Case 41: Dengue Fever
NATIONAL JOURNAL OF HOMOEOPATHY 2006
Dr Mahesh Chevva
'Ars-alb / Rhus-tox / Nux-vom / Sul / Gels / Eup-perf / Phos

This article is put in this Online Section as it is a Current Topic (Though it does not strictly belong to a case section.)

Once again its time for us to prove ourselves. No one is spared from this virus - right from doctors, ministers to workers. Hospital admissions are increasing day by day and mortality continues to rise. We as Homoeopathic doctors have great role in prevention as well as treating this disease. We and our medicines have proved very effective in all the epidemics. (Example: Recent out break of chikungunya) Govt is realizing the importance of it and freely distributing Homoeopathic medicines-which is already started in Delhi. Now it is time for us to arise, awake till we prevent this disease. First let us understand our enemy (disease) so that we will be ready to use our weapons (medicines)

Dengue
Synonyms and Related Keywords: Dengue fever, bone breaking fever- Dengue Fever, dengue virus, dengue infection, dengue hemorrhagic fever-DHF, dengue shock syndrome-DSS, dengue virus 1, DENV-1, dengue virus 2, DENV-2, dengue virus 3, DENV-3, dengue virus 4, DENV-4, Flaviviridae, Flavivirus, Aedes aegypti, A aegypti, Aedes albopictus, A albopictus, mosquitoes, viral epidemic, epidemic, saddleback fever.

History: The term "dengue" is a Spanish attempt at the SWAHILI phrase "ki denga pepo", meaning "cramp-like seizure caused by an evil spirit" It emerged during a Caribbean outbreak in 1827-1828.

Outbreaks resembling dengue fever have been reported throughout history. The first case report dates back from 1789 and is attributed to Benjamin Rush, who coined the term "breakbone fever" because it sometimes causes severe joint and muscle pain that feels like bones are breaking, hence the name.

Epidemiology: Dengue fever is found mostly during and shortly after the rainy season in tropical and subtropical areas of

·         Africa

·         Southeast Asia and China

·         India

·         Middle East

·         Caribbean and Central and South America

·         Australia and the South and Central Pacific

Cause: Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3 and DEN-4. You can be infected by at least two, if not all four types at different times during your lifetime, but only once by the same type.

Reservoir: Humans are the only vertebrate hosts of the virus. There is a jungle cycle between monkeys and mosquitoes, but this plays no role in human disease.

Mode of Transmission: The transmission of dengue by the bite of an infected Aedes aegypti mosquito. This disease occurs more frequently in the rainy season and immediately afterwards (July to October) in India.

Period of Communicability: There is no evidence of person-to-person transmission

Spread: Just like in Malaria, Dengue fever is also spread by bites of mosquitoes. The Dengue virus is present in the blood of the patient suffering from Dengue fever. Whenever an Aedes mosquito bites a patient of Dengue fever, it sucks blood and along with it, the Dengue virus into its body. The virus undergoes further development in the body of the mosquito for a few days. When the virus containing mosquito bites a normal human being, the virus is injected into the person's body and he/she becomes infected and can develop symptoms of Dengue fever.

Incubation Period: Once inoculated into a human host, dengue has an incubation period of 3-14 days (average 4-7 d). Following incubation, a 5- to 7-day acute febrile illness ensues. Recovery is usually complete by 7-10 days. DHF or DSS usually develops around the third to seventh day of illness, approximately at the time of defervescence.

Age: Dengue affects people of all ages. DHF usually affects children younger than 15 years. DSS shows no age predilection.

Symptoms of the disease
Symptoms depend upon the type of Dengue fever. There are three types of Dengue fever:

1. Classical (Simple) Dengue Fever
2. Dengue Haemorrhagic Fever (DHF)
3. Dengue Shock Syndrome (DSS)

The classical (Simple) Dengue fever is a self-limiting disease and does not kill. However, the other types (i.e. DHF and DSS) can prove fatal if prompt treatment is not started.

It is important to recognize whether Dengue Fever is Simple or DHF or DSS. The following symptoms will help in diagnosis:.

1. Classical (Simple) Dengue Fever

1.   Sudden onset of high fever with feeling of chills

2.   Severe Headache

3.   Pains in muscles and joints.

4.   Pain behind the eyeballs especially on pressing the eyes or on moving the eyeballs.

5.   Extreme weakness, loss of appetite, feeling of nausea.

6.   Change in taste sensations in mouth.

7.   Pain in abdomen by itself or on touching.

8.   Mild pain in throat.

9.   Patient feels generally depressed and very sick.

10.          Rash on the skin: Pinkish red rash appears on the skin in the form of diffuse flushing, mottling or pinhead eruptions on the face, neck and chest. Later on, the rash may become more prominent.

11.          The entire duration of Classical Dengue fever lasts for about 5-7 days and the patient recovers.

2. Dengue Haemorrhagic Fever - (DHF)
   It should be suspected if with above mentioned symptoms of Classical (Simple) Dengue Fever one or more of the following symptoms appear:
   Bleeding (haemorrhagic) manifestations: Bleeding from nose, gums, blood in the stools or in vomiting, bleeding spots on the skin which are seen as dark bluish-black, small or large patches. If a health worker carries out a Tourniquet Test, it is positive.
   Certain laboratory investigations carried out on a blood sample also confirm DHF.
3. Dengue Shock Syndrome (DSS)
   All symptoms as mentioned above in DHF are present plus the patient also develops a condition called 'shock'. Symptoms of shock in a Dengue Fever cases are -

1.   The person is very restless and the skin feels cold and clammy despite high fever.

2.   The person may start losing consciousness.

3.   If you examine the pulse rate of the patient, it is weak and rapid.

4.   Similarly, blood pressure will be low.

Clinical Features accompanied by thrombocytopenia and hemoconcentration. * Dengue Shock Syndrome

Lab Studies
Complete Blood Cell count findings include the following: Leukopenia, often with lymphopenia, is observed near the end of the febrile phase of illness. Lymphocytosis, with atypical lymphocytes, commonly is seen before defervescence or shock.

A rise in hematocrit greater than 20% is a sign of hemoconcentration and precedes shock. The hematocrit level should be monitored at least every 24 hours to facilitate early recognition of dengue hemorrhagic fever (DHF) and every 3-4 hours in severe cases of DHF or dengue shock syndrome (DSS).

Thrombocytopenia has been demonstrated in up to 50% of dengue fever (DF) cases. Platelet counts of less than 100,000 are seen in DHF or DSS and occur before defervescence and the onset of shock. The platelet count should be monitored at least every 24 hours to facilitate early recognition of DHF.

Serum Specimens should be sent to the laboratory for serodiagnosis, polymerase chain reaction (PCR), and viral isolation. Because the signs and symptoms of DF are nonspecific, attempting laboratory confirmation of dengue infection is important.

Sero Diagnosis is made based on a rise in antibody titer in paired immunoglobulin G (IgG) specimens or immunoglobulin M (IgM). Results vary depending on whether the infection is primary or subsequent. The IgM capture enzyme-linked immunosorbent assay (MAC-ELISA) has become the most widely used assay, although other tests, including complement fixation (CF), neutralization test (NT), hemagglutination inhibition (HI), and IgG ELISA are also used. Cultures of blood, urine, CSF, and other body fluids should be performed as necessary to exclude or confirm other potential causes of the patients' condition.

Activity: To help with recovery, health care experts recommend:

·         Getting plenty of bed rest

·         Drinking lots of fluids

·         Taking regular medicines to reduce fever and other symptoms

Deterrence/Prevention
No vaccine is available for the prevention of dengue infection. Prevention of Dengue Fever is easy, cheap and better. It requires some simple measures for

·         Preventing breeding of Aedes mosquitoes

·         Protection from Aedes mosquitoes’ bites.

For Protection Against Mosquitoes:

1. Mosquito breed only in water sources such as stagnant water in drains and ditches, room air coolers, broken bottles, old discarded tyres, containers and similar sources.
2. Don't allow water to remain stagnant in and around your house.
3. Fill the ditches. Clean the blocked drains. Empty the room air coolers and flower vases completely at least once in seven days and let them dry. Dispose off old containers, tins and tyres etc properly.
4. Keep the water tanks and water containers tightly covered so that the mosquitoes can not enter them and start breeding.
5. Wherever it is not possible to completely drain the water off from room cooler, water tanks etc., it is advised to put about two tablespoons (30 ml) of petrol or kerosene oil into them for each 100 liters of water. This will prevent mosquito breeding. Repeat it every week.
6. You can also put some types of small fish (Gambusia, Lebister) which eat mosquito larvae into these water collections. These fish can be obtained from the local administrative bodies (eg, Malaria Officer's office in the area).
7. Wherever possible, practicable and affordable, prevent entry of mosquitoes into the house by keeping wire mesh on windows and doors.
8. Use mosquito repellent sprays, creams, coils, mats or liquids to drive away/ kill the mosquitoes. Use of googal smoke is a good indigenous method for getting rid of mosquitoes.
9. Wear clothes which cover the body as much as possible. This is more relevant in case of children. Nickers and T-shirts are better avoided during the season of Malaria and Dengue fever, ie from July to October.
10. Don't turn away spray workers whenever they come to spray your house. It is in your own interest to get the house sprayed.
11. Use insecticidal sprays in all areas within the house at least once a week. Don't forget to spray behind the photo-frames, curtains, calendars; corners of house, stores.
12. Keep the surroundings of your house clean. Don't litter garbage. Don't allow wild herbs etc to grow around your house (at least in a radius of about 100 meters. around your house). They act as hiding and resting places for mosquitoes.
13. Do inform and take help from your local health centre, panchayat or municipality in case you notice abnormal density of mosquitoes or too many cases of fever occurring in your area. It is good to remember that Aedes mosquitoes bite even during daytime and hence you should take precautions against their bite during day time too.
14. If fencing of the doors and windows is not possible due to any reason, spray the entire house daily with pyrethrum solution. Dengue fever occurs most frequently in India in the months of July to October because this season provides very suitable conditions for breeding of mosquitoes. Hence all these preventive steps must be taken during the season.
15. Lastly, it is advisable to always keep the patient of Dengue fever under a mosquito net in the first 5-6 days of the illness so that mosquitoes don't have an access to him/her. This will help in reduction in spread of Dengue fever to other persons in the Community.

Complications 

·         Neurologic manifestations such as seizures and encephalitis/encephalopathy have been reported in rare cases of dengue infection. Some of these cases did not manifest other typical features of dengue infection. Other neurological complications associated with dengue infection include neuropathies, Guillain-Barré syndrome, and transverse myelitis.

·         Liver failure has been associated with DHF/DSS epidemics. Whether this is a viral effect or a product of prolonged liver hypoperfusion remains unclear.

·         Overhydration is a well-recognized complication of DF and DHF/DSS.

Prognosis: The prognosis of patients with DF is excellent, with complete recovery being the norm. Patients with DHF or DSS who do not die usually recover without sequelae.

Patient Education: Educate patients, especially those who have experienced prior DF, to avoid mosquito bites when traveling to dengue-endemic areas. Current evidence suggests that those with a history of DF are at highest risk for DHF or DSS if they are infected with a different dengue strain.

Homoeopathic Management
Homoeopathic treatment always stands supreme in prevention of control of all Epidemics. Our Master Dr Hahenmann has given clear cut instructions in Organon of Medicine in aphorisms 100-102 sections of 5th edition about "GENUS EPIDEMICUS". The selection of "Genus Epidemicus" need not be a single drug but a group of drugs. It need not be an exact similimum. A near similar will work.

Please Note: Genus Epidemicus depends on the totality available in a particular area. So these suggested medicines are not universally applicable wherever Dengue fever is prevailing. Please consider totality of symptoms available in a group of cases and decided upon the preventive medicines in your locality.

The above rubrics are related to disease picture to decide upon preventive medicines. If you are getting a specific totality in a given case don’t neglect. Please repertories and prescribe the indicated medicines.

Remedies which can be thought for preventive are: Ars-alb, Rhus-tox, Nux-vom, Sul, Gels,Eup-perf,Phos etc.

In Hemorrhagic type we can think of remedies like: Phos, Nat-phos, Lach, Crot-horr etc. Delhi Govt. has already started giving Eupatorium perf 200 as preventive for Simple Dengue fever and for Hemorrhagic type Ipecac 200.In Hyderabad we have started giving Ars-alb which is followed up with Phos depending upon the symptom similarity.

Here I am suggesting some of the medicines which can be thought of Dengue fever cases. Please once again note these are only suggestive and not the only medicines for prevention but one thing is guaranteed, once you form proper totality the indicated medicine does miracles.