that they have all originated in the mirthy continent, Africa. They have the potential of causing a fever which can debilitate an individual with its myalgic pains and even worse can cause an effect on the circulation causing haemorrhagic tendencies as the life of the blood i.e the red blood cells, platelets are compromised.

How is the fever contracted?
An ally is what these viruses need to spread from one to another. That is ably supported by the Aedes aegypti mosquito which is a swarmy population in the forests of Africa and earlier it was the monkeys which were the pool for the viruses but now man has become the reservoir as it has spread to the homo sapiens. This virus needs a tropical or sub-tropical climate to thrive and no wonder our country has become the second home. It has also evolved in such a way that it can survive in the urban environments by living year round in moist storage containers, able to breed in water-filled flower pots, plastic bags and cans. The virus is contracted from the bite of this striped Aedes aegypti mosquito that has previously bitten an infected person. Though it is an infectious disease, the virus needs the man-mosquito-man transimission only to cause disease.

As such the virus is now endemic in many areas of the world and more so the South Asian continent of ours. It is likely to affect infants, children and young adults. It is more likely to find its habitat in the lowered immunity individuals.

Aedes Aegypti Mosquito
((Aedes aegypti Mosquito))

Signs & Symptoms of Dengue:
Once the virus enters into the body there is an incubation period of about 5 to 8 days, but symptoms may develop after as few as three days or as many as 15 days. The onset of symptoms is sudden and dramatic. Initially, chills tend to develop, followed by a headache. Pain with the movement of the eyes leads to more generalized and extreme pain in the legs and joints. A high fever can be produced, with temperatures reaching 104° F. Also, a pale rash may appear transiently on the face.

These symptoms can persist for up to 96 hours. Often, the fever then rapidly eases. After a short period when symptoms disappear, the fever reappears. The temperature elevates rapidly but the fever is usually not as high as in previous episodes. The palms of the hands and soles of the feet may turn bright red and become very swollen.

Petechiae & Purpuric rash
((Petechiae & Purpuric rash))

In about 80% of those who are infected, recovery is complete after a convalescent period of several weeks with general weakness and lack of energy. However, in some 20% of those who are infected a severe form of dengue fever develops. This malady is characterized by the increased leakage of fluid from cells and by the abnormal clotting of the blood. These factors produce the hemorrhaging that can be a hallmark of the disease, which is called dengue hemorrhagic fever. Even then, recovery can be complete within a week. Finally, in some of those who are infected, a condition called dengue shock syndrome can result in convulsions. In addition, a failure of the circulatory system can occur, resulting in death.

The reasons for the varied degrees of severity and symptoms that the viral infection can elicit are still unclear.

Leucopenia
((Leucopenia))

Characteristics & Diagnosis:
Dengue is characterized by high fever and rashes. Apart from that there need to be three other symptoms to call it as Dengue fever. They are:

Tendency to bleed profusely (positive tourniquet test, spontaneous bruising, bleeding from mucosa, gingiva, injection sites, etc.; vomiting blood, or bloody diarrhea)
Thrombocytopaenia (<100 platelets per mm³ or estimated as less than 3 platelets per high power field)
Evidence of plasma leakage (hematocrit more than 20% higher than expected, or drop in haematocrit of 20% or more from baseline following IV fluid, pleural effusion, ascites, hypoproteinaemia)

Since the antigen-antibody reaction produces a vascular permeablility there is a bleeding across various surfaces of the body which is the deleterious and dangerous effect of this fever. This also leads to dehydration. It produces a bradycardia and decreased pulse rate which is also characteristic of this disease. There is lowered blood pressure with cold and clammy skin. A pale, pink rash spreads all over the body which disappears after a transient time. As long as these two things are not found it cannot be called as dengue haemorrhagic fever.

It is also imperative to note that only 5-10% of patients who suffer from dengue really progress to have the complication of haemorrhagic fever.

As such whenever there is fever with defervescence only to rise again one of the few differentials to be considered in the primary health care is to rule out urinary tract infections, intermittent fevers like malaria and viral illnesses like dengue. As such there would be some urinary symptoms, chills characteristic of UTI, while malaria would present with chills, ague etc. But in dengue there would be a rash and a complete blood picture would reveal reduced mean corpuscular volume, reduced packed cell volume, raised lymphocyte count, compensatory reduction of neutrophils, increased ESR due to rise in lymphocyte count and more importantly a falling platelet count.

Once there is a rash, petechiae, bleeding from any mucus surfaces to differentiate with other haemorrhagic fevers a immunoglobulin study of Dengue is done. There are four serotypes of Dengue virus. It would reveal IgM positive if the Dengue fever has occurred for the first time in the individual and IgG positive if it has occurred for the second time nonentheless with a different serotype of the same Flaviviridae family.

Prevention, Management and Treatment of Dengue:

The best preventive measure is to eliminate the places where the mosquitoes lay their eggs containers holding water, rain water stagnating in big drums, unused buckets, automobile tires, plastic ontainers etc.
As such a viral illness causes typically bad myalgia which is appropriated with rest and since this virus leads to problem with fluid balance; enough hydration needs to be maintained. It is when the electrolytes seem to fall intravenous adminstration of the same can be applied. As and when there is any fall in the platelet count plasma would need to be transfused.
To see that the dengue fever does not transform into the haemorrhagic one is the need of the hour. If there is one system of Medicine which is capable of that; then it has to be Homoeopathic Medicine. As such the fever starts with a typical flu like symptoms with predominant ague, muscular soreness and pain and thereby all remedies which match influenza and intermittent fever like malaria seem to suit the picture.

Platelet Transfusion
((Platelet transfusion))

Probably the first remedy for any viral fevers which seem to set in with a typical pain in the muscles of the whole body and seeming to penetrating into the "bones" with a typical increased thirst and also associated with nausea and vomiting is Eupatorium perf.

The muscular soreness, great prostration and violent headache with the typical thirstlessness and slow pulse all characteristics of Gelsemium is one of the remedies for the fever.

Another remedy for the acute stage of fevers is Dulcamara and this kind sets in usually in damp weather or changes in weather with the muscular soreness and sore throat and cough are the associated symptoms.

Baptisia is another remedy because of the muscular soreness it produces apart from the slow pulse but in this case the putridness of the discharges, perspiration, urine or stool carry weight to indicate this remedy.

Bryonia is a remedy when there is sore throat and the severe headache and the trouble is threatening to go down into the bronchial tree but with this remedy the pulse is full and hard which may be contradictory to the pathology of Dengue.

No fever study can be complete without the study of Rhus tox as muscular soreness as it transcends the joints, tendons and sheaths causing pain. This remedy has aborted many a pathology in the bud. Physical restlessness compelling the patient to constantly change his position is another characteristic of this drug.

Arsenicum is a remedy of individuals who are more prone to coryza with the languor and prostration unmatched and also a burning, dryness and copious, irritating secretions of the conjunctiva, nasal mucosa and the pharynx. This remedy will probably help the first half of the disease and more often than not abort its progress to the haemorrhagic phase. Also when the symptoms do not match any particular remedy this drug is the first to be thought about to check the viral fevers to carry on into their next phase. Needless to say whether it is the reduced osmolality of the blood, leucopenia, increased lymphocyte count or the impending reduction of platelets, Arsenic is a remedy of unmatched importance with any other remedy of Materia Medica.

Cinchona is a remedy which suits the later half of the disease because of the exhaustion and debility due to loss of vital fluids. Literally there may not be any loss of fluids apparently but since the blood picture is devoid of the packed cell volume, leucopenia, rise in lymphocytes and the gradual loss of platelets is the same picture. Probably the only feature that stands against this disease is that it is not usually indicated in acute phase of the disease. But for recouping this is second to none.

To see that the disease does not cause any lethal complications and which matches the second stage of the disease or dengue haemorrhagic fever perfectly is Phosphorus. The suddenness of symptoms like the sudden prostration, faints, sweats, shooting pains, extravasation of blood from the mucus surfaces, destructive metabolism in the circulating leading to leucopenia and reduced platelet count and later the debilitating condition is all covered by Phosphorus and once the diagnosis of Dengue is confirmed there need not be much thought to indicate this remedy.