Disclaimer: What you read here are thoughts of the author. This is not an official resource or text book about the disease mentioned.
My name is Dr. Richard Mata, I'm a Pediatrician by profession. For 12 years now my practice is focused in Panabo City, Davao del Norte, Philippines. My area has almost always been a Dengue epidemic area, thus, caring for Dengue patients have become almost an everyday task.
For the years of exposure, I noticed a lot of things that I haven't read in the books which I would like to share to concerned persons worldwide through this website. I do believe in one way or the other this will open a lot of eyes on the truth about this dreaded disease and somehow save lots of lives.
These are the following important learnings and observations:
Lets start with identifying the disease from its onset. Most of the time its just plain high grade fever, usually above 38 degrees celsius. I noticed that most people are looking for rashes, abdominal pain, nose bleeding as accompanying symptoms before they consider it to be a dengue case but the truth is that rashes, abdominal pain and nose bleeding are often absent on the first 3 days of the fever. For me the most important thing to ask the patient is his/her actvitiy. Most dengue patients feel very weak and sleepy consistently. What I mean of consistently is that they are weak looking during the time they have fever and even if the fever disappears they still look weak and wants to lie down.
Most kids are expected to play and become talkative when the fever decreases and becomes weak again only when the fever recurs in diseases like common flu, urinary tract infection, pneumonia and many others. But with Dengue Fever the patient looks weak when thereís fever and still weak even if the fever subsides and still doesnít play. If you see that in your kid in the first 2 days of fever, I suggest you need to be sure and have Dengue Fever a possibility, even if there are no rashes, bleeding or abdominal pain. It is also good to note that the platelet of most dengue patients appears to be normal for the 1st 3 days of fever and only decreases below 150 at the onset of the 3rd day. Therefore it is very important to look the child's activity especially on the 1st 3 days because the laboratory results most of the time will appear normal. Sometimes a patient is admitted with an initial diagnosis of pneumonia, UTI or viral infection but later it turn out to be dengue. It is because the first blood count won't show a low platelet. But if the doctor, nurses and the parent will be watchful of the persistent weakness of the kid even if there's no more fever, a repeat blood count must be done daily, especially at the 3rd day of fever.
So during hospital rounds when I notice the fever already subsided for a patient diagnosed with UTI, Pneumonia or any other disease, the next question will be, is the patient already playful? If the parent answers "no doc he is still always sleeping". I need to do a repeat CBC immediately for a possibility of Dengue. Failure to do so may mean harm to the patient. So if you are a parent with a presently admitted patient with fever, no matter what the doctor says of the diagnosis (including me) always keep watch if your kid remains sleepy or weak and not playfull when the fever is gone. If that is seen, then as a parent you have the right to ask for a repeat CBC just to be sure.
There are 3 Ls in Dengue Fever that you must know in order for you to know what to do to combat it:
- Leaking blood vessels
- Length of time the blood vessels leaks
- Levels of blood vessel leaks
- LEAKING BLOOD VESSELS:
Dengue is a disease of DEHYDRATION. Much like a Diarrhea except that the body fluids donít come out with the patientís stool but through PLASMA LEAKAGE. Imagine that the arteries and veins of a patient have thousands of pinpoint holes due to the body's reaction to the Dengue virus, causing the fluids inside the blood vessels to sip out. Thus, the feeling of a patient with diarrhea is the same with the patient with a dengue fever.
Figure 1: Dengue has blood vessels with holes, just like a cellophane filled water that has holes in it:
I always tell my patients : there are only 2 diseases that the patient still are not playful once the fever subsides: Dengue and Diarrhea. Why? Because both have the same weapon of destruction: DEHYDRATION.
Now that gives us good news. Nowadays when someone develops LBM, its no longer that scary as a life and death situation. Because we know the cure: lots of fluids, more than that comes out of the body must be taken in orally, like the oresol. And if its a bit severe LBM, you just need to apply Intravenous Fluids (Dextrose) to cope up with the fluids that are getting out. Diarrhea management is one of the best medical breakthroughs ever discovered. Prior to discovering it was only fluid replacement, millions had died to the usual LBM.
If Dengue is just Dehydration, then why are there still a lots of deaths? Around 25,000 per year worldwide? It's because many are confused of the disease. Many focus too much on how to bring the platelet back to normal immediately and somehow got diverted from the main problem which is DEHYDRATION. Thatís the purpose of this website. As you continue reading, you will understand why and somehow help decrease the unnecessary deaths.
Probably you are saying, itís because thereís a decrease in platelet count in dengue fever that makes it more dangerous. Actually that's how majority of people think and even some doctors. Thatís why there are a lot of approaches on how to increase the platelet back, like giving herbals like tawa-tawa plant, papaya leaves or giving durian or even mega doses of vitamins. This is where the problem really is. It is some sort of barking at the wrong tree scenario. Itís not the low platelet that kills a patient but itís the severe dehydration.
Figure 2 : Shows that basic solution to dehydration: give more fluids more than that goes out of the blood vessels.
Let me bring you to another disease named Idiopathic Thrombocytopenic purpura or ITP. This is a disease where in the child has a low platelet from weeks to years in duration. I have some patients who have this disease. Some will have platelets as low as 10 or lesser, but once you see them you canít believe that their platelet are that low. They are still playfull and active despite that they are on a low platelet status. Why so? Because ITP patients only has low platelet count but they are not suffering from dehydration which is not part of ITP but it is part of Dengue. I always say, if an ITP patient will develop severe diarrhea and will not be brought to the hospital, he/she will develop severe bleeding just like dengue. See... its still the fluids that matter. The low platelet will only cause harm if the patient is dehydrated.
Whatís my point? The truth is that even if the platelet of a dengue patient is low, but as long as the patient is properly hydrated, the patient will not give us any problem. Therefore we need to bark at the right tree, the right tree is the FLUIDS and not the platelets.
- LENGTH OF TIME IT LEAKS:
For many years this is what Iíve noticed something consistently, the platelet will decrease everyday from the start of fever until the 6th day (144 hours) from the start of fever then it will do a natural reverse going up. Now this is an important revelation. What do you think causes the decrease in platelet? For me the correct answer is still due to the PLASMA LEAKAGE. Plasma leakage causes the fluids to sip out of the vessels causing dehydration and the same time plasma leakage also cause the small sized platelets to sip out together with the fluids.
Now think with me. If the platelet consistently decreases until the day 6 of illness and it will do a reverse increase what would that mean? It means that in Day 6 the plasma leakage also stops and so the platelet and fluids no longer sips out and it will gradually go back to its normal level. Making the fall and rise of platelet a good gauge to determine if the patient is still in the LEAKING phase or not anymore. Therefore the decrease in platelet is not an enemy but a friend. It guides us that, if it is still decreasing, the fluids are still leaking out, and if platelet is already increasing, it means that the fluids are no longer leaking out.
I donít really agree to give the patient anything that will push the platelet to increase prior to its natural time to increase ( which is Day 6) because it will somehow remove the benefit of using the natural fall and rise of platelet in dengue as a gauge in fluid replacement. A decreasing platelet says the body fluids are still leaking out and the IVF fluids (Dextrose) must be faster the usual and if it is already increasing (usually at start of day 6) it means we need to taper down the fluids being given because the leakage is disappearing already to avoid over-fluids or congestion of the lungs.
Figure 3: Platelet goes down for 6 days from the start of fever then increases thereafter provided that the patient is fully hydrated as noted by always urinating:
The reason also why many herbals like tawa-tawa, papaya leaves, durian or balut seems to work in increasing the platelet is that as mentioned above the platelet will resume to increase back after the 6th day of illness as long as the patient is well hydrated, so many will mistakenly think that it was there magic herbals and fruits that caused it. But the truth is that it will really increase back naturally even without those additives.
Honestly I see some (very few) patients that when given tawa-tawa it seems that the platelet increases before the said 6th day. But I call this as a fake increase. A tawa-tawa increase effect doesn't solve the dehydration of the patient. Thus, some doctors can mistakenly decide to remove the IV fluids and discharge the patient prematurely because of a fake increase given by tawa-tawa plant. It will just give doctors confusion rather than help and the wrong decision can be harmful to the patient.
- LEVELS OF BLOOD VESSEL LEAKS:
Now another learning I noticed was that there are different types of dengue. Not all dengue are the same. Some are very mild and some are very strong. To understand it, we need to still look at it in the degree of fluid dehydration. The ones that are mild are those not so dehydrated and those that are toxic are those severely dehydrated.
Now that I mentioned above that Dengue produces lots of holes in your blood vessels causing your fluids and platelet to sip out. I would like to go further differentiating the different types of Dengue. Let me call them MILD type, MODERATE type, SEVERE type and VERY SEVERE TYPE. What made these dengue types different from each other are simply the sizes and the amount of the holes it gives the blood vessels of the patient.
Let me use a cellophane filled with water as an example. If I will use a needle and put a few tiny holes through it, will the water inside drain immediately? Certainly not. This is therefore the mild one. Drinking lots of fluids can easily compensate the minute loss. Thatís why you can hear dengue patients who survived without even being admitted in the hospital, they fortunately have small holes. What if I will use a nail and place holes in the cellophane, of course the leaking will be faster and sooner than you expect the cellophane will run empty. If only all dengue patients comes in with tiny leaks in their blood vessels then everything will be easy for all of us.
Figure 4: Shows the differences of the 4 strains of Dengue based on the sizes of the holes.
This is where the game is. The ones with small holes needs small amount of fluid replacement while the ones with big holes needs a lot of fluid replacement because in just a matter of time the patient will dehydrate causing kidney damage as well as other organ failures. This what makes dengue different from diarrhea. In diarrhea you can easily estimate the amount of fluids that goes out with stool and thus estimate the amount that is needed back to compensate the loss. In dengue fever on the hand, you can not see the fluid coming out literally because the plasma leakage only brings the fluids outside the blood vessels but still inside the body.
I do believe that the majority of dengue deaths were caused by lack of fluids that came in compared to the amount of fluids that came out of the blood vessels. Some may argue that other dengue deaths are due to over fluids that caused congestion in the lungs. My answer is that congestion in dengue is caused by lack fluids in the first days of illness that caused kidney failure that resulted to inability of the body to urinate thus causing congestion. Thus, it is still DEHYDRATION to begin with. Solving this balance, you will solve Dengue.
Some may say the patient died due to low platelet causing gastro-intestinal bleeding, but I say it was not really due to low platelet but due to dehydration that cause low blood supply to the intestines causing ulcer formation that caused the bleeding and of course due the fact that theres a low platelet the bleeding wonít stop. But if there was no dehydration , even if the platelet is less than 10, the patient will still not develop intestinal bleed and I have proven that so many times in my practice.
I always say: donít be afraid of a low platelet for afterall it is guaranted to increase back naturally starting at day 6 from the start of fever as long as the patient is fully hydrated.
So again to fight Dengue, understand the 3Ls:
1. Leaking blood vessels- itís about dehydration. A low platelet wonít kill if you are not dehydrated
2. Length of time the blood vessels leaks- it leaks for 6 days, so make sure you are hydrated within that 6 days to the point you will always urinate every one to 3 hours.
3. Levels of blood vessel leaks-not all dengue attacks are the same. Some have bigger leaks and some have small leaks. Assume you have the big leaks so you will be more aggressive in hydration.
These are the signs of a fully hydrated dengue patient:
- Urinates almost 1 to 3 hours interval
- Able to sit down
- Able to Walk
- Able to Talk
- Normal Blood pressure
If the patient is always lying down and the urinates more that 4 hours interval, watch out because in just a few hours the patient will show signs of severity like hypotension or coffee ground vomitus. Waiting for this to happen before you make a move can be too late. Therefore, it is highly recommeded that the patient must drink lots of water from the start of the fever even while at home to achieve a frequent urination level. The patient must already be admitted in the hospital not longer than 72 hours from the start of fever and even earlier if he/ she looks very weak. The doctor must also have a good hydration technique in order to assure survival. The patient must still be encouraged to drink water even if he/she already has a dextrose so that urination will be very often. When the patient will reach the 6 day of illness (144 hours), he/she may decrease water drinking to regular level only. Meaning after the 6th day of illness you don't need to drink lots of water as the liquid that leaked from your blood vessels will now start coming back. Thus, water drinking at this point will no longer be as high as what you do during the first 6 days that lapsed.
Below is a picture of my patient who really reached a platelet of 1 only. There was no blood transfusion done to this patient but he resolved spontaneusly. As I have mentioned the drop of the platelet will reach until the 6th day. He had a fever that started on a Sunday and was admitted on Wednesday (3rd day). In the image below, the platelet of 1, was taken at the 6 th day, Saturday. At the seventh day (Sunday) the platelet started to rise to 15 then 45 by the 8th day (Monday) then 140 by 9th day (Tuesday) without any blood transfusion or tawa-tawa or papaya. The patient was fully hydrated, urinating almost every hour, thus I assured the mother the platelet will ascend starting day 6 or 7th day. The photo of the patient himself (making a one sign) was taken at the 9th day when he was about to be discharged. Of course during the day when he had a low platelet, there where some blood at his gums but no severe bleeding because as I said he was fully hydrated to the level that he keeps on urinating.
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